Investigating Knowledge, Stress Prevalence, and Stressors in Relation to Stress and Stress Management Practices Among Medical Students in Saudi Arabia

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INVESTIGATING KNOWLEDGE, STRESS PREVALENCE, AND STRESSORS IN RELATION TO STRESS AND STRESS MANAGEMENT PRACTICES AMONG MEDICAL STUDENTS IN SAUDI ARABIA

A dissertation submitted to the Kent State University College and Graduate School of Education, Health and Human Services in partial fulfillment of the requirements for the degree of Doctor of Philosophy

Waleed Alshahrani

August 2019

A dissertation written by

Waleed Alshahrani

Assoc. Deg., Dammam University, KSA, 2005

B.S., Kent State University, USA, 2012

M.Ed., Kent State University, USA, 2014

Ph.D., Kent State University, USA, 2019

Approved by

______, Director, Doctoral Dissertation Committee Kele Ding

______, Co-Director, Doctoral Dissertation Committee Donna Bernert

______, Member, Doctoral Dissertation Committee Suzanne Holt

Accepted by

______, Director, School of Health Sciences Ellen Glickman

______, Dean, College and Graduate School of James C. Hannon Education, Health and Human Services

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ALSHAHRANI, WALEED., Ph.D., August 2019 HEALTH SCIENCES

INVESTIGATING KNOWLEDGE, STRESS PREVALENCE, AND STRESSORS IN RELATION TO STRESS AND STRESS MANAGEMENT PRACTICES AMONG MEDICAL STUDENTS IN TAIF UNIVERSITY, SAUDI ARABIA (230 pp.)

Co-Director of Dissertation: Kele Ding, M.D., Ph.D. Bernert Donna, Ph.D.

The purpose of this study was to investigate stress knowledge, stress prevalence, the source of stress, and intention of future practice of stress management techniques

(SMTs) among medical students in Taif University (TU), Saudi Arabia by gender and grade cohort. In addition, this study examined the predictive value of knowledge, attitudes, subjective norms, and perceived control of stress to the intention of stress management practices. This study aimed to create a sense of how these independent and dependent variables worked together to construct predictions about students’ behavior in regard to stress management practices. The significance of this study was to provide administrators, staff, and faculty with enough information about its medical students’ stress prevalence and their perceptions of stress. Findings from this study assist to recognize and understand the difficulties as well as health issues of TU medical students' lives. These findings revealed the overall stress prevalence was high among TU medical students as compared to other or similar populations in Saudi Arabia and Middle Eastern countries.

Among students who had high stress, attitude, subjective norm, and behavioral perceived control scores were found statistically significant predictors of intention to practice SMTs. On the other hand, among high-stress students who never practiced

SMTs, stress knowledge, attitude, subjective norm, behavioral perceived control, demographic and stressor scores were tested and only behavioral perceived control and gender were found statistically significant predictors of intention for practicing SMTs.

Surprisingly, the environmental, family, and academic stressors were not found significant predictors of intention.

ACKNOWLEDGMENTS

I would first like to thank my dissertation advisors—Drs. Kele Ding, Donna

Bernert, and Suzanne Holt. This work would not have been possible without their support. Each of the members of my dissertation committee has provided me personal and professional guidance and taught me a great deal about scientific research.

I am especially grateful to Dr. Kele Ding, the chairman of my dissertation committee, who has been supportive of my study goals and who worked actively to provide me with the protected academic time to pursue my educational goals.

I am grateful to all of those with whom I have had the honor to work during this research, who were involved in the participants’ requirement and the completion of the survey for this research. Without their passionate contribution, the accomplishment of the data collection could not have been successfully completed. I am especially grateful to Dr. Saad AlZahrani, Vice President of Postgraduates and Scientific Research at Taif

University, Dr. Sultan Alamri, Chair, Department of Radiological Sciences at Taif

University, and Dr. Jamal Allam, Head of the Research Unit, College of Medicine at Taif

University.

Finally, I must express my very profound gratitude to my mother for providing me with unfailing support, endless encouragement, and her continuous praying for me throughout my years of study as well as within the process of researching and writing this dissertation. Most importantly, I would like to thank my loving and supportive wife, Dr.

Reem Alshahrani, and my wonderful daughters, Leen and Renad, who provide

continuous inspiration. This achievement would not have been possible without their continuous support. Thank you so very much.

DEDICATION

This dissertation work is dedicated to my wife, Dr. Reem Alshahrani, who has been a continuous source of support and inspiration during the challenges of undergraduate and graduate studies. I am truly thankful for having her in my life. This work is also dedicated to my mother, daughters, brothers and sisters, who have always loved me and who encouraged me to work hard for the things that I wanted to achieve.

TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS ...... iv

DEDICATION ...... vi

LIST OF FIGURES ...... x

LIST OF TABLES ...... xi

CHAPTER

I. INTRODUCTION ...... 1 Statement of the Problem ...... 11 Purpose of the Study ...... 14 Study Objectives ...... 15 General Objective ...... 15 Specific Objectives ...... 15 Significance of the Study ...... 16 Conceptual Framework for the Study ...... 16 Research Questions ...... 19 Operational Definitions of Terms ...... 20 Basic Assumptions ...... 22 Summary ...... 23

II. REVIEW OF LITERATURE...... 24 Stressor ...... 24 What Stress Does to the Body ...... 26 Stress Among Medical Students ...... 28 Risk Factors for Stress Among Medical Students ...... 31 Physical Effects ...... 34 Psychological Effects ...... 35 Emotional Effects ...... 35 Stress Prevalence Among Medical Students ...... 36 Gender and Grade Level Difference Related to Stress ...... 39 The Controversy Surrounding Predictors of Stress Among Medical Students ...... 40 Stress Knowledge...... 41 Coping Strategies Among Medical Students ...... 42 Factors and Common Adopted Coping Strategies Among Medical Students ...... 43 Stress Management ...... 46 vii

Predictive Factors of Intention to Practice Healthy Behavior Following the Theory of Planned Behavior (TPB) ...... 50 Summary ...... 51

III. RESEARCH METHODS AND PROCEDURES ...... 52 Purpose of the Study ...... 52 Research Questions ...... 52 Study Design ...... 53 Study Population ...... 55 Sample and Sampling Method ...... 56 Sampling Procedure ...... 57 Instrumentation ...... 59 Demographic Information ...... 60 Stress Knowledge Questionnaire (SKQ) ...... 61 Perceived Stress Scale (PSS) ...... 62 Graduate Stress Inventory-Revised (GSI-R)/Stressor Questionnaire ...... 63 Attitude, Subjective Norm, Perceived Behavioral Control, and Behavioral Intention Questionnaires ...... 64 Pilot Study ...... 68 Data Collection for the Pilot Study ...... 70 Response to the Pilot Study ...... 71 Data Analysis ...... 72 Discussion ...... 79 Data Collection for the Main Study ...... 81 Response to the Main Study ...... 82 Statistical Findings ...... 84 Data Analysis ...... 84 Ethical Consideration ...... 91 Informed Consent...... 91 Summary ...... 92

IV. RESULTS ...... 94 Descriptive Statistics ...... 95 Demographics Characteristics ...... 95 Dependent Variables ...... 97 Independent Variables ...... 103 Summary of Descriptive Statistics ...... 110 Hypothesis Test ...... 111 Research Question 1 ...... 111 Hypothesis 1.1 ...... 111 Hypothesis 1.2 ...... 112 Hypothesis 2 ...... 114 Hypothesis 2.1 ...... 115 Hypothesis 2.2 ...... 116 viii

Hypothesis 3 ...... 117 Hypothesis 3.1 ...... 119 Multiple Linear Regression Assumptions ...... 122 Hypothesis 4 ...... 123 Hypothesis 4.1 ...... 126 Hypothesis 4.2 ...... 128 Additional Analysis ...... 132 Future of Stress Management Practice by Gender...... 132 Future of Stress Management Practice by Major/College Enrollment ...... 134 Summary ...... 136

V. DISCUSSION AND RECOMMENDATIONS ...... 139 Purpose of the Study ...... 139 Response Rate and Gender Proportion ...... 141 Prevalence of Stress ...... 141 Stress Management Behaviors ...... 145 Knowledge, Attitudes, Subjective Norms, and Perceived Control ...... 150 Intention of Stress Management Practices ...... 152 Recommendations for Further Research ...... 158 Health Education and Stress Management Program: Recommendations ...... 160 Health Education ...... 161 Stress Management Program ...... 162 Recommendations for Administrators ...... 170 Limitations ...... 170 Summary ...... 171

APPENDICES ...... 174 APPENDIX A. INSTRUMENT ...... 175 APPENDIX B. IRB APPROVAL AND APPLICATION ...... 195 APPENDIX C. VPGSSR SUPPORT LETTER...... 202 APPENDIX D. INVITATION LETTER AND E-MAIL REMINDERS ...... 204 APPENDIX E. ONLINE CONSENT FORM ...... 208

REFERENCES ...... 210

LIST OF FIGURES

Figure Page

1. Conceptual framework for the study...... 18

2. Flow chart for the data collection process...... 72

3. Sampling frame for the main study from two medical colleges at Taif University...... 86

4. Research design for the study ...... 94

5. Number of students who had high and low stress by gender ...... 100

6. Number of students who had high and low stress by major ...... 101

7. Number of medical students based on the frequency of practicing SMTs ...... 103

8. Stress management status by major among high stress group (n=443) ...... 104

9. Types of stressors that have an impact on students’ stress levels ...... 108

10. Graph histogram normality ...... 125

11. Regression parameter plot graph represents the significant predictors of intention to practice SMTs ...... 128

12. Regression parameter plot graph represents the significant predictors of intention to practice SMTS among high stress and never practice SMTS group ...... 130

13. Regression parameter plot graph represents the significant predictors of intention to practice SMTs ...... 134

14. Future practice of SMTs: Compression between male and female ...... 136

15. Future practice of SMTs: Compression between the two medical colleges ...... 137

LIST OF TABLES

Table Page

1. Stress in the Middle East Countries ...... 13

2. Stress Prevalence in Saudi Universities ...... 14

3. Stress Prevalence Worldwide ...... 37

4. Common Coping Strategies by Country ...... 44

5. Demographic Information Scale ...... 61

6. Constructs, Instruments, Scales, and Number of Items ...... 68

7. Demographic Characteristics of the Pilot Study Sample ...... 70

8. Frequency of Students’ Stress Knowledge Scores...... 73

9. How Women Medical Students Managed Stress ...... 76

10. Frequency Rating Scale Response ...... 76

11. Content Analysis ...... 77

12. Main Findings of the Pilot Study ...... 79

13. Null Hypotheses and Statistical Tests ...... 90

14. Demographic Characteristics of the Main Study Sample (n=447) ...... 96

15. Stress Levels for All Respondents by Gender (n=443) ...... 98

16. Stress Level by Gender Among High and Low Stress Groups (n=443) ...... 99

17. Stress Management Status by Gender for All Samples (n=444) ...... 101

18. Stress Management Status by Gender Among High Stress Group (n=443) .... 102

19. Stress Management Status by Gender Among Low Stress Group (n=443) .... 102

20. Frequency of Students’ Stress Knowledge Scores–Main Study ...... 104

21. Descriptive Statistics of Stressor Scale for the Main Study Participants...... 105

22. Descriptive Statistics of Stressor Scale by Gender for the Main Study Sample...... 105

23. Descriptive Statistics for the Top Stressors by Gender Based on Mean...... 107

24. Descriptive Statistics for the Top Stressors by Year of Schooling Based on Mean ...... 108

25. Descriptive Statistics of Attitude, Subjective Norm, Behavioral Perceived Control, and Behavior Intention by Gender for the Main Study Sample ...... 110

26. Hypotheses 1, Chi-Square Test Findings (n=443) ...... 112

27. Hypotheses 1.2, Chi-Square Test Findings ...... 113

28. Hypotheses 2, Chi-Square Test Findings (n=444) ...... 114

29. Hypotheses 2.1, Chi-Square Test Findings (n=444) ...... 116

30. Hypotheses 2.2, Chi-Square Test Findings (n=443) ...... 117

31. Mean, Standard Deviation, and P-value for Each Variable by Gender ...... 119

32. Hypothesis 3.1, Pairwise Comparisons, Tukey HSD ...... 120

33. Hypothesis 3.1, Descriptive for Dependent Variables ...... 121

34. Hypothesis 4, Multiple Linear Regression Model Results ...... 125

35. Hypothesis 4.1, Multiple Linear Regression Model Results ...... 128

36. Hypothesis 4.2, Multiple Linear Regression Model Results ...... 131

37. Saudi Universities Stress Studies, Conducted from 2007 to 2017...... 140

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CHAPTER I

INTRODUCTION

Historically, stress in the medical field has not been given the consideration it deserves (Selye, 1973). According to the National Center for Health Statistics (2004), the leading causes of death were illnesses caused primarily by infectious diseases (e.g., rubella, polio, typhoid, tuberculosis, and encephalitis). Although the term "stress" had been coined in 1936, medical professionals were focused on combating the illnesses pertinent to the times and were working towards preventative measures and seeking cures. These illnesses have since been eliminated and/or brought under control (Babbott et al., 2014).

Today, stress is recognized worldwide as a major challenge to an individual’s health and the healthiness of one’s workplace (Grossman, Niemann, Schmidt, & Walach,

2004; Edwards, Radford, Albertone, & Rinker, 2014; Halpern, 2005; World Health

Organization [WHO], & International Society of Hypertension Writing Group [ISHWG],

2003). In 1936, Hans Selye defined stress as “the nonspecific response of the body to any demand for change” (Selye, 1973, p. 32). Selye (1973) explained that, to a certain point, stress is challenging and useful. Behere, Yadav, and Behere (2011) defined stress as the “wear and tear” our bodies experience as we adjust to our continually changing environment; it has physical and emotional effects that can lead to positive and negative results. Medically, stress is the reaction the body has when a person feels threatened by, or is under pressure from a specific situation. Hormones are secreted to prepare the body for response. The heartbeat is elevated and a raise in blood pressure causes blood flow to

2 be redirected from main functions, such as the digestive system, and can lead to unwanted health consequences (Behere, Yadav, & Behere, 2011).

When stress has a positive effect on an individual, it can aid a person by inspiring them into action. An optimal level of stress is categorized by high energy, and is linked to enhanced learning ability, improved academic achievement, a boost in personal and professional development, calmness under pressure, improved memory and recall, and an optimistic outlook (Kaplan & Saddock, 2000). The idea is not to reduce stress; such a mission is not possible or required. The current issue is the levels of stress most individuals in our society experience are hardly optimal (Niemi & Vainiomaki, 2006).

When there is not an optimal level of stress, that is when an individual is affected in a negative manner by stress, and he or she could be left with feelings of distress, rejection, anger, and depression. All of these states of being have the potential to result in health problems (Behere et al., 2011). When stress becomes chronic or excessive, the body is no longer able to adapt and cope with the pressures placed upon it (Niemi &

Vainiomaki, 2006). Stress is linked to the leading causes of death in our society today that are frequently linked to lifestyle behaviors, such as inadequate physical activity, poor diet, and smoking (Mazure, Keita, & Blehar, 2002). Not only can stress be linked to these lifestyle behaviors, but new evidence based-medical studies have shown stress is a contributing factor to numerous illnesses, such as cardiovascular diseases, cancers, chronic obstructive lung diseases, hypertension, gastrointestinal disorders, tension and vascular headaches, low-back pain, and decreased immunological functioning (Cohen,

Schwartz, Epel, Kirshbaum, Sidney, & Seeman, 2006; O’Keefe, Poston, Moe, Haddock,

& Harris, 2004; Reiche, Morimoto, & Nunes, 2005; Kruk & Aboul-Enein, 2004;

Waldstein, Siegel, Lefkowitz, Maier, Pelletie, Obuchowski, & Katzel, 2004). Other illnesses believed to be caused by stress, include angina, asthma, cystitis, depression, diabetes, diarrhea, heart attack, migraine, psoriasis rheumatoid arthritis, and ulcers.

Partial loss of body hair (alopecia areata) or even total loss of all body hair (alopecia universalis) can also result from stress (Behere, Yadav, & Behere, 2011).

The Center for Disease Control and Prevention [CDC] (2004) conducted a survey for the Healthy People 2000 agenda and found 53.5 % of people aged 18 and older had experienced adverse health effects from stress within the previous year. Researchers at the American Institute of Stress estimated 90% of all visits to healthcare providers were a result of stress -related disorders (Fushchich & Zhdanov, 2003; Cummings &

VandenBos, 2001; U.S. Department of Health and Human Services, 2005). These compelling figures demonstrate the relevance of focusing on both stress reduction and stress management because a significant number of people experience stress and stress related disorders. Stress has an impact on individuals on a regular basis; studies have shown different groups of people are known to experience different types of stress

(Crandall, Preisler, & Aussprung, 2004; Sarafino & Ewing, 2001; Ross, Niebling, &

Heckert, 2000).

One group that experiences a unique and specific stress is college students. The college student population is found to be specifically more susceptible to stress (Ross,

Niebling, & Heckert, 2000). According to a recent survey conducted by the American

College Health Association (2015), about 54.0 % of college students (43.7 % male, 59 %

4 female) of 20,460 students surveyed reported they had been diagnosed with depression and treated by a professional at least once for feeling overwhelmed by the number of tasks they were required to do. Rollings and Harmon (2005) found some college students practiced unhealthy behaviors in order to manage stress, including substance abuse, binge drinking, smoking, and unprotected sexual activities. Stress prevalence among the college student population varies due to several factors that can increase the likelihood of stress, such as the unique factors that have potential for causing stress among medical college students (Sherina et al., 2003).

Stress in medical students has been identified as a global issue for decades (Jain &

Bansal, 2012). According to Shapiro et al. (2000) and Sherina et al. (2003), medical students are a unique group of individuals who face certain intrapersonal, interpersonal, environmental, and academic stressors. Many of these sources of stress are not necessarily related to other population groups (Ross, Niebling, & Heckert, 2000; Misra &

McKean, 2000; Camatta & Nagoshi, 2005; Kadison & DiGeronimo, 2004). For example, medical students often need to adjust to a new social environment; become comfortable with being first responders as healthcare providers; transition from medical school to internship; deal with real issues of life and death, and cope heightened academic challenges (Towbes & Cohen, 2001).

Medical programs and medical education have evolved and proliferated over time in a manner that has created a greater need for achieving a leading degree of academic success. In addition, the evolution of medical programs and medical education has increased the demand for high scholarly performance. The increased demand for

5 academic success, as well as a first-rate scholarly performance, subject medical students to a copious amount of stress (Sherina et al., 2003).

Stress from academic issues within the professional medical education fields are not the only stressors medical students are confronted with in their medical programs.

This population of medical students also is affronted by several factors that could lead to stress, including but not limited to the lack of health promotion programs; the lack of entertainment provision in school or the educational program itself; limited amount of time for recreation; financial issues; and the required long on-duty assignments where they are exposed to human suffering (Aktekin et al., 2001).

Problems affecting medical students in particular, vary and may include loneliness, lack of a proper diet, low self-esteem, nervousness, clinical depression, substance abuse, sleeplessness, excessive anxiety, an unhappy marriage, and suicide attempts (Grzywacz, Lang, Suerken, Quandt, & Bell, 2005; Sherina et al., 2003;

Oldendick et al., & Stoskopf, 2000). Other issues that can arise from stress among medical students include, but are not limited to a reduction in attention, decreased concentration, and difficulties in decision-making. Medical student stress has been reportedly associated with anxiety, depression, and psychological symptoms plausibly having a negative impact on students’ academic performance (Singh, Lal, & Shekhar,

2010; Elias, Ping, & Abdullah, 2011). All of these problems can decrease the student's ability to create strong relationships with patients. This could result in affecting patient lives by increasing medical errors. Medical errors, in turn, could lead to negative consequences on the community’s health as a whole (Grzywacz et al., 2005).

The sources of stress/stressors among medical students vary by year in accordance with how far along students are in their studies or medical program as well

(Colford, 2003). According to Guthrie et al. (2005), most causes of stress among medical students are linked to being enrolled as first-year medical students. In the first year of a medical program, students are faced with the challenge of being uprooted from family and friends, coupled with the challenge of adapting to a demanding new learning environment. However, as medical students make progress within the program and adapt and become more comfortable with a rigorous course load and personal challenges, the stressors these students confront shift to new facets within the medical program (Linn &

Zeppa, 2002). The human cadaver dissection is one such new aspect in the medical program that can cause a significant amount of stress. Other sources of distress occur as a student’s medical education becomes more involved. A substantially increased scholastic workload and a concern for a first-rate academic performance can lead to a compelling amount of stress that a medical student may experience (Linn & Zeppa,

2002).

Most of a medical education focuses on how to treat illness. Unfortunately for medical students, there is a limited amount of focus on their own well-being. When medical students are unaware of the amount of stress they are under, or how to handle that stress, their medical performance can become jeopardized (Kliesen & Smith, 2010).

In medical school, students are taught the pathophysiology of illness and the systematic approaches to medical practices, but not how to enlist in social and cultural activities that afford a healthy lifestyle to reduce stress (Nuzhat, Salem, Hamdan, & Ashour, 2013).

Building on cultural orientations and traditional practices were found to be a beneficial for individuals to reduce stress (Kim et al., 2007) such as, activities that students enjoy doing, these might include playing sports, walking, activities that engage parents, and the inclusion of free or low cost physical activity programs on campus to encourage student involvement (Kim et al., 2007).

Medical schools typically use a curriculum of didactic lectures, modeling, supervised practice, mentoring, and hands-on experience to augment individual study.

Some aspects of the training process have led to unintended negative consequences on students’ personal health due to stress. It is critical for medical educators to understand the prevalence and causes of student distress, potential adverse personal and professional consequences, and institutional factors that can positively and negatively influence student health (Nuzhat et al., 2013). Huebner, Royer, and Moore (2012) stated that if medical students do have high levels of stress, it is essential to investigate which aspects of the course/training are causing that stress, so that those particular factors, as well as the student's ability to cope with them may be improved.

In general, stress has been involved in the onset and maintenance of many acute and chronic diseases. Scientists’ main concerns have shifted to focus on primary and secondary prevention strategies by way of stress reduction and stress management techniques. Scientists have shifted their focus in this way, in order to reduce the burden of disease on the population (Ebrahim & Smith, 2003; Schneiderman, Antoni, Saab, &

Ironson, 2001; Kromhout et al., 2002). Due to the plethora of stressors impacting medical students, measures are required for this population group to learn coping

8 mechanisms. If medical students do not learn appropriate coping strategies to deal with these new stressors, they may experience physical and psychological consequences and distress (Sarafino & Ewing, 2000).

A widespread search failed to locate any study that showed why medical students are not practicing stress management techniques (SMT) to reduce their stress. There is also a lack of existing information in the current pedagogy that identifies personal and predictive factors that enhance students’ quality of life physically, emotionally, and spiritually in undergraduate medical programs in Saudi Arabia. As Kingdom of Saudi

Arabia (KSA) is a developing country, there are strong possibilities their medical students have higher levels of stress. Saudi medical research showed that high stress

(distress) was reported among Saudi medical students and found its average between 54

% and 77% of stress (Abdel Rahman et al., 2013; Sani et al., 2012; Zeyad et al., 2012;

Ziyad et al., 2015). Medical studies have also shown female medical students are more susceptible to stress than male medical students (Sani et al., 2012; Harel-Fisch, Abdeen,

Walsh, Radwan, & Fogel-Grinvald, 2012; Ziyad et el., 2015).

The present study, therefore, was carried out to determine the knowledge, the prevalence, and management status of stress in the medical student population in Taif

University (TU), Saudi Arabia. In addition, this study determined the intention to practice stress management among this population of students. It attempted to observe any possible association between the levels of stress as they pertain to gender and academic year.

Understanding individuals’ predictive factors presented in the Theory of Planned

Behavior (TPB) constructs (attitude, subjective norm, perceived behavioral control, and the intention) can aid in making a contribution for promoting their well-being (Dyrbye et al., 2008). Therefore, identifying these factors can also help the advancement of their academic performance, and at the same time, can facilitate the usage and the appreciation of adaptive coping mechanisms (Wolf, Schommer, Hellhammer, McEwen, &

Kirschbaum, 2001). For instance, the concept of “attitude” is meant as the degree to which performance of the behavior is positively or negatively valued towards a particular behavior (Ajzen, 2006). In this context, attitude has been identified in previous studies as having the strongest effect on students’ stress perception (Ajzen, 2006; Wolf et al., 2001).

According to Fishbein and Ajzen (1975), attitude is determined by the total set of accessible behavioral beliefs connecting the behavior to numerous outcomes and other attributes, such as acceptance, planning, positive reinterpretation, and self-distraction.

The attitude can reduce psychological morbidity, and by understanding this predictive factor, it is easier to promote the wellbeing of the medical student (Fishbein & Ajzen,

1975).

Subjective norm is another key concept in the TPB that looks at a person’s own estimation of the social pressure norms, or the beliefs of significant people in an individual's life, to perform or not perform the target behavior (Fishbein & Ajzen, 1975).

Peer discussion groups are an example that refers to the subjective norm concept

(Morrison & O’Connor, 2005). Peer discussion groups can promote the wellbeing of students (Dyrbye et al., 2008). These groups can help students’ process conflict, nurture

10 self-awareness, and promote empathy. Such groups provide opportunities for students to express, analyze, and share feelings that decrease the likelihood of burnout (Dyrbye et al.,

2008). Shared reflection helps students realize their struggles are not unique and provides insight into how colleagues solve similar problems.

Another factor that can help individuals cope with stress entails their perception of stress. This is an example that refers to the perceived behavioral control (PBC) concept (Fishbein & Ajzen, 1975). Perceived behavioral control is the extent to which a person feels able to enact the behavior (Fishbein & Ajzen, 1975). The PBC data specifically are the strongest in relation to the predictor in the TPB (Ajzen, 2006). It has two aspects: how much a person has control over the behavior and how confident a person feels about being able to perform or not perform the behavior (Ajzen, 2006). For example, having low control over the management of stress would involve a person who is not sufficiently skilled in managing stressful events. This is determined by the control of beliefs about the power of situational and internal factors that inhibit or facilitate the performance of the behavior (Francis et al., 2004). That is to say, an individual's ability to manage his/her stress is entirely up to that individual.

Similarly, intention to practice stress management is an important concept in that it helps to inform students about the effects of stress on physiological and psychological functioning. It teaches students how to plan, prioritize, and identify sources of stress, as well as how to cope with stress effectively (Ajzen, 2006). The variables in TPB can be used to determine the effectiveness of implementing intervention programs even if there

11 is not a readily available measure of actual behavior. It may be able to determine the specific beliefs that have the greatest influence on intentions.

Statement of the Problem

Stress in medical education is expected. The findings may vary from one student to another, and one situation to another as academic demands and the rigor of study increases. Variability, intensity changes, and volatility of stress are major issues in its interpolation in domains of medical studies and education.

Medical students are more likely to experience high levels of stress because of risk factors that can lead to distress, such as academic pressure, examinations, clinical hours, and family and social expectations (Yang et al., 2014). Stress in medical institutes adds to the normal baseline stress all people experience (Elias, Ping, & Abdullah, 2011).

Lack of knowledge about stress and its consequences, lack of health promotion programs provided by the school, and lack of entertainment on campus and in the education system itself all perpetuate the stress experienced by this population of students. Thus, it is the school’s responsibility to assure a less stressful environment for such a group of people

(Al-Dubai, Alshagga, Rampal, & Sulaiman, 2012).

In the Middle East countries, epidemiological data concerning psychological morbidity among medical students, suggested that medical students are at a high-risk for distress (Gilany, Amr, & Hammad, 2008; Amr, Gilany, Sayed, & Sheshtawy, 2008).

Despite the higher rate of distress in the Middle East countries, results of two recent studies from Saudi Arabia suggested high rates of anxiety and depression among TU’s medical students (Alarabi & Alswat, 2017; Alzharani et al., 2017). Therefore, it is

12 important to assure a less stressful environment for such a group of people who are attending a medical college at TU.

Alarabi and Alswat (2017) conducted the first study with the aim to determine the lifestyle patterns among TU’s medical students. Results from the study found that about

52.9% of medical students reported an unhealthy lifestyle. Also, the study showed that about 55.4% were active smokers, which indicates a stressful environment compared with other reported results from a similar population (about 33% of medical students at

King Saud University in Riyadh are active smokers).

The second study was conducted by Alzharani et al. (2017) and showed that the prevalence of depression among TU’s medical students was 41% and 28% among applied medical sciences students. The same study found about 19% of the sample reported suicidal ideation (i.e. medical students 23% and 17% medical sciences students). These two studies suggested that the medical students at Taif University had higher depression rates and suicide rates in comparison to medical students from other Saudi universities

(Alarabi & Alswat, 2017; Alzharani et al., 2017).

Currently, it is estimated that approximately 1,200 to 1,500 students are medical majors at TU (Taif University Medical Colleges, 2016). However, in general, there is a dearth of information in the literature about the effects of stress on medical students at

TU. There is some existing data that place stress prevalence among Saudi medical students in a higher rate (54% - 77%) (Abdel Rahman et al., 2013; Sani et al., 2012;

Zeyad et al., 2012; Ziyad et al., 2015) compared with the population of the Middle East countries (see Table 1).

Table 1

Stress in the Middle East Countries

Country Stress Prevalence n(%) Source

Egypt 59.9% Zaki et al., 2011

Jordan 58% Boran et al., 2012

27.7% Al-Busaidi et al., 2011 Oman

United Arab 29% Ahmed et al., 2009 Emirates Abdel Rahman et al., 2013, Sani et al., 2012, Zeyad et al., 2012, & Saudi Arabia 73.6% Ziyad et al., 2015

There is no existing knowledge about stress self-management or research studies on the issue of stress management among medical students at TU. There is currently limited information and knowledge concerning the prevalence of stress and how it affects medical students at TU as well. Among 28 Saudi public universities, only five of them have reported stress prevalence with an average of 73.6% (see Table 2). Therefore, there is a need for this study as a means to gain more statistical information from the medical students at Taif University in Saudi Arabia.

Table 2

Stress Prevalence in Saudi Universities

Country Stress Prevalence n(%) Source

King Saud University 41% Alzharani et al. (2017)

Dammam University 48.6% Al-Dabal et al., 2010 Jizan University 71.9-77% Sani et al., 2012 King Abdul-Aziz Univ. 63% % Abdulghani et al., 2011

Om AlQuar Univesity 76.4% Al Gelban et al., 2009

This study was conducted utilizing best practices of the TPB within the domains of SMTs, including an exploration of how researchers could best address and resolve issues in these domains and outline areas where additional research is needed. In addition, this study was directed with the intention to provide baseline data for future studies, for Saudi authority, and university administrators to establish education initiatives that will improve the wellbeing of future Saudi medical professionals.

Purpose of the Study

The purpose of the study had two folds. One was to investigate stress knowledge, stress levels, sources of stress, stress management practices status, and intention of future practice of SMTs by gender and grade cohort. A second purpose was to examine the predictive value of knowledge, attitudes, subjective norms, and perceived control of stress to the intention of stress management practices among medical students at TU,

Saudi Arabia. This study was significant in that it can provide TU administrators with a snapshot of medical students’ current stress prevalence, current stress management

15 practices, attitudes, and their perceptions of stress in order to recommend prevention education initiatives, as needed, based upon the study result.

Study Objectives

The general objective for this study was broken into small logically related parts to form the specific objectives. The specific objectives clearly specified what the researcher will do in this study.

General Objective

The general objective of this study was to investigate TU medical students’ stress, stressors, current status of stress management practice, and intention of future practice utilizing the TPB constructs.

Specific Objectives

The specific objectives of this study were:

1. To assess TU medical students stress knowledge, stress prevalence, and stress

management practices in both male and female medical students and by grade

cohort;

2. To assess the sources of TU medical students’ stress;

3. To assess TU medical students’ predictive factors (attitude, subjective norm,

and perceived behavioral control) and their intention to practice stress

management techniques. In other words, identify which predictive factor has

the most influence on students’ intention to practice or not to practice SMTs to

reduce their stress; and

4. To assess whether or not the demographic and stressor variables play a role in

predicting the intention to practice stress management techniques.

Significance of the Study

This study was important because it sought to present issues in their proper context. This work sought to quantify, assess, and determine the quantum of stress and stress management using appropriate theories and practical statistical tools and techniques. This research would represent a significant contribution to the health education and promotion literature on stress amongst medical students in TU, Saudi

Arabia, by gaining an understanding of how much students know about stress, the etiology and level of stress, predictive factors, and intention to practice stress management. Knowing these particular aspects of this research study can help in the development of effective stress management approaches considered essential for preparing students for a successful life and optimal future careers.

Research has indicated a high risk for instant and long-term harm due to stress in medical students (Brower, 2001). Thus, taking an action to prevent such harm would be in the best interest of TU from an ethical standpoint. This study sought to provide information that can help guide counselors, social workers, health educators, and medical educators within TU settings to create and implement stress management intervention programs to help those medical students at risk for stress.

Conceptual Framework for the Study

TPB and its deliberations were used in this context in order to best address topics of stress in TU medical studies, markedly in areas of predicting the intentions of students

17 in areas of practicing stress management. The TPB was adapted and is an extension of the Theory of Reasoned Action (TRA), developed by Fishbein and Ajzen (1972). The

TPB has become one of the leading utilized theories of health behavior (Hayes, Kelleher,

& Eggleston, 2008). The reason for choosing the TPB specifically refers to the fact that it can be applied to predict and explain numerous types of behaviors ranging from nutrition, sexual behaviors, visiting with health care providers, exercise, and environmental health (Hayes, Kelleher, & Eggleston, 2008). The TPB establishes relationships between variables and can predict human behavior by measuring the constructs of attitudes, subjective norm, perceived behavioral control, and behavioral intentions toward an action of a certain behavior (Hayes, Kelleher, & Eggleston, 2008).

Previous research has shown the TPB can be applied to college students and leisure activities (Ajzen & Driver, 1992). Applying the TPB in a research study needs theoretical constructs that are identifiable through literature reviews (Hayes, Kelleher, &

Eggleston, 2008). In regard to this study, the theoretical constructs that were included are stress knowledge, stress prevalence, sources of stress, attitude, subjective norm, perceived behavioral control, behavioral intention, and actual behavior (i.e., the actual behavior is the actual practice of SMTs) as guided by the TPB.

The TPB was a useful tool used to guide this research study to maintain its consistency. The importance of using the TPB (see Figure 1) was centered on the way it facilitates an investigation of the relationship between the variables and how the conclusion can help the researcher to identify the students’ issues in relation to their

18 ability to cope with stress. It also helped the researcher by predicting students’ behavior, as well as in this context student intention to practice SMTs.

Figure 1. Conceptual framework for the study

The research questions in this study were driven and guided by the TPB in order to increase its credibility as well as its consistency in a scientific way. In this research study, there were 11 research questions developed including their sub-questions.

Therefore, important considerations in the development of these research questions and their hypotheses were addressed in defining objectives of this research.

Research Questions

As mentioned earlier (refer to the Conceptual Framework Section), the research questions for this study were developed following the direction of the TPB and its constructs as well as based on a gap found in the literature review warranting attention as follow:

Research Question 1. What is the prevalence of stress among medical students in

Saudi Arabia’s TU?

Research Question 1.1. Is there a difference in stress prevalence between female and male medical students?

Research Question 1.2. Are there differences in stress prevalence among medical students of different grades levels?

Research Question 2. Is there a significant association between the prevalence of stress management practices and stress levels?

Research Question 2.1. Is there a difference in the prevalence of stress management practices between female and male medical students who had high stress?

Research Question 2.2. Is there a difference in the prevalence of stress management practices in different grades levels?

Research Question 3. Are there a difference in knowledge, attitudes, subjective norms, and perceived control of stress between female and male medical students who had high stress?

Research Question 3.1. Are there differences in knowledge, attitudes, subjective norms, and perceived control of stress among medical students of different grade levels who had high stress?

Research Question 4. Are knowledge, attitudes, subjective norms, and perceived control of stress predictors of the intention of stress management practices of medical students who had high stress?

Research Question 4.1. Are knowledge, attitudes, subjective norms, and perceived control of stress predictors of the intention to use stress management practices among medical students who had high stress and never practice stress management?

Research Question 4.2. Are knowledge, attitudes, subjective norms, and perceived control of stress predictors of the intention to use stress management practices among medical students who had high stress and never practice stress management when controlling for demographic and stressor variables?

Operational Definitions of Terms

This study uses the following definitions:

Attitude: A predisposition to respond positively or negatively towards a certain object, idea, person, or situation. Attitude can affect an individual's choice of action, and responses to incentives, challenges, and rewards (Minton & Khale, 2014). In this context, attitude of medical students was measured toward practicing stress management techniques.

Behavior: A response of an individual to an action, person, environment, or stimulus (Minton, & Khale, 2014). In this context, the behavior of medical students was measured toward their actual behavior of practicing stress management techniques.

Behavioral Intention: An individual’s decision to do something is most accurately anticipated by his/her intention to do it (Ajzen, 2006). In this context, the behavioral intention of medical students was measured toward their intention to practice stress management techniques.

Medical students: The population of this study consisted of all medical male and female undergraduate students attending a medical college in TU, Saudi Arabia, including medicine, dentistry, pharmacy, and applied medical colleges.

Perceived Behavioral Control: The extent to which a person feels able to enact or control over the behavior (Ajzen, 2006). In this context, the perceived behavioral control of medical students was measured toward the practice of stress management techniques.

Stress Knowledge: Refers to a person’s understanding of stress, their perception of life’s demands, and whether or not these demands are greater than one’s ability to cope

(Borden, Lee, Serido, & Collins, 2008). In this context, stress knowledge refered to the level of knowledge about stress in medical students at TU and this measured using Stress

Knowledge Questionnaire.

Stress: Stress is the body’s reaction to mental, emotional pressure or physical health issues (Babbott et al., 2014). Stress may be either distress or eustress. Distress is stress overload that may lead to health and performance deficiency. Eustress is defined as

22 a positive stress that may increase health and performance (Babbott et al., 2014). In this study, the researcher defined stress as an emotional feeling of disturbance resulting from specific events or situations that occurred throughout the medical program. In this study, stress was categorized into two types, high stress and low stress. However, in the alignment of the purpose of this study, the focus was on medical students at TU who have high stress.

Stressor: A biochemical or biological agent, environmental and external stimulus event that causes stress to an organism (Tadatoshi et al., 2006). In this context, stressor consisted of three subscales including environmental, academic, and family/monetary stressors. All three subscales were examined as external variables to identify the top stressors that caused high stress in medical students at TU. Each subscale was tested to show that if it was a significant predictor of intention to practice SMTs or not.

Subjective Norm: A person’s own estimate of the social pressure to perform or not to perform the target behavior (Ajzen, 2006). In this context, the subjective norm of medical students was measured toward the practice of stress management techniques.

Basic Assumptions

An assumption of this study was the survey tools were valid and reliable instruments to measure the relationships between stress, attitudes, behaviors, and stressors among TU medical students, and their intentions to practice SMTs. The students were able to understand the significance of the study and return the surveys back to the researcher. Another assumption was that students were able to read, clearly

23 understand, and answer the questions provided according to the instructions given. A further assumption was that the students be able to complete the surveys honestly.

Summary

This study addressed health issues in terms of stress that surround TU medical students involved in the hospitals and TU academic medical settings. It highlighted stress and how it can be an important health concern, especially among college students, and with an emphasized focus on the medical student population in TU, Saudi Arabia in particular. The study directly addressed issues like distress, lack of stress management, and the health problems associated with stress as key factors affecting this population of students. The study utilized basic constructs of the Theory of Planned Behavior and its role in students’ intention to practice stress management.

The next chapter is the review of literature section. It reviewed the health issue from multiple aspects. This also included a description about stress, stress management and sources of stress among medical student population.

CHAPTER II

REVIEW OF LITERATURE

The purpose of the study was to examine stress levels, sources of stress, stress management practices, and intention of future practice of TU medical students by gender and grade cohort. Another purpose of this study was to assess the predictive value of knowledge, attitudes, subjective norms, and perceived control of stress to the intention of stress management among TU medical students in Saudi Arabia. This study was important in that it can benefit the TU administrators gain information about medical students’ current stress prevalence, attitudes, and perceptions about stress to establish prevention education initiatives and strategies that ensure the reduction of stress.

Stress is defined as the body’s reaction to mental/emotional pressure or physical health issues (Babbott et al., 2014). It is the physical, mental, and emotional reactions that one may experience as a result of changes and demands in life. Stress is a necessary part of everyday life and can result from positive or negative events (Matthieu & Ivanoff,

2006). A typical amount of stress is acceptable in life because individuals generally can develop coping abilities. The goal is not a life without stress, but the idea is to have the typical amount of stress, meaning stressors are manageable and short-lived (Rizvi et al.,

2010). However, high levels of stress can cause health problems and can have psychological effects on individuals. Stress is an effect of stressors.

Stressor

A stressor is a biochemical or biological agent, resulting from an environmental and external stimulus event that causes stress to an organism (Tadatoshi et al., 2006).

Stressors may be related to the environment, daily stress events, life changes, a workplace, a chemical, and social stressor. How a person interprets a situation in which stressors are present determines an individual's cognitive appraisal of stress (Tadatoshi et al., 2006). Cognitive appraisal of a stressor is an individual’s perception of the relevance of the stressor, whether or not it is threatening to the individual, and a determination by the individual about whether or not they are equipped with the ability to cope with the stressor (Greenberg, 2002; Tadatoshi et al., 2006). The study of stress and stressors has led to a variety of theories on the subject.

Stress-response theory has a long history and has evolved in psychology, medicine, and nursing. It has made a contribution in numerous theoretical models, thousands of research studies, and publications, and in the development of health care curriculum and interventions (Pitman, Van der Kolk, Orr, & Greenberg, 2002).

Noteworthy contributors in the study of stress and many theorists have contributed to understanding stress and its consequences. While many experts have adopted theories about stress, they all agree that stress affects many lives, and has a major impact on the body. For example, Selye (1946) and Cannon (1932) both perceived ‘stress’ as a reaction of an organism that has been besieged by environmental demands and noxious agents.

Cannon (1929) made a sizable contribution to the study of stress in the 1920’s when he developed the fight-or-flight response model through his work with animals (Bracha,

Ralston, Matsukawa, Williams, & Bracha, 2004).

Hans Selye (1936) might be considered the founding father of stress-response theory, known as the General Adaption Syndrome (GAS). He designed GAS to describe,

26 predict, and explain living organisms’ physiological reactions to ubiquitous life stressors.

He gave physiological reaction prominence and detail with the GAS theory. GAS is able to describe and explain, in part, physiological responses to stressors. For example, in the

Alarm Phase a hormone called epinephrine, also known as adrenaline, is released among plenty of other biochemical messengers. Noticeably absent in the theory, however, is the connection between the body and the mind. This missing piece has given the theory limited usefulness (Bracha et al., 2004).

What Stress Does to the Body

The U.S. population has experienced a higher number of deaths and illnesses related to stress than in the past (CDC, 2004). Over the past decade, adults have self- reported higher levels of mental distress than before (CDC, 2001). A study conducted by the CDC (2010) indicated the self-reported health related quality of life (HRQOL) was lower than in previous years, marked partially by an increase in the mean number of days individuals were physically unwell or confined by restrictions in activity.

According to the National Research Council (NRC) (2001), stressors can have a physical, chemical, and mental effect on the body. When people become unable to cope or control changes that occur in their lives, they can experience distress or pain (Babbott et al., 2014). Stress may also lead to feelings of anxiety, anger, frustration, or depression

(Babbott et al., 2014). People who undergo stress are more likely to report anxiety, hypertension, obesity, or depression (Rizvi et al., 2010). The metabolic changes our bodies undergo have been found to be our psychological, physiological, and behavioral responses to stress (Rizvi et al., 2010).

In general, when people are stressed out, they tend to deal with it in unhealthy ways, such as poor diet choices, comfort eating, a smoking habit, and a lack of physical activity. Physical illness and restrictions in activity can lead to a great deal of stress in the lives of individuals (CDC, 1998; Landry, Quick, & Kasl, 1994; Moriarty, Zach, &

Kobau, 2003). Thus, the importance of knowing both stress symptoms and signs are essential to avoid any negative health consequences (APA, 2016).

Physical health issues can occur when stress causes chemical modifications in the bodies of individuals that can raise the heart rate, blood pressure, and in some cases, blood sugar levels (NIMH, 2014). Physical stressors yield mechanical stresses on bones, skin, ligaments, muscles, and nerves that cause tissue deformation, and in serious conditions tissue failure. There is additional evidence that has suggested extreme distress can have negative consequences on an individual's blood pressure and cholesterol levels

(NIMH, 2014). Stress can present itself in the form of physical maladies (Rizvi et al.,

2010). Physical stressors may cause chronic pain, impair work performance, and may lead to the requirement of medical attention (NRC, 2001).

Stress can contribute to an increase in hormone levels, such as epinephrine, cortisol, leptin, NPY, nitrite, ACTH, adrenomedullin, and norepinephrine pulling the body out of balance (Rizvi et al., 2010). In addition, stress can increase the level of adrenaline, cortisol, dopamine and adenosine in the bloodstream that can incite depression, behavior changes, weight problems, diabetes, fatigue, skin diseases, and heart disease (An et al., 2012). Stress has a negative bearing on the immune system and its responses as well that can result in stomach ulcers and heartburn (An et al., 2012).

Biologically, one possible mechanism involves stimulation of the hypothalamus, called corticotropin release factor (CRF). The pituitary gland releases adrenocorticotropic hormones (ACTH) and the adrenal cortex secretes various stress hormones (e.g., cortisol)

(Tovian et al., 2010). Stress consists of 30 varieties of hormones that travel in the blood stream to relevant organs, e.g., heart, glands, intestines, etc. (Tovian et al., 2010).

Flight-or-fight response is an alternate path that can be taken after the stressor is transferred to the hypothalamus, that leads to the sympathetic nervous system after which the adrenal medulla secretes epinephrine (Tovian et al., 2010). The body's reaction to stress is, for the most part, the same reaction for all people.

Stressors may influence one’s performance and mental ability. Stress can have an impact on academic performance, and productivity, and can cause absenteeism (Tovian et al., 2010). In addition, stressors affect students’ morale adversely (Iwanowicz, 2005).

Individual circumstances can cause stress to present in a unique manner for different groups of people. One group that experiences stress in a unique manner is medical students.

Stress Among Medical Students

Most medical students perceive the medical education field as being a stressful environment. Stress can affect medical students during normal life activities, routine, and daily responsibilities, such as the schoolwork they engage in on a daily basis (Babbott et al., 2014). A medical student’s life is stressful for several reasons. From managing an unfamiliar workload to fears related to taking tests, the wide range of the causes of stress

29 this population of individuals may experience can lead to many problematic consequences (Shaikh et al., 2004).

High levels of stress may have a negative impact on both cognitive functioning and student learning in a medical school setting (Dahlin, Joneborg, & Runeson, 2005).

Among medical students, stress has been linked to substance abuse, a low self-esteem, academic problems (Levine, 2007), depression, low academic performance, and many other illnesses (Broman, 2005; Ross, Niebling, & Heckert, 2000). The stress medical students experience can affect the individual and present itself psychologically, physically, or in a biological or sociological manner. Stressors experienced by medical students are commonly categorized into three groups, including environmental, academic, and family/financial related stressors (Yusoff, Rahim, & Yaaco, 2010).

First year medical students provide a good example of how individuals can be impacted by stress through all of these common categories. For instance, a First-year medical student transitioning to a new, unknown environment could cause the student to be impacted by stressors like feelings of loneliness and homesickness (Yusoff et al.,

2010). The stress a First-year student experiences when adjusting to a new environment could lead to physical issues, like an interruption of sleep patterns, fatigue, and other health problems that could then interfere with their academic performance (Yusoff et al.,

2010). Academic stresses in medical school, such as long study hours can create stress for a first-year medical student as they work to adjust to the requirements of the medical program. Some First-year medical students even have to adjust to the financial implications that coincide with a medical education. They also need to find a balance

30 between school and family life (Yusoff et al., 2010). The acclimation first year medical students have to make to adjust to a new lifestyle as a medical student is dynamic, and there is a potential for a great deal of stress during that initial transition (Sorensen et al.,

2015).

For medical students, it is essential to understand what college level work looks like in terms of the depth of the workload, assignments, and clinical practices that are required, causing this population to experience a great deal of stress. Most medical students define stress as it relates to their education related issues and the definitions revolved around stressors (Matthieu & Ivanoff, 2006). According to AMSA (2014), there are several unique stressors medical students may encounter for each year of study. For example, First-year medical students struggle with the demands of increasing workload and with the skills and effort needed to meet goals and objectives within their medical programs, Second-year medical students can develop different forms of fear when studying numerous illnesses for the first time. They may also experience stress from the forthcoming examination, such as the United States Medical Licensing Examination

(USMLE), the Comprehensive Osteopathic Medical Licensing Examination of the United

States (COMLEX), and other required examinations required for each area of specialty,

Third-year students start clinical rotations and start to deal with real life issues, such as death, possibly for the first time, and the stress that may accompany the process of determining a specialty, and Fourth-year students become busy with their residency, applications, and interviews, and deal with the stress of making the transition from medical school to the clinical practice.

Risk Factors for Stress Among Medical Students

Studies have shown that medical students are more likely to experience high levels of stress due to several risk factors (Abdel Rahman et al. 2013; Sani et al., 2012;

Zeyad et al., 2012; Ziyed et al., 2015; Xinxin, 2014). Many medical students suffer from a lack of sleep, or lack the time needed to maintain or build meaningful relationships

(Sani et al., 2012). Some students might develop unhealthy habits like smoking or develop poor dietary habits (Sani et al., 2012). Some of the risk factors affecting medical students are a transition from a preclinical to a clinical level in an education program, clinical requirements, patient treatment, hours of study (Abdel Rahman et al. 2013), workload, examinations, family, faculty, public expectations, financial issues, and physiological issues (Xinxin, 2014; Ziyed et al., 2015; Zeyad et al., 2012).

Most stressors are connected to academic matters, such as medical training, curriculum contents, examinations, workload, etc. (Kaufman, Day, & Mensink, 2001;

Kaufman & Mensink, 1999). Long hours of study and academic pressure can cause a student to undergo a significant amount of stress. Several studies have shown a significant amount of the stressors that affect the wellbeing of medical students appears to be associated with medical training (Aktekin et al., 2001; Kazak et al., 1998;

Saipanish, 2003; Kaufman, Day, & Mensink, 2001; Kaufman & Mensink, 1999).

Medical students who have higher self-expectations in medical training are at a higher risk for putting themselves under a significant amount of stress and are at a higher risk for developing mental health issues (Henning, Sydney, & Shaw, 1998).

In addition, personal organization issues have been linked to stress. A study conducted in King Saud University, a Saudi medical college, reported that personal organization issues, such as meeting deadlines and balancing responsibilities between home and school, can cause a significant amount of stress for students in a medical program (Zaid et al., 2007). Medical students who lack organizational skills can also have a negative impact on a medical program by causing misconceptions about the leadership abilities of instructors and the organizational abilities of an institution as a whole (Dewa, McDaid, & Ettner, 2007).

Language barriers often create problems in communication and comprehension.

In Saudi Arabia, proficiency in English for medical professionals is a prerequisite and required. All medical and health engineering curricula are taught in English, which allows the healthcare professionals to continue and keep abreast of developments and international scientific research. It also benefits doctors and other professionals who complete their studies abroad. Working in medicine or pharmaceutical requires a full knowledge of medical terminology, and being proficient in the English language facilitates learning and understanding. However, there are some issues that Saudi medical professionals encounter when communicating with their patients in English that can be a risk factor for stress, such as misunderstandings that may occur because of language barriers (KSA, Ministry of Education [ME], 2005).

For students in an English language based medical program who speak English as a second language, the language barriers experienced can create a multitude of problems for medical students and can create a great deal of stress. If a medical student, who

33 speaks English as a second language, is uncomfortable with the English language, they can withdraw from communicating and can become discouraged from studying and participating in the medical education process (Sørensen et al., 2015).

Medical students with lack of social as well as familial support may experience higher levels of stress and a lower sense of self-efficacy than students with strong support. Mallinckrodt, Leong, and Kralj (2001) emphasized how social and familial support have a direct effect on the amount of stress medical students experience. It was concluded the more support available to a student throughout the academic program, the less likely for a significant amount of stress to develop (Mallinckrodt et al., 2001). This includes quality relationships between the student and faculty members.

There are common student practices that can perpetuate the effects of stress among this population of students. Most medical students consume large amounts of caffeinated beverages, such as tea, coffee, and cola, in order to be alert and awake during study time (Rizvi et al., 2010). A large intake of caffeinated beverages can raise stress levels by increasing the levels of adrenaline, adenosine, dopamine, and cortisol in the blood (Rizvi et al., 2010). Caffeine sometimes prevents the absorption of nutrients, elevating the acids in the digestive system and reducing the levels of magnesium, iron, calcium, and other important minerals through urinary excretion (Rizvi et al., 2010).

Caffeine reduces blood flow into the brain by approximately 30%, and it reduces the stimulation of insulin, a hormone that regulates the blood sugar level in our bodies (Rizvi et al., 2010). When an individual experiences stress during long study hours and depends

34 on caffeine to stay alert to prolong the study period, the body can undergo negative consequences not optimal for student learning or the effectiveness of a medical program.

Physical Effects

It has become widely accepted that being exposed to a significant amount of stress, like medical students often are, can lead to a poor quality of life (NIMH, 2014).

There is a strong link between physical ailments and stress levels, and because medical students are exposed to many risk factors that can lead to stress, it puts this population at a higher risk for a wide range of physical health issues. According to a study conducted by O’Rourke, Hammond, O’Flynn, and Boylan (2010), a student can experience fatigue, nausea, and insomnia during a course, exam, or clinical practice. Metabolism can also become disturbed by constipation or diarrhea. Skin illnesses can occur like acne/spots, psoriasis, or dermatitis (O’Rourke et al., 2010). Medical students experience these physical effects across the board, despite their gender or level of study in the medical program (O’Rourke et al., 2010).

However, some of the physical effects stress can have on a student are unique to gender. For females, the hormones of the menstrual cycle, follicle-stimulating hormone

(FSH) and luteinizing hormone (LH) can be affected by stress (Rizvi et al., 2010).

Females can be especially anxious during specific aspects of a medical program, such as examinations, when they are on their menstrual cycle because both hormones of the menstrual cycle (FSH and LH) change normal levels. This can impact sleep cycles as well, and as a result, can perpetuate stress, offering the female medical student little to no reprieve from ongoing stress (Rizvi et al., 2010).

Psychological Effects

Long-term stress, or high levels of stress among medical students, can lead to psychological health issues. Psychological stress refers to what individual experiences when they are under mental and emotional pressure (National Institute of Mental Health,

2014). A study conducted by Moriarty, Zach, and Kobau (2003) showed that students who experience high levels of psychological stress repeatedly, over a long period of time

(such as every semester), are at a higher risk to develop mental and physical health issues.

According to previous studies, a significant percentage of medical students experience anxiety disorders because stress is strongly associated with emotional and behavioral issues (Rizvi et al., 2010; O’Rourke et al., 2010). Medical students, in general, remarked that there have been modifications in their behavior when they are under stress (Yussof, Rahim, Baba, Ismail, & Pa, 2013). Students who are having difficulties academically also tended to feel dissatisfied (Yussof et al., 2013). For instance, depression and irritability are common in medical students in advanced semesters. Elevated mental health issues during course of study and exams have been reported (Rizvi et al., 2010). These studies concluded most of the risk factors medical students confront can have a negative physical or psychological effect.

Emotional Effects

The American Medical Student Association (AMSA) gathered some frightening facts about medical students in the U.S in 2015 that posited 12% of medical students across all majors become clinically depressed. During the course of study in the medical

36 program, 30% of all trainees among the 50% of married medical professionals included in the sample reported unhappy marriages and listed their occupation as the reason for marital problems.

The major emotional issues that have been reported among medical students include feelings of unhappiness and depression, a tendency to over-worry, loss of sleep, constant feelings of being under strain, an inability to focus, a lack of the ability to enjoy normal life activities, low self-efficacy, failure to overcome problems/barriers, an inability to face up to difficulties, difficulty in decision making, and an inability to engage in useful things (Firth, 1986).

Medical students also appear to have higher rates of substance abuse when compared to other college students. Annual physician suicide in the U.S. is equivalent to the number of physicians who are generally in a graduating class of a medical program

(AMSA, 2015). Physicians have double the rate of suicide cases than the general public

(AMSA, 2015). In a medical school classroom, about 98% of the students stated some form of abuse verbally and physically during their course of study as a medical student

(AMSA, 2015). It is vital to understand the effects of stress in medical students, and it is equally important to understand the magnitude of the stress issue within the medical student population.

Stress Prevalence Among Medical Students

Several studies have shown stress has an effect on medical students. According to the 2015 National College Health Assessment, 30% of students reported stress had negatively affected their academic performance within the past year. A study conducted

37 by Al-Dabal, Koura, Rasheed, Al-Sowielem, and Makki, (2010) in Dammam, Saudi

Arabia found medical students have a higher rate of stress (48.6%) than non-medical students (38.7%). Medical students more often reported incompatible teaching methods, fear of failure in examinations, and an inadequate study environment than non-medical students (Al-Dabal at el., 2010).

Upon literature review, it appears the prevalence of stress varies worldwide amongst medical students with an average of 54.7% (see Table 3). Cultural and socioeconomic variables are possible factors for the differences found between institutions and various countries, such as religion, ethnicity and gender (Aktekin et al.,

2001). However, a study conducted by Breese et al. (2005) found first year medical students across different medical majors are more likely to experience a high to moderate level of stress throughout their first semester regardless of their background, sex, ethnicity, culture, etc.

Table 3

Stress Prevalence Worldwide

Country Stress Prevalence n(%) Source

USA 27.2% Lisa et al., 2016 UK 36.6% Kazak et al., 2012 China 35% Zhang, Yang, et al. 2014 Malaysia 28.9-48.6% Zaid et al., 2007 Pakistan 62.4% Shaikh et al., 2009 Malay 60.4% Youssif et al., 2009 India 39-41% Sidana et al., 2012 Bangladesh 54-55% Eliza et al., 2014 Egypt 59.9% Zaki et al., 2011 Facts found in Breese et al. (2005) research posited 48% of first year medical students experienced a high level of stress. A study conducted in UK medical school

38 found the stress prevalence to be at 36.6% for first year medical students, 30.6% for fourth year students, and 21.9% for fifth year students. This study showed a reduction in stress for medical students as they progressed through the program (Kazak et al., 1998).

A study conducted by Hurd and Powell in 2015 found stress was significantly linked to the year of study. Several studies found an increase in stress as students progressed through their medical program. For instance, a study conducted in a Thailand medical school found stress prevalence increased as the year of study increased, and reached the highest percentage in the Third year of the medical program (Spaipanich,

2003). Reported stress then decreased progressively with each new passing year in the program. In Spaipanich (2003) study, the prevalence of stress for First year students was reported at 52.3%. It increased in the Second year of the medical program to 62%, and peaked at 73% for Third year students. Fourth, Fifth, and Sixth year students reported a decline in stress prevalence at 65.5%, 56,1%, and 44,4%, respectively (Spaipanich,

2003). Similarly, the findings of a study conducted in a Turkey medical school reported an increase in the prevalence of stress with each progressing year in the medical program, though the study only examined stress in First and Second year medical students

(Aktekin et al., 2001).

Another study conducted on Saudi dental students indicated this population of students showed a relatively high perception of stress with scores increasing with the progression of each year of study (Al-Sowygh, 2013). This particular study also reported a notably higher rate of stress in female students. The study suggested single students and students at the junior class level of study were more likely to have a significant

39 amount of stress in comparison to other students in the dental program (Al-Sowygh,

2013). Further review of the literature focusing on stress amongst Saudi medical students seemed to indicate they experienced a high prevalence of stress in their first, second, and senior year levels (Al-Sowygh, 2013).

Two significant studies conducted in Malaysia exhibited a fluctuation in stress prevalence among medical students, and did not appear to follow any type of pattern at all. One study was done at a public medical school in Malaysia and found 1st, 2nd, 3rd,

4th, and 5th year students reported stress rates at 48.6%, 39.7%, 29.8%, 48.7%, and

41.4% respectively (Sherina et al., 2003). A study conducted in Malaysia by Zaid et al.

(2007) did not find a specific pattern in stress prevalence (1st, 2nd, 3rd, and 4th year students to be at 50.0%, 40.5%, 28.3%, and 62.7% respectively).

Gender and Grade Level Difference Related to Stress

Some general observations about stress and how medical students experience stressors are important when it comes to gender differences. Generally, males and females have reported the same types of stressors in the medical program. However, female medical students were more likely to report a higher number of stressors (86%) than males do (77%) (Yen Yee & Yusoff, 2013).

Research has argued that women can display more life-change stress than men typically do. In the United States, Hurd and Powell (2015) found female medical students displayed higher levels of stress than male students. The dissimilarity between male and female students was linked to cultural, physiological, and socioeconomic differences amongst the two genders (Dewa, McDaid, & Ettner, 2007).

It was postulated female students were at a higher risk of experiencing problematic levels of stress and the consequences associated with high stress due to the unique life events that women face such as career concerns, relationship concerns, academic pressure, and finding a balance between work and family duties (Mallinckrodt et al., 2001). Stress manifests itself strongly in the form of anxiety within the female population of medical students as well. In Saudi Arabia, the original epidemiologic data on stress revealed the majority of medical students suffering from the physical and psychological effects of stress were Saudis. Results of recent studies in Saudi Arabia suggested high rates of anxiety and depression among male (77%) and female (86%) medical students (El-Gilany, Hammad, 2008; Amr, El-Gilany, El-Sayed, El-Sheshtawy

2007).

The Controversy Surrounding Predictors of Stress Among Medical Students

There are conflicting views concerning the predictors of stress among medical students. According to Kressin (2001), race, culture, and sex are important elements that can help to understand the causes of stress amongst this population of individuals.

However, research conducted by Zaid et al. (2007) in Malaysian medical colleges showed that there was no significant relationship between race and sex.

Other research revealed some medical students may experience stress not only because of their demographic information, but also because of the program orientation itself (Lewis, Frierson, Strayhorn, Yang, & Tademy, 2008). The information currently available concerning the predictors of stress among medical students is too inadequate to provide solid conclusions. Thus, more research is needed to determine specific predictors

41 of stress among medical students across different medical majors. More research in this arena can help to specify whether or not cultural differences are main predictors of stress varying (El-Gilany & Hammad, 2008). It is important when conducting this type of research that the researchers determine the stress knowledge of this population, as well.

Stress Knowledge

The 2015 National College Health Assessment (NCHA) stated that about 85% of those students who had reported stress had negatively affected their academic performance, had no stress awareness/knowledge and felt overwhelmed by everything they had to do. David Sneed, director of the Growth and Purpose for Students program at

Belmont University in Nashville, Tenn., stated that many students think they know what stress is, and this is especially true for freshmen (Borden, Lee, Serido, & Collins, 2008).

However, traditionally they do not know or fully understand the symptoms and signs of stress. For example, freshmen who go through their first set of midterms often experience a high level of stress. This population of medical students often experiences the stress of first midterms, with little to no understanding of how to cope with the experience.

These students have a limited understanding of what is expected of them in the medical program, their training, and in their future career, and thus are prone to become easily overwhelmed. Often times, they adopt unhealthy coping strategies that are ineffective in dealing with stress (Reed, 2015). Many students mentioned they experienced fear due to the fact they had limited knowledge concerning coping mechanisms that could be utilized during times of stress (Borden et al., 2008). Students

42 have also expressed concerns about a lack of programs within the educational system itself that could be utilized to support them and help them to gain knowledge about stress and the different coping mechanisms that would be beneficial to their health and educational process (Borden et al., 2008).

Coping Strategies Among Medical Students

According to Shaikh et al. (2004), there is a distinction often made between active and avoidant coping strategies. Coping strategies in this context refer to behavioral and psychological efforts people utilize to manage stress. Active coping strategies refer to either behavioral or psychological reactions intended to alter the nature of the source of stress. Active coping strategies are viewed as a better approach to deal with stress than avoidant coping strategies (Carver, 2003).

Avoidant coping strategies can lead individuals into negative activities such as alcohol abuse, and a mental state that keeps them from directly addressing stressful events in a proper way (Shaikh et al., 2004). Avoidant coping strategies are more likely to be a psychological mental risk factor for an unhealthy response to a stressful event

(Kariv & Heiman, 2005). For example, avoidant coping strategies include the

“rejection/denial” strategy that refers to an attempt made to deny the truth of a stressful event (Kariv & Heiman, 2005). “Behavioral disengagement” is an avoidant coping strategy when a person ceases the attempt to reach a goal when a stressor is interfering in the process (Kariv & Heiman, 2005). “Venting” is an increased awareness of one’s emotional distress and a simultaneous tendency to ventilate those feelings (Kariv &

Heiman, 2005). And “humor” is a tendency to make jokes about the stressor (Kariv &

Heiman, 2005).

Factors and Common Adopted Coping Strategies Among Medical Students

The findings in a study conducted by Chan et al. (2009) showed that higher levels of intention to cope with stress were associated with a greater use of positive coping strategies. According to Li, Cooper, Bradley, Shulman, and Livingston, (2012), the practice of active coping strategies was linked to level of maturity, individual differences, gender, age, and environmental and situational factors. This was found to be true in terms of maturity level in other studies as well. Brown and Edelman (2000), for example, found coping strategies in practice settings among medical students differed based on their level of year in school, as well as their clinical experiences (Brown & Edelmann,

2000). A study conducted by Andrews (2004) found students at senior level preferred to ask questions, and use personal experiences, and emotional coping strategies like reinforcing their personal attitude and beliefs to cope with their stress (Andrews &

Wilding, 2004).

Previous studies have found stress management techniques medical students employed were associated with cultural, ethnic, and socioeconomic factors. Eastern medical students, such as Chinese, Japanese, and Korean medical students often used coping strategies based on cultural influences, such as meditation and yoga (Evans &

Kelly, 2004). There were several studies that found different ethnic groups and individuals from varying cultures engaged in several active coping strategies. Shaikh et al. (2004) conducted a study in Pakistan and found that Pakistani medical students used

44 music, spending time with peers, and sleeping outdoors as common ways to cope with stress (see Table 4).

Table 4

Common Coping Strategies by Country

Country Stress Management Technique Source

United States of Music, reading, smoking, denial & Dyrbye et al. 2008 America alcohol/drug use

China Meditation and Yoga Evans & Kelly, 2004

Malaysia Religious coping (praying) and acceptance, positive Youssef et al. 2015 reframing

Japan Acceptance, self-distraction, and instrument support Yamashita, Saito, & Takao, 2012

Pakistan Music, spending time with peers, and sleeping Shaikh et al. 2004 outdoors

Nepal Active coping strategies (positive reframing, Kariv & Heiman, 2005 planning, acceptance, and active coping)

Ghana Emotion-focused strategies/avoidance Esia-Donkoh et al. 2011

Egypt Music, exercise, smoking, & Zaki et al., 2011 alcohol use

Saudi Arabia Religious coping (praying) and family & peer Al-Sowygh et al. 2013 support

Another study conducted in Nepal found most of the medical students adopted active coping strategies (positive reframing, planning, acceptance, and active coping) instead of using avoidant strategies (denial, alcohol/drug use, and behavioral disengagement) (Kariv & Heiman, 2005). In a qualitative study conducted with

Malaysian students in 2009, it was found the common coping strategies adopted amongst

45 their medical population were praying, sports, watching TV, counseling, music, meditation, yoga, and tai chi (Redhwan, Sami, Karim, Chan, & Zaleha, 2009).

Higher perceived levels of stress have been associated with a greater use of avoidant coping strategies among medical students (Brown & Edelmann, 2000).

Avoidant coping strategies in practice settings among medical students differed based on their levels of year in school and gender (Brown & Edelmann, 2000). In a study conducted by Andrews and Wilding (2004), it was discovered that freshman were more likely to engage in avoidant coping strategies. Shaikh et al. (2004) found female medical students tended to use emotional and avoidant coping approaches more than their male counterparts did.

Studies conducted in the United Kingdom on medical students found the use of drugs, smoking, and alcohol abuse were the common factors associated with coping strategies (Guthrie et al., 2005; Ashton & Kamali, 1995). There have been other factors found to influence the coping strategies employed among medical students across the

World as well. For example, some North American medical schools established rules and programs to offer treatment services and wellness programs to students in order to address psychological health issues (e.g., students practice in hospital settings, thereby gaining a deeper awareness of the therapeutic power of music and exercise).

In the Middle East, some medical colleges are following the methods of their

Western counterparts to help students cope with stress. Some of the techniques employed in the Middle East include the adoption of innovative learning, teaching approaches, and problem-solving skills (Elzubeir, Elzubeir, & Magzoub, 2010). Some Saudi medical

46 students were found to practice coping strategies centered on teamwork, student-centered learning, and developing the development of problem-solving and interpersonal skills

(Elzubeir et al., 2010).

It is important to consider Saudi culture with regards to the role of Islam, the social structure, and beliefs, and how the significance of religion in stress management techniques varies from those of their Western counterparts. These factors may be essential moderators of stress among medical students. For example, Saudi nursing students who experienced distress from clinical, ward staff, and lecturers preferred to practice praying and avoidant coping strategies to reduce their stress (Albanese &

Mitchell, 1993; Silver, 2004). When students have a tendency to practice avoidant coping strategies, it is helpful to have resources available to guide them, in order to teach healthier, more appropriate ways to cope with stress.

Stress Management

Altering unhealthy trends in medical colleges might not be an easy task being that medical students seem to neglect their own health and wellbeing in the name of success.

However, patients, medical professionals, and medical students deserve to learn better ways to overcome and cope with unhealthy behaviors and stressors on daily basis.

Learning how to manage stressful events can contribute to an individual’s overall health as well as the overall health of the community (Tovian et al., 2010).

It is important to examine the different factors and predictors of stress management to help the students manage stress effectively. According to the AMSA

(2014), it is crucial for students across all medical majors to understand practicing stress

47 management techniques has several benefits. Not only can practicing stress management techniques have a personal positive impact on the student, but this practice can improve the way these individuals advise their patients about essential lifestyle concerns, such as how to cope with their daily stressors, diet choices, and the importance of maintaining a physically active lifestyle (AMSA, 2014). Thus, wellness and wellbeing among medical students should be maintained in order to encourage a healthier community (Shaikh et al.,

2004).

Student wellness offices and counseling centers have had to create more innovative stress management programs and services in order to meet the needs of the student population (Kitzrow, 2003). Mental health services have increased at universities to serve different minority groups (Kearney, Draper, & Baron, 2005; De Melo & Farber,

2005) like international students (Mori, 2000), and students with heightened psychological problems (Schwartz, 2006; Schwartz, 2006; Mowbray et al., 2006).

Communication and social support are essential to advance the academic performance and reduce unnecessary stressors among medical students (Spaipanich,

2003). Breese et al. (2005) found faculty mentors, assistantships, and administrators can be beneficial to medical students because they have the ability to create an environment that can enhance social support and teamwork. Conducting a frequent meeting with the

College Board can also help students to overcome existing stressors as well.

According to the AMSA (2010), there are several techniques medical students can practice to cope with stress, such as the basics of relaxation (e.g., when individual take deep breaths multiple times), nutrition (e.g., eat healthy food), meditation (e.g., Yoga),

48 and exercise (e.g., walking, running, etc.). AMSA (2010) highlighted several recommendations to combat stress, such as keeping in close contact with friends to avoid isolation, seeking out a relaxing place to engage in activities separate from the medical field and try to make those activities a habit, and learning material well by maintaining good study habits (ASMA, 2010).

Specific websites have been designed to serve medical students and to promote mental health (Hurd & Powell, 2015). For example, AMSA dedicates a portion of its website to “Medical Student Well-Being” to provide students with stress management techniques, such as weekly broadcasts, videos, mentoring, and tips on how to manage stress. It also helps students to take preventative measures that reduces the likelihood of stress, and provides information that promotes practices for student wellbeing (AMSA,

2010).

The Global Organization for Stress (GOS) is an independent global association dedicated to help people learn about how to deal with stress by suggesting coping mechanisms compiled from around the world. The mission of the GOS is to provide the best stress solutions, stress management techniques, and stress relief strategies to people who are experiencing stress and are seeking healthy solutions for combating it, such as providing a stress management video, recent research about stress, and, stress management kit (GOS, 2015).

The American Institute of Stress (AIS), a non-profit organization, imparts information on stress reduction, stress in the workplace, effects of stress, and various other stress related topics. AIS was founded in 1978 at the request of Dr. Hans Selye to

49 serve as a clearinghouse for all stress related information. Today, AIS provides a diverse and inclusive environment that fosters intellectual discovery, creates and transmits innovative knowledge, improves human health, and provides leadership to the world on stress related topics.

The International Stress Management Association (ISMA) is the leading professional body for workplace and personal stress management, wellbeing and performance in the United Kingdom and worldwide. A registered charity, ISMA exists to promote sound knowledge and best practice in stress management, both nationally and internationally. As an organization, ISMA exists to advance the education of the public in the field of biological stress. The work of ISMA and its membership includes providing advice to members of the public and employers/organizations. It also supports the Health & Safety Executive (HSE) in the delivery of their requirements for Stress Risk

Assessment and the implementation of the HSE Management Standards.

National Stress Awareness Day (NSAD) is acknowledged on the first Wednesday of November each year (NSAD, 2012), and incorporates ISMA members, the general public, and participating organizations to promote the awareness of stress and how it can be managed. Although NSAD is acknowledged on a specific date, the activities continue over several months. In addition, Hurd and Powell (2015) emphasized the importance of attending stress management workshops during the course of study and not to avoid stress altogether. This ensures students gain the ability to identify and manage stress in such a way that it would reduce the likelihood for the negative consequences of stress to occur.

Predictive Factors of Intention to Practice Healthy Behavior Following the

Theory of Planned Behavior (TPB)

The TPB can be beneficial in developing strategies to help individuals adopt healthy behaviors and to help clinicians and other medical professionals elevate their uptake of guidelines (Francis et al., 2004). TPB based questionnaires involve the use of quantitative methods. To predict whether an individual intends to do a certain behavior or not, it is also important to recognize the three predictive factors of the TPB constructs in a systematic and replicable manner (Francis et al., 2004).

The first predictive factor of the TPB constructs is whether the individual is in favor of a certain behavior (attitude) (Francis et al., 2004). The second predictive factor involves how much the individual feels social pressure to do a certain behavior

(subjective norm) (Francis et al., 2004). The final predictive factor of the TPB constructs is whether the individual feels in control of the action in question and able to do a certain behavior (perceived behavioral control) (Francis et al., 2004). According to Francis et al.

(2004), when the researcher examines these three predictors (attitude, subjective norm, and perceived behavioral control), the research can increase the likelihood the individual will set the intention to do a desired behavior and as a result will increase the chance of the individual actually doing it (actual behavior).

The construct names in the theory reflect psychological constructs unique meaning (Ajzen, 1985). Formulating items for the constructs of TPB (direct measures) has been proposed by Ajzen (1985), that include between 3 and 6 items to assess each of the theory’s major constructs (Attitude, perceived norm, perceived behavioral control,

51 and intention). Ajzen (2006) recommended seven-point bipolar adjective scales to be employed as a typical measure for subjective norm.

Summary

In this chapter, topics were explained including the distinctions between stress and stressors; a brief discussion about the major contributors to the field of study; the general effects of stress on the body; and the many facets of stress among medical students. Present is information on stress management and various coping techniques, as well as the organizations dedicated to reduce stress in the medical student population, and for people in general. This chapter also highlighted The Theory of Planned Behavior, along with its main components, and how the theory works from the literature perspective and how it applies into this research study, as it was be utilized as a guide in the present study.

This chapter reviewed the fact that there is limited documentation of the health issues related to stress among the Saudi medical student population in particular. This lack of information suggests little is known about the presence of depression, anxiety, and the stress rates among this population. Therefore, additional research is needed concerning stress and how stress relates to Saudi Arabian medical students.

The next chapter is the methodology section. It discusses the population used in the study sample, the instruments used, and how data were collected and analyzed. This chapter also includes a description about the pilot study findings that was conducted to verify the instruments’ reliability.

CHAPTER III

RESEARCH METHODS AND PROCEDURES

Purpose of the Study

The purpose of the study had two folds. One was to investigate stress levels, sources of stress, stress management practices, and intention of future practice of TU medical students in Saudi Arabia. A second purpose was to examine the predictive value of knowledge, attitudes, subjective norms, and perceived control of stress to the intention of stress management among TU medical students in Saudi Arabia. This study was significant in that it can provide TU administrators with a snapshot of medical students’ current stress prevalence, attitudes, and their perceptions about stress in order to recommend prevention education initiatives, as needed, based upon the study result.

Research Questions

Research Question 1. What is the prevalence of stress among medical students in

Saudi Arabia’s TU?

Research Question 1.1. Is there a difference in stress prevalence between female and male medical students?

Research Question 1.2. Are there differences in stress prevalence among medical students of different grades levels?

Research Question 2. Is there a significant association between the prevalence of stress management practices and stress levels?

Research Question 2.1. Is there a difference in the prevalence of stress management practices between female and male medical students who had high stress?

Research Question 2.2. Is there a significant difference in the prevalence of stress management practices in different grades levels?

Research Question 3. Are there differences in knowledge, attitudes, subjective norms, and perceived control of stress between female and male medical students who had high stress?

Research Question 3.1. Are there differences in knowledge, attitudes, subjective norms, and perceived control of stress among medical students of different grades who had high stress?

Research Question 4. Are knowledge, attitudes, subjective norms, and perceived control of stress predictors of the intention of stress management practices of medical students who had high stress?

Research Question 4.2. Are knowledge, attitudes, subjective norms, and perceived control of stress predictors of the intention to use stress management practices among medical students who had stress and never practice stress management when controlling for demographic and stressor variables?

Study Design

This study utilized an exploratory research design to provide researchers with a solid understanding of stress and related issues in the medical student population at TU.

Ideally for the purpose of this study, a longitudinal study was considered the best fit to

54 investigate the purpose of this study over the given period of time. According to Payne and Payne (2004), a longitudinal study is highly recommended in order to detect the developments or changes in the characteristics of the target population at the individual level that not only can extend beyond a single moment in time, but also can establish sequences of events. However, due to the time constraints as well as the cost of conducting a longitudinal study, a cross-sectional online survey design was used in this study. The benefit of selecting a cross-sectional study type instead was evident because it was a convenient quantitative design to collect data in a short period of time; it was less expensive than longitudinal or experimental studies; and it provided a good and quick picture of prevalence of exposure and prevalence of outcome (Payne & Payne, 2004). It also allowed researchers to compare many different variables at the same time (Payne &

Payne, 2004).

In this study, researchers examined age, gender, grade level and stress level in relation to students’ attitude, subjective norm, perceived control, and intention to practice

SMTs. However, a cross-sectional study did not provide definitive information about cause-and-effect relationships. This was because such a study offered just a snapshot of a single moment in time because a cross-sectional study does not consider what happens before or after the snapshot is taken (Payne & Payne, 2004). Therefore, we could not determine for certain if the medical students had low stress levels before taking up their examinations for example, or if the behavior of managing stress helped to reduce stress levels that previously were high.

Researchers collected self-reported data from medical students in TU, Saudi

Arabia via an online survey. Online survey tools have three main benefits in comparison to paper surveys including: 1) data can be gathered in very little time. 2) survey can be administered to the population via email or social media networks in a shorter time, and

3) data is collected automatically, hence, the progress of the survey can be tracked immediately (McKee, 2014).

Study Population

The population of this study consisted of all the medical undergraduate students, male and female, attending medical colleges at TU (approximately 1200-1500 students)

(TU, 2017). The location of TU is Al Hawiyah, Taif, Saudi Arabia. TU is one of the 28 public universities in Saudi Arabia (854 kilometers West of Riyadh) (TU, 2017). The population of Taif City in 2015 was estimated at 993.8 thousand people, representing

12.79% of the total population of the region (Makkah region). The Taif Center holds

883.9 thousand people at 88.9%, while the remaining 11.1% is distributed to the rest of the governorate centers (TU, 2017).

Historically, a royal order No. (115) dated in 1980 was issued by establishing the

College of Education in Taif to be affiliated to King Abdulaziz University. The College was incorporated into Umm Al-Qura University by royal order No. (24187) dated in

1982. The first semester started in 1981/1982. The number of students enrolled at that time was 85 students. However, in 2003, a royal decree No. (22042) was issued to transfer Umm Al Qura University branch in Taif to an independent university under the name of "University in Taif". Then a royal decree No. (20047) was issued in 2004 by

56 naming the University (Taif University) (TU, 2017). The numbers of students enrolled at the university of the time of this study was approximately 60,000 male and female students, including the students studying at its branches (TU, 2017). This number is expected to increase in the future, as it is the goal of the university to accept as many students as possible (TU, 2017).

TU works hard to open new branches that serve broader regions in its area and to expand its services (TU, 2017). The enrollment regulations require students to be at least

18 years of age, and no more than 30 years of age upon graduation. The Saudi government subsidizes all Saudi public universities as well as their students. Students enrolling in Saudi public universities are supported with a monthly financial reward ranging from $255 to 300 depending on the area of specialty.

Sample and Sampling Method

This study limited its study population only to the students at TU due to the practical reason that the researcher had a lack of access to the nationwide medical student population. Of four medical colleges (medicine, pharmacy, dentistry, and applied medical sciences colleges) at TU, only two (medicine and applied medical sciences colleges) were included due to their willingness to participate in this research study.

Therefore, the samples were drawn from these two medical colleges. More than 50% of the students completed the survey. Of nearly 800 medical students from the two medical colleges, 454 students respond and completed the survey.

The optimal method of recruitment, the recruitment method used for this study was performed by inviting the students via email. This method was convenient,

57 maximized reach, and was the most cost effective (Payne & Payne, 2004). Therefore, sampling started at the two colleges, followed by classrooms and gender, and finally, every student in the selected classes was invited to participate in the study. This method is called as a multistage convenient sampling method (Payne & Payne, 2004).

Sampling Procedure

The sampling process of this study was initially started by contacting the TU’s

Vice President for Graduate Studies and Scientific Research to obtain an approval to conduct the study. After the approval had been obtained, an inquiry email was sent to all of the Deans of the medical colleges at TU. The email requested the Dean's’ support as a means to gain specific information about each college population, its divisions, and to request their assistance in the data collection process. The requested information included the average number of students per classroom (both male and female), the number of levels per major, and an inquiry as to whether or not the average of male students was equal to the average of female students per classroom and level.

As mentioned earlier, response to the inquiry email was obtained from just two colleges (medicine and applied medical sciences colleges), whereas the other two colleges (the College of Dentistry and the College of Pharmacy) did not respond. The

Director of Medical Research in the College of Medicine and the Chair of The

Radiological Science Department in the College of Applied Medical Sciences were assigned to provide their support in recruitment for the study.

An average of 14 students fill the typical College of Medicine Classroom and an average of 20 students per classroom fill the typical College of Applied Medical Sciences

58 classroom. The College of Medicine at TU has seven levels. Each level has two separate classrooms, one for male and another for female students. The Applied Medical Sciences

College has four main departments, including radiological sciences, medical laboratories, physiotherapy, and nursing. Each level per department has two classrooms, one for male and another for female students. The number of male and female students in each level averages are similar.

Ideally, the method chosen for taking the sample depends on the nature of the population, and the resources available in terms of accessibility, money, and time (Payne

& Payne, 2004). The main goal of the sampling and recruitment methods in this study was to get everybody involved and participating. An equal number of participants in both genders and classes were expected in the target population. However, due to the limited accessibility of the participants (medical students at TU), one cannot directly contact subjects through such means as students’ emails. The sampling method in this study underwent several stages called multistage convenient sampling (see Figure 2).

The selection of multistage convenient sampling stems from real, built-in constraints in reaching participants (Payne & Payne, 2004). At the college level, there are two colleges that were selected conveniently (stratified convenient sampling). Within each college, classes are designed to be male only and female only which were all included (stratified convenient sampling). Each student attending one of the two colleges was invited to participate in this study (systematic sampling). More than half of the students had an opportunity to participate, and hence it was possible to achieve the desired sample size

(n≥400).

It was expected that participants came from across various medical majors within the two medical colleges. The enrollment roles regarding age in TU requires students to be at least 18 years old, and no more than 30 years of age upon graduation. Therefore, all participants were between the ages of 18 and 30. There was approximately similar number of male and female students in each of the medical classrooms. However, the response to the survey of the female students (64.5%) was higher than male students

(35.5%).

Instrumentation

As an online survey design, data collected was based on self-reported information following the instruments developed. A total of nine data collection instruments (80 items) were used in this study (see Appendix A). They were:

1. Demographic Information (6 items)

2. Stress Knowledge Questionnaire (5 items)

3. Perceived Stress Scale (10 items)

4. Graduate Stress Inventory-Revised/Stressor Questionnaire (24 items)

5. Attitude Questionnaire (13 items)

6. Subjective Norm Questionnaire (7 items)

7. Perceived Behavioral Control Questionnaire (4 items)

8. Behavioral Intention Questionnaire (3 items)

9. Actual Behavior Questionnaire (5 items)

Demographic Information

The researchers of this study developed the demographic instrument (see

Appendix A). This instrument measured six demographic characteristics including gender, age, marital status, current college enrollment status, current college major, and overall GPA. These variables were identified in the literature as the best predictors of stress (Andreou et al., 2011). Gender was measured binary, female vs. male (nominal level). Age was measured by asking participants to indicate which age bracket represents their current age (ordinal level) (e.g., 18-22, 23-25, 26-30). Marital status was measured multinomial (single, married with no children, married with children, divorced). College enrollment status was measured (ordinal level) at seven levels: preparatory year/ first year, freshman/ second year, sophomore/ third year, junior/ fourth year, senior/ fifth year, internship/ sixth year, internship for medical students. College major was measured at four categories (nominal level): medicine, dentistry, pharmacy, and applied medical sciences majors. Overall GPA was measured (ordinal/categorical) by asking the participant to enter his/her overall GPA based on 4.0 scales. Table 5 provides useful information for the demographic information scale used in this study.

Table 5

Demographic Information Scale

Demographic Variable Scale Response Choice

Gender Nominal level-binary Male & Female Age Ordinal level 18-20, 21-23, 24-26, 27-30 Marital Status Multinomial level Single, married with no children, married with children, divorced College Ordinal level Preparatory Year/First Year, Freshman/Second Year, Enrollment Status Sophomore/Third Year, Junior/Fourth Year, Senior/Fifth Year, Internship/Sixth Year, Internship for medical students College Major Nominal level Medicine and Applied Medical Sciences majors GPA Ordinal/categorical Overall GPA based on 4.0 scale

Stress Knowledge Questionnaire (SKQ)

Joyce (2008) established the SKQ-7 in 2008 to test people’s knowledge of stress.

The SKQ consists of seven items using true/false options. An example question of the

SKQ-7 is, “It is impossible to treat stress without seeking professional help” items coded as 1 = ‘True’’ and 2 = ‘‘False.’’ Reliability analysis was applied to test internal consistency of the SKQ-7; Cronbach’s Alpha value was 0.81. The content validity of

SKQ-7 was tested and validated (Joyce, 2008). For the purpose of this study only five knowledge items were used (Q3, Q4, Q5, Q6, & Q7) (see Appendix A). The two excluded items (Q1 & Q2) added more confusion to the participants as noted in the pilot study. These two items include Q1 “Anxiety and stress are the same thing” and Q2

“High levels of adrenaline in your bloodstream can be perceived negatively as stress, or positively as an aid to optimum performance.” Whereas, the five items used were more relevant to the topic of interest.

Perceived Stress Scale (PSS)

In 1983, Cohen and Mermelstein developed the PSS-10 items (see Appendix A).

The PSS-9 item is the most widely used psychological instrument to measure the degree/level (low, moderate, or high) to which situations in one’s life are appraised as stressful (Cohen & Mermelstein, 1983). An example question of the PSS-9 item is, “In the last month, how often have you been upset because of something that happened unexpectedly?” Items coded as 1 = ‘Never,’’ 2 = ‘‘Almost Never,’’ 3 = ‘‘Sometimes,’’

4= “Fairly Often,” and 5= “Very often.” It is used for measuring the levels of experienced stress by examining stressful events, coping process, and personality factors, etc. in the lives of individuals (Cohen, Kamarck, & Mermelstein, 1983).

The PSS-9 was designed for use in community samples that consist of people with at least a junior high school education (Cohen & Mermelstein, 1983). The PSS-9 utilizes a four point-scale ranging from (0) being low stress and (4) for high-perceived stress. For the purpose of this study, the PSS-9 score was calculated based on Andreou et al. (2011) directions. First, the researcher reversed coding the scores for questions 4, 5,

7, and 8. On these 4 questions, the scores changed as follows: 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0. Then scores for each item were added up to get a total score. Individual scores on the PSS can range from 0 to 36 with higher scores indicating higher perceived stress; scores ranging from 0-12 would be considered low stress, scores ranging from 13-

23 would be considered moderate stress, and scores ranging from 24-36 would be considered high stress (Andreou et al., 2011).

The PSS-9 is interesting and important because it examines an individual's perception of what is happening in his/her own life. For example, consider the idea that two people have the exact same stressful event occur in their lives for the same duration of time. Based on their individual perception, however, their total scores might show that one person is in the low stress category and the other in the high stress category (Andreou et al., 2011). The PSS-9 item version has been validated in several studies that found internal consistency between (α=0.79) and (α=0.88) satisfactory (Al-Dubai, Alshagga,

Rampal, & Sulaiman, 2012; Andreou et al., 2011; Chakraborti et al., 2013). For the purpose of this study, a pilot study was conducted and found (α=0.79).

Graduate Stress Inventory-Revised (GSI-R)/Stressor Questionnaire

In 1994, Dr. Indra Rocha developed the GSI-R-22 to assess the source of stress

(Singh, 1994). All 22 items of the GSI-R that assess stress based on three subscales were used in this study: university environment, academic responsibilities, and family

/monetary responsibilities (see Appendix A). The GSI-R-22 utilizes a seven-point Likert scale ranging from (1) being less stressful and (7) for most stressful. An example question of GSI-R-22 is, “Trying to meet peers of your race/ethnicity on campus”.

Validity and reliability of the GSI-R-22 were examined in a study conducted by Rocha-

Singh (1994). Internal consistency was established for environmental stress at .85, family/ monetary stress at .77, and academic stress at .78.

For the purpose of this study, three additional items were added to reflect academic stress (Q13, Q16, & Q17) and two original items were modified and simplified from its original (Q14 & Q15). The new added items (Q13, Q16, & Q17) and modified

64 items (Q14 & Q15) were all curriculum related. New items were added because most medical students who currently study at TU are suffering from curriculum related stress.

Thus, it was helpful for the study to investigate the curriculum issue as one of the stress determinants.

Attitude, Subjective Norm, Perceived Behavioral Control, and Behavioral Intention

Questionnaires

In 2006, attitude, subjective norm, perceived behavioral control, and behavioral intention questionnaires were developed by Ajzen as a suggested version for the investigators to use in studies and in the application of the TPB as well (Ajzen, 2006).

Seven-point bipolar adjective scales are typically employed for assessing intention and each aspect of attitude, perceived norm and perceived control (Ajzen, 2006). The reliability and validity of TPB constructs were tested in a previous study (Boyko, Lavis,

Dobbins, & Souza, 2011) as shown below.

Attitude Questionnaire (AQ). The Attitude Questionnaire (AQ) consists of 13 items designed to determine the extent that participants wish to cope with their daily stress. The AQ-13 was constructed utilizing a five-point scale ranging from (1) strongly agree to perform SMTs when experiencing stressful events to (7) strongly disagree to perform SMTs when experiencing stressful events. An example question of the AQ-13 is, “Practicing SMTs is necessary among medical school students to improve academic performance” Items are coded as 1 = ‘Strongly disagree,’’ 2 = ‘‘Disagree,’’ 3 =

‘‘Neutral,’’ 4= “Agree,” 5= “Strongly agree”. The researcher then calculates the mean of all item scores to give an overall attitude score (Francis et al., 2004). Reliability analysis

65 was applied to test internal consistency of the AQ-13. Cronbach’s Alpha value was 0.73.

The content validity of AQ-13 was tested and validated (Boyko, Lavis, Dobbins, Souza,

2011).

Subjective Norm Questionnaire (SNQ). The SNQ consists of seven items to measure what best describes the participants’ personal opinions as they pertain to how important figures view the importance of using SMTs; there might be a family member, friends, or groups of individuals who would hold the opinion the participant should or should not perform SMTs when experiencing high stress. The SNQ-7 was constructed utilizing a seven-point scale that ranges from (1) being strongly agree to perform SMTs when experiencing high stress to (7) strongly disagree to perform SMTs. An example question of SNQ-7 is, “Most people who are important to me think I should perform

SMTs when I get stressed out.” The researcher then calculates the mean of the item scores to give an overall subjective norm score (Francis et al., 2004). Reliability analysis was applied to test internal consistency of the SNQ-7; Cronbach’s Alpha value was 0.79.

The content validity of SNQ-7 was tested and validated (Boyko, Lavis, Dobbins, &

Souza, 2011).

Perceived Behavioral Control Questionnaire (PBCQ). The PBCQ consists of four items utilized to assess students' perceptions to practice SMTs when significant stress occurs (Ajzen & Fishbein, 2006). The PBCQ-4 was constructed utilizing a seven-point Likert scale ranging from (1) strongly agrees to (7) strongly disagree to perform SMTs when experiencing high stress. An example question of PBCQ-4 is, “I am confident that I can do stress management techniques when I get stressed out.” The

66 researcher then calculates the mean of the item scores to give an overall perceived behavioral control score (Francis et al., 2004). Reliability analysis was applied to test internal consistency of the PBCQ -4; Cronbach’s Alpha value was 0.68. The content validity of SNQ-7 was tested and validated (Boyko, Lavis, Dobbins, & Souza, 2011).

Behavioral Intention Questionnaire (BIQ). The BIQ consists of three items used to assess students’ behavioral intention to practice SMTs when stress is experienced

(Ajzen & Fishbein, 2006). The BIQ-3 was constructed utilizing a seven point Likert scale ranging from (1) likely and (7) unlikely to perform SMTs when experiencing high stress. An example question of BIQ-3 is, “I expect to perform stress management technique when I get stressed out.” The researcher calculated the mean of the three intention scores (Francis et al., 2004). Reliability analysis was applied to test internal consistency of the BIQ-3; Cronbach’s Alpha value was 0.89. The content validity of

BIQ-3 was tested and validated (Boyko, Lavis, Dobbins, & Souza, 2011).

Actual Behavior Questionnaire (ABQ). The ABQ consists of five items and it is a self-administered questionnaire adapted from the guidelines proposed by Ajzen and

Fishbein (2006) for the construction of a standard theory of planned behavior questionnaire. The ABQ-5 was constructed using “Yes/No” (Q1), “circle all that applies”

(Q2), open-ended question (Q3), and frequency question (Q4 and Q5) to assess students’ actual behavior when they experience significant stress. A student satisfaction survey question (Q6) was also constructed to allow students to express their expectations, or needs derived from this survey. The total score of the actual behavior questionnaire was

67 calculated based on three levels: never, occasionally, and often which reflects the stress management status among medical students.

For the purpose of this study, all three main constructs of the TPB (attitude, subjective norm, and perceived behavioral control) were applied to explain and predict medical students’ intention to practice SMTs (actual behavior) when experiencing a stressful event (see Figure 1). According to the TPB framework, the intention, in most cases, is the main predictor of engagement in a behavior. The intention is influenced mainly by whether the participant has a positive or negative attitude towards practicing

SMTs (attitude). Thus, 13 items were used in the Attitude Questionnaire (AQ) of this study to examine the extent medical students wish to cope with their daily stress.

The intention is also influenced in this study by what extent the student perceives that he/she experiences social pressure to practice SMT’s or not (subjective norm). Seven items were utilized in The Subjective Norm Questionnaire (SNQ) of this study to measure student perception of both the education system and the opinions of key individuals, such as family and friends, in relation to the importance of practicing SMT’s, and to what extent the student values those opinions. The intention is also impacted by whether the student finds it difficult to practice SMT, and to what extent the student feels he/she has the ability to control his/her stress (perceived behavioral control). In addition, four items were included in The Perceived Behavioral Control Questionnaire (PBCQ) to determine students' perception of practicing SMTs when experiencing a stressful event.

Summaries of all the instruments that were used in this study are presented in Table 6.

Table 6

Constructs, Instruments, Scales, and Number of Items

Construct Measurement Tool Scale # of Items

Demographic Data Demographic Data Questionnaire Nominal Scale 6 (DDQ-6)

Stress Knowledge Stress Knowledge Questionnaire Dichotomous Scale: 5 (SKQ-5) True/False Scale

Stress Prevalence/Level Perceived Stress Scale (PSS-9) Four-Point Likert Scale 9

Stressors Graduate Stress Inventory- Seven-Point Bipolar 24 Revised/Stressor Questionnaire Adjective Scale (GSI-R-23)

Attitude Attitude Questionnaire (AQ-13) Seven-Point Likert Scale 13

Subjective Norm Subjective Norm Questionnaire Seven-Point Likert Scale 7 (SNQ-7)

Perceived Behavioral Perceived Behavioral Control Seven-Point Likert Scale 4 Control Questionnaire (PBCQ-4)

Behavioral Intention Behavioral Intention Questionnaire Seven-Point Likert Scale 3 (BIQ-3)

Behavior Actual Behavior Questionnaire Dichotomous Scale & 5 (ABQ-5) Multiple Choices Scale

Pilot Study

According to Anderson and Prentice (1999), pilot studies play a significant role in health research by providing information for the planning and confirmation of a research study. Pilot studies can be beneficial in reducing the cost, can be more time effective, and can ensure the validity and reliability of the instrument before large amounts of money are allocated. Pilot studies may also lead to modifications in the study design including consent forms, revised instruments, etc. To prepare for this proposal, a pilot study was conducted after obtaining approval from Kent State University (KSU)

Institutional Review Board [IRB] (see Appendix B). The study was also supported by

TU in Saudi Arabia (see Appendix C).

The participants of this pilot study were selected from the College of Applied

Medical Sciences within its Department of Radiological Sciences at TU. The pilot study was administered via an Internet anonymous survey to the two Applied Medical Science classrooms in Radiologic Science. The two medical students’ classrooms were chosen from the second and fourth level of study with a total number of 41 students. The sample size was limited to the female medical students only because those are the population that was sampled through TU contact as well as the choice of the faculty members who helped recruitment. Table 7 shows the demographic characteristics of the study group.

Table 7

Demographic Characteristics of the Pilot Study Sample

Demographic Variables n(%)

Gender Female (100%) Age Majority Age between 18 and 20 (75%) Marital Status Majority Single (94%) College Enrollment Condition Excellent High School GPA > 95% & General Aptitude Test (GAT) Locality Urban (%82) Suburban (%13) Rural (%5) Student Income-given by TU Average of $275

Data Collection for the Pilot Study

With the assistance of the Vice President of Graduate Studies and Scientific

Research [VPGSSR] (see Appendix C), two faculty members were appointed to serve as recruiters for the pilot study. The researcher contacted the faculty who had agreed to coordinate the recruitment and to assist in data collection. The data collection started on

April 25, 2017. The duration of the data collection of this pilot study was two weeks until May 9, 2017. Two reminder emails were sent to the faculty. The first email was sent to the faculty (the day before to start the survey) to invite the students. The second email was sent one week later to thank those who completed the survey and remind the other students who had not completed the survey yet to participate. Two days prior to closing the survey, a final email was sent to the faculty to inform the students the survey was going to be closed and to thank those who completed the survey (see Figure 2).

Figure 2. Flow chart for the data collection process. MC: Medicine College; AMSC: Applied Medical Sciences College

Response to the Pilot Study

The pilot study was conducted among students in two female classes that had a total of 41 students. Note that, the faculty member in Saudi Arabia recruited these two female classes specifically. Due to miscommunication between the faculty members and the person who was in charge of sending the invitation email to the male medical students, the male classes were not included in this pilot study.

Of the 41 students who were invited to participate, 37 responded and completed at least a portion of the online survey, resulting in a response rate of 90.2%. Of the 37 students, four did not complete the evaluation of the instrument which may be because they felt the survey was too long, had poor understanding of the questions, or they may have felt they were asked personal or sensitive questions. These subjects were excluded from the final analysis, resulting in a final sample size of 33 subjects who competed the entire survey.

Most of the 33 subjects reported they were female (31 students, 93.4%) and had a mean age of 20.7 years whereas two students mistakenly reported themselves as male

72 students. The entire sample was identified as Saudi. A majority of the sample (93.9%) was single and 6.1% were married with children. Overall, they had a mean GPA of 2.93 based on 4 scales.

Data Analysis

The collected data in this pilot study were analyzed using Statistical Package for

Social Sciences (SPSS) version 20.0. Reliability was conducted to measure the internal consistency of the instruments. Descriptive statistics utilized in this study included means, standard deviations, frequency counts, and percentages.

Reliability. A Cronbach’s alpha test was conducted to measure internal consistency of the instruments. The results are as follows: stress knowledge α = .73, stress prevalence α = .62, attitude α = .67, subjective norm α = .74, perceived behavioral control α = .88, and behavioral intention α = .91. The stressor instrument has three subscales, environmental-8 items α =.78, academic-9 items α =.85, and family/monetary-

5 items α = .76. The overall stressor questionnaire was found to be highly reliable 22 items α = .89. Note that a reliability coefficient of .70 or higher is considered

“acceptable” in most social science research situations (Cronbach, 1951).

All variables were tested in this study and found at an acceptable level, which is greater than 0.70 except stress prevalence (.62) and attitude (.67). The lower numbers

(stress prevalence .62 and attitude .67) that have been reported in this study might have been caused by the small sample size (n=33) or due to inconsistent items. The reliability for the actual behavior questionnaire was not performed in this pilot study because the

73 questionnaire was not designed to be together (i.e., each item was treated differently based upon the scaling type).

Statistical findings. The statistical findings of this pilot study include stress knowledge, stress prevalence, stressors, attitude, subjective norm, perceived behavioral control, behavioral intention, stress management practices, and the actual behavior to manage stress.

Stress knowledge was measured using a Stress Knowledge Questionnaire-5 item

(SKQ). The SKQ revealed, on average, students answered 3.46 questions correctly out of

5 (M = 3.46, SD = 1.35). Five had a perfect score, but four students answered all of the questions incorrectly. The finding from the SKQ suggested an acceptable knowledge of stress among TU’s medical students. Table 8 shows the frequency of how many students got a perfect score versus those who scored zero.

Table 8

Frequency of Students’ Stress Knowledge Scores

# Correct answer 0 1 2 3 4 5

N (%) 4 (10.8%) 0 (0%) 0 (0%) 9 (24.3%) 19 (51.4%) 5 (13.5%)

Stress prevalence was measured using the Perceived Stress Scale-9 items (PSS).

Five-point Likert scale was used ranging from (0) never to (4) very often. The PSS revealed the majority of students (72%) had high-perceived stress (M = 3.35, SD = 0.47).

Stressors were measured using the Graduate Stress Inventory-Revised (GSI-

R)/Stressor Questionnaire-22 items (SQ). The GSI-R/SQ had three subscales, environmental-8 items, academic-9 items, and family/monetary stress-5 items. All three subscales were utilized. Seven-point Likert scale used ranging from (1) being less stressful and (7) being most stressful. The GSI-R/SQ revealed, on average, the academic stress subscale had the highest mean (M = 5.14, SD = 1.24) followed by family/monetary subscale (M = 3.21, SD = 1.36), with environmental stress as the lowest mean (M = 1.38,

SD = .16). Therefore, this confirmed the finding from the follow up question that asked,

“Among environmental, academic, and family/monetary stress what is the most stressful?” A majority of the sample (70%) reported they found academic stress to be the most problematic for them.

Attitudes toward practicing SMTs were measured using the Attitude

Questionnaire-13 items (AQ). Five-point Likert scale used ranging from (1) strongly disagrees to (5) strongly agree. The AQ revealed that on average, students had slightly positive attitudes toward practicing SMTs (M = 3.52, SD = .50) (see Table 12).

Subjective Norm was measured using the Subjective Norm Questionnaire-7 items

(SNK). Seven-point Likert scale used ranging from (1) strongly agrees to (7) strongly disagree. The SNK-7 revealed, on average, students had slightly positive subjective norm (M = 3.85, SD = 1.32) (see Table 12).

Perceived behavioral control was measured using the Perceived Behavioral

Control Questionnaire-4 items (PBCQ). Seven-point Likert scale used ranging from (1) strongly agree to (7) strongly disagree. The PBCQ-4 revealed, on average, students had

75 slightly negative perceived behavioral control over their stress (M = 4.89, SD = 1.58) (see

Table 12).

Intention to practice stress management techniques was measured using the

Behavioral Intention Questionnaire-3 items (BIQ). Seven-point Likert scale was used ranging from (1) strongly agrees to (7) strongly disagree. The BIQ-3 revealed, on average, students had a low intention to practice SMTs (M = 5.34, SD = 1.77) (see Table

12).

Actual behavior for practicing SMTs was measured using a set of questions that were not designed to be together (see Appendix A). Each question was measured separately. The first question was “Yes/No” question “In the past month, have you used any strategies to cope with your daily stressors?” which revealed that a majority of the sample (75%) answered yes.

The second question was, “In the past month, what did you do to manage stress

(circle all that apply)?” The participants were given a list of behaviors/activities they may do to manage their stress and were provided with an entry text called “Other” to allow them to enter any behaviors/activities not be listed as a given option. In the text entry, two individuals wrote in their answers by indicating one would smoke and the other would dance. The five most frequently chosen behaviors/activities were watching

TV/movies (48%, n=16), praying (42.42%, n=14), listening to music (42.42%, n=14), drinking coffee (30.30%, n=10), and calling a good friend (21.21%, n=7) (See Table 9.)

Table 9

How Women Medical Students Managed Stress

Behaviors n(%)

Watching TV/Movies 16 (48%) Praying 14 (42.42%) Listen to Music 14 (42.42%) Drink Coffee 10 (30.30%) Call a Good Friend 7 (21.21%)

The third question was, “How often do you engage in behaviors to manage your stress?” The answer for that question was based on a frequency rating scale (once a week, several times per month, once a month, and never) to show how many times individual practice SMTs. Once a day and several times per month were the most frequently selected (30.30%, n=10) and (30.30%, n=10), respectively (Table ).

The fourth question was, “How often do you engage in behaviors to manage your stress? Note the intention was for this to be, “For how long have you been engaging in behaviors to manage your stress?” The answer for that question was based on a frequency rating scale (1-3 months, 4-6 months, 7-12 months, and more than 12 months) to show how many times individuals practiced SMTs over a period of time. The “1-3 months” choice was the most frequently selected (79.17%, n=19) (see Table 10). Of the 33 subjects who responded to the survey, 9 did not complete the evaluation of this question.

Table 10

Frequency Rating Scale Response

Question n(%)

How often do you engage in behaviors to manage Once a day (30.30%) your stress? Once a week (21%) Several times per month (30.30%) Once a month (6%) Never (12%) How often do you engage in behaviors to manage 1-3 months (79.17%) your stress? [note: intention was for this to be “For 4-6 months (12.50%) how long have you been engaging in behaviors to 7-12 months (0.00%) manage your stress?” More than 12 months (8.33%)

The fifth question was, “In the past month, what did you specifically do to manage your stress?” This was an open-ended question to measure the actual SMTs. A content analysis was used to interpret the findings from this question. The most common behaviors/activities that were reported were walking (7 students), watching TV (5 students), reading (4 students), talking to a friend (3 students), visiting family and friends

(3 students), finishing my work (2 students), listening to music (2 students), organizing my time (2 students), relaxing my body (2 students), being positive (1 student), praying

(1 student), shopping (1 student), and smoking (1 student) (Table 11).

Results from the last question in the survey instrument, “Do you have any additional comments, questions, or concerns about this survey you would like to share?” revealed that two subjects showed their appreciation for participating in such a study.

One individual suggested the importance of launching a stress management program on campus.

Table 11

Content Analysis

Common Code Word # Student

Walking 7 students

Watching TV 5 students Reading 4 students Talking to a friend 3 students Visiting family and friend 3 students Finishing my work 2 students Listening to music 2 students Organizing my time 2 students Relaxing my body 2 students Being positive 1 student Praying 1 student Shopping 1 student Smoking 1 student

Table 12

Main Findings of the Pilot Study

Construct Mean, Standard Deviation Assessment

Stress Knowledge (M = 3.46, SD = 1.35) Acceptable Stress Prevalence (M = 3.35, SD = .47) High perceived stress Environmental (M =1.38, SD =.16) Low stress Stressors-Three Subscales Academic (M = 5.14, SD = 1.24) High stress Family/Monetary (M = 3.21, SD = Slightly low stress 1.36) Attitude (M = 3.52, SD = .50) Slightly positive Subjective Norm (M = 3.85, SD = 1.32) Slightly positive Perceived Behavioral (M = 4.89, SD = 1.58) Slightly negative Control Behavioral Intention (M = 5.34, SD = 1.77) Low intention Actual Behavior Not Applicable Each item measured separately

Discussion

In this pilot study, the TPB was utilized in addition to two constructs (stress knowledge and stressor). The TPB consists of five main constructs including, attitude, subjective norm, perceived behavioral control, behavioral intention, and actual behavior.

The pilot study suggested that there were several changes to the instruments that need to be made. Since the survey will be given to the participants in Arabic, translation issues were found and required an edit to three items in the PSS (item 5, 7, and 9) to make them more accurate to the original instrument meaning, written in English. Question number 4 was changed in the actual behavior questionnaire “How often do you engage in behaviors to manage your stress? to be “For how long have you been engaging in behaviors to manage your stress?”

Pilot study findings also suggested about 70% of the surveyed students had an acceptable level of stress knowledge (see Table 12). This suggested the female medical

80 students at TU played a role in understanding the stress consequences and the importance of coping with stress. However, the stress prevalence rate among TU’s female medical students was high (72%) in comparison to a similar population studying at King Saud

University (41%) (see Table 12 and Table 2). This suggested acknowledgment is required concerning TU’s medical students and the experience of distress as well as the negative consequences that stress can have on their overall health if this rate remains the same or gets progressively worse.

On the other hand, the stressor-three subscales score (see Table 12), environmental, academic, and family/monetary stress revealed academic stress was the most problematic for the TU’s female medical students followed by family/monetary as a slightly low stress. Lastly, environmental stress was reported as the lowest source of stress among the female students. The increase rate of academic stress among TU’s female medical students may be due to a heavy workload, too much responsibility, working long hours, having poor stress management, or because unclear expectations concerning the program’s curriculum.

The attitude and subjective norm scores (see Table 12) revealed that TU’s female medical students had a slightly positive attitude and subjective norm toward practicing

SMTs. This suggested that students were more likely to engage in a healthy behavior to reduce stress, which was in alignment with the interest of this research. However, the perceived behavioral control score revealed that TU female medical students had slightly negative perceptions over their stress that implied they were less likely to practice SMTs when they get stressed out. Similarly, the intention score revealed these students had a

81 low intention to practice SMTs, meaning students might have been less likely to engage in healthy behaviors to reduce stress.

The overall actual behavior score revealed stress management practices were low to moderate among TU female medical students, implying they were at risk if at current practice rates. These data relate to female medical students only who participated in this pilot study. However, male medical students were recruited in the larger scale study.

Data Collection for the Main Study

This study used the instruments pilot-tested in the data collection and maintained its strategy that was used and verified during the pilot study. The final data collection of this study was conducted following the data collection process of the pilot study and it is introduced below in detail (see Figure 2). Upon IRB approval at KSU, the researcher contacted TU’s faculty members to start the data collection process. The data collection started on Sep 26, 2017. The duration of the data collection of this main study was one- month, until Oct 26, 2017. The researcher informed the faculty members with an email that explained the data collection process, including the starting date of the survey, the date to send out first and second reminder emails, and the thank you statement.

Four reminder emails were sent to the faculty to notify them about the data collection recruitment. The first email was sent to the faculty the day before to start the survey to invite the students. The second email was sent one week later to thank those who completed the survey and remind the other students who had not completed the survey yet to participate. During the second week, the researcher noticed that the male response rate was higher than female. A third email was sent to the faculty to inform

82 them that the data collection had extended another two weeks in order to encourage female students to participate. The final reminder email was sent to notify the students the survey was going to be closed and to thank those who completed the survey.

The participants’ recruitment conducted through the faculty members using invitation email to be sent to all male and female medical students who were attending both Medicine College (n=300) and Applied Medical Sciences College (n=500) at TU.

The total number of students in those two colleges was about 800. The anticipated sample size in this study was 400 students based on 50% response rate. However, the response rate was more than 50%, and the desired sample size was achieved by the end of the data collection phase.

The survey was delivered to the participants online. Survey questions and formats had been setup at the Qualtrics website of Kent State University. The survey questions were provided in Arabic. Each participant received a letter of invitation with a clear explanation of the purpose and the anticipated outcome of the study, link to the survey web page starting with a consent form and agreement checkbox, and thank you statement for participating in the study (see Appendix D). In addition, each participant was informed within the same email they were free to quit the survey at any time, and would not be penalized if he/she chose not to participate.

Response to the Main Study

The main study of this research was conducted among students in two medical colleges that had a total of 800 students. The faculty member in Saudi Arabia helped for the participants’ recruitment. Of the 800 students who were invited to participate, 743

83 responded and completed at least a portion of the online survey, resulting in a response rate of 92.5%. Of the 743 students, 289 did not complete the survey which may be because they felt the survey was too long, had poor understanding of the questions, or they may have felt they were asked personal or sensitive questions. These subjects were excluded from the final analysis, resulting in a final sample size of 454 subjects who completed the entire survey. Of 545 subjects, 270 students participated from the College of Medicine and 167 students from their counterpart in the College of Applied Medical

Sciences (see Figure 3).

Most of the 454 subjects reported they were female (288 students, 64.43%) and had a mean age of 20.5 years whereas 159 subjects reported they were male (35.57%) and had a mean age of 21 years. The entire sample was identified as Saudi. A majority of the sample (96.3%) was single and 2.1% were married with no children. Overall, they had a mean GPA of 3.12 based on 4-point scales.

All variables were tested for internal consistency in this study and found at an acceptable level, which is greater than 0.70 except attitude α = .614. The lower numbers in the attitude scale could have occurred due to item unreliability or to respondent inconsistency. Since the Stress Knowledge Questionnaire-5 item is not a scaled instrument, the Cronbach’s alpha is unlikely to be the right test (Burton et al., 2010). The

Stress Knowledge Questionnaire-5 item was not measuring a subjective opinion because, it measured whether or not the student knew the factual answers to those five items. The reliability for the actual behavior questionnaire was not performed in this main study

84 because the questionnaire was not intended to be together (i.e. each item was analyzed separately based upon the scaling type).

Statistical Findings

The collected data in this main study were analyzed using two statistical producers, including descriptive and inferential statistics using Statistical Package for

Social Sciences (SPSS) version 20.0. More details are presented in Chapter four.

Data Analysis

The collected data analyzed using Statistical Package for Social Sciences (SPSS) version 20.0. Descriptive statistics utilized in this study included means, standard deviations, frequency counts, and percentages to analyze the demographic data based on the DQ-6 items, stress prevalence status based on PSS-9 items, the source of stress based on SQ-23 items, and the actual behavior based on ABQ-4 items. Inferential statistics were utilized in this study to test the following statistical hypotheses, according to the proposed research questions. Significant level will be determined at p <0.05.

Figure 3. Sampling frame for the main study from two medical colleges at Taif University.

Research Question 1. What is the prevalence of stress among medical students in

Saudi Arabia’s TU?

Research Question 1.1. Is there a difference in stress prevalence between female and male medical students?

Null Hypothesis 1.1. There is no statistically significant difference in prevalence rates between female and male students.

Alternative Hypothesis 1.1. There is a statistically significant difference in prevalence rates between female and male students.

Research Question 1.2. Are there differences in stress prevalence among medical students of different grades levels?

Null Hypothesis 1.2. There is no statistically significant difference in stress prevalence rates among students in different grades levels.

Alternative Hypothesis 1.2. There is a statistically significant difference in stress prevalence rates among students in different grades levels.

Research Question 2. Is there a significant association between the prevalence of stress management practices and stress levels?

Null Hypothesis 2. There is no statistically significant association between the prevalence of stress management practices and stress levels.

Alternative Hypothesis 2. There is a statistically significant association between the prevalence of stress management practices and stress levels.

Research Question 2.1. Is there a difference in the prevalence of stress management practices between female and male medical students who had high stress?

Null Hypothesis 2.1. There is no statistically significant difference in the prevalence of stress management practices between female and male medical students who had high stress.

Alternative Hypothesis 2.1. There is a statistically significant difference in the prevalence of stress management practices between female and male medical students who had high stress.

Research Question 2.2. Is there a significant difference in the prevalence of stress management practices in different grades levels?

Null Hypothesis 2.2. There is no statistically significant difference in the prevalence of stress management practices in different grades levels.

Alternative Hypothesis 2.2. There is a statistically significant difference in the prevalence of stress management practices in different grades levels.

Research Question 3. Are there differences in knowledge, attitudes, subjective norms, and perceived control of stress between female and male medical students who had high stress?

Null Hypothesis 3. There are no statistically significant differences in knowledge, attitudes, subjective norms, and perceived control of stress management between female and male medical students who had high stress.

Alternative Hypothesis 3. There are statistically significant differences in knowledge, attitudes, subjective norms, and perceived control of stress management between female and male medical students who had high stress.

Research Question 3.1. Are there differences in knowledge, attitudes, subjective norms, and perceived control of stress among medical students of different grades who had high stress?

Null Hypothesis 3.1. There is no statistically significant difference in knowledge, attitudes, subjective norms, and perceived control of stress management among medical students of different grade levels who had high stress.

Alternative Hypothesis 3.1. There is a statistically significant difference in knowledge, attitudes, subjective norms, and perceived control of stress management among medical students of different grade levels who had high stress.

Research Question 4. Are knowledge, attitudes, subjective norms, and perceived control of stress predictors of the intention to use stress management practices of medical students who had high stress?

Null Hypothesis 4. There are no statistically significant predictors of the intention to use stress management practices of medical students who had high stress among the testing variables: knowledge, attitudes, subjective norms, and perceived control of stress.

Alternative Hypothesis 4. There is statistically significant predictor(s) of the intention to use stress management practices of medical students who had high stress among the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Null Hypothesis 4.1. There are no statistically significant predictors of the intention to use stress management practices among medical students who had high stress and never practiced stress management between the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Alternative Hypothesis 4.1. There is statistically significant predictor(s) of the intention of stress management practices among medical students who had high stress

89 and never practiced stress management between the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Research Question 4.2. Are knowledge, attitudes, subjective norms, and perceived control of stress predictors of the intention to use stress management practices among medical students who had stress and never practiced stress management when controlling for demographic and stressor variables?

Null Hypothesis 4.2. There are no statistically significant predictors of the intention to use stress management practices among medical students who had high stress and never practiced stress management when controlling for demographic and stressor variables among the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Alternative Hypothesis 4.2. There is statistically significant predictor(s) of the intention to use stress management practices among medical students who had high stress and never practiced stress management when controlling for demographic and stressor variables among the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress. Table 13 shows the null hypotheses and statistical tests for this research study.

Table 13

Null Hypotheses and Statistical Tests

Null hypothesis Statistical Test

Null Hypothesis 1.1. There is no statistically significant difference in prevalence rates between female and male students. Chi-square test

Null Hypothesis 1.2. There is no statistically significant difference in prevalence Chi-square test rates among students of various grades levels.

Null Hypothesis 2. There is no statistically significant association between the Chi-square test prevalence of stress management practices and stress levels.

Null Hypothesis 2.1. There is no statistically significant difference in the prevalence Chi-square test of stress management practices between female and male medical students who had high stress.

Null Hypothesis 2.2. There is no statistically significant difference in the prevalence Chi-square test of stress management practices in different grades levels.

Null Hypothesis 3. There are no statistically significant differences in knowledge, T-test attitudes, subjective norms, and perceived control of stress between female and male medical students who had stress.

Null Hypothesis 3.1. There are no statistically significant differences in knowledge, One-way ANOVA attitudes, subjective norms, and perceived control of stress management among medical students of different grade levels who had high stress.

Null Hypothesis 4. There are no statistically significant predictors of the intention Multiple Regression to use stress management practices of medical students who had high stress among Test the testing variables: knowledge, attitudes, subjective norms, and perceived control of stress.

Null Hypothesis 4.1. There are no statistically significant predictors of the intention Multiple Regression to use stress management practices among medical students who had high stress Test and never practice stress management between the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Null Hypothesis 4.2. There are no statistically significant predictors of the intention Multiple Regression to use stress management practices among medical students who had high stress Test and never practice stress management when controlling for demographic and stressor variables among the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Ethical Consideration

The study was conducted after an approval had been obtained from the IRB) at

KSU with the permission of the Dean of The School of Health Sciences and TU’s administration. Before the study began, a request letter was sent to all of the aforementioned administrators of them in order to ask to seek permission. A signed online-consent form was obtained from each participant. The researcher provided a clear explanation to each respondent that includes purpose, the anticipated outcome of the study, and the subjects have the right to withdraw from the study at any time without penalties or obligations. The researcher informed the respondents that their answers and participation were anonymous and would only be used for the aim of academic research.

Informed Consent

Since an online survey was used as the data collection method in this study, the informed consent form was provided electronically via online as well. Participants were asked in the invitation letter to read and indicate that they understood the informed consent contents before proceeding to take the survey. The informed consent was conveyed in a clear and concise manner and was also translated into the participants’ primary language (Arabic). The informed consent contained information that enabled participants to voluntarily decide whether or not to participate as research subjects.

Participation was indicated by clicking on the “Agree” button to indicate that he/she had read the information in the informed consent form carefully, and was willing to participate voluntarily. The informed consent had an explanation that included the aim,

92 and the anticipated outcome of the study. The online-consent form used for this study can be found as Appendix E.

Subjects had the right to withdraw from the study at any time without penalties or obligations. The significance of respecting anonymity and participant privacy were explained. Identification of the participants, including names or university ID’s, was not required. After the dissertation was completed and approved, the demographic data and surveys were to be shredded.

Summary

This chapter reviewed the methodology and procedures that were utilized in the study. The targeted population was the medical students attending a medical college in the TU, Saudi Arabia. The instrumentation consisted of nine parts: Demographic Data,

Stress Knowledge Questionnaire, Perceived Stress Scale, Graduate Stress

Inventory-Revised/Stressor Questionnaire, Attitude Questionnaire, and Subjective Norm

Questionnaire, Perceived Behavioral Control Questionnaire, Behavioral Intention

Questionnaire, and Actual Behavior Questionnaire. The reliability and validity data for supporting these instruments were presented. The data analyzed consisted of descriptive statistics and inferential statistics. Research design framework is provided below to demonstrate the process that had been taken in this chapter and the following chapters

(Ch4 and Ch5).

Figure 4. Research design for the study

CHAPTER IV

RESULTS

This cross-sectional study was conducted at the College of Medicine and the

College of Applied Medical Sciences at TU, Saudi Arabia. This main study was administered via an Internet anonymous survey to the two medical colleges stated above.

The sample of this study included both male and female medical students. Table 14 shows the demographic characteristics of the main study sample.

The study determined the prevalence of stress, knowledge about stress, source of stress, current stress management practices, and intention of future practice of medical students by gender and grade cohort. The study also determined the predictive value of knowledge, attitudes, subjective norms, and perceived control of stress to the intention of practicing stress management among medical students.

A total of nine data collection instruments (80 items) were used in data collection for this study (see Appendix A). Prior to their use, a pilot study was conducted, followed by minor modifications. The following were the instruments (number of items) used in the final data collection:

1. Demographic Information (DI-6 items)

2. Stress Knowledge Questionnaire (SKQ-5 items)

3. Perceived Stress Scale (PSS-9 items)

4. Stressor Questionnaire (SQ-25 items)

5. Attitude Questionnaire (AQ-14 items)

6. Subjective Norm Questionnaire (SNQ-7 items)

7. Perceived Behavioral Control Questionnaire (PBCQ-4 items)

8. Behavioral Intention Questionnaire (BIQ-3 items)

9. Actual Behavior Questionnaire (ABQ-6 items)

Descriptive Statistics

Descriptive statistics in this study were utilized to include means, standard deviations, frequency counts, and percentages to analyze the demographic data based on the DI, dependent and independent variables. The DI measured six demographic characteristics, including gender, age, marital status, current college enrollment status, current college major, and overall GPA. The dependent variables included three main dependent variables: stress level measurements based on PSS, stress management measurements based on ABQ, and intention measurements based on BIQ. The independent variables included the source of stress measurements based on SQ, attitude measurements based on AS-14 items, subjective norm measurements based on SNQ, and perceived behavioral control measurements based on PBCQ. Inferential statistics was utilized in this study to test the statistical hypotheses.

Demographics Characteristics

The demographic information of this study was obtained by measuring six demographic characteristics, including gender, age, marital status, current college enrollment status, current college major, and overall GPA. From a total of 800 medical students who received an invitation for participation (400 males and 400 females), 454 went to the online survey website to complete the survey, yielding an overall response rate of 56.6%, including 157 males (35.4%), and 286 females (64.4%).

Table 14

Demographic Characteristics of the Main Study Sample (n=447)

Demographic Variable n(%a) Male, n(%a) Female, n(%a)

Gender 447(100%) 159(35.5%) 288(64.5%)

Age 18-20 200(45.1%) 56(35.7%) 144(50.3%) 21-23 201(45.4%) 83(52.9%) 118(41.3%) 24-26 35(7.9%) 15(9.6%) 20(7.0%) 27-30 7(1.6%) 3(1.9%) 41.4(%)

Marital Status Single 422(96.3%) 152(34%) 270(60.4%) Married with no children 9(2.1%) 2(0.44%) 7(1.56%) Married with children 7(1.6%) 3(0.67%) 4(0.89%) Divorced 1(0.22%) N/A 1(0.22%)

College Enrollment Preparatory/First Year 42(9.5%) 0(0.0%) 42(14.6%) Freshman/Second Year 149(33.6%) 55(35%) 94(32.8%) Sophomore/ Third Year 41(9.3%) 20(12.7%) 21(7.3%) Junior/Forth Year 114(25.7%) 57(36.3%) 58(20.2%) Senior/Fifth Year 43(9.7) 7(4.5%) 36(12.5%) Internship/Sixth Year 46(10.4%) 15(9.6%) 31(10.8%) Internship for Medical Students 8(1.8%) 3(1.9) 5(1.7%) Only

College Major Medicine 272(62%) 87(55.8%) 185(65.1%) Applied Medical Sciences 167(38%) 69(44.2%) 99(34.9%)

GPA 0 - 0.99 1(0.3%) 0(0.0%) 1(0.4%) 1.0 - 1.99 12(3.3%) 10(7.4%) 2(0.9%) 2.0 - 2.99 122(33.1%) 48 (35.6%) 75(31.9%) 3.0 - 3.99 231(52.0%) 76 (56.3%) 155(66%) 4.0+ 3(0.7%) 1 (0.7%) 2(0.9%) aPercentages in the table are column percent based on n=447, except gender.

The distribution of respondents by age categories were as follows: 45.4% were

21-23 years old, and 45.1% were 18-20 years old. A majority of students were single

(96.3%). Over 36% of students sampled were freshmen or sophomores, followed by

25.7% juniors or seniors, and 10.4% in their sixth year or internship phase.

Of the 454 respondents from the total sample, 369 (81.3%) reported their GPAs.

The reported GPAs varied widely from 0.99 to 4.0 on a 4-point scale. Of those who reported their GPA (n=369), 17 students (4.6%) were studying at the first-year level and had no prior college GPA yet. Because they did not have a current college GPA, they provided their high school GPA instead, which is out of 100 in Saudi Arabia. Thus, their scores were translated from the high school GPA to the college GPA, which is based on a

4-point scale. Subsequently, slightly more than half of the students (52%) reported a

GPA score that ranged between 2 and 2.99 points, another 33.1% reported a GPA that ranged between 3 and 3.99, and a few students (n=6) had a GPA of 4.0 points. Table displays the distribution of demographic characteristics of the study sample.

Dependent Variables

The dependent variable, stress level, was measured using the Perceived Stress

Scale (PSS). As a 9-item 5-point scale, the theoretical scale sum score was from 0 to 36 points, with higher scores indicating higher levels of stress. According to its author

(Andreou et al., 2011), this scale was capable of determining stress levels at three categories: low, moderate, and high stress when the total scores obtained were 0-12, 13-

23, and 24-36, respectively. For the current study, the scale received a Cronbach’s alpha score of 0.78, indicating that it is considered a reliable measure in this study. Student participants scored at a range from 4 to 29 total points; 16% students (n=71) had a low level of stress, 74% (n=326) had a moderate level, and 10.4% (n=46) had a high level of

98 stress, with an overall mean score at 17.33 and a Standard Deviation of 4.73. Table shows the stress levels as PSS measured by all samples and by gender.

Table 15

Stress Levels for All Respondents by Gender (n=443)

Stress Level Male Female Total

Low 37(24%) 34(12%) 71(16%) Moderate 106(68%) 220(77%) 326(74%)

High 14(9%) 32(11%) 46(10%)

Due to the purpose of the study to investigate stress, stress management, and intention of future stress management, samples in moderate and high stress categories were grouped into the "high stress" category, and samples in low stress were treated as

“low stress.” This resulting dichotomous variable was to provide maximum samples size in this study to possibly differentiate students at a higher level of stress from those who did stress management and who did not. Behavior intention then could be further analyzed after grouping the moderate and high stress groups in one category named “high stress.” Of the 447 respondents, 84% had high stress and nearly 16% had low stress,

57% of the female students had high stress and 27% for their male counterparts (See

Table 16). Figure 4 below shows the increasing number of female students who had high stress; this can be inferred from the higher number of their respondents to the survey than their male counterparts that would also explain why female students had a larger percentage of high stress than males. Further analysis in this regard is presented in the

Hypothesis Test section below.

Table 16

Stress Level by Gender Among High and Low Stress Groups (n=443)

Stress Level Male Female Total

Low Stress 8.3% 7.6% 16%

High Stress 27% 56.8% 84%

Figure 5. Number of students who had high and low stress by gender

Figure 6, a double horizontal bar graph, compares two series of data: the numbers of male and female medical students studying at TU in two different medical colleges (the College of Medicine and the College of Applied Medical

Sciences). The graph shows the number of students at the two-medical colleges who had high and low stress by major. As can be seen in Figure 6, the majority were female students who had high stress across the two medical colleges except one group (low stress group) in the College of Medicine. This shows that the

100 number of male students were higher than the number of their female counterparts.

Figure 6. Number of students who had high and low stress by major

The dependent variable, stress management, was measured using the Actual

Behavior Questionnaire (ABQ), a 5-item scale. Based on the questions of the scale, a three-category variable was computed to represent stress management status. These categories were never, occasionally, and often. Among female medical students, the majority of the respondents (58%) indicated they practiced stress management often, followed by occasionally (26%), and never (16%). For the male medical students, 53% reported a practice of stress management as often, followed by occasionally (24%), and never (23%), as shown Table 17. Among the female medical students with high stress,

58% indicated they practiced stress management often, followed by occasionally (26%),

101 and never (16%). For males with high stress, 53% indicated that they practiced stress management often, followed by occasionally (24%), and never (23%), as shown in Table

17. Table 17 shows stress management status by gender among low stress group.

Table 17

Stress Management Status by Gender for All Samples (n=444)

Stress Management Male Female

Never 36(23%) 45(16%)

Occasionally 38(24%) 75(26%)

Often 83(53%) 166(58%)

Figure 7 depicts the count of medical students based on the frequency of practicing stress management. Overall, the majority of the respondents were female medical students.

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Figure 7. Number of medical students based on the frequency of practicing SMTs

Table 18

Stress Management Status by Gender Among High Stress Group (n=443)

Stress Management Male Female

Never 28(23%) 41(16%) Occasionally 29(24%) 65(26%) Often 63(53%) 146(58%)

Table 19

Stress Management Status by Gender Among Low Stress Group (n=443)

Stress Management Male Female

Never 8(21.6%) 4(11.8 %) Occasionally 9(24.3%) 10(29.4 %) Often 20(54.1%) 20(58.8 %) Figure 8 represents the number of medical students based on the frequency of practicing stress management by major. As shown in Figure 8, the majority of the respondents were female medical students across the two medical colleges.

Figure 8. Stress management status by major among high stress group (n=443)

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The dependent variable, intention, was measured using the Behavioral Intention

Questionnaire (BIQ). A seven-point Likert-scale was used, ranging from (1) likely agrees to (7) unlikely for the three items. A Cronbach’s alpha test was calculated to measure internal consistency of the BIQ (α = .89). According to the scale developers

Francis et al. (2004), an average score was calculated to represent an overall intention score. On average, students had a higher score than the average intention to practice

SMTs (M = 2.22, SD = 1.44), with men receiving slightly higher scores (M = 2.38, SD =

1.48) than women (M = 2.13, SD = 1.41) (see Table 25).

Independent Variables

The independent variable, stress knowledge, was measured using a Stress

Knowledge Questionnaire (SKQ). The SKQ measured whether or not the student knew the factual answers to those five items. Since the SKQ was not a scaled instrument, the

Cronbach’s alpha was unlikely to be the right test to judge its reliability (Burton et al.,

2010).

The overall SKQ revealed, on average, that students answered 3.63 questions correctly out of 5 (M = 3.63, SD =. 82). Of 444 participants, 51 (11.5%) had a perfect score, and none had a score of zero. An independent-samples t-test was conducted to compare the stress knowledge difference between genders. There was a significant difference between gender (n= 441, t = -4.16, and p < 0.001), with women receiving a higher mean score than men. To demonstrate the proportion of correct answers by

104 gender, Table 20 shows the number and percent that students answered correctly for each question.

Table 20

Frequency of Students’ Stress Knowledge Scores–Main Study

Question # 1 2 3 4 5

Total Sample 6 (1%) 31 (7%) 131 (29%) 225 (51%) 51 (12%)

Female 1(0.3%) 11(4%) 83(29%) 154(54%) 38(13%)

Male 5(3%) 20(13%) 49(31%) 70(45%) 13(8%)

The independent variable, stressors, were measured using the Stressor

Questionnaire (SQ). The SQ had three subscales that included environmental (10 items), academic (9 items), and family/monetary stress (6 items). A Seven-point Likert scale was used, ranging from (1) being less stressful to (7) being most stressful. These subscales scores were computed as the average of their items.

The SQ revealed that, on average, the academic stressor subscale had the highest mean (M = 4.67, SD = 1.35), followed by the family/monetary subscale (M = 3.48, SD =

1.54), leaving the environmental stressor as the lowest mean (M = 2.99, SD = 1.15)

(Table 21). Therefore, this confirmed the finding from the follow up question, “Among environmental, academic, and family/monetary stress, what is the most stressful?” A majority of the sample (71%) reported they found academic stressors to be the most problematic for them (n=317). A Cronbach’s alpha test was conducted to measure internal consistency of the SQ. The three subscales were reliable with environmental (α

105

=. 78), academic (α =. 86), and family/monetary (α = .86) stressors. The overall stressor questionnaire was found to be highly reliable (n=25, α = .87).

Table 21

Descriptive Statistics of Stressor Scale for the Main Study Participants

Variable N Mean SD

Environmental Stressor 442 2.99 1.16

Academic Stressor 443 4.67 1.35

Family/Monetary Stressor 443 3.48 1.54

An independent-samples t-test was conducted to compare the mean environmental, academic, and family/monetary stress scores between men and women.

Although women had significantly more academic stress than men (t441 = -4.16, p =

.002), surprisingly men and women did not significantly differ on environmental or family stress scores (Table 22).

Table 22

Descriptive Statistics of Stressor Scale by Gender for the Main Study Sample

Male Female Variable N Mean SD N Mean SD P value Environmental Stressor 156 2.95 1.00 285 3.01 1.23 0.590 Academic Stressor 156 4.41 1.42 285 4.82 1.28 0.002 Family/Monetary 156 3.56 1.58 284 3.45 1.52 0.488 Stressor

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As can be seen in Figure 9, Using the Stressor Scale (SQ), a seven-point

Likert-scale was used on the x-axis ranging from (1) less stressful to (7) most stressful.

On average, academic stressors had the most impact on students for both genders. On the other hand, the environmental stressor had the least average impact on students for both genders. On average, the overall stressors (the combined subscales: environment, academic, and family stressors) had a moderate impact on stress levels for both genders.

Figure 9. Types of stressors that have an impact on students’ stress levels

Descriptive statistics were conducted to represent the top stressors by gender based on mean. The top stressors reported in Table 23 were arranged based on the maximum to the minimum value of the mean. Table 23 demonstrates the top three stressors in each subscale of stressor scale SQ by gender. A line graph was used to draw the pattern of frequency of the top stressors within each subscale by gender.

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Table 23

Descriptive Statistics for the Top Stressors by Gender Based on Mean

Variables Women Men 1 Living in the local community Faculty treating you differently

Environmental Stressors 2 Faculty treating you differently Living in the local community

3 Participating in class Participating in class

1 Family $ problems Repay loans Family Stressors 2 Arranging childcare Family $ problems 3 Repay loans Paying monthly bills

1 Prepare and take exams Fear of failing to meet PE Academic Stressors 2 Fear of failing to meet PE Prepare and take exams 3 Handling academic workload Handling academic workload

Descriptive statistics were conducted to represent the top stressors by year of

schooling based on the mean. The top stressors reported in Table 24 were ranged based

on the maximum to the minimum values of the mean. Table 24 shows the top three

stressors in each subscale of stressor scale SQ 25 by grade level. Pattern of frequency of

the top stressors were found across all three stressor subscales. As shown in Table 24,

the three top stressors in the Academic stressor subscale (prepare and take exams, fear of

failing to meet program expectation (PE), and handling academic workload) were found

to be the most problematic causes of stress to the medical students across all grade levels.

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Table 24

Descriptive Statistics for the Top Stressors by Year of Schooling Based on Mean

Academic Stressor Family/$ Stressor Environmental Stressor 1st Year 1 Prepare and take exams Family $ problems Faculty treating you differently 2 Fear of failing to meet PE Repay loans Living in local community 3 Handling academic Paying monthly expenses Class participation workload 2nd 1 Prepare and take exams Family $ problems Living in local community Year 2 Handling academic Arranging childcare Faculty treating you workload differently 3 Fear of failing to meet PE Repay loans Class participation 3rd Year 1 Fear of failing to meet PE Family $ problems Class participation 2 Handling academic Repay loans Meeting with faculty workload 3 Prepare and take exams Paying monthly expenses Living in local community 4th Year 1 Prepare and take exams Repay loans Living in local community 2 Fear of failing to meet PE Family $ problems Faculty treating you differently 3 Handling academic Paying monthly expenses Class participation workload 5th Year 1 Prepare and take exams Family $ problems Living in local community 2 Fear of failing to meet PE Repay loans Class participation 3 Handling academic Cost of educational Faculty treating you workload supplies differently 6th 1 Prepare and take exams Family $ problems Faculty treating you Year differently 2 Fear of failing to meet Arranging childcare Commuting to and from PE campus 3 Handling academic Repay loans Class participation workload 7th 1 Prepare and take exams Repay loans Living in local Year community 2 Writing papers Family $ problems Faculty treating you differently 3 Fear of failing to meet Arranging childcare Adjusting to the campus PE environment

The independent variable, attitude, was measured using the Attitude

Questionnaire (AQ). A five-point Likert-scale was used, ranging from (1) strongly

109 disagrees to (5) strongly agree was used for the 14 items. A Cronbach’s alpha test was calculated to measure internal consistency of the AQ (α = .614).

An independent-samples t-test was conducted to compare the difference between gender on the mean score of the attitude. There was a significant difference on the mean score of the attitude by gender (t436 = -4.14, p = .000), with women receiving higher scores (M = 3.53, SD = .35) than men (M = 3.37, SD = .42), as shown in Table 25. The

AQ revealed, on average, students had slightly positive attitudes toward practicing SMTs

(M = 3.48, SD = .38).

The independent variable, subjective norm, was measured using the Subjective

Norm Questionnaire (SNK). It was a seven-point Likert-scale ranging from (1) strongly agrees to (7) strongly disagree. An independent-samples t-test was conducted to compare the difference between gender on the mean score of the subjective norm. There was no significant difference found (t431 = 1.13, p = .257) with men receiving a slightly higher score (M = 3.79, SD = 1.10) than women (M = 3.65, SD = 1.19) (see Table 25). The SNK revealed, on average, that students had a slightly positive subjective norm (M = 3.70, SD

= 1.16).

The independent variable, perceived behavioral control, was measured using the

Perceived Behavioral Control Questionnaire (PBCQ). It was a seven-point Likert-scale ranging from (1) strongly agree to (7) strongly disagree. An independent-samples t-test was conducted to compare the difference between the two genders on the mean score of the perceived behavioral control. There was no significant difference on the mean score of the subjective norm by gender, t (430) = 1.42, p = .154, with men receiving slightly

110 higher scores (M = 3.81, SD = 1.10) than women (M = 3.64, SD = 1.19), see Table 25.

The PBCQ revealed, on average, that students had slightly positive perceived behavioral control over their stress (M = 2.82, SD = 1.22).

Table 25

Descriptive Statistics of Attitude, Subjective Norm, Behavioral Perceived Control, and Behavior Intention by Gender for the Main Study Sample

Variable Male Female

N Mean SD N Mean SD P value

Attitude 153 3.37 0.42 285 3.53 0.35 0.001

Subjective Norm 151 3.79 1.10 283 3.65 1.19 0.257

Perceived Control 151 3.81 1.10 281 3.64 1.19 0.154

Intention 152 2.38 1.48 283 2.13 1.41 0.078

Summary of Descriptive Statistics

The descriptive statistics of this main study were broken down into measures of central tendency (means, standard deviations), frequency counts, and percentages to analyze the demographic, dependent, and independent three group variables proposed to study. The six demographics characteristics described were gender, age, marital status, current college enrollment status, current college major, and overall GPA. Three main dependent variables included were stress level, stress management, and intention. Among these dependent variables, only stress level differed significantly by gender p <0.05. Five independent variables were studied, including the following: stress knowledge, source of stress, attitude, subjective norm, and perceived behavioral control. Among these five

111 independent variables, stress knowledge, source of stress-academic stressor, and attitude were significantly different by gender p < .05 (as seen in Table 25).

Hypothesis Test

For the purpose of this study, students’ stress levels/prevalence were defined as dichotomous: low or high. The high group include those whose measured scores ranged moderate and high in the original scale. Stress management practice was also categorized into three sub-groups: never, occasionally, and often. Below are the findings for the research questions and hypotheses.

Research Question 1

What is the prevalence of stress among medical students in Saudi Arabia’s TU?

In order to answer this research question, students in their grade level (five to seven levels) of study completed the Perceived Stress Scale (PSS) to measure their stress prevalence. The overall stress prevalence was 84% of the respondents who had high stress and 16% for those with low stress. The majority of respondents (57%) who had high stress were female medical students, and 27% for their male counterparts (see Table

16).

Hypothesis 1.1

Null Hypothesis. There is no statistically significant association in stress prevalence rates between female and male students.

Alternative Hypothesis. There is a statistically significant association in stress prevalence rates between female and male students.

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A chi-square test of independence was performed to examine the association between stress levels and gender. The association between these variables was significant, X2(2) = 10.348, p = 0.006. Based on this result, p < .05, null hypothesis 1 is rejected and the alternative hypothesis is accepted. Nearly 57% of the females had high stress, while the number was 27% among males. About 8% of the females had low stress compared to 8.3% for their male counterparts (see Table 26).

Table 26

Hypotheses 1, Chi-Square Test Findings (n=443)

Stress Level Male Female P-value*

Low Stress 37(8.3%) 34(7.6%) 0.001

High Stress 120(27%) 252(56.8%)

*p value was from 2x2 Chi square test.

Hypothesis 1.2

Null Hypothesis. There is no statistically significant association in stress prevalence rates among students in different grades levels.

Alternative Hypothesis. There is a statistically significant association in stress prevalence rates among students in different grades levels.

A chi-square test of independence was performed to examine the association with stress prevalence rates among students in different grades levels. The relationship between these variables was not statistically significant (X2(2) = 19.573, p > .05). Based on this result the null hypothesis 1.2 is accepted.

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As shown in Table 27, stress levels among medical students varied based on their grade levels. Preparatory/First Year (92.9%) and Internship (92.6%) students had the highest stress levels among the other grade levels across the two medical colleges. The assumption of the Chi-square test is that the expected value in each cell must be greater than 5 (Yates, 1934). Hence, the internship students in their Sixth and Seventh years of study were combined together due to the low count in each cell of each grade level. As can be seen by the frequencies presented in Table 27 across the grade levels, high stress was the most prevalent among Preparatory/First Years, followed by Internship students.

However, stress lowered during the Second, Third, and Fourth years of study. Then the high stress levels returned among students in their internship year.

Table 27

Hypotheses 1.2, Chi-Square Test Findings

Stress Levels

Grade Low Stress High Stress P-value

Preparatory/First Year 3(7.1%) 39(92.9%)

Freshmen/Second Year 29(19.5%) 120(80.5%)

Sophomore/ Third Year 7(17.5%) 34(82.9%) .076 Junior/ Forth Year 20(17.5%) 94(82.5%) Senior/ Fifth Year 8(18.6%) 35(81.4%) Internship * 4(7.4%) 50(92.6%) *Sixth and Seventh grades were combined as one group called internship.

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Hypothesis 2

Null Hypothesis. There is no statistically significant association between the prevalence of stress management practices and stress levels.

Alternative Hypothesis. There is a statistically significant association between the prevalence of stress management practices and stress levels.

A chi-square test of independence was performed to examine the association between the prevalence of stress management practices and stress level. The association between these two variables was not statistically significant (X2(2) = 0.140, p > .05).

Based on this result, null hypothesis 2 was retained. Among high stress students, 56.3% indicated “often,” followed by “occasionally” (25.2%) and “never” (18.5%) for practicing SMTs. Among the low stressed group of students, 56.3% indicated “often” followed by “occasionally” (26.7%) and 16.9% for those who indicated “never” for practicing stress management (see Table 28).

Table 28

Hypotheses 2, Chi-Square Test Findings (n=444)

Stress Level

Stress Management Low Stress High Stress P-value

Never 12(16.9%) 69(18.5%) 0.932 Occasionally 19(26.7%) 94(25.2%)

Often 40(56.3%) 210(56.3%)

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Hypothesis 2.1

Null Hypothesis. There is no statistically significant association in the prevalence of stress management practices between female and male medical students who had high stress.

Alternative Hypothesis. There is a statistically significant association in the prevalence of stress management practices between female and male medical students who had high stress.

A chi-square test of independence was performed to examine the difference in the prevalence of stress management practices between female and male medical students who had high stress. The association between these variables was not statistically different, X2(2) = .259, p > .05. Based on this result, the null hypothesis 2.1. is accepted.

Male medical students were less likely to show an interest in practicing SMTs than were female medical students. Among female medical students, 58% indicated

“often” for practicing SMTs, compared to nearly 53% for their male counterparts. About

26% of female medical students indicated “occasionally” for practicing stress management, whereas nearly 24% of their male counterparts had this response. Among male medical students, about 23% indicated “never” for practicing stress management, along with 16% for their female counterparts (see Table 29).

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Table 29

Hypotheses 2.1, Chi-Square Test Findings (n=444)

Stress Management Male Female P-value

Never 28(23%) 41(16%)

Occasionally 29(24%) 65(26%) 0.259

Often 63(53%) 146(58%)

*This table only represent high stressed group for both male and female medical students

Hypothesis 2.2

Null Hypothesis. There is no statistically significant association in the prevalence of stress management practices in different grades levels.

Alternative Hypothesis. There is a statistically significant association in the prevalence of stress management practices in different grades levels.

A chi-square test of independence was performed to examine the difference in the prevalence of stress management practices in different grades levels. The association between these variables was not statistically different, X2(12) = 6.13, p =. 909. Based on this result, p > .05, therefore the null hypothesis 2.2. is accepted.

Among all grade levels, the Internship students practiced SMTs the most. Among all grade levels, nearly 63% of the internship students indicated “often” for practicing

SMTs, followed by the Fifth (59%), and Second (58%) years of study. The proportion of students for all grade levels across the two colleges who indicated “occasionally” for practicing SMTs ranged from 19% to 32%, with internship students having the highest

(32%), while Second year students were the lowest (19%). The number of students who

117 indicated “never” for practicing stress management ranged from 12% to 21%, with

Preparatory/First Year students having the highest (21%), and Third year students had the lowest (12%), as shown in Table 30.

Table 30

Hypotheses 2.2, Chi-Square Test Findings (n=443)

Stress Management Practices

Grade Level Never Occasionally Often P-value

Preparatory/ First 9(21.4%) 12(28.6%) 21(50.5%) Year Freshman/ Second 28(18.8%) 34(22.8%) 87(58.4%) Year Sophomore/ Third 5(12.2%) 13(31.7%) 23(56.1%) Year Junior/ Forth Year 22(19.3%) 31(27.2%) 61(53.5%) .076 Senior/ Fifth Year 9(20.9%) 8(18.6%) 26(59%)

Internship* 8(17.4%) 15(32.1%) 31(63%) *Sixth and Seventh grades were combined

Hypothesis 3

Null Hypothesis. There are no statistically significant differences in knowledge, attitudes, subjective norms, and perceived control of stress management between female and male medical students who had high stress.

Alternative Hypothesis. There are statistically significant differences in knowledge, attitudes, subjective norms, and perceived control of stress management between female and male medical students who had high stress.

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An independent-samples t-test was conducted to compare the mean difference in stress knowledge, attitudes, subjective norms, and perceived control of stress between female and male medical students who had high stress. Since there were different statistical significant results among the tested variables in Hypothesis 3, differences were compared in a mean score using an independent-samples t-test as follows: The mean differences for subjective norms and perceived control of stress between genders did not find significant differences p > .05 (see Table 31). Based on this result, p > .05, null hypothesis 3 is accepted.

Alternative Hypothesis: The mean differences for knowledge and attitude of stress between gender found significant differences p <.05 (see Table 31). Based on this result, p <.05, null hypothesis 3 is rejected and the alternative hypothesis is accepted. In other words, among students who had high stress, women reported significantly higher levels of knowledge than men (3.74 vs 3.45, respectively). This test was statistically significant

(t370 = -3.312, p = 0.001). Also, among students who had high stress, women reported significantly higher levels of attitude than men (3.55 vs 3.44, respectively). This test was also statistically significant (t365 = -2.593, p = 0.01). Table 31 shows the mean, standard deviation, and p-value for each variable by gender.

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Table 31

Mean, Standard Deviation, and P-value for Each Variable by Gender

Sub-group Variable Gender N Mean SD P-value

Knowledge M 120 3.45 .91 0.001

F 252 3.74 .73

M 116 3.44 .42 Attitude 0.010 High Stress F 251 3.55 .35

M 115 3.82 1.12 Subjective Norm 0.203 F 250 3.66 1.16

M 115 2.95 1.14 Perceived Control 0.868 F 248 2.93 1.25

Hypothesis 3.1

Null Hypothesis. There is no statistically significant difference in knowledge, attitudes, subjective norms, and perceived control of stress management among medical students of different grade levels who had high stress.

Alternative Hypothesis. There is a statistically significant difference in knowledge, attitudes, subjective norms, and perceived control of stress management among medical students of different grade levels who had high stress.

One-way between-subjects ANOVA tests were conducted to compare the stress knowledge, attitudes, subjective norms, and perceived control (DVs) between grade levels. For the test of attitude between grade levels, the overall test was significant at F

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(5, 432) =5.13, p = .001 level. Based on this result, p <.05, the null hypothesis is rejected, and the alternative hypothesis is accepted.

To determine where the significance laid, a Tukey HSD post hoc test was followed to compare any pair of grades for significant differences. The test found that the mean score of the attitude for students in their Preparatory/First Year (M = 3.604, SD

= .360) was significantly higher than those in their Freshman/Second Year (M = 3.404,

SD = 0.354). Also, the mean score of the attitude for Freshman/Second Year students (M

= 3.404, SD = 0.354) was significantly lower than Sophomores/Third Year students (M =

3.661, SD = 0.327) while the mean score for Sophomores/Third Year students (M =

3.661, SD = 0.327) was significantly higher than for Juniors/Fourth Year students (M =

3.421, SD = 0.389). However, there was no significant difference in mean attitude score between Seniors/Fifth Year Students (M = 3.549, SD = 0.487) and Internship Year students (M = 3.553, SD = 0.359). Table 32 presents the test statistics in detail.

Table 32

Hypothesis 3.1, Pairwise Comparisons, Tukey HSD

Attitude_ Grade Level N Mean SD P-value

Preparatory/First Year _ 42 3.604 0.360 0.030 Freshman/Second Year 148 3.404 0.354 Sophomore/Third Year_ 38 3.661 0.327 0.003 Junior/Forth Year 114 3.421 0.389 Freshman/Second Year _ 43 3.549 0.487 0.009 Sophomore/Third Year 53 3.553 0.359 Senior/Fifth Year _ 43 3.549 0.487 1.000 Internship 53 3.553 0.359 Total 438

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However, no significant differences in the mean scores were found among the rest of the dependent variables (stress Knowledge, subjective norms, and behavioral perceived control scores). Table 33 shows a description for the dependent variables.

Table 33

Hypothesis 3.1, Descriptive for Dependent Variables

Grade Level N Mean SD P-value

Stress Knowledge Scale Preparatory/First Year 42 3.571 0.887

Freshman/Second Year 149 3.610 0.794

Sophomore/Third Year 41 3.756 0.799 Junior/Fourth Year 115 3.539 0.891 P > 0.05

Senior/Fifth Year 43 3.814 0.763

Internship 54 3.740 0.781 Total 444 3.637 0.826

Subjective Norm Scale

Preparatory/First Year 41 4.270 1.261

Freshman/Second Year 147 4.322 1.153 Sophomore/Third Year 38 4.522 0.959 Junior/Fourth Year 114 4.260 1.178 P > 0.05

Senior/Fifth Year 43 4.362 1.228

Internship 53 4.097 1.188 Total 436 4.295 1.165

Behavioral Perceived Control Scale

Preparatory/First Year 40 4.937 1.410

Freshman/Second Year 146 5.234 1.228

Sophomore/Third Year 38 5.572 1.179 Junior/Fourth Year 114 5.076 1.194 P > 0.05

Senior/Fifth Year 43 5.011 1.152

Internship 53 5.268 1.213 Total 434 5.177 1.228

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Multiple Linear Regression Assumptions

The hypotheses 4, 4.1 and 4.2 were tested using a multiple linear regression test.

For all three hypotheses, four assumptions of the multiple linear regression were tested, including linearity, normality, multicollinearity, and homoscedasticity. All of these assumptions of the multiple linear regression were met.

First, since multiple linear regression requires the relationship between the independent and dependent variables to be linear (Razali, Wah, & Yap Bee, 2011), linearity assumption was tested using scatterplots of the relationship between each of the independent variables and the dependent variable, finding a reasonable assumption.

Second, multiple linear regression analysis requires that the errors between observed and predicted values (i.e., the residuals of the regression) must be normally distributed

(Razali, Wah, & Yap Bee, 2011). This assumption was checked by looking at a Graph

Histogram Normality and was found to be normally distributed (see Figure 10), suggesting a relatively normal distributional shape (with no outliers) of the residuals.

Third, multiple linear regression assumes there is no multicollinearity in the data.

Multicollinearity occurs when the independent variables are too highly correlated with each other (Belsley & David, 1991). Multicollinearity was checked using a multiple

Correlation matrix, as well as Variance Inflation Factor (VIF) values. The matrix of

Pearson’s bivariate correlations among all independent variables showed the magnitude of the correlation coefficients was less than .800. and the VIF was less than 10 (2.100), suggesting that multicollinearity was not an issue.

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Figure 10. Graph histogram normality

Finally, multiple linear regression requires the variance of error terms to be similar across the values of the independent variables; this phenomenon is known as homoscedasticity (Hamsici, Martinez, & Aleix, 2007). A scatterplot of residuals versus predicted values was used to check for homoscedasticity. The scatterplot showed all points were equally distributed across all values of the independent variables, suggesting there was no clear pattern in the distribution.

Hypothesis 4

Null Hypothesis. There are no statistically significant predictor(s) of the intentions of stress management practices for medical students who had high stress among the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

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Alternative Hypothesis. There is statistically significant predictor(s) of the intentions of stress management practices for medical students who had high stress among the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Hypothesis 4 was restricted to only students who had high stress. Multiple linear regression was calculated to predict the intentions to practice stress management techniques based on students’ knowledge, attitude, subjective norms, and perceived behavioral control. The multiple regression model with all four predictors produced a significant regression equation (F (4, 359) =37.030, p < .001), with an R2 of .262. Based on this result, p < .05, null hypothesis 4 is rejected, and the alternative hypothesis is accepted.

As can be seen in Table 34 and Equation 1, the attitude, subjective norms, and perceived behavioral control scales had significant positive regression weights on intentions, indicating students with higher scores on these scales were expected to have higher levels of intentions to practice SMTs. However, the knowledge scale was not a significant contributor for the intentions to practice SMTs (p > .05). Students’ predicted intentions were equal to:

Equation 1

�� = .450 + 0.380(��) + 0.176(�� ) + 0.575(��ℎ�� )

In the analysis of the statistical hypotheses in this research, the attitude, subjective norms, perceived control, and knowledge scales were measured in units, with each unit equaling 1 point on a Likert-scale. Overall, Equation 1 went in a positive direction,

125 indicating that for every one-unit increase in any of the attitudes, subjective norms, or perceived control scales, the students’ intentions to practice SMTs increased by 0.380,

0.176, or 0.575, respectively (see Table 34).

Table 34

Hypothesis 4, Multiple Linear Regression Model Results

Variable B Standard Error t P

Constant 0.450 0.726 0.619 0.004 Attitude 0.380 0.172 2.211 0.028 Subjective Norm 0.176 0.058 3.023 0.003

Perceived control 0.575 0.055 10.491 0.001 Knowledge 0.074 0.080 0.918 0.359 Overall model was significant (F(4, 359)=37.030, p < .001), adjusted R2=.262

A regression Parameter Plot Graph was used to show the major predicators / significance among the tested variables (attitude, subjective norms, perceived control and knowledge). In other words, when the dot is far from the zero line/dash line, it becomes a more important estimate or a more significant predictor. As shown in Figure 11, three dots were far from the zero line, indicating they were significant predictors of intention to practice SMTs. Since the knowledge about stress was very close to the dash line, it indicated there was no significance.

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Figure 11. Regression parameter plot graph represents the significant predictors of intention to practice SMTs

Hypothesis 4.1

Null Hypothesis. There are no statistically significant predictor(s) of the intention of stress management practices among medical students who had high stress and who never practiced stress management between the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Alternative Hypothesis. There is statistically significant predictor(s) of the intention of stress management practices among medical students who had high stress and who never practiced stress management between the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Hypothesis 4.1 was restricted to students who had high stress and who had never practiced SMTs. Multiple linear regression was calculated to predict intentions to practice SMTs based on students’ knowledge, attitude, subjective norms, and perceived behavioral control. The multiple regression model with all four predictors produced a

127 significant regression equation (F (4, 57) = 9.924, p < .001), with an R2 of .411. Based on this result, p < .05, null hypothesis 4.1 is rejected, and the alternative hypothesis is accepted.

As shown in Equation 2 and Table 35, after including the sub-group (students who had high stress and who never practiced SMTs), the perceived behavioral control was the only significant predictor of intention. The attitude, subjective norms, and knowledge scales became insignificant and had both positive and negative regression weights while the stress knowledge scale remained insignificant. Students’ predicted intentions are equal to:

Equation 2

�� = 1.56 + 0.758(��ℎ�� )

Overall, Equation 2 went in a positive direction. The positive direction indicates that for every one-unit increase in the behavioral perceived control scale, the students’ intention to practice SMTs increased by 0.758 (see Table 35).

Regression Parameter Plot Graph was used to illustrate the major predicators / significance among the tested variables (attitude, subjective norms, perceived control and knowledge). As can be seen in Figure 12, the further to the right the dot is from the dash line, the more important the estimate is going to be. Perceived control was far from the zero line, indicating it was a significant predictor of intentions to practice SMTs. Since the rest of the variables were crossing or very close to the dash line, they indicated they were not significant.

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Table 35

Hypothesis 4.1, Multiple Linear Regression Model Results

Variable B Standard Error t P

Constant 1.56 1.99 0.784 0.436 Attitude -0.136 0.523 -0.261 0.795

Subjective Norm 0.208 0.144 1.449 0.153 Perceived Control 0.758 0.130 5.813 0.001 Knowledge -0.060 0.228 -0.263 0.793 Overall model was significant (F(4, 57)= 9.924, p < .001), adjusted R2=.369

Figure 12. Regression parameter plot graph represents the significant predictors of intention to practice SMTS among high stress and never practice SMTS group

Hypothesis 4.2

129 variables among the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

Alternative Hypothesis. There is statistically significant predictor(s) of the intention of stress management practices among medical students who had high stress and who never practiced stress management when controlling for demographic and stressor variables among the testing variables of knowledge, attitudes, subjective norms, and perceived control of stress.

In this model, demographic and stressor variables were included as additional independent variables besides knowledge, attitudes, subjective norms, and perceived control of stress. Demographic variables included gender, major, GPA, and enrollment status. Stressor variables included environmental, academic, and family stressors.

Multiple linear regression was used to predict intentions to practice SMTs based on students’ knowledge, attitudes, subjective norms, perceived behavioral control, and demographic and stressor variables. The F-test results showed that the overall model was significant (F (11, 41) = 5.239, p < .001), with an R2 of .584. Based on this result, p < .05, null hypothesis 4.2 is rejected, and the alternative hypothesis is accepted.

As shown in Equation 3 and Table 36, after including the demographic and stressor variables, the perceived behavioral control remained the only significant predictor of intention. Attitude, subjective norms, and knowledge scales still remained insignificant and had both positive and negative regression weights. Also, the knowledge scale did not show any significance, compared to Hypothesis 4 and 4.1. Of the added variables (the demographic and stressor variables), gender became the only significant

130 predictor of intentions for the practice of SMTs (see Table 36). In this model, students’ predicted intentions were equal to:

Equation 3

�� = 3.60 + 0.838(��ℎ�� ) + 1.23 (Gender), where gender coded as 0 = Male, 1 = Female, and major coded as 0 = Medicine, 1= Applied

Medical College Sciences, and enrollment status consists of six grade levels.

As can be seen in Equation 3 and Table 36, the equation had a positive direction.

The positive direction indicated that for every one-unit increase in any of the behavioral perceived control scale or gender, the students’ intentions to practice SMTs increased by

0.838 or 1.23, respectively. In other words, the results of the regression indicated only two predictors of intentions (behavioral perceived control and gender), thus explaining

47.3% of the variance (see Table 36).

A Regression Parameter Plot Graph was used to depict the major predicators / significance among the tested variables listed in the graph below. As can be seen in

Figure 13, perceived control and gender were far from the zero line, indicating they were the only significant predictors of intentions to practice SMTs. Since the rest of the variables were crossing or touching the dash line, they indicated there were not significant.

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Table 36

Hypothesis 4.2, Multiple Linear Regression Model Results

Variable B Standard Error t P

Constant 3.601 2.820 1.278 0.209

Attitude -0.342 0.743 -0.460 0.648

Subjective Norm 0.095 0.169 0.564 0.576

Perceived Control 0.838 0.146 5.756 0.001

Knowledge -0.379 0.294 -1.289 0.205

Environmental Stressor 0.228 0.210 1.087 0.283

Academic Stressor -0.186 0.231 -0.806 0.425

Family Stressor -0.142 0.153 -0.925 0.360

Gender 1.231 0.440 2.813 0.007

Major -0.775 0.481 -1.612 0.115

GPA -0.019 0.313 -0.062 0.951

Enrollment Status 0.040 0.138 0.286 0.776

Overall model was significant (F(11, 41)= 5.239, p < .001), adjusted R2=.473

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Figure 13. Regression parameter plot graph represents the significant predictors of intention to practice SMTs

Additional Analysis

As mentioned in the purpose of this study, the future of stress management practice by gender and major/college enrollment among medical students were examined.

Two major aspects were analyzed; one aspect was to explain the variability of what the students’ practices are likely to be in the future, and the second one was to estimate the level of students’ intentions for practicing SMTs by using the Intention Questionnaire

(IQ) measured on a seven-point Likert-scale ranging from (1) low intention to (7) high intention.

Future of Stress Management Practice by Gender

The future practice of stress management was examined by using the IQ (the intention scale was treated as a continuous scale). Since the intention is a continuous variable, the mean and standard deviations were computed using an SPSS procedure.

133

Three layers of variables were included in the procedure, including stress management status (occasionally/often and never), a 95% Confidence Interval-Intention Scale, and gender as a cluster category inside the panel chart.

As can be seen in Figure 13, the dots are the intent of the future practice of SMTs within a particular group. The bar lines crossing the dots are the narrow/precise or wider variability of what the population is likely to be in terms of practicing SMTs. In this context, as shown in Figure 13, there are two dots depicting the two genders (male and female). The bar lines overlap one another within each group (occasionally/often and never), indicating that gender had no effect on the intentions of medical students to practice SMTs. Thus, no statistically significant differences were found between the two genders in regards of their intentions to practice SMTs.

As shown in Figure 13, among students who indicated “never,” a wider bar means there is a greater variability of what the population is likely to be in terms of their practice of SMTs. On the other hand, among students who indicated

“occasionally/often,” a smaller bar means a more precise/narrow variability of what the population is likely to be in terms of their practice of SMTs.

However, Figure 14 can explain an estimation of the future practice of SMTs between male and female medical students based on their stress management status

(occasionally/often, or never) and Intention Scale. Using the IQ/Intention Scale (seven- point Likert-scale) on the x-axis ranging from (1) low intention to (7) high intention, among the occasionally/often group, the future practice of SMTs is going to be high, as well as slightly higher than the other group who indicated “never” for practicing SMTs.

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Overall, based on the Intention Scale, both genders have a high desire to practice SMTs continuously.

Figure 14. Future practice of SMTs: Compression between male and female

Future of Stress Management Practice by Major/College Enrollment

The future of stress management practice by major/college enrollment was also examined using a similar procedure used in the previous section (Future of Stress

Management Practice by Gender). The mean and standard deviation were computed using an SPSS procedure. Three layers of variables were included in the procedure, including stress management status groups (occasionally/often, and never), a 95%

Confidence Interval-Intention Scale, and Major as a cluster category inside the panel chart.

As shown in Figure 15, the bar lines crossing the dots overlap one another, implying that no statistically significant differences were found between the two colleges

135 and their intentions to practice SMTs. Thus, major/college enrollment had no effect on the intentions of medical students to practice SMTs. However, Figure 14 can explain an approximation of the future practice of SMTs between the two medical colleges based on their stress management status (occasionally/often or never) and Intention Scale. Using the IQ/Intention Scale (seven-point Likert-scale) on the x-axis ranging from (1) low intention to (7) high intention, among the occasionally/often group in the Medicine

College, the future practice of SMTs is going to be slightly higher than the other group who indicated “never” for practicing SMTs. However, among the “never practice SMTs” group across the two colleges, the variability of when they are likely to practice SMTs is greater than the group of students who indicated “occasionally/often.”

Figure 15. Future practice of SMTs: Compression between the two medical colleges

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Summary

In this study, the TPB was formulated to explain, predict, and understand the stress phenomena and its management among medical students. The theoretical framework provided a structure that could support this research study. In summary, this chapter included the analysis, Tables, Equations, and results from this study. Nine questionnaires consisting of 80 items were dealt within a quantitative analysis of data.

The analysis and interpretation of these data were carried out in two ways. First, analysis was based on the results of the descriptive statistics, including demographic, dependent, and independent variables. Overall results from these descriptive statistics revealed that stress level / prevalence among medical students was high, and that stress knowledge, sources of stress-academic stressor, and attitudes were significantly different by gender.

The second analysis was based on the results of the inferential statistics to test the statistical hypotheses. Four major hypotheses and six sub-hypotheses were proposed and analyzed in this research; the overall results from this statistical analysis revealed that, when compared to other Saudi Arabia and Middle East countries, the stress prevalence in medical students TU is high (84%) based on the PSS cut-off score (see Table 16), with females experiencing greater amounts of stress than their male counterparts. The relation between stress prevalence and gender was statistically significant. However, the relation between stress prevalence and different grade levels was not statistically significant.

Stress levels and different grades were found to not be statistically significant with the prevalence of practicing SMTs. Specifically, gender (students who had high stress) and

137 the prevalence of practicing stress management techniques were compared and found to not be statistically significant as well.

Among the independent variables (knowledge, attitudes, subjective norms, and perceived control), significant differences were found in knowledge and attitudes between the two genders, with higher scores for females than for males. In a comparison of the effect of grade levels (IVs) on knowledge, attitudes, subjective norms, and perceived control (DVs), a significant difference in the attitudes between grade levels was found. A Tukey HSD test was calculated. It found that the mean score for

Sophomores/Third Year students was significantly different than for the Juniors/Fourth

Years. However, the grade levels such as Seniors/Fifth Years did not significantly change from the Internship year of study (see Hypothesis 3.1).

Considering the sample used in Hypotheses 4, 4.1, and 4.2, the sample was only limited to students who had high stress. Specifically, Hypotheses 4.1 and 4.2 were limited to only students who had high stress and who never practiced SMTs. Multiple linear regression was used to answer Hypothesis 4, 4.1, and 4.2. The F-test results revealed that the overall models were significant for predicting students’ intention to practice SMTs based on students’ knowledge, attitudes, subjective norms, perceived behavioral control, and demographic and stressor variables.

The future practice of stress management by gender and by major/college enrollment were examined using the Intention Scale. The results revealed there were no statistical significant effect of both genders and major/college enrollment on students’

138 intention to practice SMTs. However, the variability and estimation of the future practice of SMTs differed, based on each variable (gender and major/college enrollment).

Chapter 5 provides a discussion, recommendations for future research, limitations of the study, and the implications of the findings stated in Chapter 4.

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CHAPTER V

DISCUSSION AND RECOMMENDATIONS

Purpose of the Study

The purpose of the study was to determine the prevalence, knowledge, and etiology of stress, current stress management practices, and the intentions for future practice of medical students by gender and grade cohorts at TU. The study also determined the predictive values of knowledge, attitudes, subjective norms, and perceived control of stress to intended ways for managing stress levels among medical students at TU.

A dearth of literature exists with regard to stress management and its predictive factors among Saudi medical students, along with a limited number of studies examining aspects of stress and its consequences. Those studies that did exist about medical students, for example, explored the relationships between stress and its effects (Abdel

Rahman, et al., 2013 & Abdulghani, et al., 2011), stress in relation to sleep quality

(Almojali, et al., 2017), and the impact of stress on academic performance (Atalla &

Altuwairqi, 2017) (Table 37).

This study was proposed to help bridge the gap, focusing on ten research questions that addressed stress knowledge, stress prevalence, sources of stress, and predictive factors of future stress management practices by utilizing the TPB. This study was designed to identify which factor had the most impact on students’ intention to practice SMTs. This study also examined the impact of the year of study on students’

140 intention to practice stress management, as well as the interaction between the year of study and gender in all levels.

Table 37

Saudi Universities Stress Studies, Conducted from 2007 to 2017

Author, Year Study Aim & Population Location

Abdel Rahman et al., To determine the prevalence of stress and identify the King Faisal University, 2013 risk factors of stress among medical students Al Ahsaa, KSA

Al-Sowygh et al., To determine the perceived causes of stress among King Saud University, 2012 undergraduate dental students Riyadh, KSA

To determine the association between stress and poor King Saud University, Almojali et al., 2017 sleep quality among medical students Riyadh, KSA

Atalla & Altuwairqi, To determine the prevalence of stress among junior Taif University, Taif, 2017 medical students KSA

Abdulghani et al., Stress and its effects on medical students- year one to King Saud University, 2011 year five (medicine college) Riyadh, KSA

Stress and depression among medical students King Saud University, Abdulghan, 2007 (medicine college) Riyadh, KSA

A comparative study of perceived stress among female Dammam University, Al-Dabal et al., 2010 medical and non-medical university students KSA

Sani et al., 2012 Prevalence of stress among medical students Jizan University, KSA

This chapter discusses the significant findings, as well as highlighting the key answers for the research questions and the three hypotheses (4, 4.1, and 4.2), including

141 response rate and gender proportion; prevalence of stress; current and future stress management behaviors; knowledge, attitudes, subjective norms, and behavioral perceived control; and intention of stress management practices.

Response Rate and Gender Proportion

The moderately high and acceptable response rate in this study (56.6%) suggested the students were interested in this topic, and may have felt they are in need of an intervention program that can reduce their stress levels during their study. The majority of respondents in this study were female (64.5%). The students were from

Preparatory/First Year (9.5%), Freshman/Second Year (33.6%), Sophomore/Third Year

(9.3%), Junior/Forth Year (25.7%), Senior/Fifth Year (9.7%), Internship/Sixth Year

(10.4%), and Internship for medical students only (1.8%), (Table 14 includes more details about gender proportion in each grade level).

Prevalence of Stress

Existing literature has reported little to no information regarding stress prevalence across TU medical colleges. This study found the overall stress prevalence of medical students at TU was high (84%) compared to similar populations in Saudi Arabia and the

Middle East Countries (ranging from 27.7% to 59.9%), (refer to Table 16). Results from this study reflected the national research findings in relation to stress prevalence conducted in different medical schools across several Saudi medical schools (Abdel

Rahman et al., 2013; Sani et al., 2012; Zeyad et al., 2012; Ziyad et al., 2015). This study

(as seen in Tables 2 & 32) found that the stress prevalence rate in the Saudi medical student population was higher than the average stress among other medical students from

142 other nations, such as Western, Eastern, and Middle East countries (see Table 3). In this context and among TU medical students, a possible explanation for why the stress prevalence rate was high may be due to the lack of adequate time to relax, few entertainment programs on-and off-campus, higher social expectations, and a dearth of de-stress activities. It can thus be suggested that, in the long-term, TU medical students may be at higher risk to dropout or to be dismissed from the program, thus developing higher chronic stress/distress than their counterparts from different medical schools if these stress levels remained unaddressed. Based on findings from this study and considering the wide range of possible stress effects in TU medical education settings, immediate action to deal with stress and its consequences are needed. Faculty and health educators should be aware of the impact of stress on students’ memory and other physical health issues. Moreover, medical students should be taught about the impact of stress on the body, such as memory function, in order to raise awareness and improve the efficiency of coping strategies. It is important to note that during a stressful event, an individual may not necessarily react directly to stress, but rather he/she can evaluate that situational event and use proper coping strategies to respond to the stress.

The unhealthy stress prevalence rate reported in this study identified these students to be at high risk of future chronic stress and other diseases. Therefore, to reduce the stress prevalence over the life course, Health Education and Promotion

(HEDP) professionals and policy makers at TU should target the needs of its medical students who are at short and long-term health risk due to their early exposure to high stress, as well as their stressful environmental, academic, and family/monetary

143 circumstances (see Table 23). Overall, the medical school system at TU should identify sources of stress for each medical college with respect to gender and grade level.

This study also showed that the majority (57%) of respondents who had high stress were female medical students. Female students had a higher stress prevalence than their male counterparts, remaining in agreement with similar findings from several previous studies (Bayram & Bilgel, 2008; Dahlin, Joneborg, & Runeson, 2005; Sherina,

MMed, Rampal, & Kaneson, 2004). However, this study focused on specific causes for stress that could better explain the general finding that female students were more stressed than male students. This study showed stresses in terms of commuting to and from campus, raising hands to ask teachers questions in class, and arranging childcare.

Female students, in general, seemed to have more academic and family responsibilities than male students (Bayram & Bilgel, 2008). Therefore, it can be suggested that, in the short-term, female students may be at higher risk for developing certain types of high stress than their male counterparts if their stressors as well as stress levels remain unaddressed. Therefore, medical schools with women should consider having stress reduction programming and resources specific to the challenges women experience in medical school and in the Saudi culture, taking into account findings from this study that highlighted the most common causes of stress among female students (see Table 23 and

Table 24).

Based on the results from this study, female students had a higher average GPA than males that indicated female students had better academic performance than male students (as seen in Table 14). This may point to the possibility that the type of stress in

144 female is eustress (positive stress) and motivational stress. On the other hand, male students had a lower average GPA as well as a lower stress level than female students.

That raises the point that male students, in the long term, may be at a higher risk and are more prone to develop chronic stress after the end of the program because their lower

GPA would not ensure their employment; this can affect their future career stability, as well as their overall health status and quality of life. It is necessary that medical schools at TU offer the opportunity for HEDP professionals to conduct a research study aimed at classifying the types of stress and its seriousness in the short and long term for both genders.

This study found no significant difference in stress prevalence by grade level.

Percentage wise, however, high stress was the most prevalent among Preparatory/First

Year and Internship students, declining during the Second, Third, and Fourth years of study, and rising again when the students begin their Internship years. The rest of the medical students within different programs and levels seemed to experience similar types of stress.

A possible explanation for this might be language. Since the first language of the study participants is Arabic and English is the second language, learning in English is mandatory in Saudi Arabia within its higher education institutions. This includes all medical schools, as well as some of the engineering schools. As a result, the

Preparatory/First Year students tend to experience language barriers. In addition, as they are new to the medical program, they may experience a lack of knowledge about stress

145 and its management, having poor sleep, and not giving their bodies sufficient comfort to relieve tension.

Another reason might be stress resulting from being in a new academically demanding environment. However, stress reduction and management programs within medical schools at TU should target first year students as a priority population due to their risk factors, as well as being the group who had the highest levels of stress prevalence among the other grade levels. HEDP professionals should design an intervention program that deals with the new students’ needs, including effective strategies to overcome stressors they may experience on a daily basis.

In the context of Internship students, stress may reach burnout levels among

Internship medical students due to their clinical practices (Willcock, Daly, Tennant, and

Allard, 2004). Generally, medical students who have less healthy lifestyles tend to be more stressed. It is not known if all Saudi medical students have a stress management program. For the internship students, it is important to consider the findings from this study that indicated a conflict between the negative association between the practice of

SMTs and stress level. Thus, HEDP professionals should investigate more about why

Internship students have high stress, even though they were also the best among the other grade levels in the practice of stress management.

Stress Management Behaviors

This study did not find a statistically significant association between stress levels and stress management practices. It is not in agreement with a study conducted by Al-

Dubai and others (2011) that found a significant association between perceived stress and

146 coping strategies among medical science undergraduates in a Management and Science

University in Malaysia. However, in this study among TU medical students with high levels of stress, the percentage of stress management practice was still high (56%). This suggested that the extra time and mental energy medical students put forth to meet social expectation, coursework, examination, patients, and budding clinical skills may have had no significant association between the prevalence of stress management strategies and the prevalence of stress itself. Therefore, more programs with stress reduction and stress management intervention strategies are warranted to teach Saudi medical students how to cope with stress in a healthier and a more effective way. Although medical students were practicing stress management in many different ways, health educators should focus on improving their skills to deal with stressors by developing educational materials that have more skill-based content in order to enable them to resist stressors that may be placed on them in the future.

In this context and regarding gender differences, findings from this study showed that there was a statistically significant difference in the prevalence of stress management practices between female and male medical students with high levels of stress. Due to the limitations of published literature regarding the differences of stress management prevalence between highly-stressed female and male medical students, this result has not been described. Finding found within these studies should be interpreted with caution due to a focus on those who had high stress and the practice of stress management by gender. Regardless of the types of stress management in this study, males and females reported they both managed their stress in very different ways, however, they both tended

147 to choose sedentary activities. For example, based on the results of this study, male medial students preferred to watch TV, read, talk to a friend, and visit family and friends as a way to manage stress, while female medical students preferred to pray, listen to music, and drink coffee. These sedentary activities were common strategies among TU medical students to manage their stress over healthier behaviors such as walking, running, and swimming such as listening to music, reading, and watching television.

Therefore, HEDP professionals at TU could use the information learned in this study to develop education materials that could help TU medical schools adjust to the challenges of both genders by understanding that there is a gender difference in stress management.

Thus, HEDP professionals should consider developing a gender-specific education program to increase the healthier practices of stress management that can also increases the overall effectiveness of the intervention program.

The most important relevant finding regarding stress management was that female medical students were more likely to show an interest in practicing stress management than were male medical students. A possible explanation for this might be that female students were more stressed, therefore using more coping strategies than their male counterparts (Bamuhair et al., 2015). These results may also be explained by the fact that

Saudi women have fewer privileges (e.g., women are not allowed to drive or have physical education classes in school) than their male counterparts, which in turn may make them practice SMTs more often than males do. Despite these findings, male students may experience the same stress level as female students; however, male students are just more hindered in stating these feelings. According to the American Institute of

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Stress [AIS] (2008), male students, unlike female students, think they do not need to express what they need and, therefore, they are less likely to ask for help. Since female medical students have more desire in practicing stress management than their male counterparts yet still maintain a higher stress rate than men, HEDP professionals should use this information to distinguish between the differing needs of the two genders. This may be accomplished by designing educational programs that teach women how to deal with stressors in a healthier way that ensures the reduction of stress. Meanwhile for men, programs should be designed to manage stressors with respect to teach them specifically how to express and ask for help when experiencing stressful events.

This study also failed to find a significant difference between stress management practices across the grade levels. Due to the limitations of published literature regarding the difference in the prevalence of stress management practices in different grades, this result has not been described. The current literature only discussed the coping strategies and their association with perceived stress in nursing students, an issue not in alignment with the interest of this study (Al-Dubai et al., 2011). While there was no significant difference in the practice of SMTs among different grade levels in medical schools, it can indicate that the pattern of practicing stress management is common among all levels.

Therefore, information from this study can be used by HEDP professionals at TU to develop educational programs that educate medical students on effective coping strategies, taking into account ongoing assessments to ensure that there are healthy practices among different grade levels that suit each student level.

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The one major difference in this finding was that the Internship students were the group among other grade levels to most employ stress management techniques, followed by Fifth and Second grade levels. However, the number of students who never practiced stress management was the highest among Preparatory/First Year students, with the

Third-grade level as the lowest. These results provided further support for a research study that found adaptive coping strategies were significantly associated with the greater years of study among medical students. In turn, a lack of clinical experience was negatively correlated with non-adaptive coping strategies (Vinothkumar et al., 2016).

These findings suggested that Internship students may have developed coping strategies and skills during their course of study to cope with the stress that their counterparts in different grade levels have not yet done. However, the higher rate of stress prevalence that they had may refer to uncontrolled stressful situational events such as workload and more restrictive policies. Therefore, it would be beneficial for HEDP professionals to gather information from Internship students when developing education programs to identify the causes that keep their stress at higher levels while practicing SMTs. For the increasing number of Preparatory/First Year students who have never practiced stress management before, immediate action should be taken in order to encourage and promote the practice of stress management and maintain medical students’ quality of life.

Gender and major/college enrollment had no effect on students’ intention to practice SMTs. However, an estimation of the future practice of SMTs was obtained using the students’ intention scale (refer to Figure 13 and 14). Among the Medicine

College and Applied Medical Sciences College students, the occasionally/often group,

150 the actual intentions of males and females were higher than the group of students who indicated “never” and it was about the same pattern across the two colleges, males being just slightly higher than females. Altogether, among medical students, it simply implied a similar behavior of practicing SMTs in the future as in the present unless an effective intervention program can be implemented in the near future. Therefore, medical schools should be aware of the importance of considering the future practice of SMTs among their medical students, starting immediately with developing educational programs that aim for reducing the stress throughout the course of medical programs.

Knowledge, Attitudes, Subjective Norms, and Perceived Control

A major finding on this topic is that female and male students who had a high level of stress differed significantly in their knowledge and attitude, but not in subjective norms and perceived control. In this study, female students who had high stress levels had higher stress knowledge and attitude scores than their male counterparts. AIS (2008) found that female attitudes towards handling tasks was far more likely to be positive; however, they took less time to relax and de-stress when compared to males. On the other hand, males in general were more likely than females to state that they play sports, listen to music, and play games as a way of dealing with stress (American Psychology

Association, 2010).

These findings suggested that female students have more knowledge about stress and have stronger attitudes towards coping with stress that they encounter during their medical program than their male counterparts. Therefore, medical colleges should work together with HEDP professionals to provide appropriate intervention programs that raise

151 knowledge about stress in male students. Specifically, among male students, the focus should target the improvement of attitude, taking into account that the programs should be designed based on the gender needs.

Test for grade levels on the stress knowledge, attitudes, subjective norms, and perceived control among students with high stress found that the mean score of the attitude towards the practice of SMTs for Preparatory/First Year was significantly higher than that of the Freshman/Second Year. Also, the mean score of the attitude towards the practice of SMTs for Freshman/Second Year was significantly lower than the

Sophomore/Third Year. These findings also indicated that the mean score of the attitude towards the practice of SMTs for Sophomore/Third Year was significantly higher than the Junior/Fourth Year. However, the mean score of the attitude towards the practice of

SMTs for the greater levels of enrollment, such as Senior/Fifth Year did not significantly differ from that of the Internship Year. These results confirmed an association between one year of study and the next.

Taken together, these results suggested that the grade levels have an effect on students’ attitudes for practicing SMTs. Specifically, the results suggested that when a student moves to a higher-grade level, his/her attitude towards the practice of SMTs changed significantly from the previous year of study. Woloschuk, Harasym, and

Temple (2004) stated that, in general, the reasons for the significant change in attitude scores among medical students are not yet clear. However, in this study, possible explanations for these results (variations in attitude scores) may be due to a lack of adequate time to relax, a variation of workload, and the impact of unintended curriculum

152 throughout the medical program. Therefore, the results from this study can be utilized by

HEDP professionals to establish intervention programs that target each grade level with respect to gender differences, while also taking into account the improvement of attitudes towards the practice of SMTs (since it was the only significant variable that produced differences over the course of grade levels).

On the other hand, the ANOVA (one way) showed the effect of grade levels on the other tested variables of stress knowledge, subjective norm, and perceived control were not statistically significant. It should be noted that besides attitude, stress knowledge, subjective norms, and perceived control are also important variables.

Therefore, it was surprising that the total score of each variable failed to produce a significant difference on the effect of grade levels. These results could have been due to inconsistent responding and the absence of medical skills during the coursework and clerkship. Therefore, by using information learned from this study when developing an intervention stress management program that deals with grade levels, HEDP professionals should focus more on attitude and less on attempting to improve non- significant factors such as students’ stress knowledge, subjective norm, and perceived control.

Intention of Stress Management Practices

As Ajzen (1986) stated in the TPB, behavioral intention is defined as an individual’s perceived likelihood that a person will engage in a given behavior.

Regarding this research, the intention concept was utilized to examine medical students’ intentions to practice stress management. Based on the conceptual framework of this

153 study that was basically guided and driven by the TPB, intentions were examined using the Intention Questionnaire-3 adapted from the Manual used by Francis and others (2004) for measuring the TPB constructs. Additionally, based on the TPB, predictors of intentions were examined to predict students’ intentions to practice stress management.

Predictors of intentions included stress knowledge, attitude, subjective norms, and behavioral perceived control. In term of sampling, the population of this study was sorted into two groups: the first group consisted of students who had little to no stress, while the second group were students who had high stress. In advanced analysis, a sub- set group was obtained to examine those who had high stress and who had never practiced SMTs before. Thus, in line with the purpose of this study, which focuses of students who are at higher risk than others, students who had high stress and who had either practiced SMTs, and those who had never practiced SMTs were examined using a regression test to predict their significant factors to practice SMTs.

Among the high-stress student group (this included students who had both practiced and never practiced SMTs before), the overall regression model was significant

(variables that were tested found significant predictors including attitudes, subjective norms, and behavioral perceived control), but the only non-significant predictor of intention was stress knowledge. The stress knowledge score and its coefficient was close to zero, implying no correlation with intention. The reason for this was not clear, but it may have something to do with knowledge and behavior gap concepts. The knowledge- behavior gap refers to the difference between knowledge and an individual’s intention to take an action. This concept may be common among health practitioners due to their busy

154 schedules (Kennedy et al., 2004). It is possible, therefore, that for the application of what students are mentally conscious about, they may experience a gap between what they know and what they want to do. Thus, it is important that HEDP professionals highlight key answers for why there was no significant correlation between knowledge about stress and intent to practice stress management techniques among TU medical students.

In contrast, among significant predictors (attitude, subjective norms, and behavioral perceived control), this study found that the most important one was behavioral perceived control, meaning that students with higher perceived control (i.e., stronger control over one’s stressors) were positively associated with their intentions to practice SMTs. Therefore, HEDP professionals would benefit from this study by knowing that medical students at TU had perceived behavioral control as the most influential factor for improving their intention to practice SMTs. Thus, focusing on such an important factor can maximize the effectiveness of an implemented stress management intervention program.

Another important significant predictor of intention consisted of subjective norms, meaning that students who had higher subjective norms (i.e., stronger social pressures to manage their stress) were positively associated with their intentions to practice SMTs.

Therefore, when developing a stress management intervention program, TU medical students’ parents, friends, and faculty should be involved and not ignored; however, they should be targeted with an effective education program that can teach them the importance of supporting their students to practice SMTs on a daily basis. For example, the parents, friends, and faculty of TU medical students should be trained on how to

155 better encourage their students regularly, and to improve their supportive skills, such as making phone call reminders, going together for a walk, or creating a supportive group to practice stress reduction techniques on a daily basis.

It was somewhat surprising that student attitudes were noted in this condition as the least significant predictor of intentions among other tested predictor variables, meaning that students with more positive attitudes towards stress management practices had a higher intent to practice SMTs. Regardless of this result that indicated attitude had less significant impact on students’ intention to practice SMTs, stress management program contents should still involve an effective education session with a focus on the improvement of student attitudes towards the practice of SMTs in order to maximize the benefit of the program.

Findings among the sub-set group (high-stress students who never practiced

SMTs) revealed that behavioral perceived control is the only significant predictor of intention, while attitudes, subjective norms, and knowledge were insignificant. Since this group of students had never managed stressors or practiced SMTs, they were likely to have weaknesses in knowing the factors (i.e., attitude, subjective norm, and knowledge) that could help strengthen their intentions to stress reduction techniques.

Attitudes towards the practice of stress management was not a significant predictor of intention, but it had a negative coefficient, implying that individuals with a more positive attitude about stress management practices had a lower intent to practice stress management. This can be re-examined by HEDP professionals to find out more about this phenomenon among TU medical students. Moreover, subjective norms were also not

156 a significant predictor of intentions to practice SMTs among this population, but its coefficient was positive, implying that higher subjective norms that the students had (i.e., stronger social pressures to manage their stress) were positively associated with their intentions to practice SMTs. Therefore, medical schools and their HEDP professionals should target this group of students who have high stress and who have never practiced

SMTs as a priority population with an effective intervention program. A pre-post evaluation is needed to ensure the effectiveness of the implemented program.

Among the group of students who had high levels of stress and who had never practiced SMTs, knowledge about stress was not a significant predictor of intentions. Its coefficient was close to zero, implying no correlation with intentions, similar to the findings found in this study (refer to Hypothesis 4). Therefore, this result can be used by

HEDP professionals to know that rather than spending more time on educating medical students on stress and its consequences, they should instead focus on improving students’ skills to ensure that they apply effective coping strategies. Demographic variables were added alongside stress knowledge, attitudes, subjective norms, and perceived behavioral control variables in the regression model. They found that among high-stress students who had never practiced SMTs, the only significant predictors were perceived behavioral control and gender. Therefore, it is important that HEDP professionals consider these two factors when developing stress reduction programs. As stated earlier, perceived behavioral control was the most important significant predicting factor for the intention to practice SMTs among the tested variables. Thus, HEDP professionals should primarily focus on educating TU medical students how to be able to control stressors, as well as

157 having the willingness to practice SMTs with respect to gender differences. Intervention programs should be designed based on gender needs, considering external factors such as culture, beliefs, and policies that could hinder the program’s goal and make it ineffective for both genders. Since the perceived behavioral control was the most important significant predictor factor of the intention to practice SMTs, however, it is considered as the most difficult factor that can be changed at the individual level (Woloschuk,

Harasym, and Temple, 2004)). Thus, besides the primary focus on the perceived behavioral control factor, HEDP professionals should consider the other influential factors of intention to practice SMTs as guided by the TPB, such as attitudes and subjective norms.

Family, environmental, and academic stressors were analyzed and found not to be significant predictors of intention to practice SMTs. However, they had different directions. Among these stressors, the environmental stressor scores were not a significant predictor of intention, but their coefficient was positive, implying that higher environmental stressor scores (i.e., stronger supportive environment surrounding the student to manage his/her stress) were positively associated with intent to practice SMTs.

Therefore, the medical school at TU should be aware that the more effort put forth to inhibit the environmental stressor on campus, the better and stronger the intention for their students to practice SMTs.

It was somewhat surprising that the other tested stressor variables, the family and academic stressors, were not significant predictors of intention; their coefficient was negative, implying that students with higher family and academic stressor scores had

158 lower intents to practice SMTs. These results may justify or explain why certain students never practice SMTs. Therefore, HEDP professionals at TU should utilize these results by working with students to use one-on-one strategies in order to allow students to build their own coping style in an effective way, with respect on how to deal with family and academic stressors.

Majors and GPAs were not significant predictors of intentions (see Table 36).

Enrollment status was also not a significant predictor of intention; that is, students who had higher seniority did not differ from students with lower seniority in their intention to practice SMTs. Therefore, these results regarding demographic variables should not be a concern when developing an intervention program. Instead, it is more important to focus on the significant influential factors of intention to practice SMTs.

Recommendations for Further Research

One of the key issues in conducting individual-level intervention research is the expense and effort necessary to assess the outcomes as well as the impacts, the influence of interventions on health status of an individual (Bughi, Sumcad & Bughi, S., 2009).

With regards to this study topic, research done around the world has emphasized that medical students undertaking professional programs are exposed to higher stress.

According to the National Research Council (2001), unnecessary stress as well as poor stress management can lead to physical, emotional, and psychological problems such as depression and anxiety. The aim of the current study was to evaluate the prevalence of stress, current and future stress management practices, and its association with various predictive factors of the intention to practice SMTs among TU medical students.

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Findings from the current study indicated the need for more research. Although this study used a quantitative method, possible areas for expanding the research include the combination of both qualitative and quantitative methods in order to obtain an in- depth analysis of the problem. Personal interviews are one key element to collect more evidence, becoming necessary when conducting a qualitative research, as it directly asks the students who can best provide information and insights on the sources of stress and its management across all fields. Interviewing students could be done either in person, over the telephone, or through email. All of these methods allow the researcher to inquire about issues specifically related to stress and students’ stress management practices.

Further exploration also needs to explain why the prevalence of stress among TU medical students remains higher than that of similar or other populations across Saudi

Arabia. In this study, female medical students at TU had a higher stress prevalence

(57%) than their male counterparts (27%), but more research is needed using different approaches to identify the issues from multiple perspectives, such as conducting a qualitative research. With a qualitative research, this context can help to identify the root of the problem causing this kind of difference, with respect to obtaining an optimal sample size. Investigations of social support to reduce stress are also needed to determine if parents, families, and friends provide a good supportive environment for their medical students.

This study started with identifying the sources of stress in students’ lives.

Environmental, academic, and family stressors were among the types included and tested as external variables. It is suggested that similar dynamics be explored for investigation

160 across different medical colleges with more focus on the issues related to curriculum. In this study, the First-year students were struggling from language barriers. Because of this, more research is recommended to address pragmatic solutions to overcome stress, such as establishing skill and orientation classes that provide simple ways to study the new materials in different languages, along with regular-based assessment for the students’ performance.

Although the prevalence of stress management practices and its predictive factors among medical students was addressed in this study, a more detail-oriented investigation about why medical students do not comply with the practice of stress management techniques throughout their course of study is required. Additionally, since there were a higher number of students who reported that they were practicing stress management but who still had high stress, further research is needed to examine why this group of students practicing stress management techniques often or occasionally still have high stress.

Another research recommendation is to identify the relationship between stress and academic achievement as well as clinical performance among TU medical students.

Health Education and Stress Management Program: Recommendations

While the main goal of health education is to effect health status in a positive way, intervention strategies can develop capacity and foster a social environment that enables medical students to prevent and manage stress. This in turn would improve their wellbeing as well as the overall healthcare quality. In general, a wide range of studies in the literature reported intervention strategies and their efforts on reducing stress among medical students (Camatta & Nagoshi, 2005; Jain & Bansal, 2012; Kadison &

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DiGeronimo, 2004; Misra & McKean, 2000; Ross, Niebling, & Heckert, 2000; Shapiro et al., 2000 & Sherina et al., 2003; Towbes & Cohen, 2001). For the purposes of this study, the concepts of health education and stress management program are considered and discussed in the following sections.

Health Education

According to Steckler and others (1995), health education and promotion tools can have a positive impact when the desire is to change knowledge, attitudes, behavioral perceived control, or behavior which in turn may affect recognizable changes in the health status of an individual. According to the American Institute of Stress [AIS]

(2016), stress among individuals should be transformed through awareness, education, and collaboration.

Particularly in health education settings, there are several types of strategies shown to be efficient in creating a positive climate by using stress management strategies that can involve families and communities. Such strategies should reveal a multilevel causality of the source of stress and its management to ensure that the root causes of the problem are targeted. In this context, HEDP professionals at TU should play an important role in reducing stress and improving health outcomes in a wide variety of settings, including its campuses and training clinics. Thus, HEDP professionals are important team members to work closely to reduce stress with the both the TU administration and its medical students. It is recommended that HEDP professionals at

TU expand and employ behavioral theory, effective education materials, evaluation, policy, and advocacy when developing and implementing an intervention program,

162 resulting in improving students’ skills to cope with stress in an effective way. HEDP professionals at TU also should utilize health education roles by coordinating and conducting needs assessments and building bridges between students and their clinical settings both on and-off campus. HEDP professionals at TU should be able to identify plans to reduce barriers that cause stress for students with respect to the culture. HEDP professionals at TU are responsible for planning, implementing, monitoring, and evaluating the program to reduce stress and boost healthy lifestyles, environments, and policies among TU medical students. The roles of HEDP professionals at TU in promoting healthy lifestyles throughout students’ education is necessary to increase the health literacy of students to improve their professional education and training.

Addressing a stress management program on campus to improve the overall quality of student’s health status is another area that HEDP professionals at TU should consider.

Stress Management Program

Many school and university settings today have started to use stress management programs for their students who are having problems adapting to daily stress at the college level. The process of the stress management intervention program is entitled as one of the solutions to successful life in modern culture (Susic, 2013). Although life caries many stresses that can prove challenging to handle, stress management offers a number of techniques to cope with stress and maintain overall wellbeing. Aktekin et al.

(2001), and Sherina (2003) highlighted the importance of the early identification of stress as well as the implementation of an effective intervention program that can inhibit possible mental illnesses among medical students. Steven et al. (2003) and Susan et al.

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(2007) emphasized the significance of coaching stress management and self-care skills to medical students and maintain a healthy academic environment.

A healthy academic environment is one in which students, faculty, and administrators collaborate to use a continual enhancement process to promote the health and wellbeing of all students and maintain the sustainability of a healthier environment both on-and off-campus. Thus, a healthy academic environment should be created at TU medical colleges with respect to the factors of influence that have a direct and indirect impact in making a more productive, attractive, effective, and active place for students and faculty members. It is recommended that HEDP professionals consider the environmental factors as the determinant of stress as well. This can be done in the classroom by ensuring that light and a good level of brightness, room temperature, chairs, the number of students in a classroom, access for students with disabilities, and up-to- date technology are well fitted to students’ needs and comfort. Eliminating physical barriers on campus may reduce stress. This is done by adding transportation, sidewalk, and road constructions.

While the predictive factors based on the TPB constructs were examined in this study to predict the students’ intention for practicing SMTs, an intervention program needs to be implemented. This would improve attitudes, subjective norms, and behavioral perceived controls for practicing SMTs in order to improve the overall health as well as the academic performance in those students living with high stress. It is important to note that based on the findings of this research, behavioral perceived control and gender were significant predictors of intention to practice SMTs. Because of this, future intervention

164 programs are advised to focus on these two factors (behavioral perceived control and gender) to maximize the benefit of the program being implemented. Additionally, future research needs to examine which intervention techniques could work best for each group of students. In other words, considering that cultural competency is an important aspect, tailored and modified stress management interventions can be planned precisely and successfully based on students’ demographic characteristics.

An effective stress management intervention program is best when broken into three stages: primary, secondary, and tertiary (Susic, 2013). Primary intervention in this context aims to prevent chronic stress before it ever occurs. Therefore, HEDP professionals at TU can utilize the primary stage by targeting its medical students at all levels with more focus on those students who are in the first year of study. Emphasizing the stress management techniques during the first year can help medical students to build a solid prevention strategies against stress throughout their medical program. This stage can help HEDP professionals at TU to start preventing exposures to stressors among medical students both on and-off campus, taking into account altering unhealthy or unsafe behaviors that can lead to high stress, and increasing students’ resistance to stress and stressors that they face on a daily basis.

Moreover, at this stage, HEDP professionals can work with TU policy makers to do things like promote a healthy academic environment, ban smoking on campus, promote fitness centers, reduce hazardous products that surround the students, promote healthy practices, and even provide education about healthy and safe habits that fit medical students’ lifestyles and needs (e.g., eating well, not smoking, exercising

165 regularly, managing time, and being socially engaged). Involving the social support aspect at the primary stage is also another important key element in order to aid in reducing stress among TU medical students. For those medical students with high stress, a secondary intervention program is recommended.

The secondary stage in this context aims to identify and reduce the impact of stress and stressors that have already occurred on medical students. This stage can help

HEDP professionals at TU to start detecting and treating the sources of stress as soon as possible or slow its prevalence, encouraging students to use effective copying strategies

(with respect to gender differences) to prevent stress recurrence. HEDP professionals at

TU can take action at this stage by implementing programs to return students to their original health and function, as well as to prevent long-term stress. In addition, since the findings from this study showed existing difficulties in reaching faculty, improving communications between students and faculty is a very effective approach to help in reducing stress. A few ways in which this can be done are by providing extra office hours for personal meetings, empowering the students by making them feel like they are forming an important part of the university, and by providing them with a voice in larger situations in order to demonstrate that they are trusted and their opinions are valued.

Having the students network together can also remove much of their stress. If students are engaged and help each other, the likelihood of high stress is minimal (Zeitlin et al.,

2000).

A few other examples at this stage is that HEDP professionals at TU can provide regular exams and screening tests to detect stress at its earliest stages (e.g., a short survey

166 to detect medical students’ stress levels and stressors, or by testing their cortisol level at the nearest health center); running on-going stress reduction programs; inviting students with a higher risk of distress to enroll in exercise programs to prevent further health consequences; and working with them to modify their workload so they can have a better idea of managing stress both in the short term and long term. It is important to note that some courses may have overwhelming materials that intervene simultaneously with many tasks that may affect students’ academic performance as well as health status negatively.

Thus, considering students’ workload at multiple levels is warranted to ensure the effectiveness of the implemented program.

Such multiple levels to target may include the institutional, interpersonal, and intrapersonal levels. In this context, TU plays a very important role in stress management to ensure all students are knowledgeable, skillful, and professionally oriented in managing their stress. Thus, it is recommended to establish a student health service center on campus, as it can have a role in reducing and treating students’ stress. In addition, those medical students with high stress and who have health issues resulting from stress are in need of an advanced level of intervention; thus, a tertiary stage of intervention is highly recommended.

Tertiary intervention in this context aims to soften the influence of an ongoing illness resulting from stress. This stage can help HEDP professionals at TU to start helping medical students manage long-term health problems and often-complex mental health issues (e.g., anxiety, depression, high blood pressure, diabetes, and sleep disorder) to recover their ability to function as much as possible. It is highly recommended that

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HEDP professionals at TU develop rehabilitation programs for those students who experience illnesses resulting from stress. Rehabilitation programs may include counseling and engaging medical students in support groups that allow affected students to share strategies for recovering from their stress and its consequences. HEDP professionals at TU should support the presence of rehabilitation programs as well as counseling services on campus to retrain those in the stage of recovery to a more manageable level of stress. To conclude, for an immediate reduction of stress and its consequences among TU medical students, a combination of primary, secondary and tertiary interventions is highly recommended to achieve a significant degree of prevention and protection.

Integration of stress management. In general, stress management techniques can be delivered as part of a mental health unit in a personal health course, or even in other health areas of the curriculum such as nutrition, physical health, or any other related health topic class. Decision making, personal skills, problem solving, peer resistance, ability for communication, and goal setting are important in helping medical students to cope with stress. Since the findings from this study indicated that medical students at TU are in need of effective methods to cope with stress, integrating skill-building activities in stress management is recommended. Several examples of effective coping skills that should be taught to the students include meditation, relaxation, practicing deep breathing techniques at least five times, eating healthier well-balanced meals, talking to others (e.g., a parent, friend, counselor, or doctor) to share problems, and avoiding drugs and alcohol.

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Therefore, HEDP professionals at TU can teach their medical students in the classroom with such practices that can be integrated in the curriculum.

Integration of eHealth tools in the process of stress management (e.g., electronic and mobile devices) is another efficient way to help manage stress among TU medical students. eHealth tools can raise participation, awareness, and motivation on-and off- campus (Cook, 2007; Hasson, Brown, Hasson, 2010). eHealth tools can be promoted by

HEDP professionals at TU to connect students, staff, and faculty to cope with stress in an effective way. Presently, eHealth tools are offered in all areas of health education and promotion, including healthy nutrition, sports activities, and weight loss programs, as well as applications that are concerned with psychological factors (e.g., stress reduction, improvement of recovery and coping strategies, gains and acquisition of knowledge in new competencies, and skills to cope with stress) (Koldijk, Kraaij, & Neerincx, 2016).

Up-to-date eHealth tools strongly emphasize altering students’ attitudes and behavior.

However, they are infrequently focused on the enhancement of the study environment such as analyzing and offering proposed solutions for changing the conditions surrounding medical students (e.g., environmental, academic, and family conditions). To conclude, permanent awareness health program is an effective way for implementing stress management across the TU medical colleges to improve the well-being of all students.

The importance of the presence of a Health Center at TU. An on-campus student health service center (SHSC) is essential for HEDP professionals and medical professionals at TU to detect students’ health problems that can cause stress and, if

169 undetected and untreated, can hinder both the learning process and the health status. To ensure a healthy learning environment among medical students at TU, studies show that the presence of such a center can decrease the level of physiological provocations linked to high stress (Hassed, de Lisle, Sullivan, & Pier, 2009). Individuals who master cognitive and behavioral stress-relief techniques reported less nervousness, fewer sleep disorders, and an enhanced capability to cope with stressors (Health Resources and

Services Administration, 2012). Services provided at the center may include psychological counseling for those who recover from stress consequences; lessons on how to practice meditation and yoga for those who were practicing SMTs but still had high stress; education sessions on how to work cooperatively to solve difficulties well as how to express thoughts and feelings; and lessons on the physiology of stress and relaxation responses.

SHSC may also offer needed medical treatments such as serve as the primary source of stress management (if necessary), and provide services that deal with a variety of emotional and mental health issues. Therefore, establishing a health center at TU can help retrieve data and serve as a primary resource for a student health issues database. It can also contribute in maximizing the initiative of reducing the prevalence of negative stress that the majority of TU medical students are suffering from. To be successful,

HEDP professionals at TU should advocate on behalf of the medical students and other

TU college students for the establishment of a health center on the TU campus to better provide service that benefits its students.

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Recommendations for Administrators

TU administrators may not understand what steps they should take to relieve their students stress. This study suggested that the first step TU administrators can do is to be watchful for possible dangers and taking action toward their medical students’ stress, as well as creating accessible stress management programs across its campuses. Therefore,

TU administrators should know the structure of the student body, students’ knowledge about stress, stress prevalence, and current stress management status along with the predictive factors that have the most influence on students’ behavior to practice SMTs in order to eliminate stress. Additionally, it is recommended that TU administrators and faculty routinely review the academic requirements and related demands that are placed on the medical students during their program study. This is important to not only reduce the stress prevalence, but also to enhance the overall quality of healthcare, since they will guide and serve as the future primary healthcare providers.

Limitations

This study was subject to the following limitations. The population of this study was limited to Saudi Arabian medical students attending medical colleges at TU. Due to the small sample size for the study, results may be not generalized beyond the specific student population to all students from different ethnic groups or different majors. The literature supporting the findings of this study with regard to stress and its management among Saudi medical students was limited. Additionally, there was a lack of the availability of socio-demographic records of all medical students of the sampling frame which is limited to collecting information, such as gender, class size, academic rank, etc.

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The survey was conducted using an Online-Survey method. Only students with access to a computer and the Internet were able to complete the survey, possibly resulting in a sample selection bias. In addition, because the survey was distributed online, the researcher had no control over of the environment where the participants had to take the survey. The presence of the researcher could ensure a comfortable, quiet, temperature controlled, and safe atmosphere for participants in the survey. The absence of a researcher could also have had an effect on student responses if questions or concerns would arise that only the researcher was able to address.

Summary

The overall stress prevalence was high (84%) among TU medical students when compared to similar populations in Saudi Arabia or the Middle East countries (27.7% -

59.9%). Therefore, TU administrators should be aware and recognize that stress is high among their medical students. Thus, they can support and fund an effective intervention stress management program to ensure the reduction of stress among their medical students by at least 50% of its total medical students is warranted. Although female medical students were found to show more consciousness for and had a better attitude toward practicing SMTs to reduce stress than were male medical students, they were more stressed than male students. Thus, TU administrators can be informed by these results and consider identifying these phenomena (i.e., why female students had a higher stress rate than their male counterparts even though they were more adapted to practice

SMTs) to provide pragmatic solutions. Moreover, there were a greater number of students who indicated they were practicing SMTs than those who indicated to have

172 never practiced SMTs. In other words, medical students at TU are trying on their own to control stress, so they are interested in ways of reducing their stress. Therefore, it is recommended that TU administrators support their medical students with effective coping strategies that ensure the elimination (or at least a reduction) of their stress and stressors.

Since stress was found to be the most prevalent among Preparatory/First Year students, it is recommended that TU administrators support the presence of stress reduction and management programs specifically within its medical colleges. This particularly applies to programs targeting First year students with preventive programs that deal with the personal attributes of First-year students, including ways to overcome language barriers and other important factors that cause stress. Medical colleges and HEDP professionals at TU should be supported to create a basic health class for all grade levels across its colleges in which medical students can learn health-promoting behaviors. Moreover, regularly evaluating academic performance and increasing their empathy in the subsequent course stages should show significant changes. These initiatives, however, should be supported by the policy makers at TU in order to maintain an appropriate environment that medical students need.

In line with the study purpose that focused on TU medical students who are at a higher risk than others, it is recommended that the TU administration establish a center for stress that cannot only monitor stress prevalence, but also can serve the students’ needs at a wider range, including an ongoing stress management program with three levels of intervention to target each group of students based upon their needs.

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Lastly, in this study, the future practice of SMTs among TU was predicated and found that students’ intentions to practice SMTs in the future are low. Therefore, it is necessary that TU administrators make the urgent decision to reduce the stress prevalence among its medical students by implementing an effective stress management intervention program. This can avoid further negative consequences that may result from unaddressed health issues with respect to strengthening the students’ health by integrating stress management programs with the availability of the university and community resources.

APPENDICES

APPENDIX A

INSTRUMENT

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Appendix A

Instrument

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APPENDIX B

IRB APPROVAL AND APPLICATION

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Appendix B

IRB Approval and Application

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APPENDIX C

VPGSSR SUPPORT LETTER

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Appendix C

VPGSSR Support Letter

APPENDIX D

INVITATION LETTER AND

E-MAIL REMINDERS

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Appendix D

Invitation Letter and E-mail Reminders

206

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APPENDIX E

ONLINE CONSENT FORM

209

Appendix E

Online Consent Form

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