Stress Coping Strategies Amidst Preparation for Examinations: An Analytical Study among Undergraduate Medical Students

Table 6: Model Summary - Sources of stress / Regression analysis/statistical significance for stress-coping strategies.

Table 6 shows the relationship between sources of stress and the stress-coping strategies; and the statistical significance Table (ANOVA). The first model summary that provides the R, R², adjusted R², and the standard error of estimate, which can be used to determine how well a regression model, fits the data. The “R” column is the multiple correlation coefficient, with 0.955, which indicates a good level of prediction. The “R²” column is the coefficient of determination which is the proportion of variance in the source of stress that can be explained by the stress-coping strategies “a week” and “a day” before the date of examination which is 0.912, meaning that the stress-coping strategies explain 91.2% of the variability of the source of stress. The F-ratio above tests whether the overall regression model is a good fit for the data. The table shows that stress-coping strategies statistically significantly predict the source of stress, F (2,234) = 1206.492, p = 0.000, which is < 0.0005, which implies that the regression model is a good fit of the data.

Table 6 also shows the general form of the equation to predict source of stress from stress-coping strategies “a week” before the date of examination, and stress-coping strategies “a day” before the date of examination is: predicted source of stress = 0.904 + 0.515 (stress coping strategies a week before the date of exam) +0.345 (stress coping strategies a day before the date of exam). Also, the statistical significance of each of the stress-coping strategies was tested, and this test whether the unstandardized (or standardized) coefficients are equal to 0 (zero) in the population. As can be seen from the “p-value” column that all stress-coping strategies coefficients are statistically significantly different from 0 (zero). A multiple regression analysis shows that these variables statistically significantly predicted source of stress, F (2,234) = 1206.492, p< 0.0005, R²= 0.912. The two variables added statistically significantly to the prediction, p< 0.05.

Discussion

“Real or interpreted threat to the physiological or psychological integrity of an individual that results in physiological and behavioral responses” defines stress [17]. The stress-coping strategies therefore are acts of responses to external stimuli, which is a known characteristic of every living thing. The form of response to stress is known to be determined by genetic and environmental influences, [18] and the students in this study are no exception. Out of the 237 respondents in this study, 62% were females suggesting almost twice female enrolment in this private medical university. Our finding is different from observations in other studies that highlighted limited female enrolment in Nigerian Universities [19-20]. However, these studies were carried out about 18 years ago. The trend is therefore changing as social or cultural factors are known to influence this occurrence [21]. The likely explanation for the high female enrolment in our study could be the trust the parents and guardians of the students had in the institution in grooming their female students in the relatively regimented environment of a private medical university. The location of the university in a Christian-dominate southern Nigeria State could explain why 94% of respondents were Christians. Majority of respondents were within 14 – 24 years age group. This is typical of most Nigeria universities.

A week before set examination date students studied for varied number of hours per day, and more than 50% of them invested a minimum of two hours and maximum of 6hours (or more) per day. In another study carried out among students in federal universities in Nigeria, 50% of student read for two to four hours per day [22]. In this study a few students (28.7%) had more than 6 hours of personal study per day, and the number of hours of study generally increased a day to the examination for the majority. In a study trying to understand what makes a good study day among undergraduate students, daily study satisfaction was observed to be directly related to time invested in studying [23]. Daily study satisfaction will therefore be associated with a feeling of guilt (a source of stress) for not doing enough as expected.

It is interesting to note that the females spent more time per day in personal studies than the males in this private university. It is not surprising that there were more females in the study with higher scores in their first and last examinations. Our findings differ from a Dutch study where female students were noted not to have performed as well as their male counter parts in Science, Technology, Engineering, and Mathematics (STEM) programs [24]. However, in Ethiopia, an increasing female participation in academics was noted with lower graduation rate, for which university-related factors and socio-cultural factors were implicated [25]. In another study, also in Ethiopia, the determinants were reported to be personal and university factors [26]. Our study findings differ from a study done among accounting students where no significant difference was observed in the performance of male and female students in Nigeria, [27] and among medical students in Pakinstan [28]. An Ibadan-based Nigerian study reported higher academic achievement in favour of males [29]. However, our study shares some similarity with the study in Saudi Arabia where gender differences in study time and performance outcomes were observed [30].

Numerous sources of stress among respondents were rated and some met the mean benchmark of 3.00, while others did not. All the students (100%) adopted one form of stress-coping strategy or the other. Some stress-coping strategies were used a week to examination (also a day to examination) by students and some of these included  identifying with models of physicians who prioritized their own quality of life; studying the minimum needed to pass subjects; respecting own physical limits, avoiding spending many hours without sleeping; avoiding comparing grades with other students; going for walks; getting together with families and friends; eating well; reading of literary non-medical works; playing or listening to music; playing or watching football games on television; going out to dinner; staying away from reading for some time; making humor; and practicing religious meditation/praying. Interestingly, at least 50% of the respondents strongly agreed to engaging in religious-meditation/praying and playing or listening to music (both a week and a day to their examinations). These findings are similar to those of Johari and Hassan on stress and coping strategies among medical students in national university in Malaysia where such self-distracting or stress-coping mechanisms were reported among the students [13]. In a Saudi Arabian study, planning and time management were additional stress-coping strategies reported among medical students, although others viewed them as additional stressors [31].

Amidst the stressful environment, 92.4% of respondents had ≥51% average score in their examinations. The outcome of the study revealed that the stress-coping strategies explained 91.2% of the variability of the source of stress. This implies some degree of resilience among the students. Resilience has been emphasized as a useful and interesting construct in medical education and research [32]. Another researcher expressed this phenomenon as mental toughness which varies with situation and time and with crucial role in performance, goal progress, and thriving under stress [33]. A writer in a study among university students in Mexico reported a distinction between hindrance stressors which diminish appraisals of life satisfaction, and challenge stressors which promote life satisfaction [34]. Medical training is one of the toughest programs in the University, and resilience, mental toughness and physical fitness are important and necessary attributes for every medical student to acquire in order to get through the training and graduate.

Limitations

This study is questionnaire-based, and the findings were self-reported. The study is therefore subject to the demerits of such studies in its category. The examination result scores quoted were not actual scores, but average estimations in the opinion of the respondents.

Conclusion

The identified sources of stress were numerous most of which others academic, personal, social and family issues. A wide range stress-coping strategy were adopted by the students. At least 50% of the respondents strongly agreed to engaging in religious-meditation / praying and playing or listening to music (both a week and a day to their examinations). Thirty percent or more strongly agreed to studying the minimum that was needed to pass subjects; respecting their own physical limits, avoiding spending many hours without sleeping; avoiding comparing grades with other students; and eating well. Using their preferred stress-coping strategies, at least 16% of the respondents had scores of 80% and above in their examinations, while 75% had scores of 51-80% in their last examinations. Stress-coping strategies are therefore individual-based.

Recommendations

Administrators and counsellors/mentors of students should identify which stressors are hindrance stressors and challenge stressors to properly direct counselling of the students. The stress-coping strategies adopted by the students are helping them to undertake the programs in the university, and need minimal interference. Students who are not thriving should be identified for counselling services. Students should be encouraged to draw up their personal study schedule to avoid work overload and its attendant stressful consequences. The university should look in the direction of organizing stress management workshops to entrench in the new intake students on how to cope in the medical training.

Acknowledgement

We acknowledge the contributions of our secretarial staff and respective students class representatives who worked to ensure distribution and retrieval of the questionnaires used for the study. The input of our statistician, Dr Mrs Joy N Chris-Chinedu of the Rivers State University Teaching Hospital is also hereby acknowledged.

Ethical Considerations

The approval of the Research Ethics Committee of the PAMO University of Medical Sciences was obtained before commencement of the study.

Source of Funding

The study was self-funded by the researchers.