RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-11003-0150 |
Level of Perceived Stress and Coping Mechanisms among MBBS Students at Government Medical College: A Prospective Observational Study from Delhi
1,4Department of Community Medicine, Army College of Medical Sciences, Delhi, India
2Department of Community Medicine, SGT Medical College, Hospital and Research Institute, Gurugram, Haryana, India
3Department of Community Medicine, Maulana Azad Medical College, Delhi, India
Corresponding Author: Vikram Singh, Department of Community Medicine, Army College of Medical Sciences, Delhi, India, Phone: +91 9953456616, e-mail: drvikrams87@gmail.com
Received: 06 August 2024; Accepted: 15 October 2024; Published on: 31 December 2024
ABSTRACT
Background: Stress affects medical students in various ways, such as academic performance, substance abuse, and burnout. To deal with this stress, students apply different coping strategies or mechanisms. This study aims to evaluate the level of perceived stress and the coping strategies used by students during exams.
Aims: (a) To assess the level of perceived stress among undergraduate medical students, and (b) to identify the various coping strategies used by students to handle stress.
Materials and methods: The current study was done among Bachelor of Medicine, Bachelor of Surgery (MBBS) students in a government medical college. After obtaining informed consent, all the students belonging to the 2nd and final years were included. A self-administered questionnaire was used to gather data on social factors, perceived stress, and coping strategies.
Results: The study with 423 medical students showed that final-year students faced more moderate to severe stress (70 and 11%) compared to 2nd-year students (60.7 and 6.1%) 3 months before exams, with similar patterns just before exams. Female students reported higher severe stress levels (15.4%) than males (5.1%) 3 months prior (p = 0.001), but not before exams (p = 0.305). Active coping (p = 0.011) and planning (p = 0.001) correlated with lower perceived stress, while distraction (p = 0.001), denial (p = 0.009), and self-blame (p = 0.001) were linked to higher stress.
Conclusions: As exams approached, stress levels increased, particularly among final-year students, who initially used problem-focused strategies but later shifted to dysfunctional coping strategies (distraction, venting, self-blame). In contrast, mildly stressed 2nd-year students consistently employed adaptive coping strategies such as planning and seeking emotional support.
Clinical significance: Screening students with a stress scale early on allows us to effectively help them manage stress through peer-support groups, incorporating mindfulness, physical activities, and counseling.
Keywords: Coping mechanisms, Medical students, Stress
How to cite this article: Singh V, Sharma N, Rao S, et al. Level of Perceived Stress and Coping Mechanisms among MBBS Students at Government Medical College: A Prospective Observational Study from Delhi. J Med Acad 2024;7(2):51–55.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
Stress, according to Lazarus, is caused by an individual’s belief that they lack the resources to deal with a perceived circumstance from the past, present, or future.1 Academic, psychosocial, and health-related stressors are the three most common sources of stress in medical colleges.2 Academic stressors, especially tests/exams, were identified as the most common source of stress for all students.3 Throughout this time, students should gain sufficient professional knowledge, competency, and attitudes to equip themselves to deal with lifelong professional difficulties on their own. Extensive learning and rigorous training can harm a student’s physical and mental health by causing reduced focus, decreased attention, the desire to cheat on tests, sleeping issues, substance misuse, and unacceptable social conduct.4 Chronic stress can reduce productivity and could lead to a serious public health problem. Stress in medical students is much higher when compared to engineering students, as revealed in a study conducted by Waghachavare et al.5 Another study in Canada by Rahimi et al.6 found that stress among medical students was higher compared to the general population.
To reduce, accept, and manage these stressful situations, humans frequently employ different coping mechanisms. Coping mechanisms are the psychological, emotional, and/or behavioral strategies that humans use to reduce, tolerate, and master stressful situations.7 These strategies are broadly divided into problem-focused and emotion-focused. The goal of problem-focused strategies is to alter the circumstance by planning, skill development, or problem-solving, whereas emotion-focused strategies, on the contrary, aim to alter the stressful emotion itself through the employment of strategies like denial, withdrawal, acceptance, and more.8 Studies on the effectiveness of various coping strategies in handling stressful situations have revealed conflicting results, with some claiming that active coping strategies can successfully manage stress.9 On the contrary, other studies claim that the dominant coping mechanisms, such as positive reappraisal, planning, and problem-solving, are related to increased stress in students.10 Because of the students’ roles and duties as future physicians and health care providers, research on stress and coping mechanisms in medical students is critical. Data are scarce on the levels of stress associated with examinations and the coping mechanisms used by medical students in government medical colleges. Thus, the current study was conducted with the following aims and objectives: (a) to assess the level of perceived stress among undergraduate Bachelor of Medicine, Bachelor of Surgery (MBBS) students in Delhi and (b) to assess the various coping mechanisms used by students to overcome stress.
MATERIALS AND METHODS
The current prospective observational study was carried out among undergraduate MBBS students in their 2nd and final years at Maulana Azad Medical College (MAMC), New Delhi, during the academic year 2020–21. The study received clearance from the Institutional Ethics Committee, MAMC, New Delhi. After obtaining informed consent, all 2nd- and final-year MBBS students were approached, and 455 students consented to participate in the study and returned the questionnaire. The sample size was calculated based on findings from a study conducted in 2012 in Kolkata, India, which estimated the prevalence of stress among undergraduate medical students to be 52.6%.11
The desired sample size was determined by using the formula:
n = Z21–α/2 p(1–p)/d2
where, Z = is the statistic for a level of confidence (for the level of confidence of 95%, which is conventional, Z-value is 1.96),
p (prevalence) = 52.6% which is taken from the above study, and
d = is the precision (d = 5%).
Putting all these values in the above equation, yielding a sample size of 383. Considering 10% as the nonresponse rate, the sample size is 421; however, to maximize precision, we are including all students who wish to participate in the study.
Data Collection
Data were collected through a semi-structured questionnaire containing sections such as sociodemographics, the Perceived Stress Scale-10, and the Brief COPE Scale. Age, gender, place of residence, family type, and school medium were among the sociodemographic variables.
Study Instrument
Perceived Stress Scale-10
It is a 10-item scale that assessed students’ stress levels during the previous month.12 The scale included questions about stressful thoughts and emotions on various life issues, not just academics, graded on a 5-point Likert scale ranging from 0 (never) to 4 (very often). The PSS-10 has four positive items (4,5,7,8) and six negative items (1,2,3,6,9,10) that represent perceived self-efficacy and helplessness, respectively. The total score, which ranged from 0 to 40, was computed by adding all item scores after reversing positive ones. The PSS has an internal consistency coefficient of 0.89 (Cronbach’s alpha), is a validated scale, and has good psychometric properties.
Brief COPE Scale
It examined coping mechanisms using a 28-item questionnaire graded on a 4-point Likert scale.13 Each item is coded on a 4-point Likert scale with values ranging from 1 (I haven’t been doing this at all) to 4 (I have been doing this a lot). For analysis, ”not doing this at all/doing this a little bit” was interpreted as not employing the coping technique, while ”doing this a medium amount/doing this a lot” was viewed as using the coping technique.
Statistical Analysis
The collected data were entered in MS Excel. After that, data were imported into the Statistical Package for the Social Sciences (SPSS) version 25 for analysis. Data with normal distribution were expressed as mean with SD, and data with nonnormal distribution were expressed as median with interquartile range (IQR). Categorical data were expressed in terms of percentages and proportions. The Chi-squared test/Fisher’s exact test was used to test the statistical significance of qualitative variables. A p-value <0.05 was considered significant.
OBSERVATION AND RESULTS
A total of 423 completed the study, with an overall response rate of 84.6%. It was found that 196 2nd-year and 227 final-year students participated in the study. It is worth noting that 274 (64.8%) of the study participants were male, and the mean age of the study participants was 21.69 (SD = 1.43), with a range of 18–26 years. The majority were Hindu, 381 (90.1%), and, out of the total students, 375 (88.7%) lived in urban areas. Hostelers, 339 (80%), were more than day scholars, 84 (20%), and the most common medium of education in schools was English, 417 (98.6%).
In Figure 1, we assessed stress levels (mild, moderate, severe) in 2nd- and final-year students 3 months before exams. The results show that a higher percentage of final-year students experienced moderate and severe stress compared to 2nd-year students. Furthermore, the analysis revealed that most 2nd- and final-year students, as well as both groups together, faced moderate stress, followed by mild and severe stress.
Fig. 1 Perceived stress levels among medical students 3 months before the examination
Similarly, like the pattern shown 3 months before the exam in Figure 1, the final year had a higher percentage of moderately (72.7%) and severely (17.6%) stressed students than the 2nd year (68.4 and 15.3%, respectively) just before the exam. Additionally, the percentage of moderately stressed students was consistently higher in the 2nd and final years, as well as in both years combined, than in severely and mildly stressed students.
We used the Chi-squared test to analyze the relationship between stress level and gender, and as shown in Table 1, the number of female students experiencing severe stress was higher than that of male students 3 months before exams. However, no such gender difference in stress levels was observed just before the exams.
| Characteristics | Perceived stress 3 months before exam | Perceived stress just before exam | ||||||
|---|---|---|---|---|---|---|---|---|
| Mild n (%) |
Moderate n (%) |
Severe n (%) |
p-value | Mild n (%) |
Moderate n (%) |
Severe n (%) |
p-value | |
| Male | 80 (29.2) | 180 (65.7) | 14 (5.1) | 0.001* | 40 (14.6) | 189 (69) | 45 (16.4) | 0.305 |
| Female | 28 (18.8) | 98 (65.8) | 23 (15.4) | 14 (9.4) | 110 (73.8) | 25 (16.8) | ||
*p-value inference: <0.05, significant; >0.05, not significant
Here, as shown in Table 2, we used the Chi-squared test to evaluate the association between various coping mechanisms used over academic years. It was found that 3 months before exams, active coping, planning, and positive reframing were the most frequently used coping mechanisms, whereas behavioral disengagement and self-blame were the least used. In contrast, just before the exam, students primarily relied on distraction, planning, and acceptance. A significant association was found between MBBS year (2nd vs final year) and four out of 14 coping strategies 3 months before exams, as well as three out of 14 just before exams. Final-year students more frequently employed instrumental support (66.1 vs 55.1%) and religion (57.3 vs 47.4%) compared to 2nd-year students, who used acceptance (73 vs 62.1%) and distraction (54.6 vs 41%) more. However, just before exams, final-year students significantly increased their use of venting (69.6 vs 60.2%) as a coping strategy compared to 2nd-year students. Furthermore, behavioral disengagement (29.1 vs 39.6%) and self-blame (24.5 vs 33.5%) were the least used coping strategies among 2nd-year students compared to final-year students.
| Coping strategies | 3 months before the examination | Just before examination | |||||
|---|---|---|---|---|---|---|---|
| 2nd year n (%) |
Final year n (%) |
p-value | 2nd year n (%) |
Final year n (%) |
p-value | ||
| Problem-focused coping strategies | |||||||
| Active coping | Absent | 13 (6.6) | 15 (6.6) | 0.992 | 69 (35.2) | 91 (40.1) | 0.302 |
| Present | 183 (93.4) | 212 (93.4) | 127 (64.8) | 136 (59.9) | |||
| Planning | Absent | 30 (15.3) | 43 (18.9) | 0.324 | 56 (28.6) | 66 (29.1) | 0.909 |
| Present | 166 (84.7) | 184 (81.1) | 140 (71.4) | 161 (70.9) | |||
| Using instrumental support | Absent | 88 (44.9) | 77 (33.9) | 0.021* | 93 (47.4) | 88 (38.8) | 0.072 |
| Present | 108 (55.1) | 150 (66.1) | 103 (52.6) | 139 (61.2) | |||
| Emotion-focused coping strategies | |||||||
| Positive reframing | Absent | 52 (26.5) | 46 (20.3) | 0.128 | 59 (30.1) | 86 (37.9) | 0.093 |
| Present | 144 (73.5) | 181 (79.7) | 137 (69.9) | 141 (62.1) | |||
| Acceptance | Absent | 53 (27) | 86 (37.9) | 0.018* | 56 (28.6) | 77 (33.9) | 0.237 |
| Present | 143 (73) | 141 (62.1) | 140 (71.4) | 150 (66.1) | |||
| Religion | Absent | 103 (52.6) | 97 (42.7) | 0.044* | 102 (52) | 111 (48.9) | 0.519 |
| Present | 93 (47.4) | 130 (57.3) | 94 (48) | 116 (51.1) | |||
| Dysfunctional coping strategies | |||||||
| Distraction | Absent | 89 (45.4) | 134 (59) | 0.005* | 57 (29.1) | 66 (29.1) | 0.999 |
| Present | 107 (54.6) | 93 (41) | 139 (70.9) | 161 (70.9) | |||
| Venting | Absent | 125 (63.8) | 155 (68.3) | 0.329 | 78 (39.8) | 69 (30.4) | 0.043* |
| Present | 71 (36.2) | 72 (31.7) | 118 (60.2) | 158 (69.6) | |||
| Behavioral disengagement | Absent | 150 (76.5) | 181 (79.7) | 0.426 | 139 (70.9) | 137 (60.4) | 0.023* |
| Present | 46 (23.5) | 46 (20.3) | 57 (29.1) | 90 (39.6) | |||
| Self-blame | Absent | 141 (71.9) | 165 (72.7) | 0.864 | 148 (75.5) | 151 (66.5) | 0.043* |
| Present | 55 (28.1) | 62 (27.3) | 48 (24.5) | 76 (33.5) | |||
*p-value inference: <0.05, significant; >0.05, not significant
Table 3 compares the association between different coping strategies and levels of stress using the Chi-squared test. As shown, 3 months before the exams, students with high-stress levels (i.e., severely stressed) tended to use problem-focused strategies (such as active coping and planning) and emotion-focused strategies (like positive reframing and religious coping) less frequently compared to those with mild stress. In contrast, severely stressed students frequently resorted to dysfunctional coping strategies (such as distraction and denial) as their stress intensity increased compared to mildly stressed students. Similar trends were observed just before the exams.
| Coping strategies | Perceived stress 3 months before exam | Perceived stress just before exam | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Mild n (%) |
Moderate n (%) |
Severe n (%) |
p-value | Mild n (%) |
Moderate n (%) |
Severe n (%) |
p-value | ||||
| Problem-focused: active coping | |||||||||||
| No coping | 4 (4) | 17 (6.1) | 7 (20) | 0.011* | 3 (5.6) | 125 (41.8) | 32 (45.7) | 0.001* | |||
| High coping | 104 (96) | 261 (93.9) | 30 (80) | 51 (94.4) | 174 (58.2) | 38 (54.3) | |||||
| Problem-focused: planning | |||||||||||
| No coping | 12 (11.1) | 47 (16.9) | 14 (37.8) | 0.001* | 6 (11.1) | 88 (29.6) | 28 (40) | 0.002* | |||
| High coping | 96 (88.9) | 231 (83.1) | 23 (62.3) | 48 (88.9) | 211 (70.4) | 42 (60) | |||||
| Emotion-focused: positive reframing | |||||||||||
| No coping | 14 (13) | 67 (24.1) | 17 (45.9) | 0.001* | 6 (11.1) | 108 (36.2) | 31 (44.3) | 0.001* | |||
| High coping | 94 (87) | 211 (75.9) | 20 (54.1) | 48 (88.9) | 191 (63.8) | 39 (55.7) | |||||
| Emotion-focused: religion | |||||||||||
| No coping | 43 (39.8) | 131 (47.1) | 26 (70.4) | 0.006* | 19 (35.2) | 145 (48.7) | 49 (70) | 0.001* | |||
| High coping | 65 (60.2) | 147 (52.9) | 11 (29.6) | 35 (64.8) | 154 (51.3) | 21 (30) | |||||
| Emotion-focused: emotional support | |||||||||||
| No coping | 28 (25.9) | 116 (41.7) | 15 (40.5) | 0.015* | 12 (22.2) | 97 (32.7) | 37 (52.9) | 0.001* | |||
| High coping | 80 (74.1) | 162 (58.3) | 22 (59.5) | 42 (77.8) | 200 (67.3) | 33 (47.1) | |||||
| Dysfunctional: distraction | |||||||||||
| No coping | 74 (68.6) | 136 (48.9) | 13 (35.1) | 0.001* | 26 (48.1) | 82 (27.4) | 15 (21.4) | 0.003* | |||
| High coping | 34 (31.4) | 142 (50.9) | 24 (64.9) | 28 (51.9) | 217 (72.6) | 55 (78.6) | |||||
| Dysfunctional: denial | |||||||||||
| No coping | 93 (86.1) | 199 (71.7) | 26 (70.3) | 0.009* | 24 (44.4) | 127 (42.5) | 18 (25.7) | 0.028* | |||
| High coping | 15 (13.9) | 79 (28.3) | 11 (29.7) | 30 (55.6) | 172 (57.5) | 52 (74.3) | |||||
| Dysfunctional: venting | |||||||||||
| No coping | 83 (76.9) | 181 (65.1) | 16 (43.2) | 0.001* | 28 (51.9) | 95 (31.8) | 24 (34.3) | 0.017* | |||
| High coping | 25 (23.1) | 97 (34.9) | 21 (56.8) | 26 (48.1) | 204 (68.2) | 46 (65.7) | |||||
| Dysfunctional: self-blame | |||||||||||
| No coping | 94 (87) | 194 (69.8) | 18 (48.7) | 0.001* | 50 (92.2) | 214 (71.7) | 35 (50) | 0.001* | |||
| High coping | 14 (13) | 84 (30.2) | 19 (51.3) | 4 (7.8) | 85 (28.3) | 35 (50) | |||||
*p-value inference: <0.05, significant; >0.05, not significant
DISCUSSION
In this study, we found that 25.5% of students experienced mild stress, 65.7% moderate stress, and 8.7% severe stress. Nivetha et al.14 reported similar results in Mysore, while Solanky et al.15 found higher moderate (55.6%) and severe (41.2%) stress in Surat. We noted an increase in moderate and severe stress among students as they progressed from the 2nd to the final year, likely due to heightened awareness of career uncertainties, as also indicated by studies from Patil et al.16 in Mumbai and Surve et al.17 in Aurangabad. However, Abdulghani18 found more stress in 2nd-year students than in final-year students due to better support systems. Our data showed more severely stressed female students, aligning with Madhyastha et al.19 and Brahmbhatt et al.20; this could be related to the high pressure of academics as well as the subjectivity inherent in self-reported stress assessments. However, studies by Ahmed et al.21 in Kuwait, Reang and Bhattacharjya22 in Agartala, and Solanky et al.15 in Surat found no gender association with stress. Shakthivel et al.23 noted higher male stress (75%), but it was not significant.
Comparison between Coping Mechanisms and Academic Year
Our study found that while most students used active coping, planning, and positive reframing 3 months before exams, they shifted to distraction and planning as exams approached. Like our study, Gomathi et al.24 in the UAE noted that commonly employed strategies among students were planning and positive reframing. It was also found from our study that final-year students relied more on instrumental support and religion significantly more than 2nd-year students, who preferred acceptance and distraction 3 months before exams. As the exams approached, final-year students engaged in more venting, behavioral disengagement, and self-blame. Sreeramareddy et al.2 also noted final-year students’ reliance on instrumental support, aligning with our results, likely due to advice for academic and daily challenges from seniors. Somaiya et al.,25 in contrast to our findings, observed a rise in the use of problem-focused strategies from the 2nd year onwards.
Comparison between Coping Mechanism and Perceived Stress
It was observed that 3 months before exams, severely stressed students tended to use problem-focused and emotion-focused strategies less frequently while resorting more to dysfunctional coping strategies as stress levels increased. Similar trends were observed just before the exams. Similar findings were revealed in a study conducted by Al-Dubai et al.4 in Malaysia in 2010. Conversely, in a study by Supe10 in Mumbai, medical students experiencing severe stress favored positive reappraisal and problem-focused strategies more frequently.
Limitations
The study shows significant positive outcomes, but it has limitations. The self-administered questionnaire may have led to misunderstandings due to a lack of interviewer control. Additionally, the tool used to assess perceived stress was a screening instrument rather than a diagnostic test, and there may be recall bias among participants.
CONCLUSION
The level of stress among students increased as exams approached, with final-year students more severely stressed than 2nd-year students. 2nd and final-year students utilized problem-focused strategies earlier but turned to emotion-focused (acceptance) and dysfunctional (distraction) coping just before exams. 2nd-year students relied more on acceptance and distraction, while final-year students favored religious and instrumental support strategies 3 months prior. However, just before exams, final-year students distinctly engaged in dysfunctional coping (venting, disengagement, self-blame) more than 2nd-year peers. Severely stressed students resorted to dysfunctional strategies (distraction, venting, self-blame, denial, substance use) 3 months prior, while mildly stressed students leaned toward problem-focused (active coping, planning) and emotion-focused (positive reframing, emotional support, religion) strategies, consistent just before exams.
Clinical Significance
This study found that stress levels increased as the exams approached, highlighting the need for better life skills such as time management, study planning, and relaxation techniques like yoga, meditation, and extracurricular activities. We also observed that severely stressed students tended to resort to dysfunctional coping strategies, showing the need for proper counseling and interaction between students and faculty, which is essential.
ORCID
Vikram Singh https://orcid.org/0009-0005-7716-581X
REFERENCES
1. Lazarus RS. Coping theory and research: past, present, and future. Psychosom Med 1993;55(3):234–247. DOI: 10.1097/00006842-199305000-00002
2. Sreeramareddy CT, Shankar PR, Binu VS, et al. Psychological morbidity, sources of stress, and coping strategies among undergraduate medical students of Nepal. BMC Med Educ 2007;7(1):1–8. DOI: 10.1186/1472-6920-7-26
3. Saipanish R. Stress among medical students in a Thai medical school. Med Teach 2003;25(5):502–506. DOI: 10.1080/0142159031000136716
4. Al-Dubai SAR, Al-Naggar RA, Alshagga MA, et al. Stress and coping strategies of students in a medical faculty in Malaysia. Malays J Med Sci 2011;18(3):57–64. PMID: 22135602.
5. Waghachavare VB, Dhumale GB, Kadam YR, et al. A study of stress among students of professional colleges from an urban area in India. Sultan Qaboos Univ Med J 2013;13(3):429–436. PMID: 23984029.
6. Rahimi B, Baetz M, Bowen R, et al. Resilience, stress, and coping among Canadian medical students. Can Med Educ J 2014;5(1):e5–e12. PMID: 26451221.
7. Folkman S, Lazarus RS. If it changes it must be a process: study of emotion and coping during three stages of a college examination. J Pers Soc Psychol 1985;48(1):150–170. DOI: 10.1037//0022-3514.48.1.150
8. Folkman S, Lazarus RS, Dunkel-Schetter C, et al. Dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol 1986;50(5):992–1003. DOI: 10.1037//0022-3514.50.5.992
9. Stewart SM, Betson C, Lam TH, et al. Predicting stress in first year medical students: a longitudinal study. Med Educ 1997;31(3):163–168. DOI: 10.1111/j.1365-2923.1997.tb02560.x
10. Supe AN. A study of stress in medical students at Seth G.S. Medical College. J Postgrad Med 1998;44(1):1–6. PMID: 10703558.
11. Nandi M, Hazra A, Sarkar S, et al. Stress and its risk factors in medical students: an observational study from a medical college in India. Indian J Med Sci 2012;66(1–2):1–12. DOI: 10.4103/0019-5359.110850
12. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385–396. DOI: 10.2307/2136404
13. Carver CS. You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med 1997;4(1):92–100. DOI: 10.1207/s15327558ijbm0401_6
14. Nivetha M B, Ahmed M, B P. Perceived stress and source of stress among undergraduate medical students of Government Medical College, Mysore. Int J Community Med Public Health 2018;5(8):3513–3518. DOI: 10.18203/2394-6040.ijcmph20183090
15. Solanky P, Desai B, Kavishwar A, et al. Study of psychological stress among undergraduate medical students of government medical college, Surat. Int J Med Sci Public Health 2012;1(2):38–42. DOI: 10.5455/ijmsph.2012.1.38-42
16. Patil SK, Patkar US, Patkar KU. Comparision of levels of stress in different years of MBBS student in medical college—an observational study. Int J Contemp Med Res 2016;3(6):1655–1657.
17. Surve R, Dase R, Pawar K, et al. Assessment of stress level among medical students. Int J Curr Med Appl Sci 2015;5(3):156–160.
18. Abdulghani H. Stress and depression among medical students: a cross sectional study at a medical college in Saudi Arabia. Pak J Med Sci 2008;24(1):12–17.
19. Madhyastha S, Latha KS, Kamath A. Stress, coping and gender differences in third year medical students. J Health Manag 2014;16(2):315–326. DOI: 10.1177/0972063414526124
20. Brahmbhatt KR, Nadeera VP, Prasanna KS, et al. Perceived stress and sources of stress among medical undergraduates in a private medical college in Mangalore, India. Int J Biomed Adv Res 2013;4(2):133–135. DOI: 10.7439/ijbar.v4i2.299
21. Ahmed F, Al-Radhwan L, Al-Azmi GZS, et al. Association between stress and dietary behaviours among undergraduate students in Kuwait: gender differences. J Nutr Health Sci 2014;1(1):104. DOI: 10.15744/2393-9060.1.104
22. Reang T, Bhattacharjya H. A study to assess the emotional disorders with special reference to stress of medical students of Agartala government medical college and Govinda Ballabh Pant hospital. Indian J Community Med 2013;38(4):207–211. DOI: 10.4103/0970-0218.120154
23. Shakthivel N, Amarnath VM, Ahamed F, et al. Level of perceived stress and coping strategies prevailing among 1st year medical undergraduate students: a cross-sectional study from south India. Int J Med Public Health 2017;7(2):111–115. DOI: 10.5530/ijmedph.2017.2.22
24. Gomathi KG, Ahmed S, Sreedharan J. Causes of stress and coping strategies adopted by undergraduate health professions students in a university in the United Arab Emirates. Sultan Qaboos Univ Med J 2013;13(3):437–441. PMID: 23984030.
25. Somaiya M, Kolpakwar S, Faye A, et al. Study of mechanisms of coping, resilience and quality of life in medical undergraduates. Indian J Soc Psychiatry 2015;31(1):19–28. DOI: 10.4103/0971-9962.161995
________________________
© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.