Abstract
Objectives: Medical and dental students experience poor psychological well-being relative to their peers. This study aimed to assess the psychological well-being among medical and dental students in Saudi Arabia, identify the high-risk groups and assess the association between the psychological well-being and the academic performance.
Methods: In this cross-sectional study, 422 preclinical medical and dental students at Umm Al-Qura University, Saudi Arabia, were recruited to assess their depression, anxiety, stress, self-efficacy and satisfaction with life levels using 21-items Depression Anxiety Stress Scale (DASS-21), General Self-Efficacy (GSE) scale and Satisfaction With Life Scale (SWLS). Students’ academic weighted grades were obtained later. Descriptive statistics and univariate general linear model were used to analyse data.
Results: High levels of depression (69.9%), anxiety (66.4%) and stress (70.9%) were indicated, whereas self-efficacy (mean = 27.22, sd = 4.85) and life satisfaction (mean = 23.60, sd = 6.37) were within the normal range. Female medical students had higher psychological distress in contrast to dental students. In general, third-year students were more depressed and stressed in comparison with second-year students, except for stress among dental students. Moreover, all females had higher self-efficacy than males. Life satisfaction was higher within the second-year and high family income students. Depression was the only psychological variable correlated with the academic performance.
Conclusion: High levels of psychological distress were found. Female medical students had higher psychological distress than males, whereas male dental students had higher distress than female. Medical students at third year were more depressed and stressed. Dental students were more depressed in the third year, but more stressed in the second year. Attention should be directed towards reducing the alarming levels of depression, anxiety and stress among medical and dental students.
Introduction
Increased attention has been directed to the high levels of psychological well-being among medical and dental students. Students’ psychological distress has been found to be associated with low academic performance, threatening the learning process (Roh et al. Citation2010; Mane Abhay et al. Citation2011; Abdallah & Gabr Citation2014), and found to be a predictor of psychological stigma within the professional life (Tyssen & Vaglum Citation2002). This should be taken seriously, especially when it might potentially jeopardise patient care and safety (Dahlin & Runeso Citation2007).
Medical and dental students’ distress are well-documented globally (Dyrbye et al. Citation2006; Alzahem et al. Citation2011), with levels higher than that of their peers and corresponding populations (Dyrbye et al. Citation2006; Mane Abhay et al. Citation2011). Several factors have been suggested for this distress, including the large volume of information that needs to be retained, students’ academic competition, grade average point (GPA) and fear of failure (Dyrbye et al. Citation2006; Roh et al. Citation2010; Alzahem et al. Citation2011). These factors might be accentuated in the preclinical years where the coursework units are more theoretical. This is supported by the literature, with evidence that medical students in their early years were more distressed than students in senior years (Dahlin et al. Citation2005; Al-faris et al. Citation2012), in contrast to other literature (Jadoon et al. Citation2010; Alzahem et al. Citation2011). Most medical and dental studies have found that females are more distressed than males (Dyrbye et al. Citation2006; Abdulghani et al. Citation2011; Alzahem et al. Citation2011), with the exception of a few studies that have found no gender differences (Moffat et al. Citation2004; Niemi & Vainiomäki Citation2006). Furthermore, dental students have found to be more distressed in the US (Schmitter et al. Citation2008; Birks et al. Citation2009; Murphy et al. Citation2009) and less satisfied in Germany (Jurkat et al. Citation2011) than medical students, but this needs further investigation.
The seminal work of Ryff (Citation1989) illustrated that both negative and positive aspects should be included when investigating the psychological well-being. However, few studies into medical and dental student wellbeing have investigated the positive aspects of psychological well-being, such as life satisfaction and self-efficacy. Two studies have indicated an association between the positive and negative aspects (Swami et al. Citation2007; Samaranayake & Fernando Citation2011). In fact, such investigations in Saudi Arabia are few and further studies are recommended (Inam Citation2007), especially during the current reforming period in Saudi medical education (Telmesani et al. Citation2011).
This study therefore aims to assess the prevalence of psychological well-being (both positive and negative aspects) and its relation to academic performance among preclinical medical and dental students in Makkah, Saudi Arabia. It also aims to identify groups at high risk for psychological distress.
Methods
This cross-sectional study investigated medical and dental students who were in their preclinical years at the Umm Al-Qura University (UQU), one of the largest universities in Saudi Arabia. The bachelor of medicine/dentistry in Saudi Arabia is six-year programme in which year 1 is orientation, years 2–3 are preclinical, and years 4–6 are clinical. Using sample size formula of continuous outcome in a population (Sullivan Citation2011, p. 171), the following inputs were used: (1) type I error of 5%, (2) a margin of error of two units as the most conservative (smallest) difference between anxiety categories in DASS-21, and (3) standard deviation of 10.6 as the most conservative (largest) value from a similar study (Yusoff et al. Citation2013). Thus, a minimum sample of 108 participants was needed in order to detect an effect.
Purposeful selective sampling method was used to include only medical and dental students at preclinical years at the UQU. Thus, all medical and dental students in their second and the third years at the UQU (654 students) were invited to participate in this study during the academic year 2012–2013. Students under psychological treatment or medications were excluded. The students were approached during lectures in week 12 of the first term, which was deemed the most suitable time away from student examinations. Each student received a questionnaire, a consent form to retrieve their academic data and an information sheet explaining confidentiality of the students’ information. The answered questionnaires and signed consent forms were returned within one week and included their university ID and a mobile number, so that we could follow-up on any missing data and match data with students’ academic records. After data collection was finished, the data were processed anonymously.
The prevalence of the psychological well-being was measured by self-administered hard-copy questionnaires previously mentioned that included the Depression Anxiety and Stress Scale (DASS-21) (Lovibond & Lovibond Citation1995), General Self-Efficacy scale (GSE) (Schwarzer & Jerusalem Citation1995) and Satisfaction With Life Scale (SWLS) (Diener et al. Citation1985). The 10-min questionnaire also included demographic questions about academic year, faculty, gender, marital status, nationality and family income. Finally, students’ academic grades from the first term were obtained from faculties’ administration offices.
The Depression Anxiety and Stress Scale was used to assess depression, anxiety and stress, and represents the negative aspect of psychological well-being. It is composed of 21 questions with a four-point (0–3) answer scale. Each subclass’s score equals the sum of seven corresponding questions. The sum scores were multiplied by 2 to match the original scale score in DASS-42. Each subscale score ranged from 0 to 42. On the other hand, the positive aspect of psychological well-being was represented by self-efficacy using GSE and life satisfaction using SWLS. GSE is 10 questions with a four-point (1–4) scale, providing sum score ranges from 4 to 40. SWLS is five questions with a seven-point (1–7) scale resulting in sum score ranges from 5 to 35. DASS subclasses, GSE and SWLS were represented in a continuous format, whereas DASS subclasses and SWLS were additionally displayed in a categorical format. The DASS21 and GSE scales were administered using the validated Arabic version of (Taouk et al. Citation2001; Scholz et al. Citation2002).The SWLS Arabic version was adopted from a translated version used in a recent pilot article for a similar purpose (Aboalshamat et al. Citation2013) using WHO guidelines (WHO Citation2013). The Arabic version of SWLS was face and content validated in the previous study. All of these scales had good psychometric properties and are commonly used in such research.
Academic achievement was measured by the units’ weighted grades via the following formula:
Ethical approval for this project was obtained from Queensland University of Technology (QUT) (number 1200000411) in addition to formal written approvals from UQU’s faculties.
Data were analysed by SPSS v.21 software (IBM Corp., Armonk, NY). The participants’ demographic and psychological well-being means, frequencies and percentages were displayed in tables. A univariate general linear model (GLM) was used to identify high-risk groups and predict students’ WG. The backward elimination method was used to select the variables within the GLM and all the demographic variables and interactions were included in the initial model of each psychological construct. Only the significant variables remained and are reported to form the final model. A p value of less than 0.05 was the level of significance in all statistics.
Results
A total of 422 students returned the questionnaire with signed consent, as shown in . The overall response rate was 64.52%.
Table 1. Demographic data of the medical and dental student participants in the preclinical years at UQU.
The depression, anxiety, stress, SWLS, GSE means and standard deviations (SD) were 15.05 (SD = 9.12), 11.98 (SD = 8.82), 20.62 (SD = 9.04), 23.60 (SD = 6.37) and 27.22 (SD = 4.85), respectively. shows each category’s frequencies and percentages of depression, anxiety, stress and SWLS. An overall high prevalence of depression (69.9%), anxiety (66.4%) and stress (70.9%) was revealed. Even more alarming was the prevalence of students with severe symptoms (sever plus extremely sever category) within the DASS subclasses, which were 25.4, 21.8 and 34.1%, respectively. In contrast, SWLS results displayed that only 24.9% were considered slightly below average or dissatisfied.
Table 2. Frequencies and percentages of depression, anxiety, stress and SWLS levels among preclinical medical and dental students at UQU.
General linear model results () revealed that depression was explained by academic year and the interaction between faculty and gender. Anxiety was explained only by the interaction between faculty and gender. Stress was explained by a model containing the interaction between faculty and gender, and the interaction between faculty and the academic year. On the other hand, GSE was explained by gender only, whereas SWLS was explained by a model containing the academic year, marital status and family income.
Table 3. The final models of univariate general linear analysis of the psychological constructs and student’s weighted grades.
Overall students’ WG mean was 80.49 (SD 8.65). GLM results, in , show WG as a model of depression, gender, faculty and the interaction between gender and faculty. Depression was the only psychological construct that correlated with WG. Depression, male and medical faculty correlated with WG in a reverse manner.
Discussion
This study describes the psychological well-being and academic performance of 244 medical and dental students at Makkah, Saudi Arabia. In addition, the study identified groups at risk for poor psychological well-being and risk factors for lower academic performance. The results of this study indicate that dental and medical students in Saudi Arabia do experience high levels of psychological distress. Moreover, female medical students appear to have higher psychological distress than males, whereas male dental students have higher distress than female. Medical students at third year seem to be more depressed and stressed than second year students, while dental students were more depressed in the third year, but more stressed in the second year.
Direct comparison of the levels of depression, anxiety and stress in our sample with non-university Saudi populations is difficult due to a lack of published studies in the area; however, our sample did have significantly higher levels of distress compared with Western general populations of the same age. For example, the levels of depression, anxiety and stress in our population were almost double the levels found in an Australian population of 18 to 24 year olds (Crawford et al. Citation2011). Our findings, therefore, correspond with other studies in international and Saudi literature that found medical students had higher levels of psychological distress than their peers (Dahlin et al. Citation2005; Dyrbye, et al. Citation2006; Al-Dabal et al. Citation2010). Furthermore, our results indicate that depression, anxiety and stress was affecting two-thirds of the students and one-third of these students were within the severe categories. This agrees with the internationally high prevalence of psychological distress among medical and dental students (Dyrbye et al. Citation2006; Alzahem et al. Citation2011; Yusoff et al. Citation2011). However, our prevalence seemed higher than another Saudi study on female medical students that found depression, anxiety and stress levels, using DASS, to be 19, 29.6 and 31.6%, respectively (Balaha et al. Citation2010). The difference was probably from the exclusion criteria in Balaha’s study that excluded students with medical conditions. Comparing our results with studies of Saudi medical students using different instruments revealed that the depression percentage in our study was higher than others (Inam Citation2007; Ibrahim et al. Citation2013), whereas anxiety and stress levels were similar to others (Abdulghani et al. Citation2011; Ibrahim et al. Citation2013). Interestingly, although some studies investigated psychological distress among Saudi dental students (Al-Saleh et al. Citation2010; Al-Samadani & Al-Dharrab Citation2013; Al-Sowygh Citation2013), our study might be the first according to our knowledge to indicate prevalence using an international instrument.
In contrast to the measures of negative effect, students' SWLS mean was similar to other populations that ranged between 23.6 and 26.9 (Pavot & Diener Citation2008; Abdel-Khalek Citation2013). More specifically, our SWLS results aligned with other studies on medical students in New Zealand and India that ranged between 22.45 and 24.9 (Samaranayake & Fernando Citation2011; Boparai et al. Citation2013). Also, GSE mean was slightly lower compared with a multinational study that had a mean of 29.55 (SD = 5.32) (Schwarzer Citation2011). However, our GSE mean was similar to that of a study of undergraduate students in the United Arab Emirates (27.88). In other words, the positive aspects of the psychology of medical and dental students almost matched the norm of the general population and the medical students.
Similar to other studies (Samaranayake & Fernando Citation2011), the participants in this study seemed to be able to maintain relatively good satisfaction with life and good general self-efficacy, in spite of high levels of distress. This might indicate that the positive and negative aspects of psychology act differently; that is, a high level of satisfaction might result from students’ perception of high prestige, salary and a secure job in the these fields (Al-Bitar et al. Citation2008), but it did not reduce psychological distress brought on by students’ other challenges.
We also found specific groups that were at higher risk for distress as that psychological status varied among faculty, gender, academic year and family income. DASS subclasses followed a unique pattern in which female medical students had more depression, anxiety and stress means than medical male students did, whereas male dental students had higher means than female dental students. It could be argued that this is due to higher female ratio (53.3%), however, higher medical female distress was aligned with the similar literature (Dahlin et al. Citation2005; Dyrbye et al. Citation2006; Inam Citation2007; Al-Saleh et al. Citation2010; Abdulghani et al. Citation2011). On the other hand, the higher distress within male dental students can be considered novel, because it contradicts most literature (Mathias et al. Citation2005; Polychronopoulou & Divaris Citation2005; Al-Saleh et al. Citation2010; Alzahem et al. Citation2011; Al-Sowygh Citation2013). The reason for this is not clear and needs further investigation.
The different academic years associated with depression and stress levels were as follows: (1) students in the third year were more depressed than second-year students in both faculties. (2) Third-year medical students were more stressed than second-year medical students, whereas second-year dental students were more stressed. This aligned with the contradicting results of other literature where some studies indicate that the third year (Saipanish Citation2003; Al-Saleh et al. Citation2010; Schwenk et al. Citation2010) and some studies indicating to the years preceding the third year (Aktekin et al. Citation2001; Dahlin et al. Citation2005; Jadoon et al. Citation2010) are the most distressful, while other studies found no significant difference between different years (Sugiura et al. Citation2005; Galán et al. Citation2014). This might result from the differences in curricula, teaching and assessment methods between faculties within the different years.
In terms of positive psychological aspects, females had lower GSE scores for both medical and dental faculties. This aligned with a study involving US medical students (Goodin et al. Citation2014). Our results add to the literature by showing that dental students have the same GSE difference. Other demographic variables were insignificant in regards to GSE. On the other hand, SWLS level was different according to academic year, family income and marital status. Students in their second year were more satisfied than third-year students were. This can be explained by third-year students in both medical and dental faculties in UQU take the largest academic workload, which leaves no time for a personal life. Also, low SWLS was associated with low family income; this is supported by a Canadian study on medical students (Chow Citation2005). Our results add to the literature that dental students respond the same way. Last, our results support that married participants were more satisfied than single participants. Nevertheless, this is a questionable result because of the small percentage of married participants (2.8%). Also, interesting is the finding that unlike studies in the USA, Canada and Malaysia (Dyrbye et al. Citation2006; Yusoff et al. Citation2011), family income was not significantly associated with psychological distress in our results. This might be because Saudi students are not required to pay tuition; instead, they receive monthly allowance.
Academic performance was measured using a WG formula that included the students’ grades within the first term only. GPA was not used because it is a cumulative assessment of the performance over all years and not specifically to the study time. WG was associated with faculty, gender and depression. Dental students had higher WG than medical students, which might be explained by the differences in the course units, assessment methods, faculty administrative medium, teaching staff and year of school. With regard to gender, females had better academic performance than males in general according to a systemic review finding (Ferguson et al. Citation2002) and, specifically, to a Jordanian study on dental students (Sawair et al. Citation2009). More importantly, depression was the only psychological predictor of academic performance which is similar to studies with Egyptian health students (Hamaideh & Hamdan-Mansour Citation2014) and South Korean medical students (Roh et al. Citation2010). Also, our results indicated that stress was not significantly related to academic performance which has been found in another study in Saudi Arabia (Abdulghani et al. Citation2011). Partial beta square for depression in WG model was small (0.018) and the adjusted R2 for the whole model (0.11) was mainly from the other demographic variables.
An interesting finding is that neither SWLS nor GSE was associated with WG. This is similar to otw studies in the USA that failed to find a significant relationship between academic performance and GSE (Mavis Citation2001; Choi Citation2005), though it contradicted with an older systemic review (Multon et al. Citation1991).
This study calls for serious actions to be taken by stakeholders in medical education. It is recommended that universities conduct courses and workshops on coping and study strategies, such as courses tested in other studies (Aboalshamat et al. Citation2013), as part of students' support services to vulnerable students. It is also recommended that medical and dental students are provided with access to psychological support by professionals during their university studies. Low academic performance may be an indicator of psychological distress.
Strengths and limitations
We believe our study to be the first that investigates the negative and positive aspects of psychological well-being among medical and especially dental students in Saudi Arabia using the instruments mentioned previously. GLM results, which were reported in our study, were more robust and provided more detail than the t-test used in other studies. We also believe that using our formula to calculate WG is better than using the commonly used students’ GPA, because WG measured academic performance exclusively to the study period. Our results indicated a novel difference pattern in psychological distress between medical and dental students.
In terms of limitations, the prevalence shown might not be representative of all medical and dental students in Saudi Arabia, but can be representative for the preclinical students in Makkah, as UQU is the only University in Makkah that teach medicine and dentistry. The number of dental students who participated was lower than the number of medical students; however, that was unavoidable given the lower admission rate in dentistry compared with medicine. The study’s data did not provide a justification of why male dental students are more distressed than female dental students. As such, there is a need to explore this finding, further using a longitudinal national study and a qualitative investigation. A final limitation is the lower response rate. However, the response rate was 64.52%, it aligns with similar studies in Saudi Arabia which tend to have wide ranging response rate from 45.5 to 95% (Al-faris et al. Citation2012; Soliman Citation2013).
In summary, this study found high levels of distress in medical and dentistry students enrolled in UQU, Saudi Arabia, as well as identifying particular subgroups that appear to be more at risk for developing distress. An implication of these findings is the need for more interventional studies to focus on high-risk group university student groups, and that these interventional studies are also needed in Middle Eastern countries such as Saudi Arabia.
Notes on contributors
KHALID ABOALSHAMAT, BDS, MPH, PhD candidate in epidemiology, Queensland University of Technology, and staff member at Faculty of Dentistry, Umm Al-Qura University.
XIANG-YU HOU, MD, PhD, an associated professor in epidemiology and the director of Research Development: North Asia, Queensland University of Technology.
ESBEN STRODL, PhD, is a senior lecturer in psychology at the Queensland University of Technology. His research interests and teaching are in the fields of health and clinical psychology.
Acknowledgements
The first author used Umm Al-Qura University (UQU) scholarship fund in addition to Queensland University of Technology (QUT) PhD candidature fund to conduct this study. UQU and QUT had no influence on this study.
The publication of this supplement has been made possible with the generous financial support of the Dr Hamza Alkholi Chair for Developing Medical Education in KSA.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content of the article.
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