Predictors of assertive behaviors among a sample of first-year Tunisian medical students

Figures & data

Figure 1. Study flowchart.

Table 1. Characteristics and responses of the undergraduate medical students.

Data	Unit/Category	Total sample (n = 125)	Assertive (n = 46, 36.8%)	Unassertive (n = 79, 63.2%)	p-value
Characteristics
Age	(year)	19.06 ± 0.70 (18.94 to 19.19)	19.17 ± 0.74	19.00 ± 0.68	0.1841
Sex	(male)	47 (37.6)	21 (45.7)	26 (32.9)	0.1586
Living with family	(yes)	58 (46.4)	20 (43.5)	38 (48.1)	0.8623
Assertiveness training	(yes)	14 (11.2)	7 (15.2)	7 (8.9)	0.2808
Community work	(yes)	45 (56.9)	15 (32.6)	30 (38.0)	0.5504
Personal medical field choice	(yes)	116 (92.8)	45 (97.8)	71 (89.9)	0.0987
Smoking	(yes)	6 (4.8)	3 (6.5)	3 (3.8)	0.4959
Alcohol use	(yes)	8 (6.4)	3 (6.5)	5 (6.3)	0.9665
Rathus assertiveness schedule
Assertive behavior	(score)	4.06 ± 23.14 (−0.04 to 8.15)	29.04 ± 11.89	−10.49 ± 13.68	0.0001*
Rosenberg self-esteem scale
Rosenberg self-esteem	(global score)	20.51 ± 4.85 (19.65 to 21.37)	22.20 ± 4.12	19.53 ± 5.00	0.0027*
Rosenberg self-esteem’ level	(low)	16 (12.8)	3 (6.5)	13(16.4)	0.1096
	(medium)	92 (73.6)	35 (76.1)	75 (94.9)	0.0018*
	(high)	17 (13.6)	8 (17.3)	9(11.4)	0.3530
Self-confidence	(score)	10.66 ± 2.91 (10.15 to 11.18)	11.72 ± 2.59	10.05 ± 2.92	0.0017*
Self-deprecation	(score)	9.85 ± 2.45 (9.41 to 10.28)	10.48 ± 1.92	9.48 ± 2.65	0.0274*
Interpersonal communication skills inventory
Interpersonal communication skills inventory	(global score)	65.61 ± 12.51 (63.39 to 67.82)	71.72 ± 12.91	62.05 ± 10.85	0.0000*
Sending clear messages	(score)	18.46 ± 4.92 (17.59 to 19.33)	20.48 ± 4.49	17.28 ± 4.79	0.0003*
Listening	(score)	15.56 ± 4.01 (14.85 to 16.27)	16.37 ± 3.96	15.09 ± 3.98	0.0848
Giving and getting feedback	(score)	15.76 ± 4.46 (14.97 to 16.55)	17.46 ± 4.24	14.77 ± 4.31	0.0010*
Handling emotional interaction	(score)	15.83 ± 4.56 (15.03 to 16.64)	17.41 ± 4.89	14.91 ± 4.11	0.0027*
Quality of life: short-form questionnaire
Quality of life	(global score)	62.27 ± 13.54	64.24 ± 13.51	61.13 ± 13.52	0.2172
Quality of life’ level	(altered)	22 (17.6)	25 (54.3)	47 (59.5)	0.5705
	(unaltered)	103 (82.4)	21 (45.7)	32 (40.50)
Physical functioning	(score)	79.68 ± 21.19 (75.93 to 83.43)	80.87 ± 23.67	78.99 ± 19.73	0.6339
Role physical	(score)	56.60 ± 35.94 (50.24 to 62.96)	58.15 ± 36.91	55.70 ± 35.57	0.7141
Bodily pain	(score)	72.54 ± 23.42 (68.39 to 76.69)	71.79 ± 19.53	72.97 ± 25.53	0.7869
General health	(score)	61.80 ± 14.69 (59.20 to 64.40)	66.30 ± 15.15	59.18 ± 13.85	0.0084*
Vitality	(score)	52.00 ± 14.80 (49.38 to 54.62)	54.13 ± 14.54	50.76 ± 14.89	0.2207
Social functioning	(score)	57.30 ± 21.19 (53.55 to 61.05)	58.42 ± 20.76	56.65 ± 21.54	0.6528
Role emotional	(score)	38.67 ± 36.76 (32.16 to 45.17)	38.40 ± 35.11	38.82 ± 37.91	0.9519
Mental health	(score)	53.86 ± 18.33 (50.61 to 57.10)	57.65 ± 19.04	51.65 ± 17.66	0.0772
Physical component summary	(score)	67.66 ± 17.54 (64.55 to 70.76)	69.28 ± 16.36	66.71 ± 18.22	0.4315
Mental component summary	(score)	50.46 ± 17.29 (47.39 to 53.52)	52.15 ± 17.17	49.47 ± 17.40	0.4046
General health questionnaire
Psychological wellbeing	(global score)	15.22 ± 4.58 (14.41 to 16.03)	14.65 ± 4.55	15.56 ± 4.59	0.2885
Psychological wellbeing’ level	(altered)	22 (17.6)	9 (19.6)	13 (16.5)	0.6610
	(unaltered)	93 (74.4)	37 (80.4)	66 (83.5)
Anxiety/Depression	(score)	8.94 ± 2.63 (8.48 to 9.41)	8.59 ± 2.80	9.15 ± 2.51	0.2475
Social dysfunction	(score)	4.70 ± 2.22 (4.30 to 5.09)	4.74 ± 2.23	4.67 ± 2.23	0.8693
Loss of confidence	(score)	1.58 ± 1.59 (1.30 to 1.86)	1.33 ± 1.46	1.73 ± 1.65	0.1666

*p-value (Student test or two sided chi-2 test) < 0.05: comparison between the assertive and unassertive groups.

Quantitative data were mean ± standard deviation (95% confidence interval) for the total sample and mean ± standard deviation for the assertive and unassertive groups, respectively. Categorical data were number (%)

Table 2. Univariate analysis between assertive behavior and categorical data (n = 125 undergraduate medical students).

Data	Category	Mean ± standard deviation	p-value
Sex	Male (n = 47)	9.64 ± 24.05	0.0358*
	Female (n = 78)	0.69 ± 22.06
Residency	Alone (n = 38)	6.39 ± 27.97	0.6207
	With family (n = 58)	1.91 ± 21.76
	Dormitory (n = 29)	5.28 ± 18.86
Assertiveness training	Yes (n = 14)	0.36 ± 27.30	0.5278
	No (n = 111)	4.52 ± 22.66
Community work	Yes (n = 45)	3.16 ± 20.69	0.7457
	No (n = 80)	4.56 ± 24.53
Medical field choice	Personal (n = 116)	5.19 ± 23.34	0.0488*
	Suggested (n = 9)	−10.56 ± 14.52
Smoking	Yes (n = 6)	15.83 ± 24.65	0.2026
	No (n = 119)	3.46 ± 23.01
Alcohol use	Yes (n = 8)	2.13 ± 25.61	0.8084
	No (n = 117)	4.19 ± 23.08
Self-esteem	Low (n = 16)	−11.87 ± 20.16	0.0108^†
	Medium (n = 92)	6.00 ± 22.85
	High (n = 17)	8.53 ± 22.43
Quality of life	Altered (n = 72)	1.57 ± 21.87	0.1623
	Unaltered (n = 53)	7.43 ± 24.50
Psychological wellbeing	Altered (n = 22)	9.64 ± 21.61	0.2141
	Unaltered (n = 103)	2.86 ± 23.38

*p-value (student test) <0.05: comparison between 2 groups. ^†p-value (Analysis of variance) <0.05: comparison between 3 groups.

Table 3. Univariate analysis between assertive behavior and quantitative data of undergraduate medical students (n = 125).

Data	Unit	Correlation coefficient	p-value
Characteristics
Age	(years)	0.1206	0.1805
Rosenberg self-esteem scale
Rosenberg self-esteem	(global score)	0.3872	0.0001*
Self-confidence	(score)	0.3665	0.0001*
Self-deprecation	(score)	0.3326	0.0002*
Interpersonal communication skills inventory
Interpersonal communication skills inventory	(global score)	0.3776	0.0001*
Sending clear messages	(score)	0.3769	0.0001*
Listening	(score)	0.1010	0.2625
Giving and getting feedback	(score)	0.2627	0.0031*
Handling emotional interaction	(score)	0.2838	0.0013*
Quality of life: short-form questionnaire
Quality of life	(global score)	0.1783	0.0466*
Physical functioning	(score)	0.0430	0.6337
Role physical	(score)	0.0379	0.6752
Bodily pain	(score)	−0.0233	0.7962
General health	(score)	0.2656	0.0028*
Vitality	(score)	0.2765	0.0018*
Social functioning	(score)	0.1953	0.0291*
Role emotional	(score)	0.0306	0.7348
Mental health	(score)	0.2606	0.0033*
Physical component summary	(score)	0.0802	0.3738
Mental component summary	(score)	0.2043	0.0223*
General health questionnaire
Psychological wellbeing	(global score)	−0.2275	0.0107*
Anxiety/Depression	(score)	−0.2385	0.0074*
Social dysfunction	(score)	−0.0577	0.5228
Loss of confidence	(score)	−0.1809	0.0437*

*p-value < 0.05.

Table 4. Independent data included in the assertive behavior multiple regression model.

Independent data	Unit/category	(B)	95% confidence interval around each B	p-value	Cumulative r^2
Constant		−22.203	-	0.0524	-
Rosenberg self-esteem	(global score)	1.161	−44.410 to 0.004	0.0039	0.1499
Sending clear messages	(score)	1.425	0.388 to 1.934	0.0004	0.2143
Anxiety/depression	(score)	−1.974	0.665 to 2.184	0.0043	0.25814
Sex	(0. Male; 1. Female)	−9.928	−3.304 to −0.645	0.0077	0.3100

B: non-standardized regression coefficient. r²: coefficient of determination.

Table 5. Designs and results of some studies evaluating the assertive behavior (AB) and its determinants.

1^st author(s)			Kobya Bulut	Hamouda	Kılıç and Sevinç	Maheshwari	Sarkova	AbdElAzim Ibrahim	Pourjali	Kimble	Present study
Reference (year of publication)			(18) (2019)	(16) (2018)	(19) (2017)	(20, 21) (2015)	(17) (2013)	(49) (2011)	(22) (2010)	(50) (1985)	-
Country (town)			Turkey (Trabzon)	Egypt (Benha)	Turkey (Kilis and Elazig cities)	India (Punjab)	Slovakia (Kosice)	Egypt (Port Said)	Iran (Shiraz)	USA (Texas)	Tunisia (Sousse)
Main aim: to determine the			Assertiveness and self-esteem levels and their influencing factors	Relationship between assertiveness and job satisfaction	Relationship between cultural sensitivities and assertiveness	Relationship of assertiveness and self-esteem Relationship of AB and ICSI	Associations between adolescents’ AB, psychological wellbeing, and self-esteem	Factors affecting AB among student nurses	Relationships between assertiveness, the power of saying no with mental health	Differences in assertiveness related with sex, age, cultural or ethnic group, and birth order	AB levels and its predictors
Study design			Descriptive correlational	Descriptive correlational	Descriptive, cross-sectional	Exploratory correlational, cross sectional	Correlational	Descriptive analytical	Cross sectional correlational	Cross sectional analytic	Cross sectional
Fields			Nursing students	Nurses	Nursing students	Nurses	Adolescent students	Nursing students	Undergraduate students	Undergraduate psychology students	Undergraduate medical students
Sample size (M/F)			426 (80/346)	225 (0/225)	444 (126/318)	220 (11/209)	1023 (487/536)	207 (NR/NR)	120 (58/62)	782 (279/355)	125 (47/78)
Age (year)			NR	28±10^a	21±2^a	32±8^a	15±1^a	NR	NR	17-58^b	19±1^a
Applied questionnaires			Personal information form RAS Coopersmith self-esteem inventory	AB questionnaire Job satisfaction questionnaire	Personal form Intercultural sensitivity scale RAS	Socio demographic sheet RAS RSE scale ICSI (Com-Sat)	Scale for interpersonal behavior GHQ RSE scale	RAS 12-item to measure empowerment	RAS GHQ Power of ‘saying No’ questionnaire	RAS Personal information form	Sociodemographic data RAS RSE scale SF-36 ICSI GHQ
AB		Frequency	506%	NR	NR	NR	NR	60.4%	NR	NR	36.8%
		Value	11.51±1.59^a	NR	112.64±15.6^a 52 to 164^b	-10.76±8.69^a -36to14^b	23.34±3.69^a	NR	NR	M: 12.90±22.87^a F:-4.49±23.31^a	4.06±23.14^a M: 9.64±24.05^a F: 0.69±22.06^a
		Determinants	NR	NR	Age Family income Providing care to patients whospokeforeignlanguages Willing to workabroad	Age Being graduated from public school/college Working on regular basis Working in government hospitals	Anxiety/depression Social dysfunction Positive self-esteem (only for distress dimension of assertiveness) Negative self-esteem	Residence Family income	NR	Sex Age Ethnicity	RSE global score Sending clear messages Anxiety/depression Sex

F: females. GHQ: general health questionnaire. ICSI: interpersonal communication skills inventory. M: males. NR: not-reported. RAS: Rathus assertiveness scale. RSE: Rosenberg self-esteem. SF-36: short-form-36. Data were: ^aMean±standard deviation, ^bRange;