Journal of Community Medicine & Public Health Care Category: Medical Type: Research Article
Psychological Health of Medical and Dental Students in Saudi Arabia: A Longitudinal Study
- Khalid Aboalshamat1*, Xiang-Yu Hou2, Esben Strodl3
- 1 Dental Public Health Department, Dental Faculty, Umm Al-Qura University, Brisbane, Australia
- 2 School Of Public Health And Social Work, Queensland University Of Technology, Brisbane, Australia
- 3 School Of Psychology And Counseling, Queensland University Of Technology, Brisbane, Australia
*Corresponding Author:Khalid Aboalshamat
Dental Public Health Department, Dental Faculty, Umm Al-Qura University, Brisbane, Australia
Received Date: May 20, 2014 Accepted Date: Jul 29, 2014 Published Date: Aug 12, 2014
Multiple systematic reviews have reported unfavorable levels of psychological distress among medical and dental students globally [1-4]. This distress has been suggested to negatively affect the student's health, professional life, and their patient's safety [5,6]. Similarly, other measures of psychological health such as perceived stigma have been associated with student's drop out of medical and dental programs [4,7], which in turn results in a subsequent reduction in the health care workforce.
Many academic factors have been reported to be behind medical and dental student's poor psychological health, such as a high workload, future study concerns, the long duration of academic days, and a high number of examinations [3,4,8,9]. In addition many students who enroll in medical and dental schools may experience performance pressure in order to do well in their studies due to their desire to satisfy the value of helping others, attain prestigious jobs, and achieve a stable financial future [10,11]. This might explain the high level of psychological distress that accompanies the elevated percentage of satisfaction among medical students . An investigation into these student's psychological health should therefore include both the positive and negative aspects of their health in order to achieve more who listicevaluation of psychological health in this population.
The predictors of psychological health in medical and dental students is complex with emerging evidence of moderators of these associations. For example, several studies have highlighted agender difference in psychological distress levels of depression, anxiety, and stress. These studies have indicated that females were more vulnerable to distress than males[3-5,13] however, some studies indicated that there were no differences [14,15]. In addition, year of study has been as a possible moderating factor with the evidence still being contradictory. For example, some have suggested that the early years were more distressing  where as others have suggested that distress in the student's last years was greater [4,16]. Moreover, other studies have highlighted that the discipline being studies may be a moderating factor given that dental students are more distressed [17,18] and less satisfied than medical students .
Despite the high number of publications since 2000 on the psychological health of medical and dental students, most were cross-sectional studies. Only a few longitudinal studies were conducted to assess the changes across time some found that psychological distress[14,20] and life satisfaction  deteriorated from the first years to the final years among medical students. A study in the United Kingdom found that the psychological distress was transient during the first academic year among medical students and did not persist in subsequent years . Few studies have investigated these changes across the same year. A longitudinal study in Malaysia on first-year medical students indicated that they had higher depression, anxiety, and stress levels at final examination time compared with the beginning of the year . However, such findings were not supported by other literature from other countries investigations of other years or on dental students have not been reported. Furthermore, no longitudinal study has been conducted into the psychological health of medical and dental students in the Middle East.
Thus, the aim of this study was to investigate the psychological health (positive and negative aspects) of Umm Al-Qura University (UQU), Makkah, Saudi Arabia, preclinical medical and dental students at different times. It also aimed to identify changes over time in psychological health between different demographic subgroups.
MATERIALS AND METHODS
Design, sample and ethics
|Low (<10,000 SR)||107 (33.8)|
|High (>10,000 SR)||210 (66.2)|
There was no statistical difference in psychological outcomes (using t-tests) and the demographic variables (using chi-square) between the study participants who completed the questionnaires at T1 and T2, and the students who dropped out of the study.
Depression, anxiety, and stress were significantly lower at the beginning of the second semester at T2 than the middle of first semester at T1, as shown in Table 2. Satisfaction with life was significantly higher while there was no change in general self-efficacy.
|Mean (SD)||Mean difference||95% CI|
|T1||15.15 (9.06)||2.61||1.68, 3.52||5.56 (316)||<0.001|
|T1||12.18 (9.07)||1.54||0.66, 2.40||3.48 (318)||0.001|
|T1||20.72 (8.91)||4.29||3.32, 5.26||8.72 (318)||<0.001|
|T1||27.15 (4.78)||-0.15||-0.53, 0.23||-0.77 (316)||0.442|
|T1||23.37 (6.31)*||-0.85||-1.41, -0.28||-2.95 (316)||0.003|
In Table 3, depression, anxiety, and stress were reduced in all demographic subgroups (medical, dental, male, female, second-year, third-year, and high and low family income students). Depression was reduced significantly among all the subgroups shown in Table 3 except the second-year students. Stress was also reduced significantly among all the subgroups shown in Table 3 except for dental students. Anxiety level reduction was significant only among the medical, female, third-year, and low family income students. General self-efficacy showed no significant change occurred in any subgroups (Table 3). All the demographic subgroups showed increased satisfaction with means at T2 however, the largest increase was found in the medical, dental, female, third-year, and high family income students.
|Factor||Time||Dep. M(SD)||Diff.||Anx. M(SD)||Diff.||Str. M(SD)||Diff.||GSE M(SD)||Diff.||SWLS M(SD)||Diff.|
|Medicine (259)||T1||14.98 (9.03)||2.56*||12.22 (9.27)||1.57*||20.8 (8.99)||4.81*||27.17 (4.85)||-0.12||23.2 (6.49)||-0.73*|
|T2||12.42 (9.48)||10.64 (8.89)||15.99 (9.68)||27.29 (4.55)||23.93 (6.54)|
|Dentistry(58)||T1||15.93 (9.23)||2.83*||12.03 (8.23)||1.38||20.41 (8.66)||2.01||27.12 (4.53)||-0.28||24.16 (5.46)||-1.36*|
|T2||13.1 (8.85)||10.66 (8.62)||18.41 (8.3)||27.41 (3.99)||25.52 (5.25)|
|Male (144)||T1||14.71 (9.05)||2.88*||10.76 (7.99)||0.64||19.36 (9.08)||3.77*||27.59 (4.82)||-0.14||23.49 (5.98)||-0.7|
|T2||11.83 (8.68)||10.13 (8.47)||15.59 (8.67)||27.73 (4.29)||24.19 (6.15)|
|Female (173)||T1||15.53 (9.08)||2.38*||13.36 (9.75)||2.29*||21.86 (8.65)||4.74*||26.8 (4.74)||-0.16||23.28 (6.6)||-0.97*|
|T2||13.15 (9.86)||11.08 (9.12)||17.13 (10.07)||26.96 (4.56)||24.25 (6.53)|
|Second (154)||T1||14.01 (8.78)||0.89||11.47 (8.49)||0.68||20.05 (9.04)||3.22*||26.92 (4.67)||0.05||24.66 (5.78)||-0.35|
|T2||13.12 (9.62)||10.79 (8.91)||16.84 (9.49)||26.86 (4.52)||25.01 (5.85)|
|Third (163)||T1||16.23 (9.22)||4.22*||12.86 (9.57)||2.35*||21.36 (8.78)||5.31*||27.39 (4.89)||-0.34||22.16 (6.57)||-1.32*|
|T2||12.01 (9.09)||10.51 (8.77)||16.05 (9.48)||27.73 (4.36)||23.48 (6.72)|
|Low (107)||T1||15.44 (9.62)||2.76*||13.93 (9.85)||2.76*||21.44 (8.63)||4.09*||26.84 (5.13)||-0.27||23.06 (6.71)||-0.67|
|T2||12.68 (10.07)||11.16 (9.29)||17.35 (9.73)||27.11 (4.82)||23.73 (6.89)|
|High (210)||T1||15.01 (8.78)||2.53*||11.3 (8.54)||0.91||20.36 (9.06)||4.4*||27.32 (4.6)||-0.09||23.54 (6.12)||-0.94*|
|T2||12.48 (8.99)||10.38 (8.59)||15.96 (9.33)||27.41 (4.26)||24.47 (6.06)|
Depression, anxiety, and stress status were significantly lower at T2 for the students overall, indicating an improvement in the negative aspect of psychological health. This also indicates that students at the middle of years taking classes, exams, and quizzes might manifest a higher distress in compared to beginning of a new semester after having one-week vacation. It also agrees with a previous study on first-year medical students in Malaysia that finds that depression, anxiety, and stress at the beginning of a semester are lower than during or at the end of a semester . In addition to a reduction in negative effect, the students also experienced an increase in satisfaction with life at the start of the second semester supporting the view that mid-semester vacations are important in rejuvenating university students. This appears to contradict with Kjeldstadli and colleagues' study, which indicated a deterioration of satisfaction prospectively across different years for medical students . However, this disagreement might be because their study assessed satisfaction across different years, whereas our study assessed the difference within different time points of the same year.
On the other hand, general self-efficacy did not change significantly between T1 and T2, and neither was any demographic subgroup associated with significant changes in GSE level. This seems to disagree with a previous study that found a reduction in self-efficacy among dental students over the subsequent academic years . However, again, our study was evaluating self-efficacy level across the same year, whereas the Polychronopoulou study assessed self-efficacy across different years. It is therefore possibly the insignificance of our results might be because the short time between the T1 and T2 (3 months) did not provide enough academic experience or time in the course unit to elevate GSE level. It is noteworthy that general self-efficacy was not sensitive to change in this population.
The general improvement in our results in psychological health (depression, anxiety, stress, and satisfaction) constructs suggests that the medical and dental students experience different educational environment along the semesters. The multiple examinations in the middle of the semester is suggested to be an important distressful factor. Our results also suggest that the student are rejuvenated by vacation breaks between semesters and emphasizes the importance of such breaks in promoting the psychological health of medical and dental students.
More specifically the findings of the study also suggest that there were significant differences in psychological health among the demographic subgroups such as department, gender, year of study, and family income. Neither nationality nor marital status were included in the statistics because of the low number of non-Saudi (6) and married students (7).We identified four patterns in changes in psychological health based on changes in depression, anxiety, stress and satisfaction for life. First, medical, third year, and female subgroups had larger improvements in depression, anxiety, stress, and satisfaction with life between T1 and T2 than dental, 2nd year and male subgroups.
Second, several significant results found in medical students were not significant in dental students (e.g. anxiety and stress scores) despite direction of means being consistent across groups. It is likely this is due to differences in sample size of the two groups perhaps rather than anything intrinsic to the groups themselves. However, the presence of persistent anxiety levels among dental students has another potential explanation as UQU Dental Faculty is newly established, meaning there is continuous reform in the curriculum and academic environment that could potentially increase students' anxiety about unknown challenges. Also, Silverstein indicates in her longitudinal study that stress level changes differently among different dental schools  which could be another suggested explanation to our finding in terms of stress.
Third, we noticed that second-year students' psychological health did not improve except in terms of stress levels, while third year students' psychological health improved in terms of depression, anxiety, stress, and life satisfaction. This might indicate that third-year students suffer from more challenges and distress, as indicated in another study  and brief vacations is more beneficial for third year students than second year. The significant reduction in stress level in both years can be justified as quizzes and examinations, which might increase students stress especially, are more frequents in the middle of semesters than the beginning.
Last, depression and stress level were reduced at all the demographic subclasses, unlike anxiety and SWLS. Anxiety and SWLS seem to be sensitive to gender, year of study, and family income. Male and second-year students had no improvement in anxiety or satisfaction levels at T2. In regard to income, low family income students had a significant reduction in anxiety in contrast with high-income students. This might be due to financial burden of expenses during the semester. On the other hand, high family income students had a significant increase in SWLS, unlike low family income students. This is may be because high family income students can spend extra money to enjoy their time at the beginning of the year in contrast to low-income students.
This study had the following strengths. The prospective study design gave more details about the psychological health among preclinical medical and dental students across the same academic year. Also, there were very few missing data, and the dropout percentage was justifiable in such a study design. Also, there was no demographical or psychological difference between our sample and dropped out students. The instruments used in this study had good psychometric properties and have been widely used in different cultures; this will facilitate comparisons with future studies. Finally, the study evaluated both dental and medical students.
On the other hand, caution needs to be taken in generalizing the results of this study to all preclinical medical and dental students in Saudi Arabia because the study was conducted in only one university in Saudi Arabia. The sampling method was based on self-selection and so was not random-based, which might result in participation bias. Further studies assessing these measures at multiple times across their second and third years or across the clinical years would provide more comprehensive information about the progression of psychological health of medical and dental students throughout their course.
Our results indicated that psychological health of dental and medical students in Saudi Arabia may change during the academic year with psychological health being better at the beginning of a semester than during the middle of a semester. This drew an implication on the majority of the cross sectional studies on psychological health among medical and dental students, as the differences in the cross-sectional results might be because of different data collection time. Our findings also indicate that the middle of the semester is a good time for medical and dental faculties to conduct coaching programs  to help students and vulnerable groups cope with stress. It is essential that medical and dental faculties identify and provide possible support for students facing deteriorating psychological health, especially when only a few will seek help in such specialties .
- Elani HW, Allison PJ, Kumar RA, Mancini L, Lambrou A, et al. (2014) A systematic review of stress in dental students. J Dent Educ 78: 226-242.
- Ishak W, Nikravesh R, Lederer S, Perry R, Ogunyemi D, et al. (2013) Burnout in medical students: a systematic review. Clin Teach 10: 242-245.
- Dyrbye L, Thomas M, Shanafelt TD (2006) Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Academic Medicine 81: 354-373.
- Alzahem AM, van der Molen HT, Alaujan AH, Schmidt HG, Zamakhshary MH (2011) Stress amongst dental students: a systematic review. Eur J Dent Educ 15: 8-18.
- Dahlin M, Runeson B (2007) Burnout and psychiatric morbidity among medical students entering clinical training: a three year prospective questionnaire and interview-based study. BMC Medical Education 7:6.
- Tyssen R, Vaglum P (2002) Mental health problems among young doctors: an updated review of prospective studies. Harv Rev Psychiatry 10: 154-165.
- Dyrbye LN, Thomas MR, Power DV, Durning S, Moutier C, et al. (2010) Burnout and serious thoughts of dropping out of medical school: a multi-institutional study. Academic Medicine 85: 94-102.
- Salgar S (2014) Stress in first year medical students. International Journal of Biomedical and Advance Research 5:5-6.
- Sani M, Mahfouz M, Bani I, Alsomily A, Alagi D, et al. (2012) Prevalence of stress among medical students in Jizan University, Kingdom of Saudi Arabia. Gulf Medical Journal 1:19-25.
- Al-Bitar ZB, Sonbol HN, Al-Omari IK (2008) Reasons for choosing dentistry as a career by Arab dental students. Eur J Dent Educ 12: 247-251.
- Millan LR, Azevedo RS, Rossi E, De Marco OL, Millan MP, et al. (2005) What is behind a student's choice for becoming a doctor? Clinics (Sao Paulo) 60: 143-150.
- Samaranayake CB, Fernando AT (2011) Satisfaction with life and depression among medical students in Auckland, New Zealand. N Z Med J 124: 12-17.
- Polychronopoulou A, Divaris K (2010) A longitudinal study of Greek dental students' perceived sources of stress. J Dent Educ 74: 524-530.
- Niemi PM, Vainiomäki PT (2006) Medical students' distress--quality, continuity and gender differences during a six-year medical programme. Med Teach 28: 136-141.
- Moffat KJ, McConnachie A, Ross S, Morrison JM (2004) First year medical student stress and coping in a problem-based learning medical curriculum. Med Educ 38: 482-491.
- Jadoon NA, Yaqoob R, Raza A, Shehzad MA, Zeshan SC (2010) Anxiety and depression among medical students: a cross-sectional study. J Pak Med Assoc 60: 699-702.
- Murphy RJ, Gray SA, Sterling G, Reeves K, DuCette J (2009) A comparative study of professional student stress. J Dent Educ 73: 328-337.
- Birks Y, McKendree J, Watt I (2009) Emotional intelligence and perceived stress in healthcare students: a multi-institutional, multi-professional survey. BMC Med Educ 9: 61.
- Jurkat H, Höfer S, Richter L, Cramer M, Vetter A (2011) Quality of life, stress management and health promotion in medical and dental students. A comparative study. Dtsch Med Wochenschr 136: 1245-1250.
- Aktekin M, Karaman T, Senol YY, Erdem S, Erengin H, et al. (2001) Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey. Med Educ 35: 12-17.
- Kjeldstadli K, Tyssen R, Finset A, Hem E, Gude T, et al. (2006) Life satisfaction and resilience in medical school--a six-year longitudinal, nationwide and comparative study. BMC Med Educ 6: 48.
- Quince TA, Wood DF, Parker RA, Benson J (2012) Prevalence and persistence of depression among undergraduate medical students: a longitudinal study at one UK medical school. BMJ Open 2.
- Yusoff MS, Abdul Rahim AF, Baba AA, Ismail SB, Mat Pa MN, et al. (2013) The impact of medical education on psychological health of students: a cohort study. Psychol Health Med 18: 420-430.
- Lovibond PF, Lovibond SH (1995) The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 33: 335-343.
- Taouk M, Lovibond P, Laube R (2001) Psychometric properties of an Arabic version of the Depression Anxiety Stress Scales (DASS21). Cumberland Hospital, Sydney: Report for New South Wales Trans cultural Mental Health Centre.
- Henry JD, Crawford JR (2005) The short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sample. Br J Clin Psychol 44: 227-239.
- Diener E, Emmons RA, Larsen RJ, Griffin S (1985) The Satisfaction With Life Scale. J Pers Assess 49: 71-75.
- Aboalshamat K, Hou XY, Strodl E (2013) Improving dental and medical students' psychological health using a self-development coaching program: a pilot study. Adv med Res 3: 45-57.
- Schwarzer R, Jerusalem M (1995) Generalized Self-Efficacy scale. In: Weinman J, Wright J, Johnston M, (eds). Measures in health psychology: A user's portfolio Causal and control beliefs. Windsor, Nfer-Nelson, UK: 35-7.
- Scholz U, Gutierrez-Doña B, Sud S, Schwarzer R (2002) Is general self-efficacy a universal construct? Psychometric findings from 25 countries. Eur J Psychol Assess 18: 242-51.
- Silverstein ST, Kritz-Silverstein D (2010) A longitudinal study of stress in first-year dental students. J Dent Educ 74: 836-848.
- Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, et al. (2009) The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med 84: 1182-1191.
- Dahlin ME, Runeson B (2007) Burnout and psychiatric morbidity among medical students entering clinical training: a three year prospective questionnaire and interview-based study. BMC Medical Education 7: 6.
Citation:Aboalshamat K, Hou XY, Strodl E (2014) Psychological Health of Medical and Dental Students in Saudi Arabia: A Longitudinal Study. J Community Med Public Health Care 1: 001.
Copyright: © 2014 Khalid Aboalshamat, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.