1. Introduction
Many studies from various countries had documented 26% to 75% of medical students suffered from some levels of emotional disturbances or disorders [1] - [7]. Medical programs are known to impose high academic pressures on the students due to overload of study materials, financial indebtedness, lack of leisure time, pressures of academic and clinical work, personal relationships, career choices. Although some studies have shown some stress in medical school training can enhance learning and therefore is needed [8], many have also documented the negative physical and mental health problems from experiencing excessive stress.
Academically, excessive stress may impede the students’ concentration, their ability in problem-solving and decision making, thus affecting their academic achievement [8] [9]. Professionally, the stress may reduce students’ abilities to establish good relationships with patients. Many had reported dissatisfaction with clinical practice, and eventually, affected their professional development [10] [11]. Excessive stress may also reduce students’ self-esteem, causing anxiety, depression, interpersonal conflict, sleep disturbances, decrease attention, reduce concentration, feelings of inadequacy, incompetence, fear, anger, and guilt [10] [12] [13].
If not addressed, stress has been linked to medical student suicide, drug and alcohol abuse, depression, and in a long run, may affect the lives of patients and the health of a community [11] [12] [13].
Although many studies had documented the stress faced by medical students in many countries, none was conducted in Rwanda. Stressors are culture-specific, since people with different cultures and values perceive stress differently, and respond differently [14]. It is important to understand the stressors specifically among the medical students in Rwanda, related to the local culture, in order to design appropriate strategies to address or prevent any potential negative consequences related to stress among medical students. Accordingly, this study was conducted to assess the stress level among students who are currently enrolled in medical schools in Rwanda.
2. Materials
2.1. Study Design
We conducted the study in Rwanda, utilizing a self-administered online survey.
2.2. Sample
We sent the survey link to the students who were enrolled in the two medical schools, one private and one public, in Rwanda between February and April 2021. The private medical school admits about 30 to 40 students each year, and the public school admits about 110 each year. First year medical students were excluded from this study due to their exposure to medical programs being still new. The total population was estimated to be approximately 500. This study utilized a non-probability sampling method. The survey link was sent through the known contacts at the medical schools. Considering that the usual response rate for mobile online surveys is around 20% [15], we anticipated our sample size to be 100.
2.3. Data Collection Tool
We developed the survey based on the Stress in Academic Life Scale (SALS), a previously validated questionnaire to assess the stress level among students [16]. The survey has two parts. The first part of the survey included some demographic information of respondents. The second part has 27 questions assessing stress divided into seven areas: 1) Social support (5 questions); 2) Motivation (3 questions); 3) Curriculum and teaching (4 questions); 4) Academic ambition (5 questions); 5) Self-confidence (3 questions); 6) Performance anxiety (4 questions); 7) Career-related (3 questions). Each question was set up in the format of a 4-point Likert scale, with 0 points assigned to “not stressful”, 1 point to “Fairly stressful”, 2 points for “Very stressful”, and 3 points for “Severely stressful”. The total mean score ranges from 0 to 3. One open-ended question was also included at the end to solicit respondents’ additional comments.
The University of Global Health Institutional Review Board has approved the study.
2.4. Measures
The key measure of the study was the median SALS score, as well as the stress levels, categorized as no to fairly stress level (mean score of 0.00 to 1.00), fairly to very stressful (1.01 to 2.00), and very to severely stressful (2.01 to 3.00) [16].
2.5. Data Analysis
We used descriptive statistics to summarize the demographic information and SALS scores by subcategories. Mann Whitney tests were used to analyze the associations between demographics and the overall stress score. Spearman correlation was also conducted to analyze the association between age and stress score. All quantitative analyses were conducted using SPSS, with P-value set at 0.05. Content analysis was performed for the open-ended question, responses were grouped and presented as themes.
3. Results
3.1. Demographics
A total of 137 respondents completed the survey with a mean age of 23.5 (SD = 2.7). Among all the respondents, 58 (43.6%) were females, 116 (87.2%) studying in a public university, and 91 (68.9%) resided on campus. The majority of the respondents (52.6%) were in the second year of their medical study. The funding sources for their study were mostly from the government (n = 60, 45.1%) and parents (n = 20, 15%) (Table 1).
3.2. Stress Level
The overall median SAL score was 1.23 with an IQR of 0.88. Seven (5.3%) of the respondents reported having a “very to severe” stress level, 68 (51.1%) reported “fairly to very”, and 58 (43.6%) reported a “none to fairly” level of stress. Among the different subcategories within the SALS, respondents reported experiencing the lowest stress level in Social Support (median = 0.4). The highest stress level was reported in Curriculum and Teaching (median = 1.5), followed by Self-confidence (median = 1.33), and Motivation (median = 1.33) (Table 2).
The four items causing the highest stress were: 1) I am afraid of making mistakes in school/at the hospital (median = 2); 2) Some lecturers do not present the subjects clearly, and their lectures are boring (median = 2); 3) I believe that medical students are overloaded compared with students from other programs (median = 2); 4) There are not enough meetings with staff to discuss openly our academic problems (median = 2) (Table 3).
The stress score was found to be negatively correlated to age (r = −0.205, P = 0.02), and the number of years in the program (r = −0.218, P = 0.01) (Table 4).
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Table 1. Summary of sample demographics.
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Table 2. Summary of reported stress level.
Students receiving government funding were also found to be associated with the stress score (P = 0.01) (Table 4).
3.3. Qualitative Analysis
Three main themes were generated from the 26 comments respondents provided through the open-ended questions.
Theme one: Lack of financial support.
The most common comment (n = 12, 46%) respondents provided was the lack of financial support was a source of their stress.
“There should be a special living allowance given to medical students when they start clinical rotations because expenses increase such that regular monthly living allowance becomes insufficient which is stressful to them (22 years old, female, public university).”
“Supporting yourself as a student to get the basic need is a main stressor (20 years old, female, private university).”
“Life is very complicated because of the lack of money. We are almost always hungry and can’t get additional support from parents. Suggestion: Students’ bursary must be increased. We hardly afford transport and living costs during our clinical rotations. This gives me an unimaginable stress of always being in debt (24 years old, male, public university).”
Theme two: Lack of support from instructors.
Another common source of stress mentioned by the respondents (n = 8, 31%) was related to the lack of support from their instructors, both within academic programs and clinical.
“Poor teacher-student relationship that doesn’t permit outside class asking of questions (20 years old, female, public university).”
“Some lecturers are very harsh and intimidate us (24 years old, male, public university).”
“Most lecturers don’t motivate students, instead they discourage them (22
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Table 3. Median stress score for individual items.
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Table 4. Association of socio-demographic factors to SALS score.
*Significant at P = 0.05.
years old, male, public university).”
“Professors who are not understanding and tend to not teach properly but rather want to put you in a stressful environment thinking that they’re motivating you (21 years old, female, public university).”
Theme three: Disorganized academic activities
Respondents also mentioned the disorganized school activities could cause them stress (n = 8, 31%). Examples included their grades were visible to other students, or the results of their tests were not announced.
“Not providing continuous assessment results before entering in exam (25 years old male, public university).”
“We don’t have enough time to prepare for exams. And the fact that the whole class can see your grades (20 years old, female, public university).”
“Stress of disorganized school activities. I face many surprises and things change too fast (23 years old, male, public university).”
4. Discussion
This study assessed the stress level of medical students in Rwanda. The results showed that over half of the respondents experienced a “fairly to very” level of stress (n = 68, 51.1%) and 43.6% (n = 58) experienced a “none to fairly” level of stress. The stress levels were not statistically different between those attending public versus private universities. The results were consistent with other previous studies in different countries [17] [18] [19]. There is a growing concern about the stresses involved in medical training, as medical students may suffer from various negative psychological and health consequences, including sleep deprivation, anxiety, depression, substance abuse, and even suicidal ideation [20] [21] [22]. Studies have shown high stress level was significantly associated with lower level of cortical plasticity [23] [24] which is linked to learning and memory [25] [26] [27]. Stress in medical students has also been associated with using cannabis, coffee, energy drinks and other stimulants to cope with stress for neuroenhancement [28] [29] [30]. The issue should be handled with care and sensitivity. This study was the first in Rwanda in assessing the stress levels among medical students across both universities in the country, the results can help inform program design to help reduce unnecessary stress.
Two of the four items that caused the most stress to students were related to “Curriculum and Teaching”. Medical curricula are known to be highly demanding [9] [22]. The vast amount of materials covered in medical training can be demanding. As the context of clinical and professional practices changed, the medical curriculum had to incorporate not only basic and clinical sciences but also the social determinants and population health sciences, in order to be comprehensive [31], making the curriculum even more difficult and less flexible.
Apart from the structural issue of the curriculum, stress could also be stemmed from the instructors. Many students reported that some lecturers did not present the subjects clearly, they found some lectures were boring, and there were not enough meetings with staff to openly discuss their academic problems.
Many instructors working in higher education may be content experts, that, however, does not directly translate to being educators, many instructors were not trained to help their students to learn such content [32]. Universities should invest in their faculty by providing them instructional training.
With the vast amount of materials to be taught in a relatively short time, medical students may find it hard to schedule office hours with instructors. Instructors to provide more flexible office hours for instructor-student discussions should be encouraged. That could potentially enhance students’ learning and thus reduce their stress and anxiety levels. The results also indicated that more support and encouragement from faculty seemed to be needed. The administrative arrangement of the schools to avoid unplanned changes in academic activities or provide timely feedback to students’ performance could also help. Special attention to students who are just entering the program should be given. Our results showed younger students had higher stress levels. A lot of adjustments are needed when students enter a new program, especially when transiting from classroom to clinical rotations, the uncertainties of a new environment, and taking on new responsibilities to handling patients’ life and death situation, in addition to the heavy workload, could be sources of stress. Extra effort should be provided to help them transit into the new phase of their lives.
Another major risk factor contributing to the stress reported by many respondents was finance. The 6-year medical programs in Rwanda could easily put students in prolonged financial hardship if no scholarship or sponsorship of some kind were offered. As stated by many respondents, providing financial support to medical students, especially during their clinical rotation years, should be explored. The results showed that students who received government funding experienced significantly higher stress levels compared to those who did not receive government funding. Discussions with some medical students reviewed that very often government funding was received much later than scheduled. Such inconsistent funding releases could potentially cause more stress to students than not receiving the support. However, more exploratory studies to understand the magnitude and root cause of the delay are needed.
On the other hand, most respondents felt the least stressed in the “Social Support” sub-category. Rwandan society has strong positive national cultural values, with a great emphasis on family. In the National Policy for Family Promotion 2005, it was stated that the family “is considered as an essential element for safeguarding social order, maintaining social cohesion and for reconciling an individual with the society [33].” The policy summed up the core positive cultural values in Rwanda. Any future intervention design should capitalize and build on this great asset.
Limitations
The survey was conducted using the online platform, we could not eliminate the potential selection bias, and thus the results may not be completely generalizable. The study was also conducted during the COVID-19 pandemic, we could not eliminate the possibility that the respondents were experiencing heightened stress levels due to other pandemic-related issues. Despite the limitations, this study was the first to assess the stress levels among medical students in Rwanda. The results can serve as a baseline for any further studies. Important insights gained from the study could inform future program design.
5. Conclusion
The results of this study suggested mild to moderate levels of stress were faced by the medical students in Rwanda. Finance plays a role, but the main stressors stemmed from the curriculum, teaching, and administrative organization. Medical schools should proactively create appropriate interventions, including curriculum revision and enhancing teaching and learning methodology to improve students’ physical and psychological well-being and provide mental health services in schools.
Acknowledgements
The authors would like to thank all the participants in the study.
Authors’ Contributions
L Kubwimana, G Mutatsineza, and L Tesi conceived the study. All authors conducted the literature review, study design, data collection, interpretation of data, drafting and editing the manuscript. All authors have seen and approved the final manuscript.
Ethical Approval
Ethical approval has been granted by the Institutional Review Board of the University of Global Health Equity on Feb 18th, 2021, with the reference number of 0122.
Abbreviations
SALS: Stress in Academic Life Scale.
Appendix 1. Questionnaire
Part A. Basic Demographics
1) What is your age? _______
2) What gender do you represent?
· Female
· Male
3) Which medical school do you attend?
· University of Rwanda
· University of Global Health Equity
4) What is your current year of study in medical school?
· 2
· 3
· 4
· 5
· 6
5) What is your residence?
· On-campus
· Off-campus
6) What is your main source of income? Check all that apply.
· Government-funded stipend
· Parental allowance
· Other:
Part B. Academic Stress Survey