Stress and Its Association with the Academic Performance of Undergraduate Fourth Year Medical Students at Universiti Kebangsaan Malaysia

Abstract

Student can be stressed due to different stressors such as academic, financial, health related or loss of close family member or friend, etc. Stress is the bodies' reaction both neurologically and physiologically to adapt to the new condition. Stress has a negative effect on the academic performance of the students. This study was aimed to explore the stress and stressors and also to determine the association between stress levels and the academic performances in terms of cumulative grade point average (CGPA) of undergraduate medical students. Methods: It was a cross-sectional study conducted among all 234 year-4 medical students of Universiti Kebangsaan Malaysia (UKM), session 2011-2012. Sample size comprised of 179 students after fulfilling all inclusion and exclusion criteria. A validated Medical Students' Stressor Questionnaire (MSSQ) was used to collect the data. Stress level and its association with CGPA of semester-1 examination were analysed. Results: Response rate was 76.49%, where 72% were female and 69% resided in the hostel. Academic Related and Social-related Stressors caused for severe and high stress in 84% and 49% respondents respectively, with insignificant differences between gender and residency. Respondents with a high and severe stress level were observed to have higher CGPA. Conclusion: UKM medical students are highly resourceful to manage their stress well and thus denying the negative effect of stress towards their academic performance. Medical schools should train students exposing various personal and professional developmental activities that able to face the everyday challenges and manage stress well and thereby achieve better academic performance.

Full text

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THE INTERNATIONAL MEDICAL JOURNAL Malaysia
Volume 13 Number 1, June 2014
IMJM
Stress and Its Association with the Academic Performance of
Undergraduate Fourth Year Medical Students at Universiti
Kebangsaan Malaysia
Harlina H Siraj a, Salam Aa, Roslan Rb, Hasan NAb, Jin THb, Othman MNb
aMedical Education Department, UKM Medical Centre, Malaysia
bSpecial Study Module (SSM) Research Group Students, Medical Education Department, UKM Medical Centre,
Malaysia
ABSTRACT
Introduction: Student can be stressed due to different stressors such as academic, nancial, health related or
loss of close family member or friend, etc. Stress is the bodies’ reaction both neurologically and physiologically
to adapt to the new condition. Stress has a negative effect on the academic performance of the students.
This study was aimed to explore the stress and stressors and also to determine the association between stress
levels and the academic performances in terms of cumulative grade point average (CGPA) of undergraduate
medical students. Methods: It was a cross-sectional study conducted among all 234 year-4 medical students
of Universiti Kebangsaan Malaysia (UKM), session 2011-2012. Sample size comprised of 179 students after
fullling all inclusion and exclusion criteria. A validated Medical Students’ Stressor Questionnaire (MSSQ) was
used to collect the data. Stress level and its association with CGPA of semester-1 examination were analysed.
Results: Response rate was 76.49%, where 72% were female and 69% resided in the hostel. Academic Related
and Social-related Stressors caused for severe and high stress in 84% and 49% respondents respectively, with
insignicant differences between gender and residency. Respondents with a high and severe stress level
were observed to have higher CGPA. Conclusion: UKM medical students are highly resourceful to manage
their stress well and thus denying the negative effect of stress towards their academic performance. Medical
schools should train students exposing various personal and professional developmental activities that able
to face the everyday challenges and manage stress well and thereby achieve better academic performance.
KEYWORDS: Stress, stressor, well-management, academic performance
Corresponding author:
Assoc. Prof. Dr. Harlina Halizah Siraj
Department of Medical Education,
UKM Medical Centre
Jalan Yaacob Latif, Bandar Tun Razak,
56000 Kuala Lumpur, MALAYSIA
Email: harlina@ppukm.ukm.edu.my
INTRODUCTION
Academic performance is one of the most vital
considerations among students in higher educational
level. The academic performance can be illustrated
by grade point average (GPA). Despite living in the
millennium area where education is accessible to all,
there are still some differences in performance among
the students. Several studies identied internal
and external factors associated with academic
performance. Stress is one of the factors that has
negative effect on the mastery of the academic
curriculum.1
Stress is the body's nonspecic response mechanism
towards demands or strains made on itself or the
environment.2,3 It is a process by which we perceive
and cope with environmental threats and challenges.4
Stress can be dened in Webster new world dictionary5
as “a condition typically characterized by symptoms
of mental and physical tension or strain, as depression
or hypertension, that can result from a reaction to a
situation in which a person feels threatened, pressured,
etc.” An individual can be stressed in daily life in a
different way, and stress can be viewed as the bodies’
reaction both neurologically and physiologically to
adapt to the new condition.6,7 A student can be
stressed due to different reasons or stressors such as
the academic, nancial problem, health problem or
loss of close family member or friend, etc. It is the
persons’ ability to face the everyday challenges which
will determine whether he/she will be stressed or not.
Stress in academic situation can have both positive
and negative consequences. Stress can inhibit and
suppress learning, which is called ‘unfavourable stress’
and is associated with inhibition of students’ academic
performance.8 Previous studies have reported a high
prevalence of stress in medical students, ranging from
30% to 50%.9,10 However, stress management training in
medical school is needed to promote learning through
coping of stress, which is called ‘favourable stresses’.

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MATERIALS AND METHODS
This was a cross sectional, questionnaire survey,
conducted on all 234 UKM medical students of year-
4, academic session 2011-2012. The survey period
was from June 2011 to until May 2012. Participation
in this study was voluntary and informed consent was
taken from all participants to participate in this study.
Students who did not give consent and those who
lled the questionnaire incompletely were excluded
from this study. As such, the sample size of this study
comprised of 179 students.
To collect the data, medical students’ stress
questionnaire (MSSQ) was used, which was a validated
instrument used to identify sources of stress.18 There
were 40 items in MSSQ those represented the possible
sources of stress in medical students and were grouped
into six main domains. The six domains were: Academic
Related Stressor (ARS), Intrapersonal and Interpersonal
Related Stressor (IRS), Teaching and Learning Related
Stressor (TLRS), Social Related Stressor (SRS), Drive
and Desire Related Stressor (DRS), and Group Activities
Related Stressor (GARS). The items under each stressor
were measured using a rating scale 0-4. Respondents
were asked to rate each item as 0 for 'causing no
stress at all', 1 for 'causing mild stress', 2 for 'causing
moderate stress', 3 for 'causing high stress' and 4 for
'causing severe stress'. The reliability coefcients of
the stressor groups ranged from 0.64 to 0.92. The
degree or level of stress were classied as: level 0-1.00
'causing nil to mild stress', level 1.01-2.00 'causing mild
to moderate stress', level 2.01-3.00 'causing moderate
to high stress' and level 3.01-4.00 'causing high to severe
stress'.18 Before administering the questionnaire, a
pilot test was conducted among 10 undergraduate
students and nalized the questionnaire accordingly.
Academic performance of the medical students was
measured by using the grades of all subjects in the
rst-semester examination of year-4. The cumulative
grade point average (CGPA) of semester-1 examination
was calculated in a 5.0 scale which was self-expressed
by the students. Consent was also taken to disclose
their CGPA of the semester-1 examination. All the
data regarding CGPA were kept condential. Data was
analyzed using the statistical soft ware package for
social sciences (SPSS) 17.0 version.
RESULTS
Out of 234 medical students, 186 students returned
the questionnaire from which seven were incomplete
and excluded. As such 179 respondents were included
in this study giving a response rate of 76.49%. One
hundred and twenty nine students (72%) were female
and 50 (28%) were male. Regarding the residency of
the students, 123 (69%) students were resided in the
hostel while 56 (31%) were resided out-campus (Table
I).
Table II showed percentage of individual stressor
domain. Majority of the respondents (84%) were in
severe stress, particularly with the academic related
stressors, followed by 57% in group activity related
stressor and 56% in intrapersonal and interpersonal
stressor domains. Social related stressors also cause
high stress among the respondents (49%).
Table III revealed the degree of stress level. A total of
16 (8%) students showed to have a moderate level of
stress while 93 (53%) and 70 (39%) have a high (level
2.01-3.00) and severe level (level 3.01-4.00) of stress
respectively. It also showed the stress level between
male and females.
Academic performance (Mean CGPA) of the respondents
in terms of gender and residency has shown in Table IV.
There is insignicant relationship between stress and
academic performance both in terms of gender and
residency. In total 76% respondents opined that stress
motivates them for better academic performance
while 24% denied.

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Table I. Gender and residency data of the respondents, n=179
Variables Number Percent
Gender
Reside
Male
Female
Hostel
Out campus
50
129
123
56
28
72
69
31
Table II. Stress level among individual stressor domain
Stressor
Domain
Level of stress against individual stressor domain
Mild
(0-1.00)
Moderate
(1.01-2.00)
High
(2.01-3.00)
Severe
(3.01-4.00)
1
2
3
4
5
6
%
ARS
IRS
TLRS
SRS
DRS
GARS
%
0
2
5
2
33
1
%
0.5
15
21
29
26
7
%
15.5
27
38
49
23
35
%
84
56
36
20
18
57
Average 7 16 32 45
ARS=Academic Related Stressor, IRS=Intrapersonal and Interpersonal Related Stressor, TLRS=Teaching and
Learning Related Stressor, SRS=Social Related Stressor, DRS=Drive and Desire Related Stressor, GARS=Group
Activities Related Stressor.
Table III. Distribution of level of stress among the respondents
Stress level of the respondents Total
Gender
Male
Female
Total
Mild
(0-1.00)
Moderate
(1.01-2.00)
High
(2.01-3.00)
Severe
(3.01-4.00) n %
n % n % n % n %
1 2 2 4 28 56 19 38 50 100
3 2 10 8 65 50 51 40 129 100
4 2 12 6 93 53 70 39 179 100

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Table IV. Stress level and academic performance (CGPA) of the respondents in terms of gender and residency
Stress level of respondents
Academic performance
CGPA ± SD p value
n
Gender
Residency
Male (level 3.01-4.00)
Female (level 3.01-4.00)
Hostel resides
Out campus resides
50
129
125
54
3.3200
3.2946
3.3440
3.2037
.58693
.64230
.59709
.68349
.417
.612
DISCUSSION
Recently stress has appeared as an emerging issue
among the medical students.19 Majority of the
respondents in this study were found stressful where
72% were female and 28% were male (Table I) which
actually corresponded to the male-female student
ratio of the university.
There were six domains of stress that were studied,
which were Academic Related Stressor (ARS),
Intrapersonal and Interpersonal Related Stressor
(IRS), Teaching and Learning Related Stressor (TLRS),
Social Related Stressor (SRS), Drive and Desire Related
Stressor (DRS) and Group Activities Related Stressor
(GARS). Among these domains, the stress level was
severe (84%) in the academic related stressor (ARS)
domain (Table II) that specied on the educational,
college, universities and student events. Medical
students perceived stress, mostly due to academic
related factors. Previous study showed a number of
academic related stressors that included test and
examinations, a big range of content to be learnt, lack
of time to do the revision, poor marks, having self-
expectations to do well, insufcient skill in medical
practice, falling behind in reading schedule, heavy
workload, difculty in understanding the content,
and inability to answer teachers’ questions.20-23 These
ndings have similarity with Thomas24 who reported
that school examinations, school work and homework
were the major stressors. Intra-Interpersonal Related
Stressor (IRS) rated severe stress by 49% respondents
while Social Related Stressors (SRS) rated high stress
by 56% of the respondents. This could be due to
besides pursuing knowledge in university; a student
also gets to socialize with different kinds of people
and undergo psychological development. Students
faced a changing of education system, lifestyle and
social environment. They now meet people of different
ages and backgrounds. Thus interpersonal skills were
needed to socialize with the people around them.18
Thus it was apparent that a number of factors were
related to the stress level of the students. Anyway,
none of the stress domains signicantly affected the
academic performance of the students (Table II).
The stress level among the students of this study was
found higher. Majorities (53%) were in high level stress
(2.01-3.00) and 39% were in severe level (3.01-4.00)
stress. Almost equal number of male (56%) and female
(50%) respondents experienced high level stress,
and 38% and 40% experienced severe level of stress
(Table III). In general, it is a common fact that life
of a medical student or health profession is stressful.
Mild, moderate, high or severe level of stress had been
reported among the students of medical and health
professions.17,25 In India the stress level was found
as high as 89.64%.26 Similarly, Muhamad, et al.,9 and
Miller,10 had reported a high prevalence of stress in
medical students, ranging from 30% to 50%. Medical
students are expected to learn and master a huge
amount of knowledge, attitudes and skills for which
they had to work hard which in turn put them under a
lot of stress.27 Knowhow of the management of stress
is of up most importance.
Many past researches found a signicant correlation
between stress and academic achievement19 in both
genders. The most common view of stress towards
academic achievement was its negative relationship
with academic performance. However, the present
study differs; it identied that the higher and severe
level stress experienced students achieved higher
CGPA (more than 3 in a 5 scale) with insignicant
difference between gender (p=.417) and residence
(p=.612) of this study (Table IV). This nding has some
similarity with Radah, et al.,28 where they found that
students of moderate degree stress performed to have
satisfactory GPAs. They reported that the moderate
stress experienced by the students is desirable for
attaining good academic performance. Sanders and
Lushington,14 explained in his study that stress gave
negative impact on academic performance, but it was
poorly related. Elias et al.,19 also found that there
was a signicant, but weak and negative relationship
between stress and academic achievement. Most
importantly, the medical students those can manage
the stress level well are associated with higher
academic performance.
Students’ perception on the impact of stress toward
academic performance revealed that 76% respondents
considered stress positively and agreed that stress

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IMJM
CONCLUSION
A student can be stressed due to so many stressors,
such as academic reason, nancial problem, health
problem or loss of close family member or friend,
etc. The main stressor identied in this study was
academic related. There was no negative correlation
between stress level and academic performances of
the students. Higher academic performance can be
achieved even with a higher level of stress, if the
students are able to manage their stress well. It is the
person’s ability to face the everyday challenges that
will determine whether he/she will be stressed or not.
Medical schools should expose the students to various
topics such as stress management, decision making in
a tough situation, breaking bad news, team building,
managing diversity, spiritual development, reective
skills, interfaith discussion, etc. in order to promote
and produce stress free holistic condent practitioners.
UKM medical students are highly resourceful to
manage their academic stress better thus denying the
effect of stress towards their academic performance.
This paper offers other medical schools and academic
planners a window or guideline for a comprehensive
use of personal and professional development
activities of the students to cope with the academic
related matters and also to develop condence among
students for better adjustment in classroom, group
and society.
ACKNOWLEDGEMENT
We would like to express our sincere thanks to the Eth-
ics Committee of the Faculty of Medicine, Universiti
Kebangsaan Malaysia for approval of this study.
motivated them for better academic performance.
Linn7 argued that stress is actually needed for learning
process.
Medical students in UKM are exposed with decision
making in a tough situation, breaking bad news, team
building, managing diversity, spiritual development,
reective skills, interfaith discussion, joint activities
with students association, movie watching with
reection, learning style, personality trait, publicly
speaking, etc. through a personal and professional
development module over the whole ve year period.
Probably, this is the reason of achieving higher CGPA
even though they experienced with the higher and
more severe level of stress. The important thing is
to learn how to manage stress. Respondent with a
high and severe level of stress are able to achieve
higher CGPA and able to do well academically when
they are capable to manage their stress well. This
is supported by Akgun,16 which explained that the
highly resourceful student manages academic stress
better thus denying the effect of stress towards their
academic performance. Students have to be exposed
to the different ideas those meant to facilitate their
lives.29
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