Abstract
Purpose and methods:
We surveyed a large sample of health-related sciences undergraduate students at the Medical University of Gdańsk (MUG), Poland in a pilot study to assess self-reported somatic/mental health-related issues, measure the level of burnout using Oldenburg Burnout Inventory (OLBI), the presence of depressive symptoms with Patient Health Questionnaire 9-item (PHQ-9) and assess the problematic alcohol intake (CAGE questionnaire). Additionally, stress coping mechanisms were investigated.
Results:
A total of 864 students participated in the survey. The mean total OLBI and PHQ-9 scores equalled 43.3 ± 2.7 and 11.3±5.8 points, respectively. The CAGE questionnaire was positive in 21.6% of students. Three most prevalent stress coping mechanisms included TV binge-watching, binge-eating and cigarette chain smoking (51.0%, 45.0% and 28.0% respectively).
Conclusions:
Future studies are required to confirm the obtained results, assess, and monitor trends and set-up interventions to improve the welfare of health-related science MUG students.
Introduction
The current health-care undergraduate students will become health-care professionals in the foreseeable future and are expected to alleviate the ever-present shortage of healthcare workers. The EU forecasted that in 2012 that the deficit will reach approximately 1 million professionals by 2020 (Matrix Insight, 2011), which corresponds well with Polish hospitals reporting 72% deficiencies of nursing staff and 68% of physicians (Kopacz, 2019).
Students, who pursue health-related science degrees at Polish universities enrol in their courses based on merits gained in sitting a competitive, advanced level entrance examination. Furthermore, they usually begin their education in late adolescence, a high-risk period for the onset of mental health issues and are made additionally more vulnerable by the intellectually demanding curricula and challenging expectations.
Medical school students are generally faced with higher stress levels than their peers (Firth, 1986). At the same time, the academic workload, work-life imbalance, environmental, financial and/or adaptation difficulties (Rezaei et al., 2019) are an integral part of their lives. Therefore, students are prone to develop distress (Abdel Wahed & Hassan, 2017; Farrell et al., 2019; Schwenk et al., 2010), have diminished academic performance (Stewart et al., 1999), disturbed perception of academic dishonesty (Rennie & Rudland, 2003; Woloschuk et al., 2004), are more prone to abuse/misuse pharmacological substances (Drancz, 1948), suffer from various health issues (Barry, 2002; Dyrbye et al., 2006; Rotenstein et al., 2016; Tennant, 2001; Volpe et al., 2019) and have increased school dropout rates (Dyrbye et al., 2010) throughout their training.
The stigmatisation of mental illness and mentally ill patients is deeply rooted in Polish society (Babicki et al., 2018) and the stigma extends into students and healthcare communities (Babicki et al., 2021; Kopera et al., 2015). The negative attitudes contribute to the reluctance of students and healthcare professionals to disclose such issues and seek help (Brooks et al., 2011; Zarzycki et al., 2020).
The comprehensive data on self-reported perception of well-being, mental and somatic health issues of health-related degrees students in Poland, including the prevalence of burnout, depressive symptoms, a potential for alcohol problems and stress coping mechanisms are scarce. Therefore, it is essential to better characterise students’ psychologic welfare and identify somatic/mental health issues to be able to better prepare and execute prevention/intervention strategies tailored to the needs of tomorrow’s healthcare cadre.
We devised a pilot descriptive study aimed at collecting the above specified information in a large sample of Medical University of Gdańsk (MUG) students. Additionally, we hoped that the simple act of survey participation will encourage students to self-reflect upon their health, wellbeing and self-care.
Materials and methods
The MUG with its four Faculties: Health Sciences, Medicine, Pharmacy and Biotechnology is the largest medical university school in northern Poland. It provides education to more than 6,000 students. Apart from a regular Polish curriculum, some courses: Medical Doctor, Pharmacy and Nursing are taught using English as the primary language of instruction. The international students constitute more than 15% of the MUG’s student population (MUG, 2021).
A one-off questionnaire survey was completed by students from January through September 2020. University staff and former students were not eligible for the participation. Survey participation was optional and not incentivized. The informed consent was assumed for all completers. Prior to survey completion, participants were explicitly informed in writing that data was collected and stored anonymously, and that students were not required to provide any personal identifiers as part of the study and could withdraw from the study at any time without any reprisal. Moreover, the responders were informed that in case they were worried about burning out, drinking too much and/or being at risk for nicotine/substance abuse/misuse the survey participation could help to self-reflect and screen for the above conditions. The participants were reminded that in case they were struggling with stress, grief or looking for advice they might want to talk to their partner, family, or friends, General Practitioners (family doctor), one of their peers in the research team or a worker of the psychological consultation service for MUG. The details of the latter services providing short term support to MUG students were included. The Bioethics Committee of the Medical University of Gdańsk approved the study before its initiation (Approval nr. NKBBN/433/2020).
The access link was sent to all students over the intranet mailing MUG service. The survey was conducted using the Google Forms platform. In order to be inclusive to all students and to encourage the participation of the international students, the survey was offered bilingually (Polish, English), and each participant was asked to take one survey only.
The survey consisted of the following parts:
Socio-demographic data: age, gender, self-reported nationality, year of study, health-related degree type, committed personal relationship status, student’s work status including the number of workhours per week and accommodation.
Somatic/mental health-related issues and personal situation: presence of serious somatic and mental conditions, intake of prescribed psychiatric medications, adaptation problems in the Tri-City metropolitan area and specifically at the MUG, thoughts about dropping out of the university during their course due to stress encountered, suicidal ideations, having or not a first degree relative who is a physician, responders’ motivation to study. The Tri-city metropolitan area consists of Gdańsk, Sopot and Gdynia.
Validated surveys to measure the level of burnout and depressive symptoms and alcohol abuse: Patient Health Questionnaire 9-item (PHQ-9), Oldenburg Burnout Inventory (OLBI), CAGE questionnaire, respectively.
Questions concerning students’ attitudes towards the stress coping mechanisms applied in the real world setting including among others physical exercise, the consumption of alcohol, tobacco and pharmacologic substances.
PHQ-9 measured the degree of depressive symptoms by having the participant respond to nine described situations with ‘not at all’, ‘several days’, ‘more than half the days’ and ‘nearly every day’. These answers were assigned numerical scores 0–3 respectively. A total score of 0–4 indicates minimal/no depression, 5–9 indicates mild symptoms, 10–14 represented moderate depression and ⩾15 is indicative of severe depression (Kroenke et al., 2001).
OLBI is a validated burnout inventory, which assesses two core dimensions of burnout: exhaustion and disengagement from work. The OLBI contains statements with which respondents were asked to indicate the extent of their agreement (Demerouti et al., 2001). The higher is the respondent’s total OLBI score, the greater is the level of the burnout (Tipa et al., 2019).
The CAGE questionnaire determines the alcohol abuse problems. A score of ⩾2 represents a ‘case’ of problem drinking (Kelpin et al., 2019; Mayfield et al., 1974).
Data was extracted into an Excel database in order to allow further descriptive comparisons. A visual inspection of data for the outliers have been rigorously performed by all authors. Data were presented as means or percentages, with standard deviations (SD) or 95% confidence intervals (CI), where applicable.
Results
Eight hundred sixty-five students completed the survey. One of the participants did not fulfil the inclusion criteria and was therefore excluded, resulting in a final analysis sample of 864 participants.
The majority of respondents were 17–21 years of age, Polish female medical students. The number of responding students spread fairly evenly from year 1 to 3 and declined in years 4 to 6. Slightly more than a half of the student cohort remained in committed personal relationship and 57.5% occupied lodgings in dormitories or rented apartments. Only 24.5% students were employed during their studies and 21.0% of them worked 1–32 hours/week (Table 1).
Socio-demographic characteristics of MUG students (N = 864).
Percentages may not total 100 because of rounding. **Individual, self-reported nationalities where single numbers constituted <1% of the students’ set.
Approximately 22% respondents reported having a first degree relative who is a physician and 87.3% chose to pursue a given degree of their own accord.
Most respondents have reported neither presence of a serious somatic nor mental conditions. Sixteen percent of students reported having serious mental medical condition, which corresponds well to 16.2% who declared taking prescribed psychiatric medication. Even though only 9.8% of the studied population agreed to have encountered significant adaptive problems at MUG, as many as 37.4% have seriously considered dropping out of the university due to the encountered stress (Table 2).
Somatic/mental health-related issues and individual personal situation (N = 864).
Percentages may not total 100 because of rounding. **Tri-city metropolitan area consists of Gdańsk, Sopot and Gdynia.
The fact that 26.3% had various degrees of suicidal ideations during studies might go hand in hand with the mean PHQ-9 score of 11.3 ± 5.8 and 56.6% students screening positively for moderate to severe depressive symptoms (Tables 2 and 3).
Results of validated surveys to measure the level of burnout, depression and screening for problem drinking/potential alcohol problems (N = 864).
Percentages may not total 100 because of rounding.
The mean OLBI score indicating the presence of burnout symptoms shows remarkably similar results between the disengagement and exhaustion domains and the distribution of total OLBI score remains quite flat for years 1–6 (Table 3).
The CAGE questionnaire test pointed towards the problematic drinking in approximately 22% students. The distribution of the CAGE scores shows a plateau for years 1–3 and tends to decrease in years 4–6. However, the latter cohorts, especially in years 5–6 included significantly fewer participants (Table 3).
Although 367 (42.5%) respondents were convinced that they must deal with stress by adopting a healthy behaviour (e.g. physical exercise, meditation), 106 (12.3%) students confirmed to have started smoking or drinking whilst at the university to cope with the stress connected to their studies. Additionally, only 9 (1.1%) students used pharmacological substances to stimulate learning activities.
The most prevalent stress coping mechanisms employed by MUG students to relieve stress-associated with studies included (double digit counts in decreasing order of magnitude): binge watching TV series >binge eating >chain smoking of cigarettes >drinking excessive amounts of alcohol >using prescription anxiolytics/antidepressants > pornography/excessive masturbation (see Table 4).
Stress coping mechanisms used to relieve stress-associated with studies (N = 864).
Percentages may not total 100 because of rounding and the fact that respondents could choose multiple activities.
Discussion
The aim of the present study was to investigate the wellbeing, somatic and mental health issues in a large sample of MUG health-related degree students.
Eight hundred sixty-four students completed the survey, which corresponds to 14.4% of the MUG students. The results show a high level of psychologic distress and morbidity among them, with 56.5% being screen-positive on the PHQ-9 for moderate to severe depression. This finding combined with the declaration that 26.3% had suicidal ideations is alarming and points out that the easily available psychological support for students is needed. The PHQ-9 screening showed a much higher incidence of depressive symptoms in MUG students compared to the number of self-reported depressive disorders diagnoses in Hong-Kong, Italian, Brazilian, Portuguese and Welsh medical students (Almeida et al., 2019; Castaldelli-Maia et al., 2019; Chau et al., 2019; Farrell et al., 2019; Volpe et al., 2019). The latter results relate better to the results of a recent metanalysis showing depression in 28% of medical students globally (Puthran et al., 2016). The reasons for the discrepancies remain unknown but may partly be explained by cultural differences regarding self-reported symptoms and the fact that medical diagnoses require a more complete work-up than the mere presence of symptoms.
Furthermore, in contrast to others (Castaldelli-Maia et al., 2019; Chau et al., 2019; Kelpin et al., 2019), our study involved a more heterogenous population including not only medical but also other health-related degree students. Finally, the application of different screening instruments could have also played a role. In case of the current survey, one cannot exclude the deleterious effects of the COVID-19 pandemics on the mental health of the respondents, a factor which was clearly not present during surveys conducted previously (Ettman et al., 2021). The mean OLBI scores for both burnout and disengagement domains equalled 21.7 ± 2.7 each and the mean total OLBI scores have fluctuated only a little among students of different years. In our study we have not established a baseline OLBI score prior to beginning of university education and thus cannot exclude that health-related degree students being ‘burned-out’ may be a universal phenomenon, not necessarily related to a particular stage of their training or perhaps even an aftermath of secondary school education.
Problematic drinking identified with the CAGE questionnaire is more prevalent among MUG health-related degree students (21.6%) than medical students in Morocco, India (8%), Portugal (10%), Hong-Kong (14%), England (18%) (Almeida et al., 2019; Chau et al., 2019; Farrell et al., 2019; Lemtiri Chelieh et al., 2019; Masri et al., 2019), but less prevalent than in Wales (24%) and Brazil (27.9%) (Chau et al., 2019). Contrary to the works of Ashton & Kamali (1995), Druncz (1948) and Newbury-Birch et al. (2001), which demonstrated increasing levels of alcohol consumption moving from lower to higher year groups, we have shown that alcohol consumption decreases with the academic advancement in training. The reason for the reversed trend remains unclear, however the decreasing number of respondents in years 4–6 might have contributed to the observed phenomenon. Our study demonstrated a relatively low percentage of pharmacological substances abuse/misuse of 7.2%. This remains higher than the what is reported in Sri-Lanka, similar to Italy, but lower than for instance in New Zealand (Almeida et al., 2019; Dahanayake et al., 2021; Rotenstein et al., 2016). While interpreting the latter results, one must bear in mind that the alcohol/pharmacological substance abuse/misuse are a taboo as they may have legal and professional conduct implications. It is feasible, that despite the anonymity offered by this survey, that under-reporting for fear of being de-anonymised has led to lower numbers. Additionally, studies suggest that students tend to believe that stress is ‘normal’ and they should be able to deal with it on their own. Further research is needed to test associations between variables related to the progress of medical training and the timing of mental disorders onset (Bhugra et al., 2016).
Given the high prevalence of psychological distress and morbidity detected by the survey, each faculty should adopt an adequate surveillance strategy concerning students’ health conditions to early identify the risk factors, set up adequate interventions and provide appropriate help within the shortest possible waiting times (Pietrzak et al., 2017; Reynolds & Patel, 2017). Unfortunately, this remains far from reality for the time being with several potential service access barriers identified at most of the medical universities in Poland (Walkiewicz & Guziak, 2021). It would be of value to further understand students’ perception, acknowledgement, utilisation, and feedback on such services. One barrier may be the stigma attached to experiencing difficulties with mental health and empowering students to talk about their mental health as a community would help to destigmatize mental illness. This is especially important as health-related sciences undergraduates are healthcare professionals of tomorrow and play a major role in the development of the next generation of healthcare professionals. The study shows a discrepancy between the students’ perception of the need to include healthy behaviours as a part of their stress coping strategies and the frequency of the most common stress relieving activities in everyday life.
Our study possesses limitations as no formalised survey completion training has been provided upfront to study participants. Additionally, the survey completed online, even if anonymity and confidentiality is guaranteed includes self-selected participants only and those suffering from any health issues are probably more likely to volunteer for it. Most of the students were full-time students and had no job to support themselves, as confirmed in other reports on a similar population in Italy or Morocco (Lemtiri Chelieh et al., 2019; Volpe et al., 2019). This probably means that most of the students are economically dependent on parents, who are more likely to push them into help-seeking should health issues be suspected and/or identified.
In our sample the number of female respondents was roughly three times higher than males, which is similar to the published data (Almeida et al., 2019; Castaldelli-Maia et al., 2019; Farrell et al., 2019), but precludes analyses on the gender as a confounding factor. The students’ population included international students and thus some of questionnaires were answered in English, which is not the native language of the individuals in the sample. The above-mentioned factors may on the one hand raise concerns about generalisability of results, but on the other the total number of respondents outweighs some selection bias.
Finally, the survey employed a convenience sampling method and thus the causality and trigger factors could not be quantified. Data about diagnoses, use of substances and medications were self-reported and not supported by a face-to-face interview.
Despite the apparent limitations, the results of our study raised concerns regarding the well-being and health of the future health-care professional represented in the survey. The results suggest the need for appropriate and urgent intervention. Our study documents a problem and its results provide a discussion platform for planning of future research involving among others further studies of a wide-ranging representative population.
Footnotes
Acknowledgements
The authors would like to thank their peers, who participated in the survey.
Authors’ contribution
All authors contributed to the study conception, data analysis and preparation of the manuscript.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability
The data that support the findings of this study are available from the corresponding author, PKK, upon reasonable request.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
