Depression, Anxiety, Stress, Sleep Quality, and Life Satisfaction among Undergraduate Medical Students in Gaza Strip: A Cross-Sectional Survey

doi:10.21203/rs.3.rs-4652744/v2

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Depression, Anxiety, Stress, Sleep Quality, and Life Satisfaction among Undergraduate Medical Students in Gaza Strip: A Cross-Sectional Survey

https://doi.org/10.21203/rs.3.rs-4652744/v2

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Background:

The medical study is demanding. Medical students are known to suffer above-average rates of depression, anxiety, stress, poor sleep, and life dissatisfaction. In turn, these disorders lower the students’ quality of life and negatively impact their performance. Little is known about the prevalence of these disorders among medical students in the Gaza Strip, which is an area marred by chronic conflict and poverty.

Methods:

This cross-sectional study assessed medical students at the two medical schools located in the Gaza Strip. Students were randomized according to university, sex, and academic level. Screening employed the DASS21, PSQI, and SWLS instruments. Categorical variables were described by count and percentages. Potential predictors of poor sleep quality were assessed by binary logistic regression. Multivariable logistic regression was implemented to determine the effect of covariates. Ordinal logistic regression was used to investigate predictors of anxiety, stress, depression, sleep quality, and SWLS stage. Statistical significance was set at a two-sided p-value less than 0.05.

Results:

In total, 362 medical students participated. Different stages of depression, anxiety, and stress symptoms were prevalent in 69%, 77.3%, and 65.2% of students, respectively. Poor sleep quality was prevalent in 77.9% of students. Also, 46.1% of medical students were dissatisfied with their lives. Poor sleep quality was associated with higher rates of all-stage anxiety, stress, and depression in univariate regression and with higher odds of moderate anxiety and mild, moderate, and extremely severe depression in multivariable regression.

Conclusions:

Depression

Anxiety

Stress

Life Satisfaction

Sleep Quality

Developing Nation

Medical Students

HRQOL

Medical students are generally known to be vulnerable to higher rates of anxiety, stress, depression, poor sleep quality, and life dissatisfaction (1–4). This can be attributed to time pressure, work overload, low social support, and the emotional and financial burdens attached to the medical study (4–7). Moreover, compared to other disciplines, medical study is mentally and physically demanding since students must efficiently handle academic and clinical responsibilities simultaneously. Medical students in the Gaza Strip are especially vulnerable due to the added burdens of the ongoing exposure to conflict for around two decades, the high population density, restrictions on movements, and poor living conditions (8, 9).

Medical students were shown to have significantly increased stress and depression levels throughout the whole undergraduate years, as compared to the baseline level at the time of matriculation (10, 11). Globally, around one-third of medical students were reported to suffer from depression (1, 12, 13). Also, a global meta-analysis showed a pooled prevalence of 33.7% for anxiety (13). The prevalence of these disorders varied according to sex, country, and continent (13). It is also unclear if these outcomes correlate with the year of medical school, as previous studies showed variable findings in this context (10, 14, 15).

The prevalence of poor sleep quality among medical students was variable across the literature, owing primarily to different measurement tools and cultural and environmental factors. Meta-analysis studies showed a concerning global prevalence between 52.7% and 55.6% for poor sleep quality in this population (2, 16). On the other hand, although less frequently measured, satisfaction with life is another significant outcome in medical students that reflects their general well-being. Life satisfaction is strongly linked to resilience and self-reported mental health and is inversely related to stress (17, 18). In a longitudinal nationwide study from Norway, life satisfaction gradually declined throughout medical school (19). Even more concerning is the fact that this trend was also noted among graduated doctors as far as ten years into their professional lives (20). Also, a study from Saudi Arabia reported that a quarter (24.7%) of surveyed medical students were dissatisfied with their lives (21).

This study aims to evaluate the prevalence and predictors of stress, anxiety, depression, poor sleep quality, and life dissatisfaction among medical students in the Gaza Strip. Measuring the prevalence of these conditions and investigating their predicting factors is essential to designing and implementing evidence-based strategies that tend to the needs of the local student population and attempt to improve their quality of life. Furthermore, it is important to document the prevalence of these variables in an area of chronic conflict and poor living conditions, such as the Gaza Strip.

2.1. Design and population

This cross-sectional study implemented the stratified sampling method to survey medical students from different academic levels who study at the Faculty of Medicine at the Islamic University of Gaza (IUG) or the Al-Azhar University (AUG), the two medical schools located in the Gaza Strip. The minimal sample size necessary to achieve a 95% confidence interval (CI) was 328, determined using the Raosoft Inc. online calculator. The calculator was set at CI 95%, a margin of error of 5%, a population size of 2200 students, and a response distribution of 50%. An additional 12% was then added to account for anticipated non-responders. Thus, the final targeted sample consisted of 373 students. The stratified randomization method was used. Students were divided into strata based on university, sex, and study level. Depending on the number of students in each stratum, the number of participants was calculated as a proportion of the final sample size. Then, lists, including the students' names in each stratum, were ordered alphabetically and numbered. Finally, random numbers representing participants’ numbers were generated for each list using an online randomization application (www.randomizer.org/). Data collection sheets were prepared in English, printed, and handed to the selected participants during the breaks between classes. Data was collected between March and May 2022.

2.2. Measurement tools

Demographics collected included age, marital status, monthly income, and academic level. Depression, anxiety, and stress were assessed using the Depression Anxiety and Stress Scale 21 (DASS21), which is comprised of 21 items divided over three subscales that measure Depression, Anxiety, and Stress, respectively (22). Each subscale consists of seven items graded 0–3 on a Likert scale. The following cutoff scores were used for depressive symptoms: Normal (0 to 9), Mild (10 to 13), Moderate (14 to 20), Severe (21 to 27), Extremely Severe (28 and above). As for anxiety, the cutoff scores were Normal (0 to 7), Mild (8 to 9), Moderate (10 to 14), Severe (15 to 19), and Extremely Severe (20 and above). For stress, cutoff scores were Normal (0 to 14), Mild (15 to 18), Moderate (19 to 25), Severe (26 to 33), and Extremely Severe (34 and above) (23). DASS21 has been well-validated in clinical and community populations against clinician-administered interviews, which is the gold standard (24). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) (25), which consists of 19 items covering seven sleep-related components, each yielding a score ranging from 0–3, with three indicating the most significant dysfunction. The total PSQI score ranges from 0–21, and we used a cut-off score of 5 (25). At this cutoff, the sensitivity and specificity for identifying cases with sleep disorders are 89.6% and 86.5%, respectively (26). Life satisfaction was assessed using the Satisfaction with Life Scale (SWLS), which consists of five items, each graded between one (Strongly Disagree) and seven (Strongly Agree) on a Likert scale, with possible scores ranging from 5–35 and a score of 20 representing a neutral score (27). Scores were interpreted as Extremely Dissatisfied (5 to 9), Dissatisfied (10 to 14), Slightly below average in life satisfaction (15 to 19), Average life satisfaction (20 to 24), satisfied (26–30), and extremely satisfied (31–35) (27). The validated English versions of each score were used.

2.3. Ethical considerations

Ethical approval

was obtained from the IRB at the Islamic University of Gaza (approval ID 07/2022, dated 21 March 2022). Administrative approvals were obtained from the deanships of the IUG and AUG medical schools. Written consent was obtained from participants. Data confidentiality was guaranteed and maintained throughout the collection and interpretation phases.

2.4. Statistical analysis

Categorical variables were described by count, and percentages were rounded to one decimal point. Potential predictors of poor sleep quality were assessed by binary logistic regression. Multivariable logistic regression was implemented to determine the effect of covariates. Ordinal logistic regression was used to investigate predictors of anxiety, stress, depression, and SWLS stage. Statistical significance was set at a two-sided p-value less than 0.05. Statistical analyses were performed using SPSS (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.).

3.1. Characteristics of the study sample

In total, 362 medical students completed our survey (response rate 97.0%). Females represented 54.4% of the sample, and only 3.3% were married. Nearly half (52.2%) of the students had a medium household income of 2000–4999 New Israeli Shekels (NIS), and only 14.1% had a higher income (> 5000 NIS). Table 1 lists the socio-demographic and academic characteristics of the study sample.

Table 1

Socio-demographic and academic characteristics of respondents (n = 362).
Characteristic	Frequency (%)
Sex
Female	197 (54.4)
Male	165 (45.6)
Marital status
Single	350 (96.7)
Married	12 (3.3)
Household monthly income (NIS)
<2000	122 (33.7)
2000–4999	189 (52.2)
>5000	51 (14.1)
Academic year
First	86 (23.8)
Second	82 (22.7)
Third	52 (14.4)
Fourth	59 (16.3)
Fifth	43 (11.9)
Sixth	40 (11)

3.2. Prevalence and predictors of depression, anxiety, and stress (DASS21)

Different stages of depression, anxiety, and stress were prevalent in 69%, 77.3%, and 65.2% of students, respectively. Student distribution among stages is shown in Table 2.

Table 2

Rates of mild, moderate, severe, and extremely severe depression, anxiety, and stress (DASS21) among medical students, n = 362.
Factor	Frequency (%)
Depression
Normal	112 (30.9)
Mild	48 (13.3)
Moderate	120 (33.1)
Severe	37 (10.2)
Extremely severe	45 (12.4)
Anxiety
Normal	82 (22.7)
Mild	27 (7.5)
Moderate	93 (25.7)
Severe	57 (15.7)
Extremely severe	103 (28.5)
Stress
Normal	126 (34.8)
Mild	76 (21)
Moderate	79 (21.8)
Severe	61 (16.9)
Extremely severe	20 (5.5)

No statistically significant associations were detected between depression, anxiety, or stress levels with sex, academic year, marital status, or household monthly income.

3.3. Prevalence and predictors of sleep quality (PSQI)

Poor sleep quality was prevalent in 77.9% of students. Sex, household monthly income, marital status, academic year, and SWLS score were not significantly associated with poor sleep quality. Conversely, poor sleep quality was associated with higher rates of all-stage anxiety, stress, and depression, as shown in Table 3. After multivariable regression, poor sleep quality was associated with higher odds of moderate anxiety as well as mild, moderate, and extremely severe depression.

Table 3

Univariate and multivariable binary logistic regression analysis of predictors for sleep quality (PSQI), n = 362.
Factor	Univariate			Multivariable
Factor	p value	OR	95% CI	p value	OR	95% CI
Sex
Female	ref	ref	ref
Male	0.249	0.75	0.45–1.23
Family monthly income (NIS)
< 2000	ref	ref	ref
2000–4999	0.252	1.1	0.5–2.8
> 5000	0.229	3.8	1.1–12.7
Marital status
Single	ref	ref	ref
Married	0.347	0.56	0.16–1.89
SWLS score	0.884	0.88	0.84–0.93
Academic year
1st	ref	ref	ref
2nd	0.268	1.62	0.69–3.80
3rd	0.073	2.28	0.93–5.59
4th	0.155	2.05	0.76–5.49
5th	0.755	1.15	0.47–2.80
6th	0.834	1.11	0.43–2.86
Anxiety level
Normal	ref	ref	ref	ref	ref	ref
Mild	0.018*	3.62	1.25–10.48	0.151	2.3	0.74–7.14
Moderate	< 0.001*	4.64	2.27–9.49	0.016*	2.61	1.20–5.66
Severe	0.008*	2.78	1.31–5.93	0.842	0.91	0.36–2.30
Extremely severe	< 0.001*	6.88	3.21–14.73	0.297	1.71	0.62–4.72
Depression level
Normal	ref	ref	ref	ref	ref	ref
Mild	0.001*	4.39	1.81–10.64	0.008*	3.46	1.37–8.73
Moderate	< 0.001*	4.54	2.41–8.58	0.006*	2.96	1.37–6.38
Severe	0.002*	4.8	1.74–13.23	0.169	2.36	0.70–7.97
Extremely severe	< 0.001*	10.5	3.07–35.91	0.019*	5.86	1.33–25.68
Stress level
Normal	ref	ref	ref	ref	ref	ref
Mild	0.002*	3.08	1.54–6.19	0.105	1.9	0.87–4.14
Moderate	< 0.001*	3.93	1.89–8.17	0.14	1.94	0.81–4.69
Severe	< 0.001*	7.13	2.67–19.04	0.051	3.25	0.10-10.61
Extremely severe	0.023*	5.73	1.27–25.77	0.464	1.92	0.34-11.00

3.4. Prevalence and predictors of life satisfaction (SWLS)

Just under half (46.1%) of medical students were dissatisfied with their lives. Table 4 illustrates the prevalence of varying levels of satisfaction with life among students. Life satisfaction was not significantly associated with sex, marital status, study year, or household monthly income.

Table 4

Distribution of life quality stages measured by SWLS among medical students, n = 362.
SWLS stage	Frequency (%)
Extremely dissatisfied	12 (3.3)
Dissatisfied	42 (11.6)
Slightly dissatisfied	113 (31.2)
Normal	22 (6.1)
Slightly satisfied	101 (27.9)
Satisfied	60 (16.6)
Extremely satisfied	12 (3.3)

In the present study, we evaluated a robustly randomized sample of medical students, employing several instruments to assess different aspects of their psychological, mental, and physical health and establish a multidimensional construct of their well-being. Previous studies from Palestine have yet to be conducted. Therefore, we discuss our findings in the context of insights from other countries and the global literature.

The prevalence of depressive symptoms was high in our study (69%, roughly representing two-thirds of the students), with nearly a fifth of students (22.6%) reporting scores suggesting severe or extremely severe symptoms. Pooled prevalence from different metanalyses was lower (37.9%, 18.1%, 28.0%, and 27.2%, respectively) (13, 28–30). Looking at individual studies, a lower prevalence was also reported from various regions (1, 12, 31, 32), including from neighboring Jordan, where a recent survey of female medical students using the DASS21 instrument reported a pre and post-COVID prevalence of any level of depression of 32.7% and 53.5%, respectively (33). Nonetheless, a high prevalence was not unheard of and has been seen in other regional countries that share a similar culture. For example, a 2018 study of 2562 students from Saudi Arabia using the PHQ9 instrument reported various levels of depressive symptoms in 66.6% of males and 87.6% of females, and nearly half (53.7%) showed symptoms of moderate severity and above (34). In another study from Egypt, 27.9% and 17.2% reported moderate and severe symptoms of depression, respectively (35). Part of the high prevalence in our study might be owed to differences in measurement tools and cutoff scores compared to other studies. Still, we also believe that the physical, social, and economic pressures of living in a poor enclave scarred by chronic conflict also contributed to these results.

Additionally, medical study is competitive by nature, and socioeconomic pressures naturally exacerbate this burden. This alarmingly high prevalence of depressive symptoms in our cohort must be addressed promptly and with seriousness. Stigma towards mental illness is pervasive in the medical field, which hampers student’s ability to seek help (36, 37). For instance, a meta-analysis showed that only 15.7% of positively screened medical students sought psychiatric treatment (30). Additionally, suicidal ideation is common, especially in severe depression, and has been reported in 4.9–35.6% of depressed medical students across the literature (30). Medical student depression has also been linked to substance abuse and negatively impacted their function and professionalism later in their careers (38).

Depressive symptoms in our study had no significant correlations with sex, academic year, marital status, or income. Other studies have reported mixed results in this regard. For instance, some studies and meta-analyses found that female students were significantly more likely to show symptoms of depression (13, 28), while others failed to demonstrate this relationship (29). The lack of a significant correlation between female sex and depression in our cohort may be due to cultural differences from other regions, and a similar lack of such correlation was noted in the aforementioned Saudi study from 2018 (34). The same study also did not find a significant relationship between marital status and depression.

On the other hand, studies have reported mixed results on the relationship between depression and the academic level. A higher academic level predicted depression in some studies (28), while others noted the opposite finding (29, 34), and in others, no correlations were found (30). Depression is a complex condition, and sociodemographic and cultural peculiarities may explain these interactions or lack thereof between different countries and regions. To curate depression among students, medical schools need to address the issue of stigma, guarantee high-quality psychiatric services to the students, and seek strategies to reduce stress in their environment.

Symptoms of anxiety and stress were also high among our students, found in 77.3% and 65.2% of participants, respectively. Such high levels are common among medical students and can be attributed to medical school's competitiveness, heavy workloads, responsibilities, and peer pressures. Still, the prevalence was higher than reported in several studies from neighboring countries. In the previously mentioned Jordanian survey, the rates of anxiety and stress after the pandemic were 53.2% and 35.8%, respectively. In the Saudi study, the prevalence of stress was 57%. Similarly, a prevalence of 53% was reported in an Indian study that used the DASS21 instrument (34, 39). Meanwhile, a mixed study from Pakistan revealed a 92.5% prevalence of moderate and severe stress (40). Stress negatively impacts students’ performance, worsens depression, and impacts the quality of life (34). Regarding anxiety, a meta-analysis reported a pooled prevalence of 33.8%, which was highest in Middle Eastern and Asian countries, but the range varies across individual studies (41). In India, anxiety was reported in 66.9%, while Egyptian and Saudi studies reported a prevalence of 78.4% and 60.8%, respectively, measured using DASS21 (41). On the other hand, the prevalence among Saudi clinical-level students was 31.7% when screened using GAD-7 (42). These numbers reflect the impacts of social and cultural factors and the variations in measurement tools and cohort demographics on results. Still, they do not nullify the impression that medical students are highly anxious. Stress and anxiety have been generally linked to lower academic performance among medical students, and, at the same time, a lower perceived performance was associated with higher anxiety and stress, laying forth a feedback loop that should be broken (40, 43). Potential measures include extracurricular activities, offering counseling and life coaching, practicing mindfulness, promoting mental health awareness, and advocating activities that promote personal engagement and positive interpretation and expression of emotion (44, 45).

Adequate sleep quality and quantity are important health indicators and represent physiological imperatives that must be fulfilled for an individual to achieve his or her cognitive potential (46). Poor sleep quality was highly prevalent in our sample (77.9%). In neighboring Jordan, 47.4% of medical students were found to have poor or just fair sleep quality when screened using the SQS instrument (47). An Iranian study that used PSQI and DASS21 instruments reported a 60% prevalence of poor sleep, which, similar to our study, was significantly correlated to depression and anxiety (48). Also, similarly, sex and academic level were not significantly linked to poor sleep. In Morocco, poor sleep was found in 81.7% of students (49). The trend of poor sleep among medical students is global, with a pooled prevalence in meta-analyses ranging from 52.7%-60.3% (2, 16, 50). Comparatively, insufficient sleep affects a quarter to a third of the adult population globally (51). The high prevalence of poor sleep among medical students is related to the high prevalence of mental health problems, particularly depression, anxiety, and stress, which are, in turn, associated with the remarkable burdens of medical study. These are known to influence sleep quality negatively, as demonstrated in our study and many others (48, 52, 53). Additionally, the clinical duties of medical training may include night shifts, which disturb the sleep schedule and impair sleep hygiene.

On the other hand, poor sleep itself may worsen depression, anxiety, and burnout, and it has been linked to lower performance in clinical examinations (54). It can also affect neurocognitive functioning, psychological well-being, academic performance, and metabolic and immunological systems; thereby, it is important to tackle this issue among medical students (55–58). Medical schools should address this problem by offering sleep hygiene and cognitive behavioral therapy-based interventions (52). For example, a sunrise alarm clock intervention combined with electronic device removal at bedtime proved effective in improving sleep quality and a number of mental and psychological health indicators among medical students (59). Continuous surveillance is mandatory for the effective, evidence-guided administration of the interventions. Additionally, regardless of the directionality of causation, depression and anxiety need to be treated to improve sleep. Furthermore, students should be encouraged to moderate their caffeine consumption and avoid smoking and smartphone addiction (48).

Life satisfaction is a multidimensional, subjective construct representing an important indicator of the individual’s quality of life (60). It has been defined as a subjective judgment and feeling of contentment that an individual can identify when their needs or desires are being fulfilled (61). As such, stress, anxiety, depression, and poor sleep quality can be expected to contribute to feeling dissatisfied with life. Surveys of medical students have demonstrated such inverse relationships between life satisfaction and depression (62), anxiety (62), stress (63–65), and sleep quality (65). Thus, It is not surprising that life satisfaction is lower among medical students than in other disciplines (66). Also, a temporal trend was noted where life satisfaction lowered as students progressed through medical school (66). In our study, only 55.9% of students fell on the positive end of the life satisfaction spectrum. A high prevalence of depression, anxiety, stress, poor sleep, and the burdens of living in a chronic conflict zone with a socioeconomically disadvantaged society surely contributed to this finding. In this regard, a recently published study on the general population in Gaza established a negative correlation between quality of life and rates of depression, anxiety, and stress (67). The correlation of life satisfaction with students’ academic level was not demonstrated by our cohort, which may be because the other factors mentioned played a relatively more significant role in students’ perceptions of their lives.

The present study is the first to be carried out in the Gaza Strip. It has the added strengths of a large sample size and stratified sampling. It also used different tools to provide a multidimensional overview of medical students’ well-being. On the other hand, although the study employed well-validated instruments, structured interviews remain the gold standard for a formal psychiatric diagnosis. Future studies are recommended to use mixed designs to provide deeper insights. Also, the cross-sectional design of the present study precludes the possibility of establishing causality for the findings, which future longitudinal studies should address.

Medical students in the Gaza Strip suffer from high rates of depression and anxiety symptoms, stress, poor sleep, and life dissatisfaction compared to medical students from several other countries and the pooled global prevalence reported in meta-analysis studies. The chronic conflict and poor socioeconomic conditions in the Gaza Strip likely exacerbated these rates. Medical schools in Gaza should put forward strategies to limit the psychological burdens perceived by their students. The Gaza war in 2023–2024 may further impact the students’ psychological and mental well-being; thus, another study is recommended to assess this assumption.

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Institutional Review Board (IRB) at the Islamic University of Gaza. Participants provided informed written consent. Confidentiality of the data was maintained throughout data collection and analysis.

Consent for publication

Not Applicable.

Availability of data and materials

Available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The study was not funded.

Authors' contributions

BA, RJ, OA, and MA: Conceptualization, literature review, study design, and tool development. BA: Sample randomization. All authors contributed to data collection. BA, RJ, and OA: data analysis and interpretation. BA and RJ led the writing of the study manuscript. All authors contributed to the manuscript revision and have approved the final version.

Acknowledgments

Not applicable

Islamic University of Gaza (IUG)

Al-Azhar University (AUG)

Depression Anxiety and Stress Scale 21 (DASS21)

Pittsburgh Sleep Quality Index (PSQI)

Satisfaction with Life Scale (SWLS)

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The authors declare no competing interests.

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Depression, Anxiety, Stress, Sleep Quality, and Life Satisfaction among Undergraduate Medical Students in Gaza Strip: A Cross-Sectional Survey

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Abstract

1. Background:

2. Methods

2.1. Design and population

2.2. Measurement tools

2.3. Ethical considerations

2.4. Statistical analysis

3. Results:

3.1. Characteristics of the study sample

3.2. Prevalence and predictors of depression, anxiety, and stress (DASS21)

3.3. Prevalence and predictors of sleep quality (PSQI)

3.4. Prevalence and predictors of life satisfaction (SWLS)

4. Discussion

5. Conclusions

Declarations

Abbreviations

References

Additional Declarations

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