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The impact of student life stress on health related quality of life among doctor of pharmacy students.

The purpose of this study was to examine the association between student-life stress and health related quality of life (HRQOL) among Doctor of Pharmacy (Pharm.D.) students. Data were collected for 166 students in the first three years of a Pharm.D. curriculum. Student-Life Stress Inventory scores were significantly negatively correlated to mental component SF-12 HRQOL scores (p<0.004) for the overall sample (r = -0.58), gender (rfemale = -0.56, rmale = -0.56) and within each professional year (rfirst-year = -0.50, rsecond-year = -0.49, rthird-year = -0.68). However, z-tests indicated that the magnitude of the correlations did not vary significantly by gender or year in the curriculum. Strategies are needed to reduce Student-Life Stress and improve the mental component of HRQOL.

Introduction

The intensity of the Doctor of Pharmacy (Pharm.D.) curriculum requires enormous commitment and hard work by students. The intense curriculum may produce stress on the pharmacy student's life. The Pharm.D. curriculum typically involves two years of pre-pharmacy coursework after high school, followed by four years in the professional pharmacy curriculum. The transition from the pre-pharmacy curriculum, which is similar to an undergraduate program, to the professional Pharm.D. curriculum involves significant change. Morevover, the curriculum requirements vary significantly during the four years of matriculation in the Pharm.D. program. The transition from an undergraduate program to a professional program has been reported to result in increased stress levels for students (Beck, Hackett, Srivastava, McKim, & Rockwell, 1997). In the hope of preparing students for their future roles as pharmacists, it is important to identify stressful factors that may affect their successful development. This is especially true since student stress has been associated with a variety of negative outcomes, including effects on general and health-related quality of life (Hudd, Dumplao, Erdmann-Sager, Murray, Phan, Soukas, & Yokozuka, 2000; Damush, Hays, & DiMatteo, 1997).

Lazarus and Folkman (1984) describe stress as a specific stimulus-response transaction, which threatens an individual. One study identified the major academic stressors among college students to be tests, grade competition, time demands, professors and classroom environment, and career and future success (Murphy & Archer, 1996). Another study reported that stress may be associated with the type of institution the student attends (e.g., public, private, undergraduate, professional or graduate) (Hudd et al., 2000). Misra, McKean, West, and Russo (2000) found that academic stress among college students varies across year in school and gender. Specifically, freshmen and sophomores had higher academic stress levels than juniors and seniors, and females reported higher academic stress than males. Interestingly, this study found that the levels of academic stress perceived by students and their faculty varied. Faculty members' perceptions of student academic stress and reactions to stressors were higher than students' self-perceptions. Because faculty members most often observe students during class time, the results of this observation could imply that students experience their largest amount of stress during class hours (Misra, et al., 2000).

The literature is replete with evidence that students in health professional programs also suffer from stress. Most of these studies have been performed in medical, dental and nursing students (Beck, & Srivastava, 1991 ; Coburn, & Jovaisas, 1975; Davis, Tedesco, & Meier, 1989; Hamill, 1995; Helmers, Danoff, Steinert, Leyton, & Young, 1997; Vitaliano, Maiuuro, Mitchell, & Russo, 1989). Surprisingly, only two studies have been reported that measured stress levels among pharmacy students in United States. The first study focused on perceived stress levels among students in a Bachelor of Science pharmacy program and found that stress levels were not related to any of the demographic variables, including age, gender and involvement in professional student organizations (Ortmeier, Wolfgang, & Martin, 1991). The second study, which measured stress among students in Pharm.D. programs found that financial burdens, unsupportive faculty, absence of a counseling service, excessive study load, English not being the first language and not being a minority student were significant predictors of stress (Dutta, 2001). Both of these studies have measured stress among pharmacy students during one specific academic year in the curriculum.

The limitation of the published literature related to student-life stress in pharmacy students is that no research has been reported pertaining to student-life stress and its effect on health-related quality of life (HRQOL) among pharmacy students. Additionally, the relationship between student-life stress and HRQOL across different years in the Pharm.D. curriculum has not been reported. Answers to these questions would help pharmacy educators develop first, an understanding or awareness of the impact of student-life stress on students HRQOL, and second, programs to alleviate student-life stress as pharmacy students progress though the curriculum.

The purpose of this study was to examine the association (correlation) between student-life stress and health related quality of life among Doctor of Pharmacy students at a college of pharmacy in the southwestern United States. The first objective of this study was to compare the magnitude of the association between student-life stress and health-related quality of life between male and female students in the Pharm.D. program. The second objective was to compare the magnitude of the association of student-life stress and health related quality of life between first, second, and third year students in the Pharm.D. program.

METHODS

Subjects and Data Collection

The subjects were students enrolled in fall semester 2001 courses across the first three years of the Pharm.D. curriculum at the University of New Mexico College of Pharmacy. First year students were enrolled in the required Social and Epidemiological Pharmacy course. Second and third year pharmacy students were enrolled in the required Pharmacy Practice Research course that was offered jointly to students in both years of the curriculum. Information was collected using a self-administered questionnaire which was administered to students during regular class time with the permission of the instructor of record for the above mentioned courses. Data were collected during the week after the fall semester break. Questionnaires were administered during the same week to minimize the effect of varying stress levels that may have occurred during the semester. Participation was voluntary and students were instructed that they could refuse to participate in the study or that they could stop completing the questionnaire at any time. The study was approved by the University of New Mexico Health Sciences Center Human Research Review Committee with exempt status. Therefore, completion of consent forms were not required by subjects.

Study Questionnaire

The self-administered study questionnaire (68 questions) was comprised of three sections; student -life stress, health related quality of life and a demographic section. Student -life stress information was collected using the Student-Life Stress Inventory (SLSI) developed by Gadzella (1994). The SLSI is a 51-item questionnaire with a Likert type response format (1 = never, 2 = seldom, 3 = occasionally, 4 = often, 5 = most of the time). The SLSI consists of two sections: types of stressors and reactions to stressors. The types of stressors section is comprised of five categories (frustrations, conflicts, pressures, changes, and self-imposed). The reactions to stressors section is comprised of four categories (physiological, emotional, behavioral, and cognitive). Scores can be calculated for the total inventory, for each section, or for each category by adding the responses for the respective items. Total inventory scores were used in this study. The Student-Life Stress Inventory was used in this study since it's potential respondent burden was acceptable, it was easy to self-administer and it had an acceptable previously reported internal consistency estimate (Cronbach's alpha = 0.76) (Gadzella, 1994). The Cronbach's alpha value for the Student-Life Stress Inventory was 0.93 in the current study.

Health-related quality of life was measured using the Medical Outcome Study SF-12 Health Questionnaire. The SF-12 Health Questionnaire was used to measure physical (PCS12) and mental (MCS12) domains of health-related quality of life (Ware, Kosinski, & Keller, 1995). The SF12 was used because it is a widely used HRQOL measure and has been reported to have excellent reliability and validity (Ware et al., 1995). Demographic variables collected were gender, age, marital status, race and current year in the Pharm.D. curriculum.

Data Analyses

Descriptive statistics were used to characterize the sample. Mean Student-Life Stress Inventory, PCS-12 and MCS-12 scores were compared for females and males using independent t-tests. Mean scores on the Student-Life Stress Inventory, PCS12 and MCS-12 were compared across students in the first, second and third years in the Pharm.D. curriculum using one-way ANOVA. The relationship between Student-Life Stress Inventory scores and PCS-12 and MCS-12 scores was assessed using Pearson product-moment correlation coefficients. Correlation coefficients were calculated for females and males, and for each of the three different years of the Pharm.D. curriculum. The difference in the magnitude of the correlation coefficients between females and males, and between each of the three years in the Pharm.D. curriculum were compared using a z-test (Kanji, 1993). An a priori significance level of 0.05 was used for the independent t-test and ANOVA. Since twelve correlation coefficients were calculated, a Bonferroni adjusted significance level of 0.004 was used for the correlational analyses. All statistical analyses were performed using the SPSS-PC Version 11.0 statistical package.

RESULTS

A total of 184 questionnaires were administered. Only questionnaires with all items completed on the Student-Life Stress Inventory and the SF-12 section of the questionnaire were considered useable. This resulted in 166 questionnaires (88.2% usable response rate) being used in the data analyses. Demographic characteristics and descriptive statistics for the study sample are presented in Table1. About one third of the sample were male (n = 56). The sample consisted of 65 first-year, 56 second-year, and 45 third-year students in the Pharm.D. curriculum. The mean age of the sample was 26.73 (S.D. = 5.43), with a range of 20 to 46 years.

Descriptive statistics were obtained for the Student-Life Stress Inventory (SLSI), PCS-12 and MCS-12 scores for all students in the sample. The mean Student-Life Stress Inventory total inventory score for all students in the sample was 141.06 (SD = 26.14), with a possible range of 51 to 255. Higher scores on this inventory represent more stress. The mean physical component (PCS 12) HRQOL score for the entire sample was 51.55 (SD = 8.51); the mean mental component (MCS12) HRQOL score was 38.6 (SD = 11.25). The possible range for the respective HRQOL component scores is 0 to 100, with higher scores representing better physical (PCS-12) or mental (MCS-12) health.

Comparison in SLSI, PCS-12 and MCS- 12 scores by gender are presented in Table 2. Females had significantly higher total Student-Life Stress Inventory scores and significantly lower mental component HRQOL (MCS-12) scores than males. The physical component HRQOL (PCS-12) scores for females and males were not significantly different. Mean Student-Life Stress Inventory scores were significantly higher for third year Pharm. D. students than first year Pharm. D. students (Table 3). Also, HRQOL mental component scores (MCS-12) for third year Pharm. D. students were significantly lower than first year Pharm. D. students (Table 3). No significant differences were found for physical component scores (PCS-12) across the three years in the Pharm. D. curriculum.

The correlation coefficient results between the Student-Life Stress Inventory and the physical (PCS-12) and mental (MCS-12) component health related quality of life scores for the study sample are presented in Table 4. For the overall sample, there was a negative and significant (r = -0.58, p<0.004) correlation between the Student-Life Stress Inventory score and the HRQOL mental component score (MCS12). The Student-Life Stress Inventory score was negatively, significantly, and identically correlated to the mental component (MCS- 12) HRQOL scores for both females and males (r = -0.56, p<0.004). The relationship between Student-Life Stress Inventory and mental component (MCS-12) HRQOL score was negative and significant at the p< 0.004 level for students in each of the three respective class years(r = -0.50, r = -0.49, and r = -0.68) of the Pharm.D. curriculum. However, as indicated by the z-test, the magnitude of the correlation coefficients between the SLSI and the MCS-12 did not vary significantly across the three respective class years.

The relationship between Student-Life Stress Inventory and the physical component (PCS-12) HRQOL score was not significant for males, females, or any of the three years in the Pharm. D. curriculum, respectively (Table 4). Additionally, the z-test indicated that the magnitude of the correlation coefficients between the SLSI and the PCS-12 did not vary significantly across genders or the three respective class years.

DISCUSSION

Our results suggest a moderate, negative relationship between perceived student-life stress levels and the mental component of health related quality of life among Pharm.D. students. These results are consistent with those obtained in a study conducted by Damush et al. (1997), in which college students who reported experiencing stressful life events had poorer mental health. Hudd et al. (2000), also showed that higher stress scores among college students were related to lower levels of self-esteem and reduced perceptions of general health.

It is interesting to note that student-life stress levels increased, and mental health component HRQOL scores (MCS-12) decreased, as students were at more advanced stages in the Pharm.D. curriculum. However, magnitude of the relationship (correlation) between student-life stress and the mental component of HRQOL did not vary significantly across the three years in the Pharm. D. curriculum. This indicates that student-life stress is related negatively, and uniformly, related to the mental component of HRQOL across the first three years of the Pharm.D. curriculum.

Student-Life Stress Inventory scores were significantly higher for females than males. This result is consistent with a previous study which indicated that female students experience higher stress levels than male students (Misra et al, 2000). Also, mental component HRQOL scores (MCS-12) for females were significantly lower than those for males. It is logically intuitive that since females had higher stress scores, they should have correspondingly lower mental component HRQOL scores. However, the magnitude of the correlation coefficient between student-life stress and the mental component of HRQOL did not vary across genders. This result is consistent with the findings of Damush et al. (1997) which showed that the relationship of stressful life events and mental health were not moderated by gender.

It is important to consider the implications of this study. Though it is unclear whether the relationship of student-life stress to the mental component of HRQOL affected academic performance among the Pharm.D. students in this study, there is evidence to indicate that stress does affect academic performance among graduate students and medical students (Hodgson, & Simoni, 1995; Blumberg, & Flaherty, 1985). This indicates that any strategies to alleviate life-stress among college students could help improve academic performance.

The limitations of the study need to be considered before generalizing the results obtained. Since all questionnaires were administered after fall semester break it is possible that Student-life Stress Inventory scores could have been lower and HRQOL scores could have been higher than if questionnaires were administered at other more stressful times during the semester. This study was cross-sectional in nature and therefore varying stress and HRQOL scores throughout the semester could not be captured. Longitudinal studies are needed to address this issue. Because the subjects were volunteers, it is possible that varying stress levels could have affected the students' choice to participate in the survey. We assumed that the variation seen in stress levels was due to the level of school year, rather than differences between subjects.

In our study we did not include fourth year Pharm.D. students due to the fact that they were doing clinical rotations in different parts of New Mexico and the United States, and it was difficult to track each student's location. Therefore, further studies should be performed to include fourth year Pharm.D. students in order to accurately assess stress levels throughout the whole curriculum. Finally, since this study was performed at one college of pharmacy the results should be generalized to other colleges of pharmacy with caution. A national study including all colleges of pharmacy is warranted.

CONCLUSIONS

Higher student-life stress was related to lower mental health component HRQOL scores in this sample of Pharm.D. students. Strategies should be developed to reduce Student-life Stress and improve the mental component of HRQOL in these students. Additional research is needed to assess the impact of the relationship of student-life stress and the mental component of HRQOL on academic performance among Pharm.D. students.
Table 1
Demographic Characteristics for Sample (n = 166)

           First year     Second year    Third year        All
            students       students       students       Students
             n (%)          n (%)          n (%)          n (%)

Year       65 (39.7)      56 (33.7)      45 (27.1)      166 (100)
Male       19 (29.2)      21 (37.5)      16 (35.6)      56 (33.7)
Female     46 (70.8)      35 (62.5)      29 (64.4)      110 (66.3)
Age (a)    25.41 (5.12)   28.16 (6.50)   26.86 (3.76)   26.73 (5.43)

NOTE: (a) Mean (standard deviation)

Table 2
Comparison in Student-Life Stress Inventory and Physical (PCS-12) and
Mental (MCS-12) Component Health Related Quality of Life Scores by
Gender (n = 166)

                   Female      Male        T-Test  p value
                   (n = 110)   (n = 56)

                   Mean        Mean
                   (S. D.)     (S. D.)

Student-Life       145.20      133.00      -2.90   0.004
Stress inventory
(SLSI)             (24.60)     (27.40)

Physical                       52.11       0.61    0.546
Component of       51.30
HRQOL                          (7.68)
(PCS-12)           (8.92)

Mental             36.79       42.14       2.97    0.003
Component of
HRQOL              (11.11)     (10.74)
(MCS-12)

Table 3
Comparison in Student-Life Stress Inventory and Physical (PCS-12)
and Mental (MCS-12) Component Health Related Quality of Life Scores
by Year in PharmD Curriculum
(n = 166)

                         First         Second        Third
                          year          year          year
                        students      students      students
                        (n = 65)      (n = 56)      (n = 45)

                          Mean          Mean          Mean
                        (S. D.)       (S. D.)       (S. D.)

Student-Life Stress
Inventory               133.43 *       143.87       148.60 *
(SLSI)
                        (23.95)       (22.77)       (30.44)

Physical Component
of HRQOL                 51.08         51.34         52.50
(PCS-12)
                         (7.71)       (10.20)        (7.31)

Mental Component of
HRQOL                   40.91 *        38.34         35.60 *
(MCS-12)
                        (11.38)       (10.12)       (11.87)

                         ANOVA        p value
                        F value

Student-Life Stress       5.22         0.006
Inventory
(SLSI)

Physical Component        0.38         0.683
of HRQOL
(PCS-12)

Mental Component of       3.09         0.048
HRQOL
(MCS-12)

Note: * Denotes means that are statistically significantly different
(p<0.05) using the Scheffe post-hoc test.

Table 4
Correlation Coefficient Results Between the Student-Life Stress
Inventory (SLSI) and the Physical (PCS-12) and Mental (MCS-12)
Component Health Related Quality of Life Scores

TOTAL SAMPLE
(n=166)               SLSI-PCS12           -0.18
                      SLSI-MCS12           -0.58 *
GENDER

Male (n=56)           SLSI-PCS12           -0.21
                      SLSI-MCS12           -0.56 *

Females (n=110)       SLSI-PCS12           -0.16
                      SLSI-MCS12           -0.56 *
Year In Curriculum

First (n=65)          SLSI-PCS12           -0.13
                      SLSI-MCS12           -0.50 *

Second (n=56)         SLSI-PCS12           -0.23
                      SLSI-MCS12           -0.49 *

Third (n=45)          SLSI-PCS12           -0.27
                      SLSI-MCS12           -0.68 *

Note: * Statistically significant at Bonferroni adjusted value
of p < 0.004.


ACKNOWLEDGEMENTS

The authors would like to thank Bradley Wood, Chrystal Pierce, Anette Herrera and Shoreh Biazar-Sadri for their help with data collection.

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GIREESH V. GUPCHUV, PH.D.

MATTHEW E. BORREGO, PH.D.

NIRANJAN KONDURI, B.S.PHARM

The University of New Mexico College of Pharmacy
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Author:Gupchup, Gireesh V.; Borrego, Matthew E.; Konduri, Niranjan
Publication:College Student Journal
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Date:Jun 1, 2004
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