Keywords
anxiety - depression - stress - intern - house officer
Introduction
Although clinical training aims to produce competent medical and allied health professionals
to treat the sick and advance medical knowledge, it is one of the most academically
and emotionally demanding programs.[1] The mandatory house job and internship year further compounds the stress related
to clinical training. The time and commitment devoted are extensive. This commitment
may harm the young trainees' well-being, precipitating anxiety, depression, and stress.
Studies have identified a high prevalence of depression and anxiety among young medical
professionals.[2]
Stress is a feeling of emotional pressure resulting from the body's reaction to life
events.[3] As medical interns and house officers progress with their training, they face challenges
such as academic pressures, competition with peers, lack of leisure time, and exposure
to patients' suffering. These challenges make the training more stressful. High levels
of stress harm physical and mental health.[4] In 2011, 31% of 42 house officers in teaching hospital reported high stress levels.
Several studies have reported depression, anxiety, and cardiovascular diseases to
be adverse outcomes of stress.[5]
[6]
Depression is a mood disorder that affects how a person feels, thinks, and handles
activities, such as sleeping or working.[7] The World Health Organization[8] estimates that more than 264 million people are affected globally. Symptoms of depression
may include slowness of thought, concentration problems, and indecisiveness. These
symptoms may cause academic challenges for young clinical professionals.[9]
The National Health Service, Scotland[10] defines anxiety as “a feeling of unease, such as worry or fear, which can be mild
or severe.” Symptoms of anxiety include headache, paraesthesia, fasciculations, and
shortness of breath, palpitations, tachycardia, chest pain, and tremors. Recent studies
reported a prevalence of anxiety (60.7–63.7%), depression (42.9%), and stress (57.1%)
among house officers working in Malaysia.[11] It is worthy of note that these may lead to personal or professional image harm.
Negative impact may include diminished commitment, substance abuse, suicide ideation,
clinical incompetency, medical errors, and poor job performance. These unwanted consequences
will eventually affect the quality of care offered to patients.[12]
Many studies have investigated the prevalence of anxiety, depression, and stress among
medical interns and house officers in developed countries. However, there is insufficient
information about such study in a developing country, such as Nigeria. Therefore,
this study was carried out to investigate the rate of anxiety and depression among
interns and medical house officers in Nigeria. Also, to assess the relationship between
demographic characteristics of interns and medical house officers and their perceived
stress level, as well as the relationship between perceived stress levels and rate
of anxiety and depression among interns and medical house officers in Nigeria.
Methods
This was a descriptive cross-sectional survey aimed at determining the rate of anxiety,
depression, and stress among interns and house officers in Nigeria. In this study,
purposive sampling technique was used to recruit participants into this study. Also,
all consenting interns and house officers available at the time of the survey were
included and interns or house officers not available at the time of the survey were
excluded from the study.
The sample size was determined using the formula:
n = Z
2
pq/d
2
[13]
where n = the desired sample size; Z = standard normal deviation set at 1.96, which corresponds to the 95% confidence
interval; p = prevalence of depression from a previous study in Nigeria among pharmacy students
which was 44.6%;[14]
q = complimentary probability = 1.0, p = 1.0–0.446 = 0.554; and d = the degree of accuracy (precision) set at 0.05 (acceptable margin error).
n = (1.96)2 × 0.446 × 0.554/0.052; n = 194
194 + 17% (nonresponse rate from Abdul Rashid et al, 2019 study) = 227. Therefore,
the estimated sample size was 227.
A self-report questionnaire consisting of two sections was used. The first part collects
sociodemographic data such as age, gender, marital status, profession, institution
of training, and duration of internship training. The second section measures depression,
anxiety, and stress using the Depression, Anxiety, and Stress Scale (DASS-21).[15] This is a 21-item scale that is easy to apply in both clinical and nonclinical settings
and is used to measure the negative emotions of individuals in the most recent week.
Each subscale contains seven items. Participants were asked to respond on how closely
the items applied to them in the past week on a four-level Likert scale, 0 through
3 points. The higher the score, the higher the level of negative emotions. Items 3,
5, 10, 13, 16, 17, and 21, items 2, 4, 7, 9, 15, 19, and 20, and items 1, 6, 8, 11,
12, 14, and 18 represent depression, anxiety, and stress, respectively. Scores obtained
need to be multiplied by 2 to calculate the final score. Recommended cutoff scores
for conventional severity labels (normal, moderate, severe) are as follows:
For depression: Normal 0 to 9, mild 10 to 13, moderate 14 to 20, severe 21 to 27,
and extremely severe 28+
For anxiety: Normal 0 to 7, mild 8 to 9, moderate 10 to 14, severe 15 to 19, and extremely
severe 20+
For stress: Normal 0 to 14, mild 15 to 18, moderate 19 to 25, severe 26 to 33, and
extremely severe 34
The instrument was pretested to establish its psychometric property among the intended
population and Cronbach's alpha of 0.91 was obtained. Those used for pretesting were
excluded in the main study and the responses used in the pretesting were also excluded
in the main analysis.
Ethics approval was sought and obtained from the University College Hospital Research
Ethics Committee, Ibadan (UI/EC/21/0265). The data collection was made through e-questionnaire.
The purpose of the study and the statement of informed consent were provided to the
participants together with the online questionnaire (Google Form). The link was sent
to interns and house officers of various training institutions and they were asked
to forward it to their WhatsApp groups or to any interns' house officers they know
in any training institution. A reminder link was regularly sent to increase response
rate. Data collection was done from July 10, 2021 to October 13, 2021.
Data was analyzed using SPSS version 20 software package and summarized using a descriptive
statistic of frequency and percentage. An inferential statistic of chi-square test
was used to find association between prevalence of anxiety, depression, and stress
and age, gender, profession, and duration of internship training. Probability level
was set at 0.05.
Results
One hundred and thirty-eight responses were received during the data collection. However,
four responses were excluded because the participants were not interns or house officers
under consideration in this study. Therefore, only 134 responses were analyzed giving
a response rate of 37.2%. [Table 1] showed that Majority, 77 (57.5%), of the respondents were within the age range of
20 to 25, while 55 (41.5%) were within 26 to 30 years and only 2 (1.5%) were above
30 years. Of the gender, male, 73 (54.5%), were slightly more than female, 61 (45.5%).
With regards to marital status majority were single, 123 (91.8%), with only 11 (8.2%)
married. Considering profession, majority were from physiotherapy, 59 (44%), followed
by medical lab science, 29 (21.6%), and medicine, 18 (13.4%). When it comes to month
of internship training, majority were in the last 4 months, 47 (35.1%), followed by
those in the first 4 and 8 months of the training, 38 (28.4%) and 36 (26.9%), respectively,
with only few (9.7%) on extension. Seventy-one (52.9%) were doing the training in
southern part of the country with 46 (34.7%) in the north and 17 (12.5%) missing responses.
Table 1
Socio-demographic variables of the participants
|
Variables
|
n
|
%
|
|
Age category
|
|
|
|
20-25
|
77
|
57.5
|
|
26-30
|
55
|
41.5
|
|
> 30
|
2
|
1.5
|
|
Gender
|
|
|
|
Male
|
73
|
54.5
|
|
Female
|
61
|
45.5
|
|
Marital status
|
|
|
|
Single
|
123
|
91.8
|
|
Married
|
11
|
8.2
|
|
Profession
|
|
|
|
Dentistry
|
4
|
3
|
|
Medical lab science
|
29
|
21.6
|
|
Medicine
|
18
|
13.4
|
|
Nursing
|
7
|
5.2
|
|
Optometry
|
1
|
0.7
|
|
Pharmacy
|
14
|
10.4
|
|
Physiotherapy
|
59
|
44.0
|
|
Radiography
|
2
|
1.5
|
|
Months of training
|
|
|
|
1-4 months
|
38
|
28.4
|
|
5-8 months
|
36
|
26.9
|
|
9-12 months
|
47
|
35.1
|
|
On extension
|
13
|
9.7
|
|
Region of training institution* (*17 missing responses)
|
|
|
|
North
|
46
|
34.7
|
|
South
|
71
|
52.9
|
The prevalence of depression, anxiety, and stress among the participants in this study
were 37.3, 42.5, and 15.7%, respectively ([Fig. 1]). It is important to note that, out of the 37.3% depressed respondents, most of
them were mildly depressed (48%) followed by those that are moderately depressed (20.1%),
extremely severe (18%), and severely depressed (13.9%), respectively [Fig. 2]. Also, out the 42.5% respondents with anxiety, majority were having moderate anxiety
(47.3%), 33.4% with extreme anxiety, and 14.1 and 5.2% with mild and severe anxiety,
respectively. For the 15.7% stressed respondents, majority were severely stressed
(42.7%) with 33.1% moderately stressed, 14.0% mildly stressed, and 9.6% extremely
severely stressed. Also, [Table 2] showed that only duration of training has significant association with depression
and stress (p < 0.05). However, all other sociodemographic variables showed no significant association
with depression, anxiety, and stress (p > 0.05). Finally, as it can be seen in [Table 3], depression, anxiety, and stress possess strong positive linear relationship with
one another (p < 0.05). This result implies an increase in one variable will result into an increase
in the other variable.
Fig. 1 Prevalence of depression, anxiety, and stress.
Fig. 2 Severity of Depression, Anxiety and Stress.
Table 2
Association between socio-demographic variables and each of Depression, anxiety and
stress; n = 134
|
Variables
|
X2 /exact
|
p-value
|
|
Depression
|
|
|
|
Age category
|
1.21
|
0.59
|
|
Gender
|
0.21
|
0.65
|
|
Marital status
|
0.16
|
0.69
|
|
Profession
|
4.73
|
0.73
|
|
Months of training
|
9.47
|
0.02*
|
|
Region of training institution
|
7.22
|
0.18
|
|
Anxiety
|
|
|
|
Age category
|
0.33
|
1.00
|
|
Gender
|
0.03
|
0.88
|
|
Marital status
|
0.56
|
0.45
|
|
Profession
|
6.47
|
0.48
|
|
Months of training
|
4.60
|
0.21
|
|
Region of training institution
|
7.78
|
0.14
|
|
Stress
|
|
|
|
Age category
|
3.43
|
0.15
|
|
Gender
|
0.20
|
0.65
|
|
Marital status
|
1.12
|
0.29
|
|
Profession
|
8.71
|
0.22
|
|
Months of training
|
8.51
|
0.03*
|
|
Region of training institution
|
3.78
|
0.58
|
Table 3
Relationship among depression, anxiety and stress: n = 134
|
Variables
|
r
|
p-value
|
|
Depression-Anxiety
|
0.72
|
0.00*
|
|
Depression-Stress
|
0.78
|
0.00*
|
|
Anxiety-stress
|
0.79
|
0.00*
|
* = significant at p < 0.05.
Discussion
A statistically significant relationship was found between the duration of training
and depression, anxiety, and stress among the Nigeria house officers/interns. This
could be probably due to the fact that the participants that are rounding up with
their programs are expected to have experienced more depressing factors than those
that are just starting their programs. Although there are conflicting evidences, results
from this study shows that sociodemographic attributes such as sex, marital status,
and age had no significant relationship with the reports of depression, anxiety, and
stress.
Some reports have revealed that female health care practitioners are more likely to
report depression, anxiety, stress, and dissatisfaction with work,[16]
[17] while others support the claim of this study, finding no relationship between gender
and reports of depression among resident doctors.[18]
[19] More so, as regards the marital status, report from the study done among resident
doctors at Tehran, Iran, documented that married physicians were significantly more
depressed than single ones. The authors in this finding had attributed the difference
in marital status to financial pressures and additional responsibilities usually associated
with marriage. Whereas some support the claim of this study, claiming that marital
status did not have any effect on the stress scores among the Saudi interns.[20] However, it has been shown that other sociodemographic characteristics have no relationship
with reports of depression, anxiety, and stress. This resonates with the results obtained
from this study. Our outcome in respect to marital status may also be accounted for
by the small sample size of house officers/interns who were married (123 single against
11 married).
Although a significant percentage of interns/house officers reported being depressed
or anxious (37.3 and 42.5%, respectively), and less than half of them reported being
stressed (15.7%). This implies that the depressive and anxiety symptoms may have been
caused by other factors other than job-related stress. These may include attitude
of superiors, the demand of job on social and family life, dealing with death and
terminal illness, unrealistic expectations of others, and accommodation problems.
On the contrary, this rate of depression among house officers/intern could be relatively
high (37.3%) compared to that recorded among resident doctors (17.3%) in the South
Eastern part of Nigeria.[19] This increase could be associated with some hospitals owing house officers/interns
salaries as well as the strike crisis in the health sector in the country. It is also
worthy of note that, the prevalence of anxiety among interns/house officers is considerably
lower than the report of Ahmed et al,[21] in a similar study but among different population as Ahmed et al studied the frontline
health workers during the coronavirus disease 2019 pandemic.
Similarly, unlike the 73% report of high levels of stress among interns in Saudi Arabia
by Abdulghani et al,[22] this study recorded a low stress prevalence level (15.7% reported being stressed).
However, Abdul Rashid et al[23] reported a similar prevalence of depression among house officers (38.4%), and a
slightly higher prevalence of anxiety (53%) and stress (26%) among house officers.
A job stress study conducted among junior doctors (house officers, medical officers,
and residents with less than 5years working experience) in the University College
Hospital (UCH) Ibadan, Nigeria revealed a 32% stress report.[24] This is twice the result obtained in this study. This wide difference may be attributed
to the wider scope of the study in terms of participants and study population.
The percentage of participants who reported being depressed is slightly lower when
compared with the depression report (41% incidence) among medical students in Taif
(n = 181) by Alzahrani.[25] This might be because of relief of some school stressors such as academic work and
examinations or financial stressors following salaries received as house officers
and interns or due to difference in the environment and sociodemographic characteristics
of the participants. However, Abdulghani et al[26] who examined the stress level among medical students and stress level among medical
interns in Saudi Arabia reported a higher report of severe stress levels (34.9% among
medical interns; 25% among medical students). The difference may also be simply related
to difference in sample size (n = 134).
Limitations
This study has a few drawbacks, despite the fact that it gives useful information
on depression, anxiety, and stress. For starters, as we did not clearly recruited
participants based on quota system from each specialty and the total number of participants
was small, as such, the result cannot be generalized to all interns and house officers
even though participants came from across all the geopolitical zones of the country.
Also, as with all cross-sectional research, causality between the identified factors
and depression and anxiety symptoms could not be established. In several fields, such
as optometry, radiography, and dentistry, the sample size was quite small. Additionally,
only 134 responses were gotten from the calculated 194 minimum sample size despite
the use of 95% confidence interval.
Moreover, because this study was limited to interns and house officers, the results
cannot be applied to all medical facilities in Nigeria. Despite the fact that this
study was conducted with interns/house officers in Nigerian large tertiary hospitals,
the etiology of depression, anxiety, and stress was not discovered. In this study,
response distortion is also considered a constraint. Volunteers may favor the extreme
or moderate response style, particularly on a questionnaire's rating scale. One of
the known disadvantages of self-administered questionnaires is negative affectivity
bias. The correlations between depression, anxiety, and stress and the outcome variables
may be significantly inflated as a result of this.
Furthermore, the sole metric used in this investigation was the DASS-21. DASS severity
ratings are based on mean population scores acquired from large, highly varied groups,
despite the fact that DASS-21 has strong psychometric qualities. It is only designed
to be used as a screening test for depression, anxiety, and stress, and should not
be used to replace a comprehensive psychiatric evaluation for diagnosis purposes.
As a result, implementing stratified random sampling, increasing the study's sample
size, and performing a reliability test to eliminate information bias are all feasible
routes for future research.
Conclusion
The outcome of this study revealed that depression, anxiety, and stress are public
mental health concern among the Nigerian house officers and interns as a significantly
high level of depression, anxiety, and stress were found among the participants. These
may have negative effects on cognitive functioning, learning, and patient care. Hence,
house officers/interns need support and subsequent interventions to cope with stress.
