Evaluation of perceived stress and its impact on study habits in preclinical medical students

INTRODUCTION

The academic journey of medical students, especially during the preclinical years, is marked by intense study loads, frequent assessments, and adjustment to a demanding learning environment. This often leads to elevated stress levels that can adversely affect cognitive function, emotional stability, and academic performance.^[1-3] Several studies have highlighted the multidimensional sources of stress among medical students, including academic burden, future career concerns, and personal health issues.^[4-7]

Medical education systems vary globally, but common stressors such as examination pressure, time constraints, and lack of personal time remain consistent.^[8-10] The concept of perceived stress refers to how individuals interpret and respond to stressors, influenced by both external pressures and internal coping mechanisms.^[11] Previous research, including that by Brahmbhatt et al.^[12] and Shah et al.,^[13] reported high stress prevalence among South Asian medical students, with significant correlations to academic dissatisfaction and emotional exhaustion.

However, limited studies have specifically explored the direct impact of perceived stress on students’ study habits—defined as their routine, concentration, and participation in academic tasks. Understanding this relationship is key to designing interventions that not only manage stress but also improve learning outcomes.

MATERIALS AND METHODS

A close-ended, structured questionnaire was administered electronically through Qualtrics to 1^st- and 2^nd-year medical students 8 weeks after the commencement of their academic courses, following approval from the institutional review board. Participation was voluntary, and responses were collected anonymously. The questionnaire included demographic information (age, gender, marital status), medical college admission test (MCAT) score, undergraduate grade point average (GPA) score, undergraduate major and regular physical exercise (150 min/week), Cohen’s 10-item perceived stress scale (PSS) and 32 items adapted from Gazzaz et al.^[14] to assess sources of stress, categorized into academic, psychological, and health-related stressors. In addition, four items were included to evaluate the impact of stress on students’ study habits. The PSS score was calculated using 4 items (positive) of Cohen’s scale,^[11] with a maximum score of 16. For interpretability, raw scores were converted to percentages of the maximum possible score. Low, medium, and high stress categories were defined according to tertiles of the sample distribution in this study and should not be interpreted as universal cut-points. Responses were recorded using a five-point Likert scale ranging from 0 (never) to 4 (very often). Descriptive statistics and multiple linear regression analyses were performed to examine the relationships between PSS scores and identified stressor categories. Data analysis was conducted using Microsoft Excel (version 16.0.1) and R (version 4.3.1). The Shapiro– Wilk test was used for normality check, and data were expressed as mean ± standard deviation wherever applicable.

RESULTS

The questionnaire was distributed to 320 students, and a total of 73 complete responses were obtained (response rate was 22.8%). The internal consistencies of the questionnaire (Cronbach’s alpha) for different sections were 0.86, 0.70, and 0.77 for PSS, sources of stress (academic, psychological, and health), and impact on study habits, respectively. Most of the participants were females (71%), followed by males (26%), and others (3%). Age was 26.6 ± 4.9 (range 22–45), and 13.6% were married. The mean PSS was 10.2 ± 2.5 (63.75% of maximum 16); for high perceived stress: PSS >67.5%, and for low perceived stress: PSS <35%). Out of a possible 4 score for individual stressors and study habits, the scores were obtained as follows: key academic stressors [Figure 1] included limited recreation time (2.49 ± 1.21), examination performance (2.34 ± 1.27), and examination frequency (2.21 ± 1.19). The main psychological stressors [Figure 2] were future concerns (2.63 ± 1.37), financial strain (2.44 ± 1.40), and loneliness (1.99 ± 1.30). Health-related stressors [Figure 3] included sleep difficulties (2.26 ± 1.29), poor nutrition (2.14 ± 1.38), lack of exercise (2.14 ± 1.38), and class attendance (1.79 ± 1.40). Stress affected study habits notably, particularly concentration span (2.78 ± 1.07), regular study patterns (2.58 ± 1.15), and participation in academic activities (2.10 ± 1.31).

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Figure 1:

Mean values for perceived contribution of academic stressors to the perceived stress score among the preclinical medical students (n = 73, X-axis: The maximum possible score for individual stressors was 4, and the maximum possible perceived stress scale score was 16).

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Figure 2:

Mean values for perceived contribution of psychological stressors to the perceived stress score among the preclinical medical students (n = 73, X-axis: The maximum possible score for individual stressors was 4, and the maximum possible perceived stress scale score was 16).

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Figure 3:

Mean values for perceived contribution of health-related stressors to the perceived stress score among the preclinical medical students (n = 73, X-axis: The maximum possible score for individual stressors was 4, and the maximum possible perceived stress scale score was 16).

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The results also indicated a relationship between perceived stress and study habits. Students most frequently reported a reduced concentration span (2.78 ± 1.07), followed by disruption of regular study patterns (2.58 ± 1.15) and decreased academic participation (2.10 ± 1.31) [Figure 4]. These findings, along with regression analysis, demonstrated a statistically significant association between high stress levels and both impaired concentration and irregular study patterns (P < 0.05).

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Figure 4:

Mean values for impact on study habits due to the perceived stress among the preclinical medical students (n = 73, X-axis: the maximum possible score for individual study habits was 4).

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Multicollinearity statistics were assessed using variance inflation factor (VIF) values, which indicated high collinearity when all variables were included. Undergraduate major and marital status showed particularly elevated VIFs (1106.3 and 13.4, respectively) and was removed to improve model stability. Following their removal, the recalculated VIFs for all remaining variables were below 1.3, suggesting minimal multicollinearity and acceptable independence among predictors [Table 1].

A multiple linear regression analysis was performed to examine the relationship between PSS and five independent variables [Table 2]: Age, sex, MCAT score, undergraduate GPA, and physical exercise. The model revealed a statistically significant association between male sex and lower perceived stress scores (β = −1.3, 95% confidence interval = −0.16–−0.03, P = 0.0156). Age, MCAT score, GPA, and physical activity were not significantly associated with stress scores (P > 0.05) [Table 2]. The adjusted R² for the model was 0.14, indicating that approximately 14% of the variability in perceived stress scores was explained by the included predictors.

These results present the stressors most frequently reported by students, along with their associated effects on concentration, study habits, and academic participation. They also reflect the extent to which measured demographic variables accounted for variability in perceived stress scores.

DISCUSSION

This study reveals that most preclinical medical students experience moderate levels of perceived stress, as reflected by a mean PSS of 10.2 ± 2.5 (63.75% of maximum 16) which is the upper level in the moderate stress score as explained by Cohen et al. for high perceived stress: PSS >67.5%, and for low perceived stress: PSS <35%.^[11] Earlier studies also reported similar findings on the medical students’ stress levels.^[12-15] Such findings on the prevalence of perceived stress in preclinical students underscore the universal challenges faced by medical students during their early years of training. Such stress not only reflects the demanding nature of medical curricula but also highlights the broader psychosocial pressures that students encounter.

Academic stress, however, remains a core issue for preclinical students. Specifically, examination-related anxiety and the challenge of managing time effectively dominate the academic stress landscape. However, in our findings, lack of recreation time was the notable academic stressor, followed by worry about examination performance [Figure 1]. A similar pattern was observed by Shah et al.^[13] and Sreeramareddy et al.^[15] in their findings. The rigor of medical curricula demands lots of time and dedication from medical students. Examinations in medical school are frequently high-stakes and often viewed as gatekeepers to future academic or career opportunities, which intensifies the pressure to perform. Coupled with voluminous curricula, limited time, and frequent assessments, this environment can overwhelm students and heighten anxiety.

Notably, our findings emphasize psychological stressors related to concerns about the future [Figure 2]–such as career uncertainty (residency training opportunities) and financial burden– that ranked higher than other academic stressors. This can be explained by the fact that in the US medical education system, after 4 years of training, students must be matched to start their residency programs, and these matching rates are not always 100%. In addition, due to the high cost of medical education, many students are in academic loan assistance programs. These factors might have contributed to the findings of the study. The implication is that while academic demands are significant, the uncertainty and anxiety surrounding life beyond medical school profoundly contribute to students’ psychological distress.

Beyond academic stressors and psychological, health-related issues emerged as significant contributors to students’ stress profiles. Sleep disturbances were among the health-related factors contributing most strongly to perceived stress scores, with students attributing 56.5% of their stress to this issue [Figure 3]. A growing body of evidence supports the detrimental impact of poor sleep quality and sleep deprivation on cognitive domains critical for academic success, including attention, memory consolidation, and executive functioning.^[16-18] Chronic sleep problems among medical students not only impair learning but also exacerbate emotional distress and reduce resilience. This cyclical relationship suggests that interventions targeting sleep hygiene could have a compounding effect in reducing stress and improving academic performance. In addition, dietary factors may also influence student well-being and cognition. Hence, dietary interventions such as probiotic supplementation may support gut–brain axis health and cognitive performance. Although these aspects were not assessed in the present study, future research could explore their potential as adjunctive strategies for enhancing the academic environment and student wellness.

The repercussions of stress extended to students’ study behaviors, as many reported diminished concentration, irregular study routines, and reduced engagement with learning activities. Such maladaptive study behaviors have been widely recognized as early warning signs of academic burnout and predictors of suboptimal academic performance.^[19-21] This is reflected in Figure 4, where impaired concentration and irregular study habits were among the highest-rated contributors to overall perceived stress, accounting for 68.5% and 64.4% of the stress impact, respectively. These patterns were similarly noted by Brahmbhatt et al. in their study of Indian medical students, suggesting a cross-cultural consistency in how stress influences medical students’ academic engagement.^[12] When students struggle to maintain effective study habits, the quality of their learning suffers, which may in turn perpetuate a negative feedback loop of increasing stress and declining academic outcomes.

Age, sex, and MCAT score were associated with decreased perceived, even though the regression was not significant (except for male sex). The possible hypothesis to explain these findings is that older students, male sex, and students with higher MCAT scores have developed stress coping mechanisms and are more confident in handling stressful situations. On the contrary, students with higher GPA and having no regular physical exercise perceived a higher level of stress, although it was not statistically significant. This can be explained by the fact that GPA scores are records of students’ academic achievement and are longitudinal in nature, whereas MCAT scores are based on, usually, 1-time assessments. Hence, students may perceive less pressure to maintain entrance-examination performance. Likewise, lack of regular physical exercise is associated with higher perceived stress, which could be due to concern about physical fitness. VIF diagnostics indicated that sparse categories (marital status and undergraduate major) produced inflated VIF values (>1,000), leading to their removal from the model. Future analyses could examine the predictive value of domain-specific stressor scores.

Given these findings, it is imperative that medical education institutions implement comprehensive preventive strategies aimed at alleviating student stress and fostering well-being. Interventions such as peer mentorship programs can provide social support and normalize stress experience, helping students develop coping strategies through shared experiences. Counseling services tailored to medical students’ unique challenges offer crucial psychological support, while stress-management workshops can equip students with practical skills to handle anxiety and workload pressures.^[22-25] In addition, flexible academic scheduling that allows students to balance their study demands with personal wellness activities may reduce the intensity of stress experienced during peak periods, particularly during high-stakes assessments, which were significantly correlated with stress in regression analysis [Table 2].

Furthermore, institutions should promote physical wellness through regular exercise programs and sufficient recreational opportunities, which have been shown to buffer against stress and improve mood. Integrating mental health resources into medical school environments – such as mindfulness training,^[26] cognitive-behavioral therapy options, and resilience-building initiatives – can further enhance students’ capacity to manage stress effectively. Such holistic approaches, combining academic, psychological, and physical wellness supports, are crucial to fostering an educational climate that emphasizes not only knowledge acquisition but also prioritizes the well-being of future physicians.

In addition, if academic stress contributes to concentration difficulties, distributing assessments more evenly across the term may alleviate peak stress periods. Where psychological stress reduces participation, peer-support or mentorship programs could foster engagement. Health-focused interventions, such as sleep-hygiene education, may also mitigate stress impacts on study habits.

In summary, this study assesses the multidimensional nature of stress, as evidenced by PSS scores and the reported impact on concentration span, study behavior, and academic participation among preclinical medical students. It highlights psychological, academic, and health-related factors as key contributors. Addressing these challenges through targeted institutional interventions is essential to mitigate the negative impact of stress on students’ academic performance and mental health, ultimately promoting a more supportive, sustainable medical education environment.

CONCLUSION

Preclinical medical students experience multifaceted stressors that notably affect their concentration span and study habits. Recognizing these stressors and implementing systemic solutions is imperative for ensuring student well-being and academic success. Future studies should explore longitudinal changes and the effectiveness of targeted interventions. Furthermore, a functional medicine–inspired approach – which integrates personalized lifestyle modifications such as balanced nutrition, regular physical activity, adequate sleep, targeted stress-reduction techniques, and optimization of the study environment – may provide a holistic framework for supporting medical student health and academic performance. Future studies could evaluate the effectiveness of such multidimensional interventions in the undergraduate medical education setting.