INTRODUCTION

‘Stress՚ is a neuroendocrine, immune, and behavioral response of the organism, in the face of any demand that is presented to it (stressor) as a result of an interpretation of threat or danger, allowing the adaptation and survival of the living being (^{Herman et al., 2016}). Perceived stress is defined as a condition or emotion experienced when an imbalance is perceived between the demands of daily life and a person՚s ability to respond (result of their personal resources and coping strategies; ^{Wang, Liu, Zhang, Xie, & Yang, 2021}; its nature is psychological and subjective induced by the perception and interpretation of facts and experiences. When it arises in the context of an educational process, it is called perceived academic stress (PAS; ^{Aihie & Ohanaka, 2019}). Several studies have shown that PAS increases as the student progresses through educational levels (^{Abdel Wahed & Hassan, 2017}; ^{Barbayannis et al., 2022}; ^{Dyrbye, Thomas, & Shanafelt, 2006}). Going to college is a time of transition and challenge, and students are particularly vulnerable to psychological distress (^{Gómez- Molinero, Zayas, Ruíz-González, & Guil, 2018}).

Undergraduate medical education is a long process in which students face multiple stressors, such as the large amount of information to learn in short periods of time, being in a very competitive environment, constant examinations, the structure of the curriculum design, ethical dilemmas throughout the training, cumulative exams, lack of sleep, violence (internal or external) towards medical students, lack of social support from professors and university, less time to rest and relax, restricted opportunities for social and recreational activities, poor eating practices, fear of failure, self-demand, idealism, dysfunctional defense mechanisms, perfectionist and neurotic traits, academic load, sleep problems, exposure to disease and death of patients, culture and parenting styles (^{Amir, Dahye, Duane, & Wendy, 2018}; ^{Heinen, Bullinger, & Kocalevent, 2017}; ^{Hill, Goicochea, & Merlo, 2018}; ^{Weber, Skodda, Muth, Angerer, & Loerbroks, 2019}). Furthermore, family problems such as lack of social and emotional support and financial instability in the family are associated with stress levels in undergraduate medical students (^{Bergmann, Muth, & Loerbroks, 2019}). Students, throughout their training they encounter factors that threaten their well-being as a highly hierarchical organization and authority figures that sometimes, far from being a positive mentoring, can be a source of abuse and stress (^{Ng, Lin, & Henning, 2020}); ^{Fnais et al. (2014)} reported that 59.4% of physicians had experienced at least one form of harassment or discrimination during their training, with verbal harassment being the most frequent form of harassment (63%) followed by gender discrimination (53.6 %). They have been reported to suffer from higher perceived stress compared to undergraduate students from other academic fields (^{John & Naik, 2020}). The high degree of perceived stress that medical students face requires “a call to action” (^{Dyrbye & Shanafelt, 2016}).

^{Romo-Nava et al. (2016)} reported that during exam season, the prevalence of depression in MS is 16.2%, and that depression is associated with PAS. The consequences of prolonged stress are widespread. Decreased academic performance, substance abuse, and detrimental effects on physical and mental well-being (including psychological distress and burnout) have been reported. Studies focusing on emotional distress as a consequence of prolonged exposure to stressors found an increase in anxiety and depression scores in medical students compared to the general population (^{Mirza, Baig, Beyari, Halawani, & Mirza, 2021}; ^{Philip, Molodynski, Barklie, Bhugra, & Chaturvedi, 2021}; ^{Salvagioni et al., 2017}). To cope with pressures, students can employ a variety of personal resources (optimism, motivation, self-efficacy) and coping strategies, which may be focused on the problem (planning; asking others for advice) focused on emotions (venting; seeking emotional support from others) or focused on avoidance by nature (denial; alcohol / drug use), which can be classified as adaptive or maladaptive (^{Collin, O’Selmo, & Whitehead, 2020}; ^{Freire, Ferradás, Regueiro, Rodríguez, Valle, & Núñez, 2020}; ^{Neufeld & Malin, 2021}). Social support is a survival mechanism for stress, since those medical students who are satisfied with their life and with their support network show low perception of stress, adequate coping strategies and high resilience (^{Ozbay et al., 2007}). Academic stress can contribute to depression rates in medical students (^{Alzahrani et al., 2020}; ^{Avila-Carrasco et al., 2023}; ^{Mirza et al., 2021}). Other factors associated with an increased risk to suffer mental health problems are a particularly academically and emotionally demanding training, competitive school environment, constant academic evaluations, the lack of family support, a personal and family history of mental health problems (anxiety, depression, etc.), and gender (^{Bergmann, Muth, & Loerbroks, 2019}; ^{Broks, Stegers-Jager, van der Waal, van den Broek, & Woltman, 2022}; ^{Lasheras et al., 2020}; ^{Pacheco et al., 2017}; ^{Thomas & Bigatti, 2020}; ^{Zeng, Chen, Wang, Zhang, & Deng, 2019}). It is not known how the levels of perceived academic stress (PAS) and associated factors focusing on academic-social support and coping strategies. Therefore, the aim of the study was to determine the prevalence of PAS and possible risk factors focusing on sex differences, burnout, emotional distress, academic-social support, and coping strategies in a sample of medical students in Mexico.

METHOD

RESULTS

210 medical students were recruited, 57% (n = 120) were women, with a mean age of 19.8 (SD ± 1.09) years. Most participants were single (96.6%, n = 203), cohabited with their family (96.2%, n = 202), and received sufficient financial resources for costs of living (64.8%, n = 136). All students reported perceived academic stress, the majority a moderate degree (64.16%, n = 77; Table 1). In addition, 41.4% (n = 87) referred a personal history of depression, and 48.1% (n = 101) had a family history of depression.    

Burnout was reported by all students, with the majority with a moderate degree (69%, n = 145). About 52.9% (n = 111) refer at least one type of violence within the school environment, verbal violence being the most frequent (30.5%), followed by physical (25.2%) and sexual (11%). Also, 47% (n = 100) perceived moderate academic social support from their peers, followed by teachers (24.3%, n = 51) and family members (19.5%, n = 41). Regarding social support received. 31.9% (n = 67) referred a moderate increase by peers, followed by relatives (21.4%, n = 45) and teachers (15.2%, n = 32). As seen in Table 1, similar demographic features were found between men and women. (Table 1). Regarding family and / or personal history of mental illness, differences were found between men and women regarding family (32.2% vs. 48.3%, p = .004) and personal history of depression (36.6% vs. 56.6%, p = .019). Comparing the presence of abuse within the academic environment between men and women, differences were found in the frequency of reporting emotional abuse (20% vs. 38.3%, p = .004) and sexual (2.2% vs. 17.5%, p ≤ .001). Mean item and total scores on Kessler Psychological Distress Scale were higher among females compared to males except for nervous and worthless. The comparation between the types of stressors described in the SISCO show that women scored higher on all perceived academic stress items compared to men. At the IASA. Differences were found in moderate perceived academic social support from teachers (men = 43.3% vs. women = 10%, p ≤ .001) and family members (men = 28.5% vs.12.5%, p = .003). Also, we did not find differences in social support received (Table 1).

The total score and the types of stressors described in the SISCO show that women scored higher on all perceived academic stress items compared to men.

Correlation analysis showed that the total score on the SISCO scale, and therefore of the perception of academic stress, increases while the total score on the WCQ scale (lower coping strategies), perception of academic social support from teachers and family decreases (Table 2).

Simple linear regression analysis showed a significant association between PAS scores and variables such as being a woman (OR = 3.25, IC 95% = [1.08, 9.5], p = .004), father´s scholar years (OR = 1.065, IC 95% = [1.015, 1.117], p = .010), family history of depression (OR = 1.943, IC 95% = [1.09, 3.4], p = .023), current emotional abuse (OR = 1.064, IC 95% = [1.022, 1.108], p = .003), problem-directed coping (OR = .867, IC 95% [.807,.932], p ≤ .001), positive reassessment (OR = .834, IC 95% = [.730, .950], p ≤ .001), perceived Mild Social Support from Companions (OR = 2.972, IC 95% = [.1.350, 6.54], p = .007), Teachers (OR = 3.012, IC 95% = [1.210, 7.496], P = .018) and Family (OR = 3.37, IC 95% = [1.179, 9.58], p = .023) and received Mild Social Support from family (OR = 3.358, IC 95% = [1.365, 10.2], p = .010; Table 3).    

A multiple logistic regression analysis model was constructed using the variables with a significant association to an increased risk for perceived academic stress. In this multivariate model, a significant association to an increased risk for current perceived academic stress remained in the following factors: sex (OR = 2.94, p = .03), problem-directed coping (OR = .814, p = .001), positive reassessment (OR = .765, p = .001), perceived Mild Social Support from Companions (OR = 2.88 p = .011), Teachers (OR = 2.68, p = .040) and Family (OR = 3.18, p = .040) and received Mild Social Support from family (OR = 4.2, p = .006; Table 3).

DISCUSSION AND CONCLUSION

In the present study, two main findings emerged: 1. being a woman, a family history of depression coping strategies (WCQ; problem-directed coping and positive reassessment) and perceived academic social support from companions, teachers and/or family correlates with perceived academic stress, and 2. women reported: higher levels of PAS and subscales, emotional distress, current emotional and sexual abuse inside the academic setting, a family history of depression, as well as less perceived social support from family and teachers.

Medical students reported higher levels of academic stress, which plays an important role in the overall mental health and academic performance of medical students, they showed more signs of stress, anxiety, and depression than other university students (^{Liu & Cao, 2022}). The isolation experienced by medical students occurs from the moment they enter medical school, as educational demands prevent them from maintaining the family, social roles, and social relationships they had outside of medicine up to that point. Isolation also breaks with the ordinary spheres of life: sleep, work, and recreation, where everything converges in the same physical space, always in the company of the same people and under a hierarchical organization that imposes rigid schedules and plans.

Social support is the perception and/or actuality of being cared, receiving assistance from a teacher, family member and a college, and belonging to a supportive social environment. The supportive resources can be emotional, verbal, tangible, or companionship. In a stressful situation, social support is a survival mechanism (^{Kim, Jee, Lee, An, & Lee, 2018}) , since those medical students who are satisfied with their life and with their support network show low perception of stress, adequate coping strategies and high resilience (^{Kilic, Nasello, Melchior, & Triffaux, 2021}; ^{Liu & Cao, 2022}; ^{Torales, Barrios, Samudio, & Samudio, 2018}; ^{Ulupinar & Tayfur, 2016}). Low social support is related to high perceived academic stress, poor academic self-perception, as well as mental health problems among medical students (^{Kim et al., 2018}; ^{Shao et al., 2020}; ^{Torales et al., 2018}; ^{Ulupinar, & Tayfur, 2016}). Like stress, insufficient social support could continue after the qualification of these already graduate students as physicians, potentially affecting their future clinical practice and reduced positive emotion and experience and lessened psychological well-being of medical students.

Similarly, female medical students display significantly higher values for perceived stress levels, with more females indicated more moderate levels of stress compared to their male counterparts. Being a female has been positively associated with PAS, similar to our findings (^{Castro & Villanueva Lozano, 2018}; ^{Graves, Hall, Dias-Karch, Haischer, & Apter, 2021}). Women experience difficulties achieving their goals in a world dominated by men. Several researchers have corroborated the increased pressure on the medical curriculum, especially academic achievement. The numerical increase of women in medical schools has not significantly improved their position, which can be attributed to the highly hierarchical and androcentric nature of the medical field (^{Castro & Villanueva Lozano, 2018}; ^{Fnais et al., 2014}). These hierarchical relationships are manifested in discrimination and violence against women, which persists openly as part of the university culture, for example, through the manifest rejection of some professors who still consider that women should remain in the domestic space and take care of the family, for which they experience throughout their professional lives the constant need to demonstrate their academic ability to their peers and teachers (^{Fnais et al., 2014}; ^{Graves, Hall, Dias-Karch, Haischer, & Apter, 2021}). Our results showed that women students have a significant inclination towards academic stress compared to men. However, despite that, the stress conditions have negative consequences for both genders; women generally tend to feel pressured by their academic environment, family, and social environment.

At the same time, stress during medical training drives medical students to develop certain skills, resources, and strategies to cope with these situations, a phenomenon known as coping. Coping strategies play an important role and may contribute to the variability of responses among individuals facing similar sources of stress. Students who utilize maladaptive coping usually would not deal with their problems in a constructive manner. Although maladaptive coping may temporarily suppress stressful situations and distract students from the sources of stress, it could eventually lead to emotional distress.

This study presents several limits. First, our findings were derived from a cross-sectional and correlational design, and, therefore, our interpretations do not represent causal inferences. Second, our participation rate might also limit the generalizability of our results. Third, we collected self-reported measures and cannot exclude bias associated with self-assessment, such as social desirability.

Despite the limitations above, this study was conducted to resolve the issue of the lack of comprehensive empirical support of the prevalence of PAS and to evaluate gender differences in the association between demographic features, burnout, emotional distress, academic-social support, and coping strategies with PAS. Focusing on current abuse experiences suffered inside the academic setting.

Mental health interventions should be included in the crisis response by destigmatizing mental health problems, encouraging communication, and providing psychological support. Quarantined medical students should be initiated on coping skills and stress management techniques, while opportunities for personal and curricular development should be provided.

The findings point to the crucial need for stress management programs and training in coping skills in medical students. Special attention is required in the design, planning and evaluation of the curriculum with a gender perspective. Educative settings should prevent students from stress by planning brief periods of acute stress rather than a long period of stress.

It is essential to generate public policies that denature and evidence violence. It is necessary to create specialized and reliable centers for the complaint that support the student body with effective solutions that ensure confidentiality without fear of reprisals, and thus be able to make visible the magnitude and significance of the problem. To increase confidence in the university՚s fight against abuse, it is necessary to implement university policies and actions against bullying and abuse in general (for example, posting policies on the front page of the university՚s website, displaying folders and posters on this topic at the university, announcing activities on this subject, training university staff in non-humiliating ways to teach students).