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Note: Tables and figures
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Introduction
A student’s life is subjected to
different kinds of stressors, such as the pressure of
academics with an obligation of success, uncertain
future, and difficulties envisaged for integration into
the system. These students face social, emotional and
physical and family problems which may affect their
learning ability and academic performance (Fish & Nies,
1996; Chew-Graham, Rogers, & Yassin, 2003).
In
recent years there is a growing appreciation of the
stresses involved in legal training. Many students
experienced stress as they pursue a law degree (Dammeyer
& Nunez, 1999). Archer & Peter (1986) suggested that
much of this excessive stress may have its origins in
law school. The Socratic method of teaching, high
expectations, competitive environment, heavy work load,
final examinations, social isolation, and family tension
have been identified as stressors, though they are not
necessarily ranked in that order. There have been very
few studies to assess the perception of stress among
students, and still fewer are those done on law student
population. The primary objective was to identify the
sources of stress amongst the law students' community.
We also wished to estimate the prevalence of perceived
stress and to observe any association between the high
level of stress, sources of stress, socio-demographic
profile, psychiatric symptoms and year of study.
Population and Methods
Study design and participants:
This is a cross
sectional study among law students in Mansoura
University, Egypt, conducted during October and December
2007 G. Filled questionnaires were collected one month
before first term examination period so as to minimize
the extra stress symptoms. The undergraduate law program
is four years of theoretical and practical courses.
Written approval was obtained from the college authority
to conduct the survey in the setting. After obtaining
this approval for data collection the researchers
introduced themselves to the student in each grade and
informed them about the aim of the study and about
guarantees of anonymity and confidentiality and the need
for verbal consent. The students were allowed to respond
in their own time and privacy. The participation was
entirely on voluntary basis in a multistage cluster
sampling study. All students who agreed to participate
were given questionnaires; all incomplete questionnaires
were not included. A total of 434 students who provided
complete questionnaire were involved in the study.
Data collection: The
questionnaire (Amr, El-Gilany, El-Sayed, & El-Sheshtawy,
2007) provided information on demographic details,
sources of stress during the past year. They were 15
items divided into 4 categories of potential sources of
stress: 3 items representing relationship sources of
stress, 5 representing personal sources of stress, 5
representing academic sources of stress, and 2
representing environmental sources of stress.
Relationship issues result from interactions with other
people, such as trouble with course mates; personal
troubles result from internal sources such as personal
injury or illness or death of a family member. Academic
pressures arise from college related activities such as
relationship with the instructor. Environmental problems
result from problems in the environment outside the
academics such as accommodation problems.
Sample
size was calculated using Epi info program version 6.02.
According to students' affairs administration, the total
number of registered law students in 2007 was 9405
students of both sexes in the four years. The pilot
study on 40 students (10 from each year) revealed that
40% of students suffer high level of stress. With the
worst acceptable level 35%, the sample needed for the
study was estimated to be at least 355 students at a
study power of 80% and 95% confidence level. To overcome
the non response and the attrition due to cluster
sampling 20% was added to the sample size with a final
of 426 students.
Students were selected through stratified cluster
sampling technique. First students were stratified into
the different academic years (first to fourth). From
each year a section or group (cluster) was randomly
chosen. All students in the chosen clusters were
included. A total of 605 students were registered in
chosen clusters. The response rate was 71.7% (434/605),
representing 4.6% of total students enrolled. None
participation was due to lack of interest in the study,
absence during the study period and incomplete
questionnaires.
Stress was measured by a previously validated 14-item
perceived stress scale (PSS). Cronbach
 coefficient
of internal consistency was reported to be 0.85,
and test-retest reliability during a short
retest interval (several days) was 0.85
(Cohen, Kamarck & Mermelstein, 1983). The
Arabic version was tested among a sample of US Arab
immigrants (Jaber, Brown, Hammad, Zhu, & Herman, 2003).
The PSS does not tie appraisal to particular situation;
it is sensitive to the non-occurrence of events as well
as to ongoing life circumstances. The stress score was
stratified into no, mild, moderate (merged as low level)
stress or severe (high level) stress according to first,
second and third quartiles. The degree of anxiety and
depressive symptoms were measured by Hospital Anxiety
and Depression Scale (HAD), where a score of 12
or more for either the anxiety or the depression
components denotes possible anxiety or depression (Zigmond
& Snaith, 1983). This cut off point had sensitivity
0.89, specificity 0.75 (Olssøn, Mykletun, & Dahl, 2005).
The Arabic version of the HAD scale was validated by El-Rufaie
and Absood (1995). The overall Cronbach alpha measures
of internal consistency were 0.7836 and 0.8760 for
anxiety and depression, respectively.
Statistical analysis:
Data was analyzed
using SPSS (Statistical Package for Social Sciences)
version 11. The relationship between outcome variables
(high level of stress, different categories of
stressors) and each of the explanatory variables was
first tested by chi square; as appropriate. Explanatory
variables with significant association in the univariate
analysis were entered simultaneously into a multivariate
logistic regression model using the stepwise Wald
forward method. Logistic regression predicts the
independent predictors of the specified outcome
variable. These independent effects were measured by
odds ratios and their 95% confidence intervals (Le,
2003). The explanatory variables were student's age in
years (continuous), sex (male and female), year of study
(first to fourth), family residence (rural and urban),
family income (satisfactory and unsatisfactory with
monthly income of 500 EP), family size (less than 5 and
five or more persons), parental education (less than
secondary, secondary and above secondary), fathers work
(farmers/manual workers, professional/semiprofessional,
trades/business and others), and mothers work
(housewives and working). P
£
0.05 was considered statistically significant.
Results
Students were distributed in the four
years (119, 103, 113, and 99 in first, second, third and
fourth years, respectively). Their age ranged from 17-30
years with a mean of 18.9±1.9
years, 54.8 % of them are females, and 53.7% were from
rural areas. Family income was reported to be
unsatisfactory in 27.0% of students and a family size of
less than 5 persons was reported by 51.8% of students.
Only 18% and 12.2% of fathers and mothers were of above
secondary education, respectively. The majority of
fathers are working as non-professional (58.5%) and
69.8% of mothers were housewives (data not shown in
tables).
Table 1
reveals that the number of stressors reported by
students ranged from none to 13, with a mean of 4.6.
Personal troubles were the commonest (80%) followed by
environmental problems (60.4%), relationship issues
(59.7%) and lastly academic pressures (58.8%). The most
frequently reported items of stressors were especially
anxiety and depression (65.9%), fear of social situation
(46.8%), problems with opposite gender (42.4%) and
congested class rooms (40.1%).
High
level of stress was reported by 42.2% of students.
Anxiety and depressive symptoms were reported by 59.2%
and 18.2%, respectively (table 2).
Table 3
reveals that presence of anxiety symptom was the
strongest independent predictor of high stress level
(OR=4.3), relationship issues (OR=2.3), personal
troubles (OR=4.1), academic pressures (OR=1.9) and
environmental problems (OR=2.6). Rural family residence
is an independent predictor of personal troubles
(OR=1.8) and environmental problems (OR=3.1)
Discussion
The
young student population has always been vulnerable to
stressful life conditions especially in pursuit of
higher professional education in a highly competitive
environment (World Health Organization, 1994; Saipanis,
2003). A descriptive self administered questionnaire
based study got a response rate of 71.1%, which provides
an adequate sample size to fulfill the objectives of
this study.
We found that
personal and environmental sources of stress were the
most common, with the most frequently reported stressors
having anxiety and depression, fear of social
situation, problems with opposite gender and being in
congested class rooms. The year of study, gender and
residence turn out to be a significant factor in
stress reporting, the first year was more likely to
report personal and academic sources of stress, students
from rural areas and female gender had a significant
association with reporting of personal and relationship
problems respectively.
Most of the law
students come from remote villages and towns outside
Mansoura and study for four years in that city. Thus for
these students particularly in first year, living away
from their families may cause more stress than for those
who live in Mansoura. In addition, this data was
collected during the first term when students are at the
beginning of their courses, and are away from home, have
difficulty of adjustment to a new environment and must
take the responsibility of themselves.
There are more
relationship problems in females as most of them are
from rural conservative communities and facing a world
of mixed values. Also, Female students face additional
pressure to succeed in a male dominated field and thus
often exhibit higher levels of stress than do men
(Goring, 1995; McIntosh, Keywell, Reifman, & Ellsworth,
1994). They experience law school differently than men (Granfield,
1994) expressed stronger and more passionate feelings of
alienation and outrage than the male students and
described their first-year as a radical, painful, or
repressive experience (Guinier, Fine, Balin, Bartow, and
Stachel, 1994). Moreover, a study by McLean and Kalin
(1994) found that although dominance was a trait
associated with Canadian lawyers in general, only female
law students saw themselves as slightly more dominant
and less "affiliative" than the mean. These
results indicate that their self perceptions were less
warm and agreeable and more cold and quarrelsome than
were those of other graduate students.
Mule & Barthel
(1992) described the social changes in Egypt,
where there has been an increase in women's
participation in the work force and to some extent,
political life. Furthermore, globalization and exposure
to Western culture have presented in this traditionally
Islamic country with alternative gender ideologies. The
participation of women in Egypt's workforce has risen
from 15.4 percent in 2001 to 23 percent in 2006 (CAPMAS,
2007), also, the number of women in decision-making
positions in the private sector has increased in recent
years. In 2003 President Mubārak, for the first time in
Egypt's history, appointed a female judge to the Supreme
Constitutional Court, and two other women became members
of the panel of Commissioners of the same institution.
Thirteen women are members of the Shura Council 20 and
774 women were elected in 2002 to local government
councils (Alquézar, Panzica and Popova, 2009).
The results of
this study indicate higher prevalence of stress in our
undergraduate law students. Prevalence of high stress in
this study is 42.2% which is similar to 47.3% reported
by Ko, Kua, & Fones (1995) but higher than Michigan law
students (15.67%) (Hengstler, 1993). It was found that
law students reported significantly higher levels of
academic stress and fear-of-failing stress than medical
students (Heins, Fahey, & Henderson, 1983).
In college
students, some stress is motivating, whereas too high a
level interferes with teaching. Excessive stress can be
harmful to a student's academic performance and students
who perceive their stress as very high may often lead to
depression, anxiety, attrition and serious health
problems (Evans & Kelly, 2004).
In our study,
anxiety and depressive symptoms were reported by 59.2%
and 18.2%, respectively. Benjamin, Kazniak, Sales, &
Shanfield, (1986) found that 17-40% of the group studied
reported significantly elevated levels of depression,
and 20-40% of the same group "reported other
significantly elevated symptoms, including obsessive
compulsive, interpersonal sensitivity, anxiety,
hostility, paranoid ideation, and (psychoticism) social
alienation and isolation, as compared to only 2.27% of
the general population.
High perceived
stress and anxiety scores in Mansoura law students could
be accounted by the following:
First, the legal
profession in Egypt has a long, illustrious history but
the current education policy allows increasing number of
admitted law students depending on the total marks
alone, and this does not reflect the student's real
desire to choose the field of specialization (Moustafa,
2004). This policy increases pressure on the limited
resources of universities, reduces performance of
faculty members and lowers the efficiency of the
graduates. By then, they dispossessed of the means to
make a success of their careers. The legal education
program was of the traditional type and students lack
the skills of the labor market as multi-language
abilities, international law specialists and
technological skills (Kenawy, 2006). So these students
experienced more anxiety about their future and
employment.
Second, the law
students had a lower socio-economic state and belong to
the low and middle classes. The study examined the
family income, education and occupation of the parents
as markers of socio-economic state. In contrast of our
finding, Astin (1984) reported that law students do not
mirror the socio-economic makeup of the society from
which they come; instead, they come from an elite
background of higher socioeconomic status than the
general population. PSS scores generally increased as
household income decreased, the number of people living
in the respondent' household increased (Cohen &
Willamson, 1988). This social disadvantage is associated
with increased stress. One explanation for this pattern
is that individuals lower down the socioeconomic status
ladder have fewer psychological resources for meeting
the stress of the increasingly more challenging
environment that may negatively impact physical and
psychological well-being (Grant et al., 2006).
Finally, many
students succumb to first-year myths, an enduring set of
irrational beliefs that corrode one’s quality of life
(Lake, 2000). These include (a) I must study all the
time, (b) I must be at the top of my class to be
successful, and (c) I can’t have a social life in law
school (Granfield, 1986). Such irrational beliefs are
correlated with anxiety (Day & Maltby, 2003); their
internalization by law students is a likely contributor
to stress.
Several studies
have explored the relationship between level of
perceived stress and student anxiety (Dyrbye, Thomas, &
Shanafelt, 2006). Perceptions of stress were found not
only to correlated with depression and anxiety (Katz,
Monnier, Libet, Shaw, & Beach, 2000; Mosley et al.
1994), but also predict future risk of depression (Rosal
et al., 1997). Okasha, Kamel, Sadek, & Lotaif (1977)
concluded that most cases of anxiety among Egyptian
college students had been reactive to either
maturational or environmental stresses rather than
endogenous.
Although stress
may cause physical and psychiatric (depression and
anxiety) symptoms it is possible that elevated stress
may cause these symptoms or a third factor for example
socioeconomic status, influenced both stress and health
(Cohen, Kamarck, & Mermelstein, 1983; Cho, 1988).
Because of data in the present study were
cross-sectional, the direction of any association
between stress and different physical and mental
predictors cannot be determined. Moreover, research by
Misra and McKean (2000) investigated the
interrelationship among independent predictors of stress
in undergraduate university students. It was
hypothesized that a student's academic stress would show
a positive correlation with anxiety.
It appears that
the law students have a high level of perceived stress
and majority of it generates from persona factors and
less from the academic or environmental factors. Due to
the major impact that perceived stress levels may have
on law students, it is important that the problem be
identified and dealt with effectively. Stress management
skills should be an integral part of the routine
clinical facilities caring for university students to
help them to make smooth transitions between different
learning environments with changing learning demands and
a growing burden. Studies of the effects of stress on
practicing members of the legal profession are needed to
further explore the possible effects of law school
stress in the subsequent career years and to examine the
specific effects of excessive stress on practicing
attorneys.
Study
limitations
1)
The findings of
this study are based on self reported information
provided by students and some potential for reporting
bias may have occurred because of respondents’
interpretation of the questions tutors explained the
study and the scales used to the students or desire to
report their emotions in a certain way or simply because
of inaccuracies of responses.
2)
The study toke
place at one university which will affect the
generalizability to other institutions. Consequently,
the results will only be applicable to similar
institutions in similar settings.
3)
The study toke
place at one point in time which will limit the ability
to generalize the findings to other time periods, this
is referred to as a threat to temporal validity.
4)
The study did not
account faculty characteristics or teaching styles which
could have an effect on the student's perceived stress
levels.
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