{"id":70460,"date":"2021-04-13T11:55:13","date_gmt":"2021-04-13T03:55:13","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/taps\/?post_type=issues&#038;p=70460"},"modified":"2021-07-13T09:09:43","modified_gmt":"2021-07-13T01:09:43","slug":"validation-of-the-perceived-stress-scale-pss-10-in-medical-and-health-sciences-students-in-hong-kong","status":"publish","type":"issues","link":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/validation-of-the-perceived-stress-scale-pss-10-in-medical-and-health-sciences-students-in-hong-kong\/","title":{"rendered":"Validation of the perceived stress scale (PSS-10) in medical and health sciences students in Hong Kong"},"content":{"rendered":"<p>Submitted: <span lang=\"EN-GB\">24 June <\/span> 2020<br \/>\r\nAccepted: <span lang=\"EN-GB\">8 September <\/span> 2020<br \/>\r\nPublished online: <span lang=\"EN-GB\">4 May, TAPS 2021, <\/span><span lang=\"EN-GB\">6(2), 31-37<\/span><br \/>\r\n<a href=\"https:\/\/doi.org\/10.29060\/TAPS.2021-6-2\/OA2328\">https:\/\/doi.org\/10.29060\/TAPS.2021-6-2\/OA2328<\/a><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Julie Yun Chen<sup>1,2<\/sup>, Weng-Yee Chin<sup>1<\/sup>, Agnes Tiwari<sup>3<\/sup>, Janet Wong<sup>3<\/sup>, Ian C K Wong<sup>4<\/sup>, Alan Worsley<sup>4<\/sup>, Yibin Feng<sup>5<\/sup>, Mai Har Sham<sup>6<\/sup>, Joyce Pui Yan Tsang<sup>1,2<\/sup> &amp; Chak Sing Lau<sup>7<\/sup><\/span><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><i><sup><span lang=\"EN-GB\">1<\/span><\/sup><\/i><i><span lang=\"EN-GB\">Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; <sup>2<\/sup>Bau Institute of Medical and Health Sciences Education, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; <sup>3<\/sup>School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; <sup>4<\/sup>Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; <sup>5<\/sup>School of Chinese Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; <sup>6<\/sup>School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; <sup>7<\/sup>Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong, Hong Kong<\/span><\/i><\/p>\r\n<p style=\"text-align: center\"><b><span lang=\"EN-GB\">Abstract<\/span><\/b><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Introduction:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">The demanding nature of medical and health sciences studies can cause stress among students in these disciplines affecting their wellbeing and academic performance. The Perceived Stress Scale (PSS-10) is a widely used measure of perceived stress among medical students and healthcare professionals that has not yet been validated among medical and health sciences students in Hong Kong. The aim of this study is to establish the construct validity and reliability of the PSS-10 in this context.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Methods:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">267 final year medical and health sciences students were surveyed using the PSS-10. The data were analysed using exploratory factor analysis for construct validity and Cronbach\u2019s alpha coefficient and corrected item-total correlations for reliability.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Results:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Exploratory factor analysis revealed a two-factor structure for PSS-10, with Cronbach\u2019s alpha of 0.865 and 0.796, indicating good internal consistency. Corrected item-total correlations showed satisfactory correlation ranged from 0.539 to 0.748 for all items and their respective subscale. Both tests supported PSS-10 as a two-factor scale.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Conclusion:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">The PSS-10 is a valid measure for assessing perceived stress in Hong Kong medical and health sciences students.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Keywords<\/span><span lang=\"EN-GB\">:<\/span><\/b><span lang=\"EN-GB\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span><i><span lang=\"EN-GB\">Undergraduate Students, Medicine, Nursing, Pharmacy, Health Sciences, Validation, Perceived Stress<\/span><\/i><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Practice Highlights<\/span><\/strong><\/p>\r\n<ul>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">It is important to have a valid instrument for early detection of stress in health science students.<\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Perceived Stress Scale (PSS-10) has a two-factor structure, a finding that is consistent with most other studies.<\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">PSS-10 has satisfactory internal consistency and reliability.<\/span><\/li>\r\n\t<li style=\"text-align: justify\">PSS-10 can be used to assess the level of stress in medical and health sciences students.<\/li>\r\n<\/ul>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">I. INTRODUCTION<\/span><\/strong><\/p>\r\n<ol><\/ol>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Undertaking studies in healthcare disciplines can be stressful as the programmes are demanding and students are often competing with higher achieving peers from admission to graduation. Significant stress can lead to psychological distress that has negative implications on current and future performance. Medical students have a higher prevalence of distress and poorer mental quality of life than their non-medical peers (Dyrbye et al., 2006; Shin et al., 2016), and also experience sleep deprivation, anxiety, and feelings of social isolation as revealed in focus group interviews conducted by Henning et al. (2010). There may also be a negative impact in quality of patient care (Firth-Cozens, 2001) and higher rate of medical errors (West et al., 2009). High perceived stress level correlated to impaired clinical performances in nursing students, including application of knowledge, clinical skills and communication (Ye et al., 2018). High level of stress and impaired quality of life were also found in third year pharmacy students in the United States (Marshall et al., 2008). In a study on pre-medical and health sciences students, higher perceived stress was a predictor of poor academic achievement (Henning et al., 2018).<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">As in many Asian cultures, Hong Kong students in general are under pressure to perform well in school as education is viewed as a crucial stepping-stone to success (S. Chan, 1999; Tan &amp; Yates, 2011). This pressure may be particularly pronounced in medical students who manifest a greater degree of psychological distress, including perceived stress, depressive symptoms and anxiety, than other university students (Wong et al., 2005). A survey on medical students from the University of Hong Kong also revealed that majority of medical students were screened positive for minor psychiatric disorders and up to 95% of them were burned out (Chau et al., 2019). Many students may be \u201cpushed\u201d into a career path by extrinsic factors such as parental expectation (Sreeramareddy et al., 2007) or as a part of family tradition. Asian medical students may also tend to focus on academic achievement and seek to outperform their peers (Henning et al., 2011). Given the risk for developing high level of stress for these students, and the particularly intense environment in Hong Kong, it is important to have a valid instrument for early detection of stress so that appropriate strategies may be instituted at an early stage. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The Perceived Stress Scale (PSS-10) (Cohen, 1988) is widely used to measure perceived stress among healthcare students and doctors in different countries (Jones et al., 2015; Wongpakaran &amp; Wongpakaran, 2010), and healthcare workers in Hong Kong (Chua et al., 2004). Healthcare students and healthcare workers may respond differently to a stressful event, as shown in the studies by Chua et al. (2004) and Wong et al. (2004), where the psychological effects of the SARS outbreak were different for healthcare students and workers. PSS-10 has been translated and validated in various languages, including Spanish, Turkish, Portuguese, Chinese, Thai and Japanese, among different populations such as patients, students, pregnant women, and adults in the general population (Lee, 2012). These validation studies are fundamentally robust, yet validating the PSS-10 is important in the specific undergraduate medical and health professions educational context in Hong Kong. Our study population is subject to different cultural, societal and educational influences that affect the perception of stress and the understanding of the items in the instrument so validation studies done elsewhere may not be applicable to our local context. The aim of this study is therefore, to establish the construct validity and reliability of the PSS-10 for use in this population.<\/span><\/p>\r\n<p style=\"text-align: center\"><strong><span lang=\"EN-GB\">\u00a0II. <\/span><span lang=\"EN-GB\"><\/span><span lang=\"EN-GB\">METHODS<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><i><span lang=\"EN-GB\"><\/span><\/i><i><span lang=\"EN-GB\">A. Participants and Data Collection<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">All final year students undertaking studies in Li Ka Shing Faculty of Medicine in the University of Hong Kong (HKUMed) in the academic year of 2014-2015 were the target population of this study. A research assistant, who was not involved in teaching and assessment of the students, invited the students to participate in the study during a designated compulsory face-to-face teaching session for each programme. Those who provided written consent completed a written questionnaire in January &#8211; February 2015 or June 2015. The specific time for each cohort was chosen to avoid known stressful periods such as exams. The questionnaire included the PSS-10 and demographic information.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">\u00a0<em>B. <\/em><\/span><em><span lang=\"EN-GB\"><\/span><span lang=\"EN-GB\">Measure<\/span><\/em><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The Perceived Stress Scale (PSS-10) (Cohen, 1988) was chosen as the instrument for measuring perceived stress. We considered other often-used instruments including the Depression Anxiety Stress Scale (DASS) (Lovibond &amp; Lovibond, 1995) that measures depression and anxiety, in addition to stress and the General Health Questionnaire (GHQ) (Goldberg &amp; Hillier, 1979) that measures medical complaints as a reflection of emotional stress, but these looked at broader conceptualisations of psychological distress beyond the scope of our study. PSS-10 was the most fit-for-purpose in measuring stress in terms of respondents\u2019 views about their lives. In addition, we wished to be able to compare the stress in medical and health professions students to other key local comparator populations (e.g. university students, doctors, general population etc) and using the same instrument would facilitate this comparison.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">PSS-10 is a 10-item instrument that assesses the extent of stress of respondents. PSS-10 is the abbreviated version of the original instrument with 14 items (PSS-14). A brief version with four items (PSS-4) is also available. Among the three versions of PSS, PSS-10 was found to be superior in psychometric properties, in terms of validity and reliability, than the other two versions (Lee, 2012). In the PSS-10, respondents rate statements about how unpredictable, uncontrollable, and overloaded they find their lives on a 5-point Likert scale from \u201cnever\u201d to \u201cvery often\u201d. Each response is converted to a score of 0 to 4 with the overall PSS score computed as the total score of the 10 items, with four reverse-coded items. The higher the score, the worse the perceived stress, with a maximum score of 40. There is no specific cut-off score that corresponds to high or low stress. We used the original English version of PSS-10 because as an English-medium university, students at HKUMed are taught in English (except during bedside teaching and clinical practicums) and students are proficient in English.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\"><em>\u00a0C<\/em>. <\/span><i><span lang=\"EN-GB\"><\/span><\/i><i><span lang=\"EN-GB\">Data Analysis<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">To establish the construct validity of the PSS-10, exploratory factor analysis (EFA) was performed on the responses to PSS-10 items by final year medical students, using principal component extraction with varimax rotation and the criterion of eigenvalue greater than 1.00. The Kaiser-Meyer-Olkin (KMO) measure equal to or greater than 0.5 was used to indicate sampling adequacy, while the Barlett\u2019s Test of Sphericity with p&lt;0.001 was used to ensure the appropriateness of the data set for EFA. Cumulative variance explained in the factor structure identified by EFA model was reported. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Cronbach\u2019s alpha coefficient and corrected item-total correlations were used to examine reliability. Cronbach\u2019s alpha coefficient was calculated to assess the internal consistency of each scale, which was considered acceptable if greater than 0.7 (Nunnally, 1994). Corrected item-total correlations were evaluated by Pearson\u2019s correlation coefficient. A correlation of more than 0.4 was considered satisfactory (Wolfinbarger &amp; Gilly, 2003).<\/span><\/p>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\">\u00a0<strong>III. <\/strong><\/span><strong><span lang=\"EN-GB\"><\/span><span lang=\"EN-GB\">RESULTS<\/span><\/strong><\/p>\r\n<p><span lang=\"EN-GB\">A total of 267 students completed the survey, with an overall response rate of 86.5%. 104 (39%) of the respondents were male (Table 1). Female students had significantly higher perceived stress than male students (20.84 vs 18.59; p&lt;0.001). Table 2 shows the descriptive statistics for PSS-10 items and total score by programme of study.<\/span><\/p>\r\n<div>\r\n<div align=\"center\">\r\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"0\">\r\n<tbody>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>All (n=267)<\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>Average PSS-10<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>Age (mean)<\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>22.71<\/p>\r\n<\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>19.95<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>Gender<\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\"><\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\"><\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p><i>Male<\/i><\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>104<\/p>\r\n<\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>18.59<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p><i>Female<\/i><\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>160<\/p>\r\n<\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>20.84<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>Programme of study<\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\"><\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\"><\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p><i>MBBS<\/i><\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>120<\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>18.17<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p><i>BNurs<\/i><\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>94<\/p>\r\n<\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>21.20<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p><i>BChinMed<\/i><\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>13<\/p>\r\n<\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>21.77<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p><i>BPharm<\/i><\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>28<\/p>\r\n<\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>22.39<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p><i>BBMS<\/i><\/p>\r\n<\/td>\r\n<td width=\"139\" valign=\"bottom\">\r\n<p>10<\/p>\r\n<\/td>\r\n<td width=\"139\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>20.20<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"485\" nowrap=\"nowrap\" colspan=\"3\" valign=\"bottom\">\r\n<p>MBBS: Bachelor of Medicine and Bachelor of Surgery; BNurs: Bachelor of Nursing; BChinMed: Bachelor of Chinese Medicine; BPharm: Bachelor of Pharmacy; BBMS: Bachelor of Biomedical Sciences<\/p>\r\n<p>*Numbers may not add up to the total number of respondents due to missing data<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<p align=\"center\"><span lang=\"EN-GB\">Table 1. Demographic of respondents and average PSS-10 score<\/span><\/p>\r\n<div align=\"center\">\r\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"0\">\r\n<tbody>\r\n<tr>\r\n<td width=\"33\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"222\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"bottom\">\r\n<p>All (n=265)<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"bottom\">\r\n<p>MBBS (n=120)<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"bottom\">\r\n<p>BNurs (n=94)<\/p>\r\n<\/td>\r\n<td width=\"68\" valign=\"bottom\">\r\n<p>BChinMed (n=13)<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"bottom\">\r\n<p>BPharm (n=28)<\/p>\r\n<\/td>\r\n<td width=\"65\" valign=\"bottom\">\r\n<p>BBMS (n=10)<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"595\" nowrap=\"nowrap\" colspan=\"8\" valign=\"bottom\">\r\n<p><b><i><span lang=\"EN-NZ\">In the last month, how often have you\u2026<\/span><\/i><\/b><b><i><\/i><\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>1.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>been upset because of something that happened unexpectedly<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>2.10<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.83<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.27<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.62<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>2.39<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.30<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>2.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>felt that you were unable to control the important things in your life<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>2.05<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.79<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.19<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.31<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>2.46<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.40<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>3.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>felt nervous and \u201cstressed\u201d<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>2.19<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.87<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.39<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.31<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>2.64<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.60<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>4.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>felt confident about your ability to handle your personal problems<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>2.19<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.25<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.21<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.00<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>1.93<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.20<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>5.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>felt that things were going your way<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>2.11<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.21<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.07<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.00<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>1.93<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.90<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>6.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>found that you could not cope with all the things that you had to do<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>1.97<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.77<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.07<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.23<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>2.39<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.00<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>7.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>been able to control irritations in your life<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>2.19<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.25<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.12<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.15<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>2.14<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.40<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>8.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>felt that you were on top of things<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>1.79<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.00<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>1.66<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.46<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>1.46<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.90<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>9.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>been angered because of things that were outside of your control<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>1.94<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.81<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.19<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.85<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>1.82<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.60<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>10.<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>felt difficulties were piling up so high that you could not overcome them<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"top\">\r\n<p>1.96<\/p>\r\n<\/td>\r\n<td width=\"53\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.77<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"top\">\r\n<p>2.15<\/p>\r\n<\/td>\r\n<td width=\"68\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>2.08<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"top\">\r\n<p>2.14<\/p>\r\n<\/td>\r\n<td width=\"65\" nowrap=\"nowrap\" valign=\"top\">\r\n<p>1.70<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"222\" valign=\"top\">\r\n<p>Total*<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"bottom\">\r\n<p>19.93<\/p>\r\n<\/td>\r\n<td width=\"53\" valign=\"bottom\">\r\n<p>18.17<\/p>\r\n<\/td>\r\n<td width=\"47\" valign=\"bottom\">\r\n<p>21.20<\/p>\r\n<\/td>\r\n<td width=\"68\" valign=\"bottom\">\r\n<p>21.77<\/p>\r\n<\/td>\r\n<td width=\"54\" valign=\"bottom\">\r\n<p>22.39<\/p>\r\n<\/td>\r\n<td width=\"65\" valign=\"bottom\">\r\n<p>20.20<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"595\" nowrap=\"nowrap\" colspan=\"8\" valign=\"top\">\r\n<p>MBBS: Bachelor of Medicine and Bachelor of Surgery; BNurs: Bachelor of Nursing; BChinMed: Bachelor of Chinese Medicine; BPharm: Bachelor of Pharmacy; BBMS: Bachelor of Biomedical Sciences<\/p>\r\n<p>*Total score is calculated by the sum of the 10 PSS items, with item 4, 5, 7 and 8 reverse coded.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<p align=\"center\"><span lang=\"EN-GB\">Table 2. Mean score for PSS-10 items by programme of study<\/span><\/p>\r\n<p style=\"text-align: justify\"><em><span lang=\"EN-GB\">A. Exploratory<\/span><span lang=\"EN-GB\"> Factor Analysis on PSS-10<\/span><\/em><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Using the final year medical and health sciences student data for EFA (Table 3), the KMO measure for PSS-10 was 0.823, indicating sampling adequacy. The scale had a p-value of &lt;0.001 for the Bartlett\u2019s Test of Sphericity, confirming variability in the data was sufficient. The factor loadings of varimax rotated solution and the eigenvalue of the two factors identified (Perceived Helplessness and Perceived Control) are shown in Table 3. The cumulative variances explained were 61.386%. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">\u00a0<em>B. <\/em><\/span><em><span lang=\"EN-GB\">Reliability<\/span><\/em><\/p>\r\n<p align=\"justify\" style=\"text-align: justify\"><span lang=\"EN-GB\">Cronbach\u2019s alpha for the two factors were 0.865 and 0.796 respectively, which indicates good internal consistency reliability (Table 4). To determine the robustness of the analysis, each item was deleted in turn from the calculation and the resulting Cronbach\u2019s alpha remained high (0.724-0.859). Corrected item-total correlations showed satisfactory correlation for all items and their respective subscale (range from 0.539 to 0.748) (Table 4). Items with the highest corrected item-total correlation were item 2 (\u201cfelt that you were unable to control the important things in your life\u201d), item 3 (\u201cfelt nervous and \u2018stressed\u2019\u201d), and item 10 (felt difficulties were piling up so high that you could not overcome them). Both tests supported the PSS-10 as a two-factor scale.<\/span><\/p>\r\n<div align=\"center\">\r\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"0\">\r\n<tbody>\r\n<tr>\r\n<td width=\"384\" colspan=\"3\" rowspan=\"2\" valign=\"bottom\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"193\" colspan=\"3\">\r\n<p>Factor loading<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"91\">\r\n<p>Perceived helplessness<\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\">\r\n<p>Perceived control<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"576\" colspan=\"6\" valign=\"bottom\">\r\n<p><b>In the last month, how often have you\u2026<\/b><\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>2.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>felt that you were unable to control the important things in your life<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p><b>0.826<\/b><\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p>-0.168<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>1.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>been upset because of something that happened unexpectedly<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p><b>0.793<\/b><\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p>0.021<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>3.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>felt nervous and \u201cstressed\u201d<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p><b>0.793<\/b><\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p>-0.167<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>10.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>felt difficulties were piling up so high that you could not overcome them<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p><b>0.782<\/b><\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p>-0.154<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>9.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>been angered because of things that were outside of your control<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p><b>0.712<\/b><\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p>0.099<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>6.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>found that you could not cope with all the things that you had to do<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p><b>0.698<\/b><\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p>-0.132<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>4.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>felt confident about your ability to handle your personal problems<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p>-0.017<\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p><b>0.815<\/b><\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>5.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>felt that things were going your way<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p>-0.102<\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p><b>0.811<\/b><\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>7.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>been able to control irritations in your life<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p>-0.100<\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p><b>0.774<\/b><\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\" valign=\"top\">\r\n<p>8.<\/p>\r\n<\/td>\r\n<td width=\"351\" colspan=\"2\" valign=\"top\">\r\n<p>felt that you were on top of things<\/p>\r\n<\/td>\r\n<td width=\"91\" valign=\"top\">\r\n<p>-0.086<\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"top\">\r\n<p><b>0.732<\/b><\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\"><\/td>\r\n<td width=\"351\" colspan=\"2\">\r\n<p>Eigenvalue<\/p>\r\n<\/td>\r\n<td width=\"91\">\r\n<p>3.879<\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\">\r\n<p>2.260<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\"><\/td>\r\n<td width=\"351\" colspan=\"2\">\r\n<p>% of variance<\/p>\r\n<\/td>\r\n<td width=\"91\">\r\n<p>38.791<\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\">\r\n<p>22.595<\/p>\r\n<\/td>\r\n<td width=\"6\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"38\" colspan=\"2\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"346\">\r\n<p><b>Cumulative % of variance<\/b><\/p>\r\n<\/td>\r\n<td width=\"181\" colspan=\"2\">\r\n<p><b>61.386<\/b><\/p>\r\n<\/td>\r\n<td width=\"18\" colspan=\"2\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"33\"><\/td>\r\n<td width=\"5\"><\/td>\r\n<td width=\"346\"><\/td>\r\n<td width=\"91\"><\/td>\r\n<td width=\"90\"><\/td>\r\n<td width=\"12\"><\/td>\r\n<td width=\"6\"><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<p align=\"center\"><span lang=\"EN-GB\">Table 3. Factor loadings by exploratory factor analysis for PSS-10<\/span><\/p>\r\n<div align=\"center\">\r\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"0\">\r\n<tbody>\r\n<tr>\r\n<td width=\"29\" nowrap=\"nowrap\" valign=\"bottom\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"369\" valign=\"bottom\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"bottom\">\r\n<p>Corrected Item-Total Correlation<\/p>\r\n<\/td>\r\n<td width=\"101\" colspan=\"2\" valign=\"bottom\">\r\n<p>Cronbach&#8217;s Alpha if Item Deleted<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"600\" nowrap=\"nowrap\" colspan=\"4\" valign=\"bottom\">\r\n<p><b>In the last month, how often have you\u2026<\/b><\/p>\r\n<\/td>\r\n<td width=\"0\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"600\" nowrap=\"nowrap\" colspan=\"4\">\r\n<p><i>Perceived helplessness <\/i>(Cronbach&#8217;s Alpha = 0.865 )<i><\/i><\/p>\r\n<\/td>\r\n<td width=\"0\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>1.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>been upset because of something that happened unexpectedly<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.674<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.840<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>2.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>felt that you were unable to control the important things in your life<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.748<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.826<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>3.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>felt nervous and \u201cstressed\u201d<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.705<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.835<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>6.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>found that you could not cope with all the things that you had to do<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.591<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.854<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>9.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>been angered because of things that were outside of your control<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.562<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.859<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>10.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>felt difficulties were piling up so high that you could not overcome them<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.688<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.838<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"600\" nowrap=\"nowrap\" colspan=\"4\">\r\n<p><i>Perceived control <\/i>(Cronbach&#8217;s Alpha = 0.796)<i><\/i><\/p>\r\n<\/td>\r\n<td width=\"0\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>4.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>felt confident about your ability to handle your personal problems<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.635<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.732<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>5.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>felt that things were going your way<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.652<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.724<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>7.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>been able to control irritations in your life<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.609<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.745<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\">\r\n<p>8.<\/p>\r\n<\/td>\r\n<td width=\"369\">\r\n<p>felt that you were on top of things<\/p>\r\n<\/td>\r\n<td width=\"101\" valign=\"top\">\r\n<p>0.539<\/p>\r\n<\/td>\r\n<td width=\"101\" nowrap=\"nowrap\" colspan=\"2\" valign=\"top\">\r\n<p>0.781<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"600\" nowrap=\"nowrap\" colspan=\"4\" valign=\"bottom\">\r\n<p>Cut-offs for item-total correlation: &lt;0.4 indicates poor correlation between item and total score.<\/p>\r\n<\/td>\r\n<td width=\"0\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"29\"><\/td>\r\n<td width=\"369\"><\/td>\r\n<td width=\"101\"><\/td>\r\n<td width=\"101\"><\/td>\r\n<td width=\"0\"><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<p align=\"center\" style=\"text-align: center\"><span lang=\"EN-GB\">Table 4. Corrected Item-Total Correlation<\/span><\/p>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">IV. DISCUSSION<\/span><\/strong><\/p>\r\n<p><i><span lang=\"EN-GB\">A. Exploratory Factor Analysis<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Exploratory factor analysis for PSS-10 revealed a two-factor structure, which was consistent with the findings in the original study (Cohen, 1988) and other validation studies (Andreou et al., 2011; Chaaya et al., 2010; Lesage et al., 2012; Leung et al., 2010; \u00d6r\u00fcc\u00fc &amp; Demir, 2009; Siqueira et al., 2010; Wongpakaran &amp; Wongpakaran, 2010). The two factors identified in our study were related to the concept of control and ability to cope, as reflected in the positively-worded items, and the concept of helplessness, as reflected in negative items, respectively. The three items that loaded most heavily on the helplessness factor related to a lack of control (item 2), anxiety (item 3) and feeling overwhelmed (item 10). <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">\u00a0<em>B. <\/em><\/span><em><span lang=\"EN-GB\">Locus of Control<\/span><\/em><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">It was evident that feeling unable to control important things in life (Item 2) greatly contributed to perceived stress of students. (Table 4) External locus of control, where people believe external factors control success or failure, is associated with higher stress (Linn &amp; Zeppa, 1984) and understandable for healthcare students. For example, the teaching timetable is often changed at the last minute as the teachers might have urgent clinical duties or they may be expected to do more self-directed learning in which the breadth or depth of the learning may not be made clear. The expectations for clinical skills in clinical settings are often different from what was taught in school (Gibbons et al., 2008). The uncertainty of the curriculum, progress and assessment also contribute to stress in healthcare students (Elzubeir et al., 2010). Moreover, as the most junior member of the healthcare team, students have no decision-making capacity and may feel helpless when confronted with situations beyond their expertise or observe actions contrary to their personal views (Jennings, 2009).<\/span><\/p>\r\n<p style=\"text-align: justify\"><em><span lang=\"EN-GB\">C. <\/span><\/em><em><span lang=\"EN-GB\">Anxiety<\/span><\/em><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Feeling nervous (item 3) was another contributing factor for perceived stress (Table 4). Medical and health sciences students are required to sit high-stakes examinations in order to be promoted to the next year of study or to graduate, where test anxiety is understandably prevalent (Encandela et al., 2014). Clinical competency exams such as OSCEs are particularly anxiety-provoking (Muldoon et al., 2014). This is especially relevant to the final year students in this study, as the final summative exams in all programmes are intense. In particular, the written final Bachelor of Medicine and Bachelor of Surgery (MBBS) exam covers material from the whole year and all disciplines including medicine, surgery, psychiatry, obstetrics and gynaecology, paediatrics, orthopaedics, and family medicine, and also includes a clinical competency test in each discipline. This final exam constitutes the licensing exam to become a doctor in Hong Kong. \u00a0<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">In addition, the vast majority of students admitted to undergraduate healthcare professions studies in Hong Kong are secondary school graduates. The age-related level of maturity may affect their ability to cope with a strenuous, content-rich curriculum as well as the pressures of clinical practicums and clerkships. Students have raised concerns about exam-induced anxiety and the heavy academic workload and in fact, the most common reason for students to seek counselling support at our institution is because of academic-related stress or psychological distress. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Working in the clinical environment also produces anxiety, especially when starting a new rotation in a new discipline when students often lack clinical experience, are unfamiliar with the ward, encounter difficult patients, and have a fear of making mistakes (Sharif &amp; Masoumi, 2005). The hierarchical medical culture is more pronounced in healthcare settings and can be intimidating for undergraduate healthcare professions students who are seen as the lowest rung on the ladder. Other situations where the students are singled-out, such as during simulations, being observed, evaluated or video-recorded, also increases anxiety (Nielsen &amp; Harder, 2013) especially as these teaching sessions are done in small groups. The style of learning for our students in these clinical years also require a more proactive, interactive and self-reliant style of learning. In addition to scheduled bedside teaching with a clinician, students have to seek out patients to clerk in order to hone their clinical skills and gain clinical experience. This may be an adjustment to students used to a more traditional classroom style and textbook learning.<\/span><\/p>\r\n<p style=\"text-align: justify\"><i><span lang=\"EN-GB\">D. Overwhelmed<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The third most important item contributing to high perceived stress was the feeling of being overwhelmed with the workload and difficulties (item 10) (Table 4). Healthcare studies are well-known for being content heavy. Students have a heavy workload including long hours of lectures, tutorials, laboratories and clinical attachments, and are also expected to spend substantial time on independent study. Because most healthcare professions students in Hong Kong are admitted to such programmes directly upon completion of secondary education, higher diploma or associate degree, the curricula are even more packed with basic foundational as well as profession-specific advanced content. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Students in their final year of study have to contend with clinical experiential learning but must also further develop their knowledge base. This entails acquiring a huge volume of factual content as well as applying concepts to clinical scenarios. Students must work more independently in clinical attachments and may have some responsibility for patient care or administrative work. For example, nursing students\u2019 progress from having practicums in small groups to shadowing a practising nurse, and working as a member of the nursing team in the ward in their senior years.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">In addition, clinical teaching settings in Hong Kong, can be challenging learning environments especially the tertiary care teaching hospitals where much of the training takes place. The business of routine patient care already involving a multitude of staff makes it a daunting place for healthcare professions students who have to compete with each other for the opportunity to clerk patients. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">In the clinical environment, students also come face-to-face with difficult situations and experience feelings that they may have difficulty resolving. This may include having problems communicating communication with patients or their families, struggling with ethical dilemmas such as witnessing a medical error, or experiencing the illness experience of patients and the helplessness of not being able alleviate their suffering. Medical students can be overwhelmed by the burden of suppressing their own natural emotions when facing the pain and suffering of their patients (Jennings, 2009). Likewise, nursing students also expressed that workload from clinical work and their own studies exceeded their physical and emotional capacity (C. K. Chan et al., 2009).<\/span><\/p>\r\n<p style=\"text-align: justify\"><i><span lang=\"EN-GB\">E. Limitations<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">At the time of data collection, no data were collected for other scales of similar or opposite construct. Hence no convergent or divergent validity could be calculated. Also, test-retest reliability could not be done as this was a one-off cross-sectional survey. Despite these limitations our data supported a two-factor structure of the PSS-10, consistent with the original and other previous studies.<\/span><\/p>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\">\u00a0<strong>V. <\/strong><\/span><strong><span lang=\"EN-GB\"><\/span><span lang=\"EN-GB\">CONCLUSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Demonstrating good construct validity and internal consistency, PSS-10 is a valid measure for assessing self-reported stress in medical students as well as in health sciences students. Longitudinal studies on student stress using this measure will help to assess the extent and patterns of stress in a high-risk population in order to develop timely interventions.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Notes on Contributors<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">JY Chen and JPY Tsang reviewed the literature, designed the study, performed data collection and data analysis, and developed the manuscript. WY Chin, A Tiwari, J Wong, ICK Wong, A Worsley, Y Feng, MH Sham and CS Lau advised on the study design, facilitated data collection and gave critical feedback on the manuscript. All authors have read and approved the final manuscript.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Ethical Approval<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Ethical approval of this study was granted by the Institutional Review Board of the University of Hong Kong\/Hospital Authority Hong Kong West Cluster (Reference No.: UW 14-472). All participants have given written consent for their data to be used in the research and for publication.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Acknowledgements<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">We would like to thank the students of HKUMed for participating in the study, and the administrative staff of Li Ka Shing Faculty of Medicine, School of Nursing, School of Chinese Medicine, Department of Pharmacology and Pharmacy, and School of Biomedical Sciences for helping with the logistical arrangement of the questionnaire administrations.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Funding<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">This work was supported by a Teaching Development Grant funded by the University of Hong Kong.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Declaration of Interest<\/span><\/strong><\/p>\r\n<p><span lang=\"EN-GB\">The authors declare that there is no conflict of interest.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">References<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Andreou, E., Alexopoulos, E. 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Three versions of Perceived Stress Scale: validation in a sample of Chinese cardiac patients who smoke. <i>BMC Public Health<\/i>, <i>10<\/i>(1), 513. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Linn, B. S., &amp; Zeppa, R. (1984). Stress in junior medical students: Relationship to personality and performance. <i>Journal of Medical Education<\/i>. <i>59<\/i>(1), 7-12.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Lovibond, S. H., &amp; Lovibond, P. F. (1995). <i>Manual for the Depression Anxiety Stress Scales<\/i>. (2nd. Ed.) Psychology Foundation.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Marshall, L. L., Allison, A., Nykamp, D., &amp; Lanke, S. (2008). 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Association of resident fatigue and distress with perceived medical errors. The <i>Journal of the American Medical Association<\/i>, <i>302<\/i>(12), 1294-1300. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Wolfinbarger, M., &amp; Gilly, M. C. (2003). eTailQ: Dimensionalizing, measuring and predicting etail quality. <i>Journal of Retailing<\/i>, <i>79<\/i>(3), 183-198. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Wong, J. G. W. S., Cheung, E. P., Cheung, V., Cheung, C., Chan, M. T., Chua, S. E., McAlonan, G. M., Tsang, K. W. T., &amp; Ip, M. S. (2004). Psychological responses to the SARS outbreak in healthcare students in Hong Kong. <i>Medical Teacher<\/i>, <i>26<\/i>(7), 657-659. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Wong, J. G. W. S., Patil, N. G., Beh, S. L., Cheung, E. P., Wong, V., Chan, L. C., &amp; Lieh Mak, F. (2005). Cultivating psychological well-being in Hong Kong&#8217;s future doctors. <i>Medical Teacher<\/i>, <i>27<\/i>(8), 715-719. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Wongpakaran, N., &amp; Wongpakaran, T. (2010). The Thai version of the PSS-10: An Investigation of its psychometric properties. <i>BioPsychoSocial Medicine<\/i>, <i>4<\/i>(1), 6. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Ye, Y., Hu, R., Ni, Z., Jiang, N., &amp; Jiang, X. (2018). Effects of perceived stress and professional values on clinical performance in practice nursing students: A structural equation modeling approach. <i>Nurse Education Today<\/i>, <i>71<\/i>, 157-162. <\/span><\/p>\r\n<\/div>\r\n<p style=\"text-align: justify\">*Julie Chen<br \/>\r\nDepartment of Family Medicine &amp;<br \/>\r\n<span lang=\"EN-GB\">Bau Institute of Medical and Health Sciences Education,<\/span><br \/>\r\n<span lang=\"EN-GB\">Li Ka Shing Faculty of Medicine,<\/span><br \/>\r\n<span lang=\"EN-GB\">University of Hong Kong<br \/>\r\n21 Sassoon Rd, Pok Fu Lam<br \/>\r\nHong Kong<br \/>\r\nEmail: juliechen@hku.hk<\/span><\/p>","protected":false},"featured_media":0,"parent":0,"menu_order":4,"template":"","issues_category":[12],"archive_category":[],"issue_type":[25],"volume_category":[61866],"class_list":["post-70460","issues","type-issues","status-publish","hentry","issues_category-original-articles","issue_type-past-issue","volume_category-volume-6-number-2-may-2021"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Validation of the perceived stress scale (PSS-10) in medical and health sciences students in Hong Kong - The Asia Pacific Scholar<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/validation-of-the-perceived-stress-scale-pss-10-in-medical-and-health-sciences-students-in-hong-kong\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Validation of the perceived stress scale (PSS-10) in medical and health sciences students in Hong Kong - The Asia Pacific Scholar\" \/>\n<meta property=\"og:description\" content=\"Submitted: 24 June 2020 Accepted: 8 September 2020 Published online: 4 May, TAPS 2021, 6(2), 31-37 https:\/\/doi.org\/10.29060\/TAPS.2021-6-2\/OA2328 Julie Yun Chen1,2, Weng-Yee Chin1, Agnes Tiwari3, Janet Wong3, Ian C K Wong4, Alan Worsley4, Yibin Feng5, Mai Har Sham6, Joyce Pui Yan Tsang1,2 &amp; 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