PHYST-834; No. of Pages 7
ARTICLE IN PRESS
Physiotherapy xxx (2015) xxx–xxx
Social support contributes to resilience among physiotherapy students: a cross sectional survey and focus group study Éva Bíró a,∗ , Ilona Veres-Balajti b , Karolina Kósa a,1 a
Division of Health Promotion, Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Kassai st. 26/b, H-4028 Debrecen, Hungary2 b Department of Physiotherapy, Faculty of Public Health, University of Debrecen, Kassai st. 26/b, H-4028 Debrecen, Hungary2
Abstract Objective The present study, taking a resource-oriented approach to mental health, aimed at investigating mental resilience and its determinants among undergraduate physiotherapy students using quantitative and qualitative tools. Design A questionnaire-based cross-sectional survey supplemented by 2 focus groups. Setting One university in Hungary. Participants 130 physiotherapy students at years 1, 2, and 3. Main outcome measures Sense of coherence, a measure of dynamic self-esteem, as well as social support from family and peers were used to assess mental well-being. A screening instrument for psychological morbidity and perceived stress were used as deficiency-oriented approaches. Student opinions were gathered on positive and negative determinants of mental health. Results Resilience was lower [mean difference 4.8 (95% CI −3.4; 13.1)], and the occurrence of psychological morbidity (32.5% vs. 0%) was higher among female compared to male students. However, the proportion of students fully supported by their peers was higher among females (63% vs. 37.5%). Female students, unlike their male counterparts, experienced higher stress compared to their peers in the general population. Social support declined as students progressed in their studies though this proved to be the most important protective factor for their mental well-being. Conclusions Results were fed back to the course organizers recommending the implementation of an evidence-based method to improve social support as delineated by the Guide to Community Preventive Services of the US the outcomes of which are to be seen in the future. © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Mental health; Psychological resilience; Social support; Physiotherapy students
Introduction Competent and credible health professionals who are fit to practice [1] are essential for the provision of patient care [2]. Having uncovered and/or untreated health problems is but one of numerous reasons of impaired fitness for service ∗ Correspondence: Kassai st. 26/b, H-4028 Debrecen, Hungary. Tel.: +36 52 460 190; fax: +36 52 460 195. E-mail addresses: [email protected] (É. Bíró), [email protected] (I. Veres-Balajti), [email protected] (K. Kósa). 1 Present address: Department of Behavioural Sciences, Faculty of Public Health, University of Debrecen, Hungary. 2 Postal address: POB. 2, 4012 Debrecen, Hungary.
[1], especially in an environment like health care where high levels of occupational stress are pervasive [3]. Stress, and especially chronic stress is an important health problem that has been linked, among others, to anxiety, depression, posttraumatic stress disorder [4,5]. Occupational stress is also a known risk factor for burnout that severely impairs the quality of care [6,7] and is difficult to act upon [8]. However, even cumulative stress experiences do not inevitably lead to mental disorders if individual coping resources and psychosocial factors, such as social support, self-esteem and personal control, moderate the effects of stressors [9]. Improvement of the mental well-being of care providers increases job performance and the quality of patient care, and decreases absenteeism, turnover,
http://dx.doi.org/10.1016/j.physio.2015.05.002 0031-9406/© 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bíró É, et al. Social support contributes to resilience among physiotherapy students: a cross sectional survey and focus group study. Physiotherapy (2015), http://dx.doi.org/10.1016/j.physio.2015.05.002
PHYST-834; No. of Pages 7
2
ARTICLE IN PRESS É. Bíró et al. / Physiotherapy xxx (2015) xxx–xxx
job burnout, and retaliatory behaviours. There is evidence from the past decades that positive emotions and cognitive processes are mutually formative, both contributing to mental well-being [10]. Positive emotions may be the critical mediator underlying the relationship between happiness and success, that is, happiness may lead to successful outcomes rather than merely following from them [11]. Multi-modal cognitive-behavioural therapy can elicit significant changes in emotions, even turning a pessimist into an optimist by teaching skills to decrease negative automatic thoughts and increase more constructive thoughts [12]. Our goals were to survey the mental health of physiotherapy students who received less attention in the scientific literature, using a resource-oriented approach as well as quantitative and qualitative methods. Three quantitative indicators of psychological resilience were used such as sense of coherence (SoC), a dynamic concept of self-esteem developed by Antonovsky composed of three dimensions that reflect general resistance resources [13]. Higher scores indicate stronger SoC, in strong association with measures of health [14]. Another aspect of psychological resilience is social support assessed by the resources that are embedded within an individual’s social network [15] and is conceptualized as information leading people to believe that they are cared for and loved, esteemed and valued, and members of a network of communication and mutual obligations [16]. A third indicator was support perceived to be obtained from peers at the university. Based on the results of the quantitative part of the study, focus groups were organized to uncover determining factors of stress and resilience in depth in order to make suggestions for improvement. Our research questions were the following: 1. What are the features of the mental health status of physiotherapy students? 2. What are the predictors of resilience among them? 3. What factors contribute to the mental health status of physiotherapy students?
Methods Study population A cross-sectional study was carried out among physiotherapy (PT) students of years 1 to 3 at the University of Debrecen, Hungary. Students at year 4 could not participate in the study because they spent their practice at different parts of the country at the time of the data collection. Altogether 77% of all physiotherapy students at the Faculty were invited to participate in the survey, comprising onefifth of all full-time 1st to 3rd year physiotherapy students in Hungary.
Procedure Each student was asked after class to fill a paper-based, self-administered, anonymous questionnaire and to participate in focus groups, organized during the last month of the spring semester in time slots convenient for the students. Two focus groups were conducted; one composed by 9 students from year 1, and another with 5 participants from year 2 (approximately 11% of those who participated in the questionnaire survey). One master student of health promotion led the focus groups as facilitator while another master student took notes that were later subscribed verbatim. Sound recording was not used at the request of the participants. Sessions lasted for one hour. Data collection The questionnaire was similar to that used in previous surveys among medical [17], public health [18], and preschool teacher students [19], and included scales on perceived health, mental health, demographic (age, sex, residence) and socioeconomic (parents’ educational level, family’s economic status) data. Items not referred separately were taken from the tool of the Hungarian National Health Interview Survey of 2003 [20]. Mental health was assessed with various scales,3 two of them based on resource-oriented values (sense of coherence, social support) and two based on deficiencyoriented values (psychological distress, perceived stress) [21]. The validated Hungarian version of the abbreviated Sense of Coherence (SoC) scale [22] was used in the present survey. Social support was measured by a validated scale as described elsewhere [18], scores ranging from 7 to 21. The maximum score of 21 indicated no lack, scores of 18 to 20 indicated a partial, and scores of 17 a complete lack of social support. One question was used to assess social support from peers at the university. Assessment of mental health from a deficiency-oriented approach was made by the 12-item General Health Questionnaire (GHQ-12), a screening tool to detect psychological distress in the general population on which a total score higher than 4 is considered high [23], and the perceived stress scale (PSS-14) [24]. For the focus group interview open-ended questions were formulated regarding causes of stress at the university; personal and private problems encountered during university studies; and possible ways to reduce stress. Data analysis Statistical analysis was executed by Intercooled Stata 10.0 for Windows. Normality was tested with the Shapiro–Wilk test and proved for SoC and PSS. The two-sample unpaired t 3
See more detail in the supplement.
Please cite this article in press as: Bíró É, et al. Social support contributes to resilience among physiotherapy students: a cross sectional survey and focus group study. Physiotherapy (2015), http://dx.doi.org/10.1016/j.physio.2015.05.002
PHYST-834; No. of Pages 7
ARTICLE IN PRESS É. Bíró et al. / Physiotherapy xxx (2015) xxx–xxx
3
Table 1 Socioeconomic characteristics of students. Parents’ educational level (%)
College High school Vocational training Elementary school Less then elementary or not known
Fathers
Mothers
26 26 42 4 2
36 35 23 4 2
Perceived economic status of the family (%)
Good or very good
30
Satisfactory
51
Bad or very bad
19
test was used to compare means for SoC and PSS, and the twosample test of proportion to compare proportions regarding social support and psychological distress for which the level of significance was set at 0.05. Multiple linear regression was carried out to find the predictors of resilience assessed by SoC among physiotherapy students. Perceived health (very good or good vs. satisfied or worse), psychological distress (normal vs. high) and social support from family and peers (fully satisfactory vs. partially or completely lacking), age, gender and study year were defined as independent categorical (except age) variables. Results were compared with that of a representative survey of the Hungarian adult population [25] in terms of variables of mental health which were identically measured in both studies. In the case of the focus groups the transcripts were read several times by the authors to identify key words for coding. Codes were assigned to the text based on which major themes were identified. Relevant narratives were grouped into themes.
Results
Ethics
Mental health Mental health variables in the young (≤25 years old) and mature (>25 years old) students were analyzed separately but no difference was found, so the mental health status of the entire group is reported.
The research was carried out in accordance with the Helsinki Declaration. Ethical permission for the study was issued by the Commission on Research Ethics of the Medical and Health Science Centre of the University of Debrecen, Hungary (DEOEC RKEB/IKEB: 3007-2009). Students were informed in writing and in person that participation was voluntary and they had the right to refuse to participate. No personal data were collected. In order to avoid any pressure for participation, a master student specializing in health promotion was asked to distribute and collect the questionnaires.
Questionnaire survey The overall response rate was 85% (130/153). Demographic and socioeconomic data, perceived health Majority of the students were female (121/130, 93%) with a median age of 21 years (19 to 41 years, IQR: 2), and with the majority (124/130, 95%) being under 26 years of age. Socioeconomic status of the students measured by the parental education level and perceived economic status can be seen in Table 1 in detail. Nearly one-third of respondents (47/130, 36%) had mothers with college degree, while this proportion was one-quarter (34/130, 26%) among the fathers. Almost one-fifth (25/130, 19%) of the students perceived the economic status of their families as bad or very bad. Virtually all of them (127/129, 98%) thought that they could do much or very much for their health, and 65% (84/129) rated their health as very good or good.
Resource-oriented approaches of mental health. The mean score for sense of coherence based upon the answers of 128 students was 60.7 (SD: 11.4, min. 25, max. 85), 4.8 points higher in males compared to females [64.9 (SD: 9.6) vs. 60.0 (SD: 11.5), mean difference 4.8 (95% CI −3.4; 13.1)] without statistical significance (p = 0.25). This score was compared to that obtained from a representative survey of the Hungarian
Table 2 Parameters of resilience and deficiency variables of mental health of physiotherapy students and their peers from the general population. Variables of mental health
Females (
ARTICLE IN PRESS
Physiotherapy xxx (2015) xxx–xxx
Social support contributes to resilience among physiotherapy students: a cross sectional survey and focus group study Éva Bíró a,∗ , Ilona Veres-Balajti b , Karolina Kósa a,1 a
Division of Health Promotion, Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Kassai st. 26/b, H-4028 Debrecen, Hungary2 b Department of Physiotherapy, Faculty of Public Health, University of Debrecen, Kassai st. 26/b, H-4028 Debrecen, Hungary2
Abstract Objective The present study, taking a resource-oriented approach to mental health, aimed at investigating mental resilience and its determinants among undergraduate physiotherapy students using quantitative and qualitative tools. Design A questionnaire-based cross-sectional survey supplemented by 2 focus groups. Setting One university in Hungary. Participants 130 physiotherapy students at years 1, 2, and 3. Main outcome measures Sense of coherence, a measure of dynamic self-esteem, as well as social support from family and peers were used to assess mental well-being. A screening instrument for psychological morbidity and perceived stress were used as deficiency-oriented approaches. Student opinions were gathered on positive and negative determinants of mental health. Results Resilience was lower [mean difference 4.8 (95% CI −3.4; 13.1)], and the occurrence of psychological morbidity (32.5% vs. 0%) was higher among female compared to male students. However, the proportion of students fully supported by their peers was higher among females (63% vs. 37.5%). Female students, unlike their male counterparts, experienced higher stress compared to their peers in the general population. Social support declined as students progressed in their studies though this proved to be the most important protective factor for their mental well-being. Conclusions Results were fed back to the course organizers recommending the implementation of an evidence-based method to improve social support as delineated by the Guide to Community Preventive Services of the US the outcomes of which are to be seen in the future. © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Mental health; Psychological resilience; Social support; Physiotherapy students
Introduction Competent and credible health professionals who are fit to practice [1] are essential for the provision of patient care [2]. Having uncovered and/or untreated health problems is but one of numerous reasons of impaired fitness for service ∗ Correspondence: Kassai st. 26/b, H-4028 Debrecen, Hungary. Tel.: +36 52 460 190; fax: +36 52 460 195. E-mail addresses: [email protected] (É. Bíró), [email protected] (I. Veres-Balajti), [email protected] (K. Kósa). 1 Present address: Department of Behavioural Sciences, Faculty of Public Health, University of Debrecen, Hungary. 2 Postal address: POB. 2, 4012 Debrecen, Hungary.
[1], especially in an environment like health care where high levels of occupational stress are pervasive [3]. Stress, and especially chronic stress is an important health problem that has been linked, among others, to anxiety, depression, posttraumatic stress disorder [4,5]. Occupational stress is also a known risk factor for burnout that severely impairs the quality of care [6,7] and is difficult to act upon [8]. However, even cumulative stress experiences do not inevitably lead to mental disorders if individual coping resources and psychosocial factors, such as social support, self-esteem and personal control, moderate the effects of stressors [9]. Improvement of the mental well-being of care providers increases job performance and the quality of patient care, and decreases absenteeism, turnover,
http://dx.doi.org/10.1016/j.physio.2015.05.002 0031-9406/© 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bíró É, et al. Social support contributes to resilience among physiotherapy students: a cross sectional survey and focus group study. Physiotherapy (2015), http://dx.doi.org/10.1016/j.physio.2015.05.002
PHYST-834; No. of Pages 7
2
ARTICLE IN PRESS É. Bíró et al. / Physiotherapy xxx (2015) xxx–xxx
job burnout, and retaliatory behaviours. There is evidence from the past decades that positive emotions and cognitive processes are mutually formative, both contributing to mental well-being [10]. Positive emotions may be the critical mediator underlying the relationship between happiness and success, that is, happiness may lead to successful outcomes rather than merely following from them [11]. Multi-modal cognitive-behavioural therapy can elicit significant changes in emotions, even turning a pessimist into an optimist by teaching skills to decrease negative automatic thoughts and increase more constructive thoughts [12]. Our goals were to survey the mental health of physiotherapy students who received less attention in the scientific literature, using a resource-oriented approach as well as quantitative and qualitative methods. Three quantitative indicators of psychological resilience were used such as sense of coherence (SoC), a dynamic concept of self-esteem developed by Antonovsky composed of three dimensions that reflect general resistance resources [13]. Higher scores indicate stronger SoC, in strong association with measures of health [14]. Another aspect of psychological resilience is social support assessed by the resources that are embedded within an individual’s social network [15] and is conceptualized as information leading people to believe that they are cared for and loved, esteemed and valued, and members of a network of communication and mutual obligations [16]. A third indicator was support perceived to be obtained from peers at the university. Based on the results of the quantitative part of the study, focus groups were organized to uncover determining factors of stress and resilience in depth in order to make suggestions for improvement. Our research questions were the following: 1. What are the features of the mental health status of physiotherapy students? 2. What are the predictors of resilience among them? 3. What factors contribute to the mental health status of physiotherapy students?
Methods Study population A cross-sectional study was carried out among physiotherapy (PT) students of years 1 to 3 at the University of Debrecen, Hungary. Students at year 4 could not participate in the study because they spent their practice at different parts of the country at the time of the data collection. Altogether 77% of all physiotherapy students at the Faculty were invited to participate in the survey, comprising onefifth of all full-time 1st to 3rd year physiotherapy students in Hungary.
Procedure Each student was asked after class to fill a paper-based, self-administered, anonymous questionnaire and to participate in focus groups, organized during the last month of the spring semester in time slots convenient for the students. Two focus groups were conducted; one composed by 9 students from year 1, and another with 5 participants from year 2 (approximately 11% of those who participated in the questionnaire survey). One master student of health promotion led the focus groups as facilitator while another master student took notes that were later subscribed verbatim. Sound recording was not used at the request of the participants. Sessions lasted for one hour. Data collection The questionnaire was similar to that used in previous surveys among medical [17], public health [18], and preschool teacher students [19], and included scales on perceived health, mental health, demographic (age, sex, residence) and socioeconomic (parents’ educational level, family’s economic status) data. Items not referred separately were taken from the tool of the Hungarian National Health Interview Survey of 2003 [20]. Mental health was assessed with various scales,3 two of them based on resource-oriented values (sense of coherence, social support) and two based on deficiencyoriented values (psychological distress, perceived stress) [21]. The validated Hungarian version of the abbreviated Sense of Coherence (SoC) scale [22] was used in the present survey. Social support was measured by a validated scale as described elsewhere [18], scores ranging from 7 to 21. The maximum score of 21 indicated no lack, scores of 18 to 20 indicated a partial, and scores of 17 a complete lack of social support. One question was used to assess social support from peers at the university. Assessment of mental health from a deficiency-oriented approach was made by the 12-item General Health Questionnaire (GHQ-12), a screening tool to detect psychological distress in the general population on which a total score higher than 4 is considered high [23], and the perceived stress scale (PSS-14) [24]. For the focus group interview open-ended questions were formulated regarding causes of stress at the university; personal and private problems encountered during university studies; and possible ways to reduce stress. Data analysis Statistical analysis was executed by Intercooled Stata 10.0 for Windows. Normality was tested with the Shapiro–Wilk test and proved for SoC and PSS. The two-sample unpaired t 3
See more detail in the supplement.
Please cite this article in press as: Bíró É, et al. Social support contributes to resilience among physiotherapy students: a cross sectional survey and focus group study. Physiotherapy (2015), http://dx.doi.org/10.1016/j.physio.2015.05.002
PHYST-834; No. of Pages 7
ARTICLE IN PRESS É. Bíró et al. / Physiotherapy xxx (2015) xxx–xxx
3
Table 1 Socioeconomic characteristics of students. Parents’ educational level (%)
College High school Vocational training Elementary school Less then elementary or not known
Fathers
Mothers
26 26 42 4 2
36 35 23 4 2
Perceived economic status of the family (%)
Good or very good
30
Satisfactory
51
Bad or very bad
19
test was used to compare means for SoC and PSS, and the twosample test of proportion to compare proportions regarding social support and psychological distress for which the level of significance was set at 0.05. Multiple linear regression was carried out to find the predictors of resilience assessed by SoC among physiotherapy students. Perceived health (very good or good vs. satisfied or worse), psychological distress (normal vs. high) and social support from family and peers (fully satisfactory vs. partially or completely lacking), age, gender and study year were defined as independent categorical (except age) variables. Results were compared with that of a representative survey of the Hungarian adult population [25] in terms of variables of mental health which were identically measured in both studies. In the case of the focus groups the transcripts were read several times by the authors to identify key words for coding. Codes were assigned to the text based on which major themes were identified. Relevant narratives were grouped into themes.
Results
Ethics
Mental health Mental health variables in the young (≤25 years old) and mature (>25 years old) students were analyzed separately but no difference was found, so the mental health status of the entire group is reported.
The research was carried out in accordance with the Helsinki Declaration. Ethical permission for the study was issued by the Commission on Research Ethics of the Medical and Health Science Centre of the University of Debrecen, Hungary (DEOEC RKEB/IKEB: 3007-2009). Students were informed in writing and in person that participation was voluntary and they had the right to refuse to participate. No personal data were collected. In order to avoid any pressure for participation, a master student specializing in health promotion was asked to distribute and collect the questionnaires.
Questionnaire survey The overall response rate was 85% (130/153). Demographic and socioeconomic data, perceived health Majority of the students were female (121/130, 93%) with a median age of 21 years (19 to 41 years, IQR: 2), and with the majority (124/130, 95%) being under 26 years of age. Socioeconomic status of the students measured by the parental education level and perceived economic status can be seen in Table 1 in detail. Nearly one-third of respondents (47/130, 36%) had mothers with college degree, while this proportion was one-quarter (34/130, 26%) among the fathers. Almost one-fifth (25/130, 19%) of the students perceived the economic status of their families as bad or very bad. Virtually all of them (127/129, 98%) thought that they could do much or very much for their health, and 65% (84/129) rated their health as very good or good.
Resource-oriented approaches of mental health. The mean score for sense of coherence based upon the answers of 128 students was 60.7 (SD: 11.4, min. 25, max. 85), 4.8 points higher in males compared to females [64.9 (SD: 9.6) vs. 60.0 (SD: 11.5), mean difference 4.8 (95% CI −3.4; 13.1)] without statistical significance (p = 0.25). This score was compared to that obtained from a representative survey of the Hungarian
Table 2 Parameters of resilience and deficiency variables of mental health of physiotherapy students and their peers from the general population. Variables of mental health
Females (
