Original Article

Academic Stress and Prevalence of Stress-Related Self-Medication among

Undergraduate Female Students of Health and Non-Health Cluster
Colleges of a Public Sector University in Dammam, Saudi Arabia
Fatima Al Rasheed, Atta Abbas Naqvi1, Rizwan Ahmad2, Niyaz Ahmad3
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Pharm.D 5th Year student, Objective: The objective was to report academic stress and prevalence of

Abstract
Departments of, 1Pharmacy stress-related self-medication among undergraduate female students of health
Practice, 2Natural Products
and nonhealth cluster colleges at a public sector university in Dammam, Saudi
and Alternative Medicines
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and 3Pharmaceutics, College Arabia. Materials and Methods: A 5-month cross-sectional survey was conducted
of Clinical Pharmacy, in the university. The survey included the English version of 10-item Perceived
Imam Abdulrahman Bin Stress Scale (PSS) to report self-perceived stress. Student responses were analyzed
Faisal University, Dammam by SPSS version 22 software. Results: The majority of students (85%) perceived
31441, Saudi Arabia examinations as a stressor. Most of the students (64%) had perceived moderate stress
that increased as students progressed from preparatory year to 4th year. It declined in
students of 5th and 6th year. The prevalence of stress related was reported at 39.58%.
Highest prevalence of stress-induced self-medication was reported from College
of Nursing (59.09%) and lowest (29.69%) from clinical pharmacy. Most common
drug used to self-medicate during stress was caffeine (49.5%). The PSS score was
significantly associated with colleges and study levels. Conclusion: Students studying
in health cluster colleges reported high academic stress and self-medication practice.
The major stressors identified were examination and course load. Student counseling
sessions and counseling by pharmacists regarding self-care may help in the reduction
of such stressors and may promote responsible self-medication. Self-evaluation and
quality assurance process of curriculum may highlight areas for improvement in the
courses. This may help in lowering academic stress among students.
Keywords: Academic stress, perceived stress scale, undergraduate students, Saudi
Arabia, self-medication, social pharmacy

Introduction the events in an individual’s life that may have different

S    tress is a psychological disorder and one of the most
common causes behind psychological problems
in individuals belonging to all age groups.[1] It is an
innate response of the body that may be either physical,
mental, or emotional to an unforeseen event that occurs
in the life of the individual. The event that aggravates
this innate response is referred to as a stressor.[2] World
Health Organization estimates that stress will become
one of the major causes of death by the year 2020.
Stress is adaptive and manageable in acute conditions.
However, experiencing chronic high levels of stress can
lead to significant problems.[2] Academic life is one of
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stressors. Contemporary literature suggests that
university life is subjected to different stressors arising
from academic pressure, social problems, and personal
issues.[3] It demands a great deal of determination,
dedication, and commitment from the individual.
It may also involve living away from the family
Address for correspondence: Dr. Atta Abbas Naqvi,
Department of Pharmacy Practice,
College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal
University, P.O. Box 1982, Dammam 31441, Saudi Arabia.
E-mail: naqviattaabbas@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribute on-NonCommercial-ShareAlike 3.0 License, which allows others to remix,
tweak, and build upon the work non-commercially, as long as the author is credited
and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

How to cite this article: Al Rasheed F, Naqvi AA, Ahmad R, Ahmad N.

Academic stress and prevalence of stress-related self-medication
among undergraduate female students of health and non-health cluster
DOI: 10.4103/jpbs.JPBS_189_17
colleges of a public sector university in Dammam, Saudi Arabia. J Pharm
Bioall Sci 2017;9:251-8.

© 2018 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow 251
 Al Rasheed, et al.: Academic stress and stress-related self-medication
which brings social isolation and adds to personal
vulnerability. The students may not be prepared to
incorporate this change and may experience academic
stress.[4,5]
Proper management of stress is important as its
mismanagement may lead to untoward outcomes
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regarding health, emotional well-being, and academic
performance. Studies conducted in the USA among
undergraduate pharmacy students reported an increased
academic stress as students progressed to higher levels
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of pharmacy education. The study also established an
inverse relationship between stress and quality of life.
Other studies reported academic stress in Malaysia,
Pakistan, and the UAE with similar findings.[2,6-11]
Perceived stress can be determined using developed
research instruments. One of the commonly used research
instruments is Perceived Stress Scale (PSS). It contains
ten items related to individual’s response to his/her recent
social and personal events in life and grades the response
quantitatively in the form of a score which is interpreted
as low, moderate, and high perceived stress.[12]
Evidence indicates that stress is quite prevalent in Saudi
academia, particularly in female students studying
health-related courses.[3-5] A study conducted in the
same university previously investigated stress among
the males but did not include female students. To fill this
gap, we conducted this study in females to document
self-perceived stress and observe self-medication
practice in this condition.
Materials and Methods
A cross-sectional survey was conducted among
undergraduate female students of different colleges at
Imam Abdulrahman Bin Faisal University (University
of Dammam) located in the city of Dammam, Saudi
Arabia. The study methodology adhered to STROBE
guidelines. This study was of 5-month duration. It
began in January 2017 and was completed in May 2017.
Target population and exclusion criteria
Female students studying in different colleges at study
levels ranging from preparatory year to 6th year of
professional bachelor education were identified as target
segment. Only those female students who were currently
enrolled and studying at the university were included in
the study. Dropout students, those studying in other
universities, male students as well as those who did not
consent to participate were excluded from the study.
Research instrument, piloting, and validation
The research instrument was designed in the form of a
survey questionnaire in English language. It was given
to the respondents after obtaining their consent. The
252 Journal of Pharmacy and Bioallied Sciences ¦ Volume 9 ¦ Issue 4 ¦ October-December 2017
questionnaire consisted of two open-ended questions
regarding demographic variables, i.e., age and illness,
as well as five close-ended questions, i.e., gender,
college, study level, residence, and marital status.
The questionnaire employed 5-item Likert scale (1=
strongly agree, 2= agree, 3= neutral, 4= disagree, and
5= strongly disagree) to assess predictors of academic
stress, i.e., course load, assignments, examination,
academic competition, career prospects, cumulative
grade point, family issues, and health. A 10-item
self-reported PSS was used to report stress among
students.[12] Other items included prevalence, stressors,
and stress-induced self-medication practice.
The questionnaire was subjected to physical validation
including face and content validity as well as reliability
analysis that reported a Cronbach’s alpha value of
0.772 for N = 10 items. PSS was not included in
statistical validation as it has already been validated
by Almadi et al.[13] Only the items related to stressors
were statistically validated using exploratory factor
analysis (EFA) with principal component analysis
method and varimax rotation. The resulting solution
highlighted a 4-factor structure with eigenvalues above
1.0. The values for Kaiser-Mayer-Olkin measure of
sampling adequacy was reported at 0.752 which was
considered satisfactory. The Bartlett’s test of sphericity
was significant with P < 0.0001. The questionnaire was
piloted in 23 students and was validated with some minor
corrections in spelling. The Likert Scale category (df) of
“strongly agree,” was merged with “agree,” and similarly
the category, “disagree,” with “strongly disagree,” to
increase data reliability. The 4-component structure
obtained from EFA was then confirmed using partial
confirmatory factor analysis with maximum likelihood
analysis and direct oblimin rotation. The values for
fit indices were obtained to assess a 4-factor structure
model fit. The values for normed fit index, Tucker-Lewis
index, and comparative fit index were reported at 0.981,
0.987, and 0.997, respectively, i.e., >0.95. The value for
root mean square of error approximation was reported
at 0.02, i.e., <0.06. All these values indicated a good
model fit and were therefore acceptable.
Sampling procedure and sample size calculation
The study employed convenient sampling and collected
data from students in their free time. According to the
official figures, the total number of female pharmacy
students was 2810.[14] This figure was considered as
study population. Sample size was calculated by
Raosoft, Inc., sample size calculator.[15] The confidence
level was set at 95% with a 5% margin of error and
recommended sample size obtained was 339. The study
gathered a total of 386 responses.
 Al Rasheed, et al.: Academic stress and stress-related self-medication
Data analysis
The responses of the students were analyzed by IBM
SPSS Statistics for Windows, Version 22.0. Armonk, NY:
IBM Corp. The results were presented in the form of
sample counts (N), percentages (%), and P values. The
prevalence data were reported in 95% confidence interval.
The association between variables was analyzed using
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cross tabulation and Chi-square (χ2) test for association
and was interpreted in terms of significant P < 0.05.
Ethical approval and consent
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The students were briefed about the purpose of the
study and their consent was obtained before handing
them the questionnaire. The study was approved by the
Department of Pharmacy Practice, College of Clinical
Pharmacy of Imam Abdulrahman Bin Faisal University
(previously University of Dammam) (Ref# 2130020050).
Results
Response rate
The cumulative response rate obtained was 84.65%.
The response rates obtained from various colleges were
clinical pharmacy (96.9%), nursing (55%), medicine
(74.2%), dentistry (95%), medical engineering (94%),
information technology (IT) (54%), applied sciences
(92%), design (100%), and science college (100%).
Demographic information
The mean age of respondents was between 20 and
21 years, i.e. (X = 20.7 years). The youngest respondent
was 18 years old and oldest was 26 years old. An
overwhelming majority (N = 343, 88.9%) belonged to
age group between 18 and 22 years. This study included
only female students (N = 386, 100%) and most of them
were single (N = 299, 77.5%). The study incorporated
responses from nine colleges of the university, i.e.,
clinical pharmacy (N = 64, 16.6%), nursing (N = 22,
5.7%), medicine (N = 77, 19.9%), dentistry (N = 38,
9.8%), medical engineering (N = 47, 12.2%), IT (N = 27,
7%), applied sciences (N = 46, 11.9%), college of design
(N = 15, 3.9%), and college of science (N = 50, 13%).
Further to this, the study incorporated students from all
study levels, i.e., preparatory year to 5th year. Most of the
students indicated that they lived with families (N = 326,
84.5%) and did not suffer from any disease (N = 325,
84.2%). However, few students indicated migraine (N = 11,
2.8%) and anxiety and depression (N = 20, 5.2%). More
than a third segment of the females (N = 122, 31.6%) never
indulged in self-medication during stress. The students also
mentioned the drugs they have been using during stress.
Almost half of target segment (N = 191, 49.5%) used
caffeine and one student reported using amphetamines.
Journal of Pharmacy and Bioallied Sciences ¦ Volume 9 ¦ Issue 4 ¦ October-December 2017
More than half of the students (N = 245, 63.5%)
provided various reasons for practicing self-medication.
Some students resorted to self-medication with the
purpose of treat insomnia (N = 12, 3.1%), improve
concentration (N = 18, 4.7%), and address health
issues (N = 12, 3.1%). The summary of demographic
information and reasons to indulge in self-medication
during stress is presented in Table 1.
Information about stressors
Most of the students identified examinations (N = 328,
85%) and course load (N = 286, 74.1%) as stressors. Similar
figures were obtained for assignment load (N = 257,
66.6%) and cumulative grade point average (N = 273,
70.8%). Thoughts about career and future prospects were
highlighted as stressors by a half proportion of students
(N = 200, 52%). Lack of free time was also reported
to cause stress among students (N = 241, 62.5%). The
summary of various stressors is presented in Table 2.
Perceived stress among students
The study reported perceived stress among students
using PSS. The mean score reported was 19.99;
minimum score (3) and maximum score (35) (standard
deviation: 6.53). The majority of students (N = 247,
64%) were found to be in moderate stress according
to PSS scoring criterion. The results of the perceived
stress score are interpreted in Table 3.
Prevalence of self-medication in stress
The cumulative prevalence of self-medication during
stress was reported at 39.58% (34.27% to 45.07% for
95% confidence interval). The lowest prevalence was
reported from College of Clinical Pharmacy (29.69%)
and the highest from College of Nursing (59.09%). The
detail is tabulated in Table 4.
Cross tabulation of demographic variables with
stress and self-medication variables
The cross tabulation between colleges and perceived
stress score revealed significant association with χ2 value
of 54.95 and P = 0.0001 (<0.05) with moderate strength,
i.e., phi reported at 0.377. Only four cells had minimum
expected count <5; therefore, results were reliable.
Similarly, Chi square reported from College of Clinical
Pharmacy value reported for association between level
of study and stress score was 83.301 and P = 0.0001
(<0.05) with significant strength, i.e., phi reported at
0.465. Only one cell had minimum expected count <5;
therefore, results were reliable. The cross tabulation of
age groups and residence status with perceived stress
score was not significant with P value reported larger
than 0.05. However, the association of marital status
with stress score was significant as χ2 value reported
253
 Al Rasheed, et al.: Academic stress and stress-related self-medication

Table 1: Demographic information Table 1: Contd...

Demographic information (n=386) Sample, n (%) Demographic information (n=386) Sample, n (%)
Age groups Health issues 12 (3.1)
Between 18 and 22 years 343 (88.9) More than one reason 245 (63.5)
Between 23 and 25 years 42 (10.9) None of the above reasons 99 (25.6)
26 years and above 1 (0.3) IT: Information technology, G6PD: Glucose-6-phosphate
Marital status
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dehydrogenase, HTN: Hypertension, IBS: Irritable bowel

Married 87 (22.5) syndrome, GI: Gastrointestinal
Single 299 (77.5)
Colleges was 8.62 and P = 0.013 with low strength, i.e., phi
Clinical pharmacy 64 (16.6) reported at 0.149. The number of cells with minimum
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Nursing 22 (5.7)
count <5 was zero, i.e., reliable results. The summary of
Medicine 77 (19.9)
Dentistry 38 (9.8)
cross tabulation is tabulated in Table 5.
Medical engineering 47 (12.2) The correlation between prevalence of self-medication
IT 27 (7) and the percentage of students in stress was not
Applied sciences 46 (11.9) significant (P > 0.05). Hence, a relationship of
Design 15 (3.9)
self-medication practice with academic stress could not
Science college 50 (13)
be established.
Level of study
Preparatory year 33 (8.5)
2nd year 138 (35.8) Discussion
3rd year 74 (19.2) This study was conducted among the female students
4th year 59 (15.3) of Imam Abdulrahman Bin Faisal University formerly
5th year 57 (14.8) known as University of Dammam. The overall response
6th year 25 (6.5)
rate of the survey was 84.65%. The mean age of students
Residence status
was 20.7 years and most of them (77.5%) were single.
With family 326 (84.5)
University accommodation (away from family) 60 (15.5)
Studies conducted in the region reported similar age,
Disease information residential, and marital status of the students.[3,4]
Cardiovascular disease (e.g., HTN) 2 (0.5) The majority of students (64%) had moderate perceived
Anxiety and depression 20 (5.2) stress. A similar proportion of moderately stressed
Obesity and G6PD 6 (1.6)
students (61%) was also reported by a study conducted
Migraine 11 (2.8)
in a Thai medical college.[16,17] The proportion of
Respiratory disease, e.g., asthma 1 (0.3)
GI diseases, e.g., IBS 3 (0.8)
students with moderate perceived stress in a UK
Thyroid diseases, e.g., hypothyroidism 1 (0.3) university was slightly higher than our findings, i.e.,
Comorbidity 17 (4.4) 77.6%. However, the percentage of students with high
No disease 325 (84.2) perceived stress in our study was more (17.4%) than the
Self-medication practice in stress figure obtained in the UK (10.4%).[18] This implies that
Always (3 days per week) 36 (9.3) universities in Saudi Arabia have more students who
Often (1 day per week) 59 (15.3) perceive high stress as compared to others.
Sometimes (once in every 2 weeks) 66 (17.1)
Rarely (once in a month) 103 (26.7) Our study found that most students studying in clinical
Never 122 (31.6) pharmacy had moderate perceived stress whereas
Drugs used for self-medication in stress students of medicine and dentistry reported high
Caffeine (coffee/tea/energy drinks) 191 (49.5) perceived stress. The students of College of Medical
Amphetamine (methylphenidate) 1 (0.3) Engineering reported moderate to high perceived stress.
Mood enhancers (escitalopram, alprazolam) 3 (0.8) Students of College of Applied Sciences perceived
Memory enhancers (Ginseng, Ginkgo) 2 (0.5) moderate stress. A low perceived stress was reported
Personal issues (yohimbine) 2 (0.5) from the students of College of IT. All findings were
Analgesics (paracetamol) 2 (0.5)
subjected to cross tabulation and χ2 test and were
More than one drug 40 (10.4)
statistically significant, i.e., P = 0.0001.
No drug 145 (37.6)
Reasons for self-medication A noteworthy observation in our study was about the
Insomnia 12 (3.1) figures for stress among students studying in different
Improve concentration 18 (4.7) academic years. Students of preparatory year had low
Contd... perceived stress, whereas those of 2nd and 4th year mainly

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 Al Rasheed, et al.: Academic stress and stress-related self-medication

Table 2: Predictors of stress among undergraduate Table 3: Perceived stress score interpretation
students Score interpretation Sample, n (%) P
Predictors of stress (n=386) Sample, n (%) 0–13 (low stress) 72 (18.7) <0.01
Course load 14–26 (moderate stress) 247 (64)
Agree 286 (74.1) 27–40 (high perceived stress) 67 (17.4)
Neutral 89 (23.1) Total 331 (100)
Disagree 11 (2.8)
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Assignments load
Agree 257 (66.6) Table 4: Prevalence of self-medication in stress among
Neutral 103 (26.7) students of different colleges at IAU
Disagree 26 (6.7) College Prevalence (%) 95% CI
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Examination load All 39.58 34.27–45.07

Agree 328 (85) Clinical pharmacy 29.69 18.91–42.42
Neutral 50 (13) Nursing 59.09 36.35–79.29
Disagree 8 (2) Medicine 41.56 30.43–53.36
Academic competition Dentistry 50 33.38–66.62
Agree 125 (32.4) Medical engineering 42.55 28.26–57.82
Neutral 132 (34.2) IT 33.33 16.52–53.96
Disagree 129 (33.4) Applied science 54.35 39.01–69.10
Career and future prospects Design 46.67 21.27–73.41
Agree 200 (51.8) Science college 48 33.66–62.58
Neutral 116 (30.1) IT: Information technology, CI: Confidence interval, IAU: Imam
Disagree 70 (18.1) Abdulrahman Bin Faisal University
Lack of free time during semesters
Agree 241 (62.4)
from clinical pharmacy students, i.e., 29.69%, whereas
Neutral 82 (21.3)
the highest was reported from nursing students, i.e.,
Disagree 63 (16.3)
cGPA
59.09% [Figure 1]. Studies report a figure of 67% for
Agree 273 (70.7) self-medication prevalence among students in Pakistani
Neutral 87 (22.6) universities. However, prevalence of self-medication
Disagree 26 (6.7) to cope up with stress and depression resulting from
Family issues study burden was reported at 8.34% in Pakistani
Agree 124 (32.1) academia.[20,21] In comparison with figures obtained
Neutral 107 (27.7) from Pakistani students, our results highlight that
Disagree 155 (40.2) self-medication practice during stress is quite high
Health concerns among Saudi students. However, this phenomenon
Agree 128 (33.1)
needs to be further investigated in other universities
Neutral 101 (26.2)
before these findings could be generalized in Saudi
Disagree 157 (40.7)
academia at large.
cGPA: Cumulative grade point average
Furthermore, our study reported that as many as
49.5% students consumed caffeine as a drug for
had moderate to high perceived stress. Students of 3rd
self-medication during stress. Caffeine is consumed
year had moderate perceived stress, whereas students
mainly in the form of coffee or tea and energy
of 5th and 6th year reported low perceived stress. The
drinks. Our study considered caffeine as a drug for
findings were statistically significant, i.e., P = 0.0001.
self-medication only when the students indicated that
This fluctuating level of stress as perceived by students
they consumed it in more quantity than usual. Previous
during academic years can be attributed to the fact that
study reported high consumption of energy drinks
students are subjected to rigorous and exhaustive course
containing caffeine by students during examinations
load and examinations during studies. However, as they
in Saudi universities.[22] Hence, our findings are in line
gradually progress to higher levels of education, they
with results of Al Malak et al. Only a single student
familiarize themselves with the academic environment
reported using amphetamine which is an encouraging
and exhaustive curriculum. Hence, there is a drop in
sign keeping in view previous studies that reported the
self-perceived stress.[19]
growing use of such drugs among this population.[23,24]
The overall prevalence of self-medication in stress was This observation also confirmed the finding of
reported at 39.58%. The lowest prevalence was reported Albusalih et al. in the same population.[25]

Journal of Pharmacy and Bioallied Sciences ¦ Volume 9 ¦ Issue 4 ¦ October-December 2017 255
 Al Rasheed, et al.: Academic stress and stress-related self-medication

Table 5: Cross tabulation between study variables and perceived stress score
Demographic variables PSS score (n=386) P
Observed n (expected n)
0–13 (low stress) 14–26 (moderate stress) 27–40 (high stress)
Colleges
Clinical pharmacy 9 (11.9) 48 (41) 7 (11.1) 0.0001
Nursing 3 (4.1) 14 (14.1) 5 (3.8)
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Medicine 16 (14.4) 47 (49.3) 14 (13.4)

Dentistry 7 (7.1) 20 (24.3) 11 (6.6)
Medical engineering 2 (8.8) 34 (30.1) 11 (8.2)
IT 9 (5) 12 (17.3) 6 (5)
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Applied sciences 1 (8.6) 38 (29.4) 7 (8)

Design 2 (2.8) 11 (9.6) 2 (2.6)
Science college 23 (9.3) 23 (32) 4 (8.7)
Study level
Preparatory year 22 (6.2) 11 (21.1) 0 (5.7) 0.0001
2nd year 14 (25.7) 90 (88.3) 34 (24)
3rd year 5 (13.8) 58 (47.4) 11 (12.8)
4th year 7 (11) 39 (37.8) 13 (10.2)
5th year 14 (10.6) 34 (36.5) 9 (9.9)
6th year 10 (5) 15 (16) 0 (4.3)
Age groups
18–22 years 63 (64) 217 (219.5) 63 (59.5) 0.621
23–25 years 9 (7.8) 29 (26.9) 4 (7.3)
26 years and above 0 (0.2) 1 (0.6) 0 (0.2)
Residence status
With family 55 (60.8) 213 (208.6) 58 (56.6) 0.111
 University accommodation (away from 17 (11.2) 34 (38.4) 9 (10.4)
family)
Marital status
Married 19 (16.2) 62 (55.7) 6 (15.1) 0.013
Single 53 (55.8) 185 (191.3) 61 (51.9)
IT: Information technology, PSS: Perceived Stress Scale

Figure 1: Prevalence of self medication in stress among students of different colleges at IAU

The majority of students perceived examinations (85%) and Malaysia, and Thailand also highlighted that examinations
course load (74.1%) as stressors. This is reported worldwide and amount of taught content throughout the academic
as studies conducted in universities of the UK, India, session were perceived as stressors by students.[16-18,24-27]

256 Journal of Pharmacy and Bioallied Sciences ¦ Volume 9 ¦ Issue 4 ¦ October-December 2017
 Al Rasheed, et al.: Academic stress and stress-related self-medication
Conclusion
Academic stress and stress-related self-medication
practice is quite high among students of health cluster
colleges at Imam Abdulrahman Bin Faisal University
(IAU). Conducting student counseling sessions may
help in lowering stress. Moreover, counseling by
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pharmacists regarding self-care may help in promoting
responsible self-medication among students.[26, 28]
Further investigation is needed to identify the reasons
for relatively higher stress level among students
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studying in health cluster colleges as compared to
nonhealth cluster college students. A self-evaluation
and quality assurance process may be initiated to have
an insight into the curriculum design that might help
in restructuring the courses so as to decrease academic
load and subsequently academic stress.[29]
Supporting information
This research paper is based on undergraduate
thesis submitted by Fatima Al Rasheed (ID
2130020050) student of Pharm.D 5th year for partial
fulfillment of the degree of Doctor of Pharmacy
(Pharm.D) at College of Clinical Pharmacy, Imam
Abdulrahman Bin Faisal University (previous
University of Dammam), Dammam 31441, Eastern
Province, Saudi Arabia. This article was a continuation
effort under the Evidence-Based Improvement
Initiative undertaken at a Pakistani pharmacy teaching
institution.[30–32]
Limitations
The study only incorporated the students from a single
public sector university in Dammam, Saudi Arabia
using convenient sampling. Therefore, the results of
the study cannot be generalized. However, the findings
of our study can be used as a primary source to further
investigate the phenomenon.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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