A cross-sectional analysis of barriers to health-care seeking among medical students across training period

Vikas Menon; Siddharth Sarkar; Santosh Kumar

doi:10.4103/jmhhb.jmhhb_34_17

ORIGINAL ARTICLE

Year : 2017 | Volume : 22 | Issue : 2 | Page : 97-103

A cross-sectional analysis of barriers to health-care seeking among medical students across training period

Vikas Menon¹, Siddharth Sarkar², Santosh Kumar³
¹ Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
² Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
³ Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication

2-Apr-2018

Correspondence Address:
Siddharth Sarkar
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmhhb.jmhhb_34_17

Abstract

Background and Aims: Very little information is available on how needs and perceptions to service utilization may change with duration of medical training. Our objective was to compare the self-reported barriers to health-care seeking for mental and physical health services separately between 1^st year and final year medical students. Methods: In this cross-sectional study, we invited all medical students of the concerned cohorts to complete a prevalidated checklist and 28-item self-reported questionnaire about perceived barriers to health-care seeking. The questionnaire had separate items pertaining to usage of mental and physical health-care services. Results: The response rate of the 1^st year and final year cohorts were 83.8% and 86.6%, respectively. Lack of time, unawareness about where to seek help, cost issues, and fear of future academic jeopardy were more common concerns among 1^st year students to the usage of mental health services (odds ratio [OR] 0.27, 0.45,0.09, and 0.49, respectively) whereas issues of stigma were more commonly reported by final year students for using mental health services (OR = 2.87). In contrast, the barriers in using physical health services were broadly comparable between the two cohorts. Conclusion: Differences exist between medical students in various years of training particularly with regard to self-reported barriers and perceptions particularly about using mental health-care services. This may have key implications for designing and delivery of service provisions in this group.

Keywords: Health-care seeking behavior, medical school, medical students, mental health, physical health, psychiatry

How to cite this article:
Menon V, Sarkar S, Kumar S. A cross-sectional analysis of barriers to health-care seeking among medical students across training period. J Mental Health Hum Behav 2017;22:97-103

How to cite this URL:
Menon V, Sarkar S, Kumar S. A cross-sectional analysis of barriers to health-care seeking among medical students across training period. J Mental Health Hum Behav [serial online] 2017 [cited 2023 Jun 4];22:97-103. Available from: https://www.jmhhb.org/text.asp?2017/22/2/97/229103

Introduction

Several studies, both from India and other countries, have shown that medical students experience high levels of stress and psychological morbidity compared to students pursuing other professional courses as well as the general population.^[1],[2],[3] The reported sources of stress in them are many but mostly include academic and social factors such as the extent of syllabus, frequency of examinations, high parental expectations, and lack of time for recreation among others.^[4],[5],[6] This negatively impacts their long-term professional capabilities in multiple ways, such as increased rates of student burnout and medical errors, which in turn affect the society at large.^[7],[8] Notwithstanding these obvious implications and availability of help at close quarters, medical students are often found to be hesitant to seek professional help for their perceived physical and mental health issues.^[9],[10]

Recently, it has been shown that mental and physical health-care seeking barriers may differ among medical students. Particularly, issues such as stigma, confidentiality, and lack of awareness are the foremost concerns for utilizing mental health services while fear of adverse effects and lack of time are general concerns for health-care seeking.^[11] One would expect that with increasing time spent in the medical school, many of these systemic barriers to service utilization would gradually fade away and students become more confident and aware about their health issues translating into increased service utilization rates. Of note, some findings have emerged that medical students in the preclinical years of training experience more psychological distress when compared to clinical year students.^[12]

It is therefore, important, to analyze the influence of the medical school experience on perceived barriers to service utilization among medical undergraduate students. To date, limited information has accrued regarding differences in health-care utilization patterns and self-reported barriers between medical students in different years of training. Further, the prevalent attitudes toward mental illness may vary significantly across cultures, and this may have implications for key concepts such as stigma that may hamper service utilization rates. Against this background, we undertook the present research with the objective of comparing the barriers to health-care seeking reported by 1^st year and final year students at a medical school in South India. These two cohorts were chosen, representatively, to examine the impact of the medical school training process on student perceptions and perceived barriers to health-care seeking. We hypothesized that the barriers to mental and physical health-care seeking would differ between the two chosen cohorts.

Methods

Setting and participants

All medical students of a government medical college in South India belonging to the 1^st year and final year were invited to participate in the present study that was carried out in 2014. Student selection in the college is done through a yearly national competitive examination and students are admitted from all over the country. The institution follows a quota-based reservation system, as mandated in the Indian constitution, to give adequate representation to the traditionally underrepresented groups in the society. The seat matrix distribution, structure, and design of the undergraduate medical course followed in this particular medical school are similar to other government medical institutions in India. Broadly, there are nine semesters (6 months each) of training spread over 60 months (4½ years). The present study included only responses from students belonging to the first and ninth semesters of training. For each cohort, we approached an allied department (e.g., Department of Anatomy for semester 1) so as to fix a mutually agreeable time and day to administer the questionnaire. Apart from failure to provide informed consent, there were no other exclusion criteria. The 1^st year medical students, within a week of enrolling into the course, receive a welcome address by the head of the institute but there is no formal or dedicated orientation program as such. This practice is only for the 1^st year students, and subsequently, there is no such address once they get promoted.

Data collection and instrument

All volunteering participants were asked to fill out an anonymized structured questionnaire. Data collection was done within the 1^st month of the new academic session for each batch of students. The first part of the questionnaire dealt with demographic data such as age/gender/residential background and year of study. Subsequently, details about any physical/psychological illnesses as well as whether any self-medications/informal consultations from peers/seniors were elicited. Any substance use (specifically alcohol, tobacco and/or cannabis) and consequent harms were also enquired. Next, the participants were asked about their perceived barriers to physical and mental health-care seeking using a checklist prepared following a review of literature done independently by two of the authors (VM and SS) and mutual discussion among the investigators. The checklist included items such as lack of time, fear of academic jeopardy, stigma, and confidentiality, and the participants were asked to tick as many as they thought were relevant to them. The checklist underwent content validation by two experts, not involved in the study, before its usage for this research. Following this, the participants completed the barriers to health-care seeking questionnaire (BHSQ) that inquired about their perceptions about various aspects of health-care seeking. This 28-item questionnaire had 14 items each related to barriers for physical and mental health-care seeking. The details of procedure followed for its content development and validation have been described in detail elsewhere.^[13] The test-retest reliability of the instrument was evaluated on a small sample of students drawn from both the first and final semesters (n = 13) by administering the questionnaire 1 week apart and examining the correlation between responses at these two-time points. We found moderate-to-good correlation for the total scale scores (Spearman r_s= 0.714, P = 0.006) as well as the mental health subscale (Spearman r_s= 0.761, P = 0.003) and physical health subscale (Spearman r_s= 0.674, P = 0.012), respectively. All the questionnaires were administered in a single session on the designated day in their respective classrooms and collected back by the investigators who were available throughout the process for any clarifications or queries. The present paper deals with the comparison of the self-reported barriers and perceptions between first semester and final semester students. The study protocol had prior approval from the Institutional Ethics Committee.

Data analysis

The data analysis was conducted using SPSS version 17 (SPSS Inc, Chicago, IL). Descriptive statistics was used to represent the basic demographic details and clinical information. Comparison of 1^st year and final year students was done using Chi-square test and Student's t-test. The comparison of self-reported barriers to physical and mental health care was done using Chi-square test, and odds ratios with confidence intervals were computed to estimate the magnitude of effect size. The responses on individual items of BHSQ were compared between the 1^st and the final year using Mann–Whitney U-test. P < 0.05 was considered significant for all tests of inference. All the tests were two-tailed. Missing value imputation was not carried out as a part of this study.

Results

Baseline characteristics of the sample

The analysis included responses from 119/142 students from the 1^st year of MBBS course and 58/67 students from the final year (response rate of 83.8% and 86.56%, respectively). The difference in the actual number of students in the 1^st and final years was due to expansion in the number of undergraduate seats. The characteristics of the sample are depicted in [Table 1]. A greater proportion of final year cohorts were females. As compared to 1^st year, the final year cohort more frequently self-medicated themselves with medications used to treat psychiatric disorder and had sought consultation or help from seniors/peers for physical health problems. As shown [Table 1], the rates of substance use and consequent harms were generally higher for final year students as compared to 1^st year students.

Table 1: Characteristics of 1^st and final year cohorts

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Barriers to health-care seeking

The reported barriers to treatment are depicted in [Table 2]. It was seen that as compared to 1^st year, the final year cohort less frequently reported lack of time, unsure where to seek help, cost factors, and fear of impact on academic performance as barriers to seeking treatment for mental health care. On the other hand, they more frequently reported stigma as a barrier to treatment for mental health issues than the 1^st year students. The barriers of seeking physical health care did not significantly differ between 1^st year and final year cohorts except the latter less frequently reported being unsure about where to seek help.

Table 2: Reported barriers to treatment among 1^st and final year cohorts

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Responses on the barriers to health-care seeking questionnaire

The responses of the 1^st year and final year cohorts on the BHSQ are shown in [Table 3]. Those in final year were more likely to disagree about medical student not needing services of general physician, disagree about seeking help for physical and mental health care in the hospital hampering the grades and had lesser proclivity toward alternative and complementary medicine as compared to 1^st year students. The final year cohort also more frequently remarked that mental health problems would be seen as sign of weakness by teachers and peers. They were more worried about confidentiality issues for physical and mental health care and were more likely to be aware about making an appointment with a general physician outside the hospital.

Table 3: Responses on Barriers to Health-care Seeking Questionnaire by 1^st year and final year cohorts

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Discussion

The present study shows that certain health-care barriers and perceptions of medical students differ as a function of their period of training. Some of the barriers such as the lack of awareness about location of services, paucity of time, and fear of negative academic impact were more common among the fresh medical students. This can be remedied using educational campaigns and hospital tours aimed at increasing knowledge about the availability and accessibility of services. Prior reports have shown that such approaches have benefitted other nonmedical student groups.^[14],[15] We suggest that this can be incorporated into the formal orientation programs that many institutions conduct for new entrants. Interestingly, we also found that some barriers such as lack of confidentiality, fear of unwanted intervention, and concerns about side effects were comparable among the 1^st and final year cohorts. This implies that certain barriers seem to start and persist throughout medical school. Therefore, orientation programs that address these concerns need to be initiated at the beginning of training and continued throughout medical school to result in meaningful impact. A good time to have these programs would be within 2 weeks of every new academic session. Interventions such as having separate student clinics to ensure confidentiality need to be strongly considered by the administration to optimize service utilization.

Disquietingly, we found that issues such as stigma, confidentiality, and social ostracism continue to before most concerns among the final year students when accessing mental health-care services. The results resonate with previous reports, from different cultural settings, that medical students and professionals carry significant stigma toward mental illness ^{[16],[17],[18]} and that such negative attitudes persist even among experienced medical students.^[19] In low- and middle-income countries such as India, mental illness is often equated with certain unique and pervasive negative assumptions such as persons being violent, unable to work at all, and lacking insight.^[20],[21] In addition, the poverty levels and prevalent caste system in the Indian society further compound the stigma against people with mental illness.^[22] This interaction is pertinent both from a student health perspective and larger public health standpoint as it has been shown that carrying stigmatizing attitudes to mental illness can deter medical students from seeking formalized care for their mental health issues.^[23] In turn, this negatively impacts their ability to practice, influence, and disrupt the stigmatizing views about mental illness among other medical professionals as well as the general public.^[24] Hence, as suggested earlier,^[25],[26] there is a need to target attitudes toward mental illness among medical students. Various interventional strategies, mostly comprising of sessions of psychiatric knowledge dissemination and contact-based educational programs involving patient experiences about mental illness, have been advocated for mitigating stigma among medical students.^{[27],[28],[29]} In a recently published randomized control trial that sought to compare a 4-week mandatory psychiatry course and a one-time contact-based intervention, the authors found that broad-based psychiatric education had a more robust effect on reducing the stigma of mental illness and also increased student confidence in dealing with mentally ill clients.^[30] Based on these findings, we suggest that a comprehensive medical education program should be designed based on the tripartite model of stigma: knowledge (misinformation), attitudes (prejudice), and behavior (discrimination).^[31] This model allows for setting clear intervention targets and outcomes and is widely used in health education and promotion. Including personal contact time with people suffering from mental illness may also help in reducing stigma as such negative attitudes are found to be less prevalent among those who have worked previously with or having known an individual with mental illness.^[32] Lack of privacy in consultation is also another impediment to the care process pertaining to medical students. Under the existing model of clinical postings, a student wanting to go for a consultation pertaining to mental health issues is likely to encounter other students (of the same or other batch) in the same room. If the treating consultant/doctor fails to provide privacy, then the anticipated stigma of being considered “weak” is likely to be a deterring factor.

There are a few limitations of the present study that must be kept in mind while drawing conclusions. This includes our use of a cross-sectional design and grouping various kinds of medical/surgical problems into a single “physical” health-care group for sake of convenience. We have only explored finite domains of health-care seeking which was based on previous published literature and may not have been comprehensive. Although we contacted all students in the respective cohorts, the fact remains that ours is essentially a small-scale sample situated in a potentially unique cultural context and therefore needs wider replication for validation. The possibility of a respondent bias cannot be ruled out. Gender disparity, in the 1^st and final year cohorts, may have influenced the observations. The strengths of the work include trying to study the influence of medical school experience on self-reported barriers and perceptions among medical student perspectives – an area on which there is practically no literature. The study had a high response rate and representative sampling to assess the impact of medical training on outcomes of interest.

Conclusion

To conclude, the present study shows that the needs and perceptions of medical students toward seeking health-care services may differ across training. It is likely that different student groups may be benefitted better by studying their individual needs and targeting them separately which may be more resource effective in the long run. Special attention needs to be paid to mental illness, which continues to be profoundly stigmatized among medical students even at advanced stages of their training. One must keep in mind that if an intervention is to bring about a change in final year students, it needs to be planned and implemented much earlier during the training. For certain barriers such as concerns about confidentiality and side effects, an approach starting right from the 1^st year at medical school and continued throughout may make a difference. Future research should also focus on the optimal method of service delivery to increase service utilization rates and satisfaction among medical students.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Behere SP, Yadav R, Behere PB. A comparative study of stress among students of medicine, engineering, and nursing. Indian J Psychol Med 2011;33:145-8. [PUBMED] [Full text]
2.	Saipanish R. Stress among medical students in a Thai medical school. Med Teach 2003;25:502-6. [PUBMED]
3.	Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ 2005;39:594-604. [PUBMED]
4.	Yusoff MS, Abdul Rahim AF, Yaacob MJ. Prevalence and sources of stress among Universiti Sains Malaysia medical students. Malays J Med Sci 2010;17:30-7.
5.	Sreeramareddy CT, Shankar PR, Binu VS, Mukhopadhyay C, Ray B, Menezes RG, et al. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Med Educ 2007;7:26.
6.	Brahmbhatt KR, Nadeera VP, Prasanna KS, Jayram S. Perceived stress and sources of stress among medical undergraduates in a private medical college in Mangalore, India. Int J Biomed Adv Res 2013;4:128-36.
7.	Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: Prospective cohort study. BMJ 2008;336:488-91.
8.	West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA 2009;302:1294-300.
9.	Menon V, Sarkar S. Barriers to service utilization among medical students. Int J Adv Med Health Res 2014;1:104. [Full text]
10.	Roberts LW, Hardee JT, Franchini G, Stidley CA, Siegler M. Medical students as patients: A pilot study of their health care needs, practices, and concerns. Acad Med 1996;71:1225-32.
11.	Menon V, Sarkar S, Kumar S. Barriers to healthcare seeking among medical students: A cross sectional study from South India. Postgrad Med J 2015;91:477-82.
12.	Yen Yee L, Yusoff MS. Prevalence and sources of stress among medical students in Universiti Sains Malaysia and Universiteit Maastricht. Educ Med J 2013;5. Available from: http://www.eduimed.com/index.php/eimj/article/view/190. [Last accessed on 2015 Nov 08].
13.	Sarkar S, Menon V. Development and validation of a scale to assess barriers to health care seeking among medical students. Med Sci Educ 2015;25:377-82.
14.	Boltena AT, Khan FA, Asamoah BO, Agardh A. Barriers faced by Ugandan university students in seeking medical care and sexual health counselling: A cross-sectional study. BMC Public Health 2012;12:986.
15.	Vidourek RA, King KA, Nabors LA, Merianos AL. Students' benefits and barriers to mental health help-seeking. Health Psychol Behav Med 2014;2:1009-22.
16.	Jorm AF, Korten AE, Jacomb PA, Christensen H, Henderson S. Attitudes towards people with a mental disorder: A survey of the Australian public and health professionals. Aust N Z J Psychiatry 1999;33:77-83.
17.	Nordt C, Rössler W, Lauber C. Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophr Bull 2006;32:709-14.
18.	Schulze B. Stigma and mental health professionals: A review of the evidence on an intricate relationship. Int Rev Psychiatry 2007;19:137-55.
19.	Korszun A, Dinos S, Ahmed K, Bhui K. Medical student attitudes about mental illness: Does medical-school education reduce stigma? Acad Psychiatry 2012;36:197-204.
20.	Link BG, Phelan JC. Conceptualizing stigma. Ann Rev Soc 2001;27:363-85.
21.	Loganathan S, Murthy RS. Living with schizophrenia in India: Gender perspectives. Transcult Psychiatry 2011;48:569-84.
22.	Trani JF, Bakhshi P, Kuhlberg J, Narayanan SS, Venkataraman H, Mishra NN, et al. Mental illness, poverty and stigma in India: A case-control study. BMJ Open 2015;5:e006355.
23.	Gonzalez JM, Alegria M, Prihoda TJ. How do attitudes toward mental health treatment vary by age, gender, and ethnicity/race in young adults? J Community Psychol 2005;33:611-29.
24.	Abbey S, Charbonneau M, Tranulis C, Moss P, Baici W, Dabby L, et al. Stigma and discrimination. Can J Psychiatry 2011;56:1-9.
25.	Cutler JL, Harding KJ, Mozian SA, Wright LL, Pica AG, Masters SR, et al. Discrediting the notion “working with 'crazies' will make you 'crazy'”: Addressing stigma and enhancing empathy in medical student education. Adv Health Sci Educ Theory Pract 2009;14:487-502.
26.	Feldmann TB. Medical students' attitudes toward psychiatry and mental disorders. Acad Psychiatry 2005;29:354-6.
27.	Kassam A, Glozier N, Leese M, Loughran J, Thornicroft G. A controlled trial of mental illness related stigma training for medical students. BMC Med Educ 2011;11:51.
28.	Pinfold V, Thornicroft G, Huxley P, Farmer P. Active ingredients in anti-stigma programmes in mental health. Int Rev Psychiatry 2005;17:123-31.
29.	Sartorius N, Gaebel W, Cleveland HR, Stuart H, Akiyama T, Arboleda-Flórez J, et al. WPA guidance on how to combat stigmatization of psychiatry and psychiatrists. World Psychiatry 2010;9:131-44.
30.	Papish A, Kassam A, Modgill G, Vaz G, Zanussi L, Patten S, et al. Reducing the stigma of mental illness in undergraduate medical education: A randomized controlled trial. BMC Med Educ 2013;13:141.
31.	Thornicroft G, Rose D, Kassam A, Sartorius N. Stigma: Ignorance, prejudice or discrimination? Br J Psychiatry 2007;190:192-3.
32.	Svensson B, Brunt D, Bejerholm U, Eklund M, Gyllensten AL, Leufstadius C, et al. Health care students' attitudes towards people with schizophrenia – A survey of eight university training programs. Open J Psychiatry 2014;4:309-16.