Indian J Physiol Pharmacol 1999; 43 (2) : 218-224

STRESS DUE TO EXAMS IN MEDICAL STUDENTS - ROLE OF YOGA

A. MALATHI* AND A. DAMODARAN**

Department of Physiology,Lokmanya Tilak Municipal Medical College & General Hospital,Sion, Mumbai - 400 022

and

**Medical Division,BARe, Mumbai

(Received on May 18, 1998)

Abstract: A student under optimal stress does bring out his or her best,However extremes of stress can result in stress induced disorders anddeteriorating performance. Can yoga be of benefit in stress induced effectsin medical students? The present study was conducted in first MBBSstudents (n=50) to determine the benefit if any of yogic practices on anxietystatus during routine activities and prior to examination. Feedback scoreswere assessed to determine how the students had benefited from thepractices.

Anxiety status as assessed by Spill berger's anxiety scale showed astatistically significant reduction following practice. In addition the anxietyscore which rose prior to exams showed a statistically significant reductionon the day of exam after practice. These results point to the beneficialrole of yoga in not only causing reduction in basal anxiety level but alsoattenuating the increase in anxiety score in stressful state such as exams.The results of the exam indicated a statistically significant reduction innumber of failures in yoga group as compared to the control group. Theimprovement in various parameters such as better sense of well being,feeling of relaxation, improved concentration, self confidence, improvedefficiency, good interpersonal relationship, increased attentiveness, loweredirritability levels, and an optimistic outlook in life were some of thebeneficial effects enjoyed by the yoga group indicated by feedback score.

Key words: stress anxiety yoga exam

INTRODUCTION

A vast majority of teenagers frommedical colleges are undergoing psychiatric

treatment which is a tip of the iceberg forthere are many more who are not availing

*Corresponding Author

of any psychiatric treatment in spite ofbehavioural problems, disturbed inter­personal relationships or deterioratingperformance. Psychiatrists attribute thisdisturbing trend to stress created bycompetitive education systems. The modern

Indian J Physiol Pharmacol 1999; 43(2)

youth is at cross-roads. On enteringinto the professional colleges the studentis in a new challenging and stressfulenvironment.

Factors contributing to high levels ofstresses in professional colleges could behighly competitive curriculum, intenseacademic competition, excessive demands oncoping abilities in physical, emotional,intellectual, financial and social terms.Possibly these and many more factorscontribute to high levels of stress in medicalstudents. With the above facts in mind therelevance of yoga in medical education wasevaluated.

Apart from periodically and regularlyreleasing the accumulated stresses andtension which is essential to begin with, itis imperative to move towards a life witheustress retaining all the powers andcapabilities obtained by a sensitive mind anda sharp intellect vital for day to dayfunctioning in a highly competitive andstressful life of the student. "Working inrelaxation "with total "Awareness in Action"would enable one to interact in the societyjudiciously and effectively (l).

In the ancient system of eduction variousyogic practices like Suryanamaskar,Pranayama, meditation as well as goodvalue systems were introduced with theformal education to enable the developmentof good physique, strong ethical values andgood stress tolerance (2). A state of mentaltranquility is achieved by the practice ofyoga as revealed by increase in alpha indexof eletroencephalogram after short termyoga (2,3). Yoga can protect the individualby bringing harmony between mind and

Stress Due to Exams in Medical Students 219

body, modulating stress responses and one'sattitude to stress as also improving mentalfaculties such as attention, memory,learning efficiency and positive attitude tolife (4,5,6).

Total growth of personality at physical,mental, intellectual and social level canresult with the regular practice of yoga (6).At physical level regular practice of asanas,pranayama bestows a proportionate, flexible,normally relaxed body with an ability towithstand stress efficiently (7). At criticaltimes necessary energy gets evoked to dealwith the stressful state (1). A calm still mindcan bring forth the best performance evenwhen one is under stress states like examsas in the present study and helps in thedevelopment of ones personality. Atintellectual level yoga can sharpen memory,concentration, decrease anxiety levels (6,7).At spiritual level yoga creates an awarenessto look for happiness from within oneselfand to be at peace with oneself. Thefollowing study was carried out in studentsof 1st MBBS to study the effects of shortterm yoga on anxiety score at the time ofexams. Feedback was elicited from thestudents with the help of a proforma toknow their attitude towards yoga and howit had benefited them.

METHODS

50 students of First MBBS, 18-19 yrsvoluntarily participated in the study. Noneof them was suffering from any majormedical or psychiatric illness and notundergone any yogic practices earlier. Theywere randomly divided into two groups­control and yoga groups.

220 Malathi and Damodaran

The yoga group underwent the followingprogram for 1 hour, thrice a week for 3months namely

Indian J Physiol Pharmacol 1999; 43(2)

ii. On the day of exam to determine theanxiety state due to exam stress.

After practice:

a) Prayer

b) Sthithapragnyasan

---1 min

---2 mins1. 1 month before the exams which served

as the new basal reading

c) Ananas Talasan, Hastapadaasan,Utkatasan, Parvatasan, Sashankasan,Yogamudra, Uthitekapadasan, Uthited­wipadasan, Shalabhasan, Sulabhabhu­jangasan, Ushtrasan ---25 mins

d) Anulomvilom, Ujjayi, Bhramari ---5 mins

e) Yoganidra with visualisation ---20 mins

D Meditation on Onkar & Tratak ---5 mins

g) Prayer & Stithapragnyasan ---2 mins

The various asanas were chosen toimprove their concentration, coordination,memory, and attitudinal behaviour.

ii. On the day of exam to determine theeffect of practice sessions on the anxietystatus at the time of exam.

Scores were compared in both groupsbefore and after practice sessions usingpaired t test on both occasions. (Table O.

TABLE I: Mean anxiety score

Control group :-

Time of measurement Before After Signifi-sessions sessions cance

One month before 30.64±3.02 32.45±2.95 NSexam.

On the day of exam 46.21±3.15 47.76±3.42 NS

Ns = Not significant

On the day of exam 46.75±2.82 30.84±2.45 P<O.OOI

2. Feedback evaluation of the program:

30.92±2.36 20.36±2.12 P<O.OOI

The control group were allowed to carryon with any work such as reading, writingetc. for 1 hour during the time the yogagroup underwent the yoga practices.

1. Spillberger's anxiety scale; was used todetermine the anxiety score of both groups(8). The anxiety score was determined ontwo occasions before and after the practicesessions as follows ;-

Control Group:-

Time of measurement Beforesessions

One month beforeexam.

After Signifi-sessions cance

Before practice:

1. 1month before the exams which servedas basal reading

A subjective assessment of the sessionswas done in the yoga group using aproforma in which 14 parameters wereassessed. Each of these parameters wasgraded and score allotted (Table II)

Indian J Physiol Pharmacol 1999; 43(2) Stress Due to Exams in Medical Students 221

TABLE II : Proforma for feedback (scores alloted) Answer every question honestly. Has the training inyoga made any change in the following parameters to you. Tick in the appropriate column.

Increased orParameters improved Moderate No change Moderate Decreased

greatly increased decrease greatly

Sense of well being +2 +1 0 -1 -2Calm & relaxed feeling +2 +1 0 -1 -2Attention, concentration +2 +1 0 -1 -2Hrs required to feel fresh -2 -1 0 +1 +2Self confidence +2 +1 0 -1 -2Efficiency in any task +2 +1 0 -1 -2Irritability levels -2 -1 0 +1 +2Stamina +2 +1 0 -1 -2Tiredness -2 -1 0 +1 +2Appetite +2 +1 0 -1 -2Optimistic outlook in life +2 +1 0 -1 -2Headache, bodyache etc -2 -1 0 +1 +2Interpersonal relationship +2 +1 0 -1 -2

Scores alloted for feedback score calculation is indicated.

Students were asked to tick against thecolumn which was most appropriate asregards their experience and attitude foreach of the parameters. The scores weretotalled to determine the positive score. Thenumber of students who have chosen aparticular grade is expressed as percentageof students (Table III).

b) Correlation of attendance with feedbackscore:

Score as determined from the feedbackevaluation proforma was compared withtheir attendance. As 40 sessions wereconducted in all this was taken as 100%attendance. (Table IV)

TABLE III : Feedback score for various parameters expressed as % of participants.

Increasedor Some what Remained Some what Decreased

Parameters improved increased same decreased greatlygreatly

% % % % %

Sense of well being 48 40 12 0 0Feeling of relaxation & calmness 68 28 4 0 0Ability to concentrate & attentiveness 52 40 8 0 0No. of hours required to fee fresh 4 4 44 48 0Self confidence 32 48 20 0 0Efficiency in any task 40 52 8 0 0Irritability levels 0 0 16 0 0Stamina 36 48 16 0 0Tiredness 4 4 16 64 12Appetite 8 20 68 4 0Optimistic outlook in life 30 52 28 0 0Headache, bodyache etc 4 4 12 48 32Interpersonal relationship 48 32 20 0 0

222 Malathi and Damodaran

TABLE IV : Correlation between average attendanceof yoga classes and average feedbackscore.

Total no. of classes conducted=40

Attendance Average attendance Average(% of classes) (no. of classes) Feedback score

90-100 38.4 22.8

80-90 33.6 18.2

70-80 28.5 11.5

<70 22.6 7.4

c) Performance in the exam as determinedby number of failures of failures in controland yoga group was compared in bothgroups using chi sq test.

RESULTS

1. Spillbergers anxiety score: (Table I)

Before Practice

A month before exam (basal reading)

The mean anxiety score was 30.64 &30.92 a month before exams in yoga &control groups respectively before thepractice sessions.

On the day of exam:

The mean anxiety score rose to 46.21and 46.75 in control and yoga grouprespectively indicating increased anxietystatus at the time of exam in both groups.

Indian J Physiol Pharmacol 1999; 43(2)

significant (P<O.OOl) as compared to thescore prior to practice. There was nostatistically significant change in theanxiety score in control group.

On the day of exam:

On the day of exam the mean anxietyscore was 46.75 prior to yoga practice and30.84 in yoga group following practice. Thedecrease in anxiety score at the time ofexam was statistically significant. (P<0.001The mean anxiety score did not showstatistically significant change in controlgroup.

II. Feedback score

a) The effect of yogic practices on thedifferent parameters have been shown. Thenumber of students who have chosen aparticular grade for a specific parameter isexpressed as % (Table III)

b) There was direct correlation between thefeedback score and average attendance ofclasses which indicates that when averageattendance of classes is more then averagefeedback score is significantly high (r=0.97,P<0.01) (Table IV)

c) Performance (Table V) :

TABLE V : Number of failures before & after practicein Yoga and control group

N = 25

After practice

A month before exam

Group

Con'trol (N=25)

Yoga (N=25)

Before

7 (28%)

8 (32%)

After

11 (44%)

2 (8%)

2.2*

4.5**

The mean anxiety score reduced to 20.30In yoga group which was statistically

*Not significant (P>0.05)**P<0.05

Indian J Physiol Pharmacol 1999; 43(2)

The number of failures before and afterm control group did not show statisticallysignificant change (P.>0.05) while in yogagroup there was a statistically significantreduction in failures in exam following yogicpractices (P<0.05).

DISCUSSION

Stress is known to modulate the activityof autonomic nervous system and centralnervous system in a way so as to cope upwith the stress to get adapted to it. Stressmay be external (environmental), internal(emotions) or sometimes there may becombinations of both interacting with eachother. (6,7). In stressful states withpreponderance of sympathetic activity, yogicasanas and pranayama can lead to a stateof reduced sympathetic activity shifting theautonomic balance towards relativeparasympathetic dominance (9, 10, 11).

The present study revealed a definitereduction in the anxiety score followingyoga. In challenging situations such asexams no doubt a certain element of anxietyis beneficial as an individual performs bestunder optimal stress but beyond limitsperformance deteriorates. It is in suchchallenging situations that yoga is beneficialas seen in the present study wherein anoptimal level of arousal did persist at thetime of exam resulting in better performanceas compared to control group with highlevels of anxiety.

A high positive feedback score of yogagroup with regard to the parameters suchas sense of well being, feeling of relaxation,improved concentration, self confidence,improved efficiency, good interpersonal

Stress Due to Exams in Medical Students 223

relationship, increased attentiveness,lowered irritability levels, and an optimisticoutlook in life are some of the beneficialeffects enjoyed by the yoga group. Similarresults have been shown by Schell et al (4).These are useful traits for success in anyprofession. As indicated by a positivecorrelation of positive score & attendance,regular practice of yoga would be useful.Since it was the first time yoga wasintroduced in the college we also determinedwhether the students enjoyed the yogasessions. 95% thoroughly enjoyed thesessions while 5% enjoyed it to some extent.If given an opportunity to join yoga classeswhen arranged in future whether theywould like to join the classes-there was anoverwhelming response of 100%. Opinionsexpressed by the students regarding yoga-

a) Should be a continuous on-going activity

b) Yoga should be included as a part of thecurriculum in theory.

c) Should be started from the time ofadmission into professional colleges soas to benefit one in the long run.

Yoga with physical, emotional, mental,personality developmenta and holisticunderstanding offers to cope with stressfulstates. To meet the modern lifestyle full ofchallenges, stress and tensions an all roundpersonality development has becomemandatory for the student. The aspect ofrelaxation and detachment is lacking in oureducation process and it is this newdimension that needs to be added to thecurriculum. Thus yoga can be beneficial inachieving a tranquil state of mind duringroutine activities and yet providing theconcentration and arousal essential indemanding or stressful situations likeexaminations.

224 Malathi and Damodaran

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