Stress among Indian Doctors: A Gender Variation

Objective: Variations in work related stress and physical activity levels have been seen with a emphasis on sex difference. This cross-sectional study was designed to report the gender difference in stress dynamics and physical activity, and propose a framework for finding out the source causing these differences and associated lifestyle risk factors for cardio-metabolic disorders. Design: A cross-sectional study was designed which analysed 113 doctors (58 females and 55 males) for perceived and measured stress using validated questionnaires and methods. Long term time domain index of Heart Rate Variability was used to measure stress. Physical activity levels were also measured along with history questionnaire focusing on risk factors of lifestyle disorders. Results: The perceived stress measured by PSS-14, MSP-9 and VAS(stress) showed higher recorded values in female doctors (45.50±4.08, 36.21±7.52, 6.07±2.26) as compared to male doctors (44.00±5.58, 34.40±6.81, 5.47±2.25), respectively. The measured stress showed a significant comparison between both the genders putting males (44.79±10.69) under more stress than females (50.76±11.69) (p<0.05). The energy expenditure was higher in female doctors (2171.09±1703.66) than male doctors (1981.21±1440.17). Conclusion: Female doctors had high perceived stress levels with high levels of physical activity whereas male counterparts had high measured stress with low measured physical activity levels.

In past decades, special attention has been paid in understanding work related stress with an emphasis on sex difference (Jick & Mitz, 1985). The risk factor for developing cardiac arrhythmias, hypertension, coronary heart disease, diabetes mellitus, and variations in lipid profile has been associated with psychological stress (Zipes, Libby, Bonow, & Braunwald, 2005)(8). This cross-sectional study was designed to report the sex difference in stress dynamics and propose a framework for finding out the source causing these differences and associated lifestyle risk factors for cardio-metabolic disorders.

METHODOLOGY
The doctors working in various departments in Government Medical College, Amritsar, Punjab, India, were recruited for an analytical cross-sectional study design. A total of 113 participants who volunteered were from various departments under surgical, medical and para-clinical and pre-clinical specializations. The categorisation was made according to gender which included 58 female and 55 male doctors. Those who had incomplete participation in the study and those who underwent recent cardiovascular surgery were excluded from the study. Those with any metabolic disorders or cardiovascular disorders were included in the study.
The study protocol was approved by Departmental Ethics Committee, Department of Sports Medicine and Physiotherapy, Guru Nanak Dev University, Amritsar. The participants were briefed about the protocol and signed the written informed consent before the data collection.

Data Collection
The doctors were assessed for various parameters for stress and physical activity along with the history associated with the risk factors for cardio-metabolic disorders. The data collection started when the doctors arrived in their respective departments. All the doctors in a particular department were assessed at a time. Prior to the filling of questionnaires doctors were assessed for anthropometric measurements (height (cm), weight (kg), hip circumference (cm), and waist circumference (cm), waist to hip ratio (WHpR) and Body Mass Index (BMI). Later they were asked to fill up the questionnaires, including history, Perceived Stress Scale 14 Questionnaire (PSS 14), short 9-item Psychological Stress Measurement (MSP-9) questionnaire, and International Physical Activity Questionnaire (IPAQ) short form questionnaire. Following which they were assessed for physiological parameter like Heart Rate Variability (HRV) using accelerometers (Zephyr BioHarness 3.0 (BioHarness, Zephyr Technology, Auckland, New Zealand)) which were worn around the chest. The HRV was recorded for 3 consecutive working days (Martinez De Tejada, et al., 2013) (Nang, et al., 2011. These accelerometers are wireless ambulatory physiological monitoring system which records raw one lead electrocardiography (ECG). The data was analyzed using HRV 2.1 software (Kubios1, Kuopio, Finland) and a note was made for the long term time domain index of HRV, i.e. standard deviation of the heart beat intervals in ms (SDNN). At the end of the working day the accelerometer belts were returned and doctors were asked to fill the Visual Analogue Scale for daily perceived stress and physical activity.

Statistical analysis
The data was assessed gender-wise using IBM SPSS Statistics (Version 20) software. The frequency distribution and Mean (Mean± SD) for variables were compared using One way analysis of variance (ANOVA) and Mann-Whitney U test. The sample size calculated was 109.98, with 95% confidence interval, expected population size of (p) 0.35 and precision of 0.05.

RESULTS
The study included 58 female doctors and 55 male doctors with an average age of 33.03±10.24 and 36.51±11.48, respectively. The measured stress, SDNN, showed a significant comparison between both the genders putting males ( Measured physical activity levels by accelerometers did not show any difference while the perceived daily physical activity on VAS scale showed females to have more physically active day. The energy expenditure was higher in females (2171.09±1703.66) than males (1981.21±1440.17) (Table 1), where 15.52% females indulging in high grade physical activity (>3000 METs-minutes/week) as compared to 10.91 % males ( Table 2).
None of the female doctors in this population reported intake of alcohol while 83.64% male doctors consumed alcohol varying from an average of 1 drink per day to more than 3 drinks per day, showing a significant comparison (p<0.05). The consumption of coffee and tea also showed significant comparison between both the sex (p<0.05). 36.36% male doctors consumed an average of more than 3 cups of tea per day. Higher number of females than males did not indulge in sporting activity (82.76%) but 43.10% did meditation or yoga. Male doctors had shown high values on anthropometrical scales, where 81.82% were obese (BMI ≥25) and 83.64% were centrally obese (WHpR ♂≥0.88; ♀≥0.81). (Table 2) DISCUSSION It is been postulated by sociologists that according to differential vulnerability hypothesis, the employed females are under more stress than employed men under the same social environmental cues (Roxburgh, 1996), explaining high perceived stress among female doctors working in this setup of public teaching hospital. The measured stress was high among male doctors. We can cite that an additional domestic workload to the routine occupational work could lead to the high perceived stress in females. A meta-analysis by Jick, et al. has stated that psychological distress is higher among women which make them more prone for severe physical illness (Jick & Mitz, 1985).

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The female doctors were found out to be more physically active by indulgence in high grade physical activities than male doctors, reflected by increased values of time domain indices of HRV (SDNN) in this study. The physical activity causes enhanced vagal tone which is reflected by higher values of HRV (Aubert, Seps, & Beckers, 2003) (Luque-Casado, Zabala, Morales, Mateo-March, & Sanabria, 2013) (Hautala, et al., 2010). The high indulgence in physical activity can be cited as a mode of coping strategy adopted by female doctors to overcome the perceived stress. The participation of female doctors have been more in para-clinical and pre-clinical fields with predominance of laboratory, research and teaching work, apart from the more frantic and stressful specialities of internal medicine, and obstetrics and gynaecology. The work in paraclinical and pre-clinical fields can be considered to cause less burnout without hampering their domestic life. Acceptance and learning of coping strategies and less work related physical strain may be cited as the reason for better care, greater empathy and practice of evidence-based guidelines in medicine (Wen, December).
On the contrary, it was found that the male counterparts had lower values for recorded SDNN. This decreased HRV among male doctors reflected high measured stress and poor cardiovascular response to physical activity leading to genesis of lifestyle disorders. High alcohol and tea consumption among male doctors along with association of central obesity makes them more prone for health problems. The consumption of coffee and tea has shown its association with cardiovascular diseases (Yano, Rhoads, & Kagan, 1977) (Peters, Poole, & Arab, 2001). The consumption of alcohol and tobacco was recorded negligible among females which can be reasoned to the social taboo in this part of the country. Anthropometrical variables have also shown an association with dyslipidaemia and hypertension (Bertsias, Mammas, Linardakis, & Kafatos, 2003) and can be cited as a reason for higher future incidence of cardio-metabolic disorders among doctors.
It is been required to identify work related stressors and those who are suffering from this stress, so that adequate coping strategies and health promotion programs can be developed and implemented among the medical fraternity. The programs must be gender specific, must consider doctors working on various designations in medical specialities and include the promotion of various ways of living healthy lifestyle by including physical activity and healthy eating habits. A special emphasis should be given to doctors under training, irrespective of the gender, by inclusion of counselling and learning of coping strategies in their training curriculum. This might help to lead a healthier and less stressful life among doctors themselves without hampering their efficacy at work.
To the best of our knowledge the literature have lacunae for the gender differentiation of psychological stress among Indian doctors. This study being one of its kinds to fills in the void by inclusion of validated questionnaires and modalities for assessment of psychological stress and physical activity levels among male and female doctors in a public teaching hospital.