|Year : 2019 | Volume
| Issue : 6 | Page : 495-502
Prevalence of stress and its relation to different precipitating factors among urban females of reproductive age group in Burdwan, India
Arunima Chaudhuri1, Manjushree Ray2
1 Department of Physiology, Rampurhat Government Medical College and Hospital, Rampurhat, West Bengal, India
2 Department of Anesthesiology, Calcutta Medical College, Kolkata, West Bengal, India
|Date of Submission||13-Nov-2018|
|Date of Acceptance||27-Feb-2019|
|Date of Web Publication||17-Oct-2019|
Department of Physiology, Rampurhat Government Medical College and Hospital, Rampurhat, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Women in emerging economic and social markets are more stressed than those in developed countries. Aims: We aimed to study the prevalence of stress and its relation to different precipitating factors among urban females of reproductive age group. Materials and Methods: This descriptive cross-sectional study was conducted in a tertiary care center of West Bengal after taking institutional ethical clearance and informed consent of the participants. A sample of 7500 women was selected after proper randomization using an online randomizer. On the first appointment, history of the participants was carefully taken, pulse and blood pressure were recorded, and body mass index (BMI) and waist/hip (W/H) ratio were measured. Parameters assessed were Presumptive Stressful Life Events Scale (PSLES) scores and Perceived Stress Scale (PSS) scores. Results: Among 7500 participants, 3245 (43.27%) had mild-to-moderate stress and 4255 (56.73%) had severe stress. Mean ± standard deviation value of PSLES score of participants recruited for the study was 237.99 ± 79.45, and PSS score was 23.76 ± 5.24; there was a positive correlation between PSLES scores and PSS scores with r = 0.8. There was no significant difference in age between the two groups (22.8 ± 3.22 vs. 22.64 ± 3.15; P= 0.26). There was a significant difference in PSLES scores between the two groups (312.93 ± 27.19 vs. 162.99 ± 25.63; P < 0.001). There was a significant difference in values of PSS scores, BMI, W/H ratio, and pulse rate between the two groups. Marital conflicts, family conflict, and conflict with laws were the highest percentages of problems reported by these groups of participants as cause of stress. Conclusions: We observed that 100% of our participants were stressed, and family conflict, marital conflict, problems with in-laws, and abuse by husbands were some of the main contributors of stress in the population studied. Stress levels are increasing in females and require early intervention. To address gender disparities in mental health, multiple actions need to be implemented at various levels. In particular, national mental health policies must be developed that are based on an explicit analysis of gender disparities in risk and outcome.
Keywords: Contributing factors, females, stress
|How to cite this article:|
Chaudhuri A, Ray M. Prevalence of stress and its relation to different precipitating factors among urban females of reproductive age group in Burdwan, India. Med J DY Patil Vidyapeeth 2019;12:495-502
|How to cite this URL:|
Chaudhuri A, Ray M. Prevalence of stress and its relation to different precipitating factors among urban females of reproductive age group in Burdwan, India. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Nov 19];12:495-502. Available from: http://www.mjdrdypv.org/text.asp?2019/12/6/495/269422
| Introduction|| |
Recent researches have proved that most women (across cultures and borders) are too much stressed. As has been proved, 25% of females in the United States die of heart diseases,,, while 87% of Indian women feel stressed most of the times, with 82% having insufficient time to relax. As is evident from Neilson's reports, women in emerging economic and social markets are more stressed than those in developed countries. Violence and several other factors add up to the stress levels in females. Unhealthy competitions at workplace, performative gender roles, and insecurities at home and outside are only a few of the several factors. Females and males differ in the way they communicate, deal in relationships, express their feelings, and react to stress. The gender differences are based in physical, physiological, and psychological attributes.
Although violence has many faces, gendered violence has specifically become a prominent topic of discussion in India in recent times. Dowry deaths, honor killings, witchcraft-related murders, female infanticide, female feticide, sexual crimes, rape, human trafficking and forced prostitution, domestic violence, forced and child marriage, abduction, and acid attacks are on rise. According to the National Crime Records Bureau of India, crime against women was increased by 6.4% in 2012. Only 7.5% of Indian women live in West Bengal, and in this state, 12.7% of the total crimes against women have been reported. One of the most common crimes against women in India is rape. Incidents of reported rape have increased 3% between 2011 and 2012. In between 2011 and 2012, there was a 5.3% increase in violations of the Immoral Traffic (Prevention) Act of 1956 in this subcontinent. In India, 70% of women are victims of domestic violence and have been reported that every 9 min, a case of cruelty is being committed by either of husband or a relative of the husband. Cruelty by husband or his relatives is the greatest occurring crime against women in our country. Compared to women throughout the world, women in India are at a higher risk of being victims of acid attacks.,
Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups in geographic regions in both genders., Stress at work is an important risk factor for the emergence of metabolic syndrome. Plausible pathophysiological mechanisms involve direct neuroendocrine effects., Autonomic imbalance is associated with stress and results in decrease of parasympathetic influence decreases and increased sympathetic activity.,
Negative emotions have been found to be strongly related to the development of heart diseases. A reduction in positive mood and increase in worry can reduce blood supply to the heart just within 15 minutes, a condition known as silent transient myocardial ischemia. The Women's Ischemic Syndrome Evaluation study is changing the concept that women suffer less from heart diseases., The cardiovascular death rate has declined steadily only in men., Women who have angioplasties and bypasses do not do as well as their male counterparts. Most of them suffer from heart attacks or congestive heart failure after treatment., The discovery of widespread microvessel disease helps to explain why so many women with ischemic heart disease are misdiagnosed and undertreated., In coronary artery disease patients, mental stress is a well-described provocateur of ischemia. Mental stress increases myocardial oxygen demand. The physiologic response to mental stress encompasses an increased heart rate and often a peripheral vasoconstrictor response that increases left ventricular afterload.,,,,
The World Health Organization (WHO) estimated that globally over 450 million people suffer from mental disorders and currently mental and behavioral disorders account for about 12% of the global burden of diseases and are likely to increase to 15% by 2020. Major proportions of mental disorders come from low- and middle-income countries (WHO, 2001). Hence, globally, the issues of mental health considered one of the health issues that people suffer. Epidemiology of mental health in India shows that there is an increasing trend of mental health morbidities from 9.5 to 102.8 per 1000 persons.
It is a well-accepted fact that both women and men have fundamental right to mental health. It is not possible to examine the impact of gender on mental health without considering gender-based discrimination and gender-based violence. A human rights framework is needed to interpret gender differences in mental health and to identify and redress the injustices that lead to poor mental health. Many of the negative experiences and exposures to mental health risk factors that lead to and maintain the psychological disorders in which women predominate involve serious violations of their rights as human beings, including their sexual and reproductive rights.
Health programs directed toward women have usually a narrow focus on reproductive health and fertility control, in developing countries. The preoccupations of health planners, aid agencies, and researchers are not necessarily shared by the women toward whom these programs are directed. There is considerable evidence of stress due to dual role women who have to play at home and workplace which negatively impacts their quality of life. In a survey conducted in 2011, it was found the highest stress is perceived by women between 25 and 55 years who have to manage multiple roles in various fields. The present study was conducted to find the prevalence of stress among women of reproductive age group in an urban population of West Bengal and factors associated. This group of women faces multiple challenges of life at a time, and in the present competitive modernized society, it is very difficult to overcome these challenges which also add to their stress, so they were chosen as the study population.
Reducing the stress levels in women must be tackled as a matter of urgency in order to lessen the global burden caused by mental and behavioral disorders by 2020. This requires a multilevel, intersectoral approach, gendered mental health policy with a public health focus and gender-specific risk factor reduction strategies, as well as gender-sensitive services and equitable access to them.,
| Materials and Methods|| |
This descriptive cross-sectional study was conducted in a tertiary care center of West Bengal after taking institutional ethical clearance and informed consent of the participants. A sample of 7500 women was selected after proper randomization using an online randomizer. Participants were selected from different outpatient departments of Burdwan Medical College. Burdwan Medical College caters patients from Burdwan, Birbhum, Bankura, Murshidabad, Arambagh, and Hooghly districts.
We were conducting a longitudinal interventional double-blinded randomized control trial on females of reproductive age group in a time span of 3 years between May 2014 and April 2017. The sample size for the longitudinal study was calculated using online sample size calculator at calculator.net (confidence level 99.99%; confidence interval 3%; population proportion 87% as per global research firm Nielsen survey 5; population size 29,437,212 as per census report of India 2011), and the calculated sample size was 1902 or more. Two thousand and twelve participants were finally included in the study for final analysis of data. Although the calculated sample size was 1902, we selected 2012 participants considering dropout cases as the study required 3 months of progressive muscle relaxation practice and follow-up.
Randomization was done using this online randomizer to select the participants for allocation to different groups according to the Presumptive Stressful Life Events Scale (PSLES) scores. Following inclusion and exclusion criteria, 7500 participants were initially screened and divided into three Groups A, B, and C using the above online randomizer (as according to PSLES scores, participants can be grouped into three categories) with 2500 participants in each group. All were given a unique identification number. They were then asked to fill up PSLES scale. No participant had PSLES score <40. Hence, the third group, i.e., Group C had to be excluded. In Group A, 1425 (57%) participants had PSLES scores >200 and 1075 (43%) had PSLES scores <200; In Group B, 1410 (56.4%) participants had PSLES scores >200 and 1090 (43.6%) had PSLES scores <200; In Group C, 1420 (56.8%) participants had PSLES scores >200 and 1080 (43.2%) had PSLES scores <200; among all participants, 4255 (56.73%) had PSLES scores >200 and 3245 (43.27%) had PSLES scores <200. Using Chi-square test, no significant difference was found between these three groups. From Group A, 1006 participants with PSLES scores >200 were chosen serially and were taken as G1 and from Group B, the same number of participants G2 with PSLES scores <200 but >40 were included according to the numbers allotted to them using the randomizer (G1 = participants with PSLES >200; G2 = participants with PSLES <200 but >40).
All the 7500 patients who were screened for the above study were thus selected for the present study.
Women without any gross systemic, metabolic, and infective disease in the reproductive age group were selected having educational level minimum up to the 12th standard and belonging to middle socioeconomic class.
Participants suffering from chronic debilitating diseases such as:
- Cardiac arrhythmias
- Diabetes mellitus
- Ischemic heart disease
- Respiratory diseases
- Smokers and alcoholics
- Females receiving any drugs that may affect the autonomic reflexes
- Postmenopausal females and participants on treatment from psychiatry problem or with past history of treatment were excluded
- Pregnant women, puerperal mothers, adolescent girls, lactating mothers, perimenopausal women, sportswomen, yogis, and participants on regular meditation and exercise regimen were not included.
Research Randomizer (https://www.randomizer.org/) is a free resource for researchers and students in need of a quick way to generate random numbers or assign participants to experimental conditions. Randomization was done using this online randomizer to select the participants.
On the first appointment, particulars of the subject, personal history, family history, history of past illness, treatment history, and dietary history of the participants were carefully recorded. Pulse and blood pressure were recorded, and body mass index (BMI) and waist/hip (W/H) ratio were measured.
Informed consent was obtained from the participants. Demographic variables included age, sex, and education. Physical activity was assessed through survey questions about participation in household chores and in leisure time physical activity. Dietary habits were assessed through survey questions about overall dietary status (vegetarian vs. nonvegetarian), fruit and vegetable intake, fish consumption, oil consumption, and intake of salty foods. All females in our study were engaged in household work and outdoor activities. They had very little time to relax as they came from lower-middle-income group. About 60% patients were from Burdwan district, 20% from Birbhum, 12% from Hooghly, 6% from Arambagh, and rest 2% from Murshidabad district. All our participants were nonsmokers and nonalcoholic, and none were addicted to any drug.
Parameters assessed were PSLES and Perceived Stress Scale (PSS) scores. The PSLES paper says that Indians are likely to experience an average of two stressful life events in the past 1 year and ten events in a lifetime without suffering any adverse physical or psychological disturbance. The respondents were instructed to fill up only those life events that occurred in the past 1 year.
Increased sympathetic activity has been observed during the premenstrual phase, and this was positively correlated with the stress levels in previous studies. To avoid stress effects of the premenstrual phase, we have examined our participants during the postmenstrual phase.
The computer software “Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc., Released 2007. SPSS for Windows, version 16.0. SPSS Inc., Chicago, Illinois, USA)” was used in this study to analyze the data; P < 0.05* was considered significant, and P < 0.01** was considered highly significant.
| Results|| |
A total of 7500 females in the reproductive age group residing in West Bengal participated in this study. About 98% of our participants were married. All our participants were literate, and they had education level of minimum 10 + 2 level and they belonged to lower-middle-income group. Most of them were on nonvegetarian diet. About 66% of the participants in the present study were homemakers, and only 44% were working women.
No participant had stress score according to PSLES <40. Hence, no person in this study was found to be without stress. Among 7500 participants, 3245 (43.27%) had mild-to-moderate stress and 4255 (56.73%) had severe stress. Mean ± standard deviation value of PSLES score of participants recruited for the study was 237.99 ± 79.45 and PSS score was 23.76 ± 5.24; there was a positive correlation between PSLES scores and PSS scores with r = 0.8 [Figure 1]. There was no significant difference in age between the two groups, but there was a significant difference in PSLES scores between the two groups [Table 1]. There was no significant difference in dietary habits between the two groups [Table 2]. Results showed a significant difference in values of PSS scores, BMI, W/H ratio, and pulse rate with no difference in blood pressure between the two groups [Table 3] and [Figure 2]. Analysis of PSLES scale sheets showed that marital conflicts, family conflicts, and conflicts with laws constituted the highest percentages of problems reported by these groups of participants [Table 4].
|Figure 1: Correlation of Presumptive Stressful Life Events Scale scores and Perceived Stress Scale scores of 7500 participating in the study|
Click here to view
|Table 1: Comparison of age and Presumptive Stressful Life Events Scale scores between two groups|
Click here to view
|Table 3: Comparison of different parameters of participants with Presumptive Stressful Life Events Scale scores >200 and <200|
Click here to view
|Figure 2: Comparison of Perceived Stress Scale scores of participants with Presumptive Stressful Life Events Scale scores >200 and <200|
Click here to view
|Table 4: Percentage of participants who gave a positive response according to different parameters of Presumptive Stressful Life Events Scale scores|
Click here to view
| Discussion|| |
Psychological stress has been frequently found to be associated with a broad spectrum of negative health outcomes. This research focuses on the multidimensional social model that affects mental health of women in reproductive age group in West Bengal. In the present study, we have explored the various aspects of social, socioeconomic, cultural variables and the interaction of these factors with women's psychological. The main purpose of the study was to identify and analyze different factors which increase stress level among females and create awareness about them. A woman's mental health and psychological well-being are deeply affected and influenced by her society and the roles she plays in her society. Women may play different roles; it may be the role of a daughter, a wife, a mother, a sister, a homemaker, a manager, a teacher, etc.; all these influence her quality of life. In the present study, 7500 women of reproductive age group participated and none of them had PSLES score of <40. Most of them were married and homemakers. Marital conflicts, family conflict, and conflict with laws were the highest percentages of problems reported by these groups of participants.
Women have higher rates of depression and anxiety disorders which are attributed to some gender-specific risk factors such as gender-based violence, poor income, inferior social status, and burden of responsibility and care of others., In one survey covering 6500 women in 21 developed and developing countries, it was found that Indian women are most stressed in the world, 87% of Indian women felt stressed most of the time, and approximately 82% of Indian women had no time to relax. It is seen that women have more mental distress in South East Asian countries, and sociocultural factors have a major contribution to the stress. In the developing countries such as India, the major burden of care of the family falls on the female members and they accept responsibilities being the wife or mother or daughter.
In the present study, we found that all our participants were stressed, but the survey conducted in 2011 had observed that 87% women in India are stressed. The time gap of years may have further increased the prevalence of stress.
The objectives of a study in 2017 were to:
- Assess the prevalence of anxiety and stress in Indian women
- Evaluate the relationship of occupation to the prevalence of anxiety and stress.
A cross-sectional study was performed on women (aged between 18 and 50 years) who were randomly selected from different occupations in Gujarat. Anxiety levels were evaluated using Spielberg's State and Trait Anxiety Inventory scale, and stress was assessed using the International Stress Management Association questionnaire. Serum cortisol concentration was measured. The association of occupation with stress and anxiety was analyzed. Among all women participants, 26% were the most prone and 66% were somewhat more prone to stress and 35% of women showed high anxiety levels. Homemakers had 1.2 times higher anxiety and 1.3 times higher stress than working women. The prevalence of stress (37%, P < 0.001) and anxiety (40%, P = 0.068) was also higher in homemakers compared to working women. No significant difference in serum cortisol levels was observed. The findings of this study are similar to the present study.
Psychological and health-related stressors often negatively influence our health. Till date, there is a lack of extensive research about perceived stress in elderly population. A study in 2015 was aimed to test the hypothesis that levels of perceived stress increase with increasing age and to detect the factors associated. A dementia-free cohort of 1,656 adults aged 66–97 years participating in the Swedish National Aging and Care study were included. PSS score 20+ was observed in 7.8% in adults aged 81+ years, 7.5% in adults aged 72–78 years, and 6.2% in adults aged 66 years (P = 0.020). Women reported higher stress levels as compared to males, 8.3 versus 5.4% (P = 0.001). Levels of stress increased with increasing age (P = 0.001).
A cross-sectional study was conducted among medical students at a medical institution in Puducherry. Beck Depression Inventory Scale was used for screening of depression and Cohen's PSS to assess perceived stress level. The overall prevalence of depression was found to be 48.4%. Depression was significantly less among those students with mild stress (adjusted odds ratio [OR] = 0.010) and moderate stress level (adjusted OR = 0.099) as compared to severe stress level and those without interpersonal problems (adjusted OR = 0.448). The researchers in the study concluded that depression is more common among medical students.
To assess the mental health status of school-going adolescents in Chandigarh in 2017, a study was conducted. The objectives of the study were:
- To study the prevalence of Depression anxiety stress (DAS) among school-going adolescents
- To study the correlates of DAS.
Ten government schools in Chandigarh were randomly selected. Forty students were selected from each school, and a total sample of 470 students were finally analyzed. DAS scale 21 questionnaires were used. The prevalence of DAS was 65.53% (depression), 80.85% (anxiety), and 47.02% (stress), respectively. Comorbidity between depression and anxiety was found to be 57.65%. The prevalence of DAS was higher in females. For depression and anxiety, the peak age was 18 years in this study. Analyzing the results of the above studies, we had observed that women in Indian scenario are more prone to mental stress-related problems, so we had included only females in the present study.
From the above discussions, it is evident that stress levels are on the rise in females, which requires early intervention. To address gender disparities in mental health, multiple actions need to be implemented at various levels. In particular, national mental health policies must be developed that are based on an explicit analysis of gender disparities in risk and outcome.
| Conclusions|| |
We observed that 100% of our participants were stressed, and family conflict, marital conflict, problems with in-laws, and abuse by husband were some of the main contributors of stress in the population studied. Stress levels are increasing in females and require early intervention. To address gender disparities in mental health, multiple actions need to be implemented at various levels. In particular, national mental health policies must be developed that are based on an explicit analysis of gender disparities in risk and outcome.
Limitations and future scope
We only studied a specific age group and our participants belonged to middle-income group and all were educated up to at least 10 + 2 level. This was also a cross-sectional study. Hence, this study does not represent the whole population. Future studies with representation of the whole population are on the way. While administering PSLES and PSS scale to the participants, it was not possible for us to recruit participants below this education level, as participants with lower education levels were unable to understand and answer the questions on their own. Utilization of cross-sectional data limits our ability to assess causality. The survey relied on self-reporting for demographic and behavioral variables, which potentially led to underreporting in certain variables.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Varvogli L, Darviri C. Stress management techniques: Evidence-based procedures that reduce stress and promote health. Health Sci J 2011;5:74-89.
Känel RV. Psychological distress and cardiovascular risk. J Am Coll Cardiol 2008;52:2163-5.
Kohli P, Gulati M. Exercise stress testing in women: Going back to the basics. Circulation 2010;122:2570-80.
Das A. Epidemiology of mental health and mental health issues of women in India: A literature review. Int J Indian Psychol 2017;4:2349-3429.
Crimes against Women. National Crime Records Bureau; 2013. Available from: http://www. Ncrb.gov.in
. [Last retrieved on 2014 Mar 02].
Avon Global Center for Women and Justice at Cornell Law School; Committee on International Human Rights of the New York City bar Association, Cornell Law School International Human Rights Clinic; the Virtue Foundation. Combating Acid Violence. Bangladesh, India, and Cambodia: Avon Foundation for Women; 2011. p. 1-64. Available from: www.virtuefoundation.org. [Last retrieved on 2014 Mar 20].
Chandola T, Brunner E, Marmot M. Chronic stress at work and the metabolic syndrome: Prospective study. BMJ 2006;332:521-5.
Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet 2007;370:1089-100.
Gupta R, Mohan I, Narula J. Trends in coronary heart disease epidemiology in India. Ann Glob Health 2016;82:307-15.
New View of Heart Disease in Women. The Harvard Women's Health Watch; February, 2007.
Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al.
Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:953-62.
Parashara M, Singha M, Rambha JK, Pathaka R, Pandaa M. Prevalence and correlates of stress among working women of a tertiary health center in Delhi, India. Indian J Med Specialities 2017;8:77-81.
Singh G, Kaur D, Kaur H. Presumptive stressful life events scale (PSLES) – A new stressful life events scale for use in India. Indian J Psychiatry 1984;26:107-14.
] [Full text]
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
Patel PA, Patel PP, Khadilkar AV, Chiplonkar SA, Patel AD. Impact of occupation on stress and anxiety among Indian women. Women Health 2017;57:392-401.
Patel V, Araya R, de Lima M, Ludermir A, Todd C. Women, poverty and common mental disorders in four restructuring societies. Soc Sci Med 1999;49:1461-71.
Kumar S, Jeyaseelan L, Suresh S, Ahuja RC. Domestic violence and its mental health correlates in Indian women. Br J Psychiatry 2005;187:62-7.
Niaz U, Hassan S. Culture and mental health of women in South-East Asia. World Psychiatry 2006;5:118-20.
Trivedi JK, Sareen H, Dhyani M. Rapid urbanization – Its impact on mental health: A South Asian perspective. Indian J Psychiatry 2008;50:161-5.
] [Full text]
Osmanovic-Thunström A, Mossello E, Škerstedt T, Fratiglioni L, Wang HX. Do levels of perceived stress increase with increasing age after age 65? A population-based study. Age Ageing 2015;44:828-34.
Kumar SG, Kattimani S, Sarkar S, Kar SS. Prevalence of depression and its relation to stress level among medical students in Puducherry, India. Ind Psychiatry J 2017;26:86-90.
] [Full text]
Sandal RK, Goel NK, Sharma MK, Bakshi RK, Singh N, Kumar D, et al.
Prevalence of depression, anxiety and stress among school going adolescent in Chandigarh. J Family Med Prim Care 2017;6:405-10.
] [Full text]
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]