SA JOURNAL OF PHYSIOTHERAPY 2002 VOL 58 NO 2 21 from such communities. The programs promote an interdisciplinary approach to health care at primary, secondary and tertiary levels. The programs include 4-year honours degree programs in Dietetics, Human Ecology, Human Movement Studies, Nursing, Occupa- tional Therapy, Pharmacy, Physiotherapy, Social Work, and a 51/2-year program in Dentistry. Students in one of the health profes- sional education programs at UWC identified various factors that contri- buteed to stress during their training (Nicholas and Amosun, 1997). These students come into close contact with serious illness and death (Amosun, 2001), in addition to meeting the demands of their curricula (Simuzingili and Amosun, 1998). The factors causing stress vary with the stage of the edu- cational program, causing moderate to high levels of emotional exhaustion among senior students (Amosun and Dantile, 1996). In addition, some of the choices in lifestyle behaviours made by the students in the health professional ABSTRACT: Studies in well-defined populations contribute to the body of evidence that the psychosocial aspects of people’s environment can have a substantial effect on their physical health. Senior students in health professional education programs were interviewed using structured instruments to assess the prevalence of psychological distress and tension-type headaches in a young adult university population. Almost 70% of the study sample was either at risk of becoming distressed, or already distressed with somatic or depressive symptoms. About two-thirds of the students reported symptoms of either tension-type headache or other types of headache, while over 30% of all the students complained of tension-type headache. Almost 20% of the students who reported symptoms of tension-type headache were also distressed, while another 47% were at risk of being distressed. The possible impact on the academic performance of the students and their future role as health care professionals is discussed. KEY WORDS: DISTRESS, TENSION-TYPE HEADACHE, HEALTH PROFESSIONAL EDUCATION PROGRAMS, STUDENTS PSYCHOLOGICAL DISTRESS AND TENSION-TYPE HEADACHE AMONG HEALTH PROFESSIONAL SENIOR STUDENTS IN A HISTORICALLY BLACK UNIVERSITY IN SOUTH AFRICA. AMOSUN SL, B.Sc. Physiotherapy, PhD Physiology1; NAIDO P, B.Sc. Physiotherapy, MSc Physiotherapy2 1 Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Cape Town. 2 Department of Physiotherapy, University of the Western Cape. CORRESPONDENCE TO: Prof. SL Amosun Division of Physiotherapy School of Health and Rehabilitation Sciences Faculty of Health Sciences University of Cape Town Anzio Road, Observatory 7925 Tel: (021) 406 6402 Fax: (021) 448 8157 E-mail: damosun@uctgsh1.uct.ac.za R E S E A R C H A R T I C L E INTRODUCTION Since the introduction of a democratically elected government in South Africa in 1994, there have been different attempts at redressing the unequal distribution of health care. One of the attempts was to increase the number of health care professionals from historically disadvan- taged populations in order to adequately address the health needs in previously disadvantaged communities. Therefore, there has been an appreciable increase in the number of students from such communities admitted into tertiary academic programs in the area of health care. However, given the impoverished background of many black South African students, Bowerbank (1990) predicted that black students may be disadvan- taged in their ability to cope with the academic programs. The University of the Western Cape (UWC) is committed to the develop- ment of historically disadvantaged com- munities in South Africa. Therefore the students admitted into the health profes- sional education programs are mostly education programs could also add to the stress (Nkandu and Amosun, 1997). Some of the choices included the use of tobacco products, as well as sexual practices. All these factors can result in a general decrease in the physical health and emotional wellbeing of students (Lee and Graham, 2001; Pickering, 2001). Stress is known to influence the development and symptoms of various physical illnesses such as hypertension, tension headache, sleeping disorders, backache, and the common This paper has not been presented nor published elsewhere. 22 SA JOURNAL OF PHYSIOTHERAPY 2002 VOL 58 NO 2 cold (Allen et al. 1999; Solomon, 1997). Sutherland and Cooper (1995) defined stress as a psychological and physical response of the body that occurs whenever individuals must adapt to changing conditions, whether those conditions are real or perceived. Distress is stress due to an excess of adaptive demands placed on the body that may lead to bodily and mental damage. Thus distress may be defined as damaging, excessive or pathogenic stress. Studies in well-defined populations are useful in identifying the frequency and severity of factors that impact on specified populations. Two studies have already shown headaches to be a concern among students at UWC (Nicholas and Amosun, 1997; Nicholas, 1997). Headache disorders constitute a public-health problem of enormous proportions, with an impact on both the individual affected and society. Bigal et al. (2001) confirmed the profound impact of tension headache and migraine on the work productivity, quality of life, and academic perfor- mance of university students. The Distress and Risk Assessment Method (DRAM) is a simple and straightforward first-stage psychological assessment method to either confirm a clinical impression of distress, or to alert the appropriate medical personnel that a more comprehensive psychological or psycho-physiological assessment is indicated (Main et al., 1992). DRAM comprises the Modified Somatic Percep- tion Questionnaire (MSPQ), which assesses somatic awareness in distress, and the Modified Zung Questionnaire which assesses depressive symptoms in distress. Similarly, the International Headache Society (1988) developed a set of subjective characteristics to con- firm the diagnosis of tension headache, and differentiate it from other types of headache such as migraine. Therefore, the aims of this study were to: (i) Determine the prevalence of psycho- logical distress among senior stu- dents in health professional education programs at the University of the Western Cape, (ii) Determine the prevalence of tension- type headache among the senior stu- dents. METHODOLOGY The study was conducted among senior students in the last 2 years of the health- related education programs in Physio- therapy, Occupational Therapy, Dietetics, Human Ecology, Social Work, Human Movement Studies, Pharmacy and Dentistry. Students in the Nursing pro- gram were excluded because the Head of the Department did not give her consent for their participation in the study. A self-administered questionnaire was administered at the beginning of the second semester (July-August, 2000) after students returned from a three- week vacation. The first part of the questionnaire sought demographic infor- mation about the students. The second part of the questionnaire comprised the Distress and Risk Assessment Instrument, made up of the Modified Somatic Perception Questionnaire (MSPQ) and the Modified Zung Depression Question- naire (MZDQ). The MSPQ was a 22- item questionnaire containing a list of brief phrases describing physical symp- toms of distress, and respondents were expected to indicate if they were expe- riencing such feelings. Each item had four response alternatives, namely ‘not at all’ (given a score of 0), ‘a little’ (given a score of 1), ‘a great deal’ (given a score of 2), and ‘extremely often’ (given a score of 3). Of the 22 items, 13 items were related to symptoms of stress and were scored. The remaining ques- tions were leading questions, which were not scored. Therefore the possible maximum score was 39 and the mini- mum score was 0. The MZDQ is a 23-item instrument containing a list of negative and positive statements expressing the emotions experienced by the respondents. The respondents were required to rate the frequency at which they experienced the emotions, either rarely, sometimes, moderate period of time, or most of the time. For each positive statement, a respondent who indicated ‘rarely’ scored 3, but scored 0 if ‘most of the time’ was indicated. For each negative statement, ‘rarely’ was scored 0, and ‘most of the time’ was scored as 3. The higher the frequencies of negative emotions, the higher the score for the MZDQ. The maximum score obtainable was 69, and the minimum was zero. Based on the scores obtained, the stu- dents were put into four clusters, namely Normal (N), At Risk (R), Distressed- Somatic (DS), and Distressed-Depressive (DD). Type N students showed no evi- dence of psychological distress or abnormal illness behaviour (MZDQ<17), and scores for type R students were MZDQ 17-33 and MSPQ<12. The scores for type DD students were MZDQ>33, while scores for type DS students were MZDQ 17-33 and MSPQ>12. The third part of the instrument consisted of the subjective characteristics of migraine and tension-type headache according to the criteria of the Inter- national Headache Society (1988). Individuals with tension-type headache often describe the pain they experience as ‘a feeling of a tight band around the head, or pressure-squeezing discomfort around the head’. The pain is often bilaterally located, of mild or moderate intensity. The respondents who com- plained about headache completed this section. The Research and Fellowship Committee of the University of the Western Cape approved the study proto- col before implementation. Similarly, permission was sought from the Heads of the participating health professional education programs. RESULTS Table 1 shows the characteristics of the 320 students who volunteered to take part in the study, out of 447 students who qualified to take part. Using the recommended cut off scores on MSPQ and MZPQ, about 23% of the students were already distressed with either somatic or depressive symptoms, while another 46% were at risk. Sixty-eight percent of the students complained of either tension headache or other types of headache. Among those who complained of tension headache (n=100), 18% were already distressed with either somatic or depressive symptoms, while another 47% were at risk (Table 2). In addition, a higher proportion of female students who complained of tension-type head- SA JOURNAL OF PHYSIOTHERAPY 2002 VOL 58 NO 2 23 ache were already distressed with either somatic or depressive symptoms. How- ever, looking at the overall study sample, 5.6% of the 320 students were distressed with either somatic or depressive symptoms and complained of tension-type headache, while almost 15% complained of tension-type headache and were at risk of being distressed. DISCUSSION The main aim of this study was to deter- mine the prevalence of psychological distress and tension-type headache among senior students in health profes- sional education programs at the University of the Western Cape. Students in health care education programs face various challenges like other students, often, students face the challenge of striking a healthy balance between their personal and academic lives. Many times, students place greater priority on one to the detriment of the other, leading to imbalanced lifestyles which contribute to physical and emotional exhaustion and depression. Studies to evaluate levels of distress among students in health care education programs tend to concentrate mainly on medical students (Raj et al., 2000; Hudd et al., 2000). The demands of a competitive educa- tional environment have been reported to be also potentially stressful to students in allied health programs (Balogun et al, 1995). An appreciable number of stu- dents in the health professional educa- tion programs at UWC were already distressed. In addition, over one-fifth of the students who were already distressed also complained of either tension-type headache. A similar study on stress, coping, depression, and somatic distress among 69 medical students at the University of Mississippi found clinical levels of depression in almost one- quarter of the group, and high levels of somatic distress in over one half (Mosley et al., 1994). The findings in this study would have far reaching impact on the efforts of the university to contribute to increasing the number of health care personnel from previously disadvantaged communities. While a more detailed assessment may be required to confirm the occurrence of distress with somatic or depressive symptoms, the current findings have an immediate and direct impact on the life of the affected student. Students who do not cope effectively with the stress encountered at university are at a higher risk of developing health problems and academic failure. This will negatively affect the pass through rates in the dif- ferent education programs. It is there- fore recommended that students iden- tified as being distressed or at risk of being distressed be advised to seek immediate assistance, especially through the Students Counselling Centre at the university. In addition, the centre should develop both preventive and combative strategies, in the form of health promo- tion programs, to reduce the effects of stress on students’ health and academic performance. However, it will be neces- sary to first identify the possible stres- sors in the programs. Similarly, it will be helpful to confirm if the students at UWC were more prone to the develop- ment of distress and tension-type head- ache due to the type of community they come from. The findings of this study may also have a future impact on the work productivity of affected students. Wolf (1994) has shown that medical students are worse off psychosocially when they graduate than when they entered univer- sity. A similar report was observed among physiotherapy students at UWC (Amosun and Dantile, 1996). The pur- pose of education is to bring about beneficial change. Unfortunately, if the current scenario persists, health care professionals graduating from UWC may not be able to contribute maximally to meeting the health care needs of the Table 1: Characteristics of the students Features Frequency (N=320) Gender: Males 91 Females 226 Unknown 3 Mean Age (years): Males 23.5 (s.d.=3.7; range=18-40) Females 23.6 (s.d.=4.0; range=19-42) Range 19-42 Prevalence of headache (n=218): Tension headache 100 Other types (including migraine) 118 Classification of distress: Normal 98 At risk 148 Distressed with somatic symptoms 38 Distressed with depressive symptoms 36 Table 2: Students with distress and tension headache (n=100) Prevalence of distress N R DS DD Prevalence of tension headache 35 47 7 11 Gender: Males 11 9 0 3 Females 24 38 7 8 N = Normal, no psychological distress R = At risk DS = Distressed with somatic symptoms DD = Distressed with depressive symptoms 24 SA JOURNAL OF PHYSIOTHERAPY 2002 VOL 58 NO 2 communities they were trained to serve. Unfortunately, they may add to the health care burden. It must be emphasised that the stu- dents who took part in this study were not physically assessed to confirm the reported symptoms of distress and ten- sion-type headache. The findings of the study may therefore vary if a physical assessment were carried out. The study has also not confirmed whether the students were distressed before the onset of headache, or whether the headache led to the distress experienced. CONCLUSION Appreciable proportions of students in the health care education programs at UWC are distressed and experience symptoms of tension-type headache. There is a need for both preventive and combative strategies to reduce stress among the students. REFERENCES Allen K D, Mathews J R, Shriver M D 1999 Children and recurrent headache: assess- ment and treatment implications for school psychologists. School Psychology Review 28: 266-280 Amosun S L 2001 Experiences of physio- therapy students in a clinical setting for elderly adults. South African Journal of Physiotherapy 57(2): 3-6 Amosun SL, Dantile ND 1996 Are we graduating physiotherapists with the burnout syndrome? Evaluating physiotherapy educa- tion at the University of the Western Cape. South African Journal of Physiotherapy 52(3): 69-72 Balogun JA, Helgemoe S, Pellegrini E 1995 Test-retest reliability of a psychometric instru- ment designed to measure physical therapy students’ burnout. Perceptual and Motor Skills 81: 667-672 Bigal ME, Bigal JM, Betti M, Bordini CA, Speciali JG 2001 Evaluation of the impact of migraine and episodic tension-type headache on the quality of life and performance of a university student population. Headache 41(7): 710-719 Bowerbank P 1990 Towards 2000 - Strategy planning for South African Physiotherapy. South African Journal of Physiotherapy 46: 3-5 Hudd SS, Dumlao J, Erdmann-Sager D, Murray D, Phan E, Soukas N, Yokozuka N 2000 Stress at college: Effects on health habits, health status and self-esteem. College Student Journal 34(2): 217-228 International Headache Society 1998 Classification and diagnostic criteria for headache - neuralgias and facial pain. Cephalgia 8(Suppl. 7): 1-96 Lee J, Graham AV 2001 Students’ perception of medical school stress and their evaluation of a wellness elective. Medical Education 35: 652-659 Main CJ, Wood PLR, Hollis S, Spanswick CC, Waddell G 1992 The distress and risk assess- ment method: A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine 17(1): 42-52 Mosley TH, Perrin SG, Neral SM, Dubbert PM, Grothues CA, Pinto BM 1994 Stress, coping, and well being among third-year medical students. Academic Medicine 69(9): 765-767 Nkandu EM, Amosun SL (1997) Health-related behaviours of health professional students at the University of the Western Cape. CHASA Journal of Comprehensive Health 8(3/4): 135- 141. Nicholas L 1997 Patterns of utilisation of university counselling services: A comparison of a South African and a North American university. International Journal for the Advancement of Counselling 19: 65-71 Nicholas L., Amosun SL 1997 A descriptive analysis of the personal, career, and learning skills needs of physiotherapy students at the University of the Western Cape. Proceedings of the International Congress of the South African Society of Physiotherapy 132-142 Pickering T 2001 Job stress, control, and chronic disease: Moving to the next level of evidence. Psychosomatic Medicine 63: 734- 736 Raj S R, Simpson C S, Hopman W M, Singer M A 2000 Health-related quality of life among final year medical students. Canadian Medical Association Journal 162(4): 509-511 Simuzingili T, Amosun S L. 1998 What clini- cal competencies do we expect from physio- therapy students at the University of the Western Cape? South African Journal of Physiotherapy 54(4): 10-14 Solomon S 1997 Diagnosis of primary headache disorders. Neurologic Clinics: Advances in headache 15: 15-27 Sutherland VJ. Cooper CL 1995 The nature of stress. In: Understanding Stress - A psycho- logical perspective for health professionals, pp25-58. Chapman and Hall, London Wolf TM 1994 Stress, coping and health: enhancing wellbeing during medical school. Medical Education 28: 8-17