Hindawi Publishing Corporation

Evidence-Based Complementary and Alternative Medicine

Volume 2016, Article ID 9251849, 7 pages
http://dx.doi.org/10.1155/2016/9251849

Research Article
Medical Students’ Stress Levels and Sense of Well Being after
Six Weeks of Yoga and Meditation

Lona Prasad, Aneesha Varrey, and Giovanni Sisti

Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68th Street,
Suite J-130, New York, NY 10065, USA
Correspondence should be addressed to Lona Prasad; [email protected]

Received 16 June 2016; Revised 18 September 2016; Accepted 8 November 2016

Academic Editor: Yong Tai Wang

Copyright © 2016 Lona Prasad et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. To determine the effect of six weeks of yoga and meditation on medical students’ levels of perceived stress and sense of
wellbeing prior to taking their exams. Methods. We conducted a prospective case-control study of first-through-third-year medical
students at our academic institution, measuring levels of perceived stress and sense of wellbeing before and after a six-week yoga
and meditation intervention. Questionnaires used for evaluation included the perceived stress scale (PSS) and self-assessment
surveys (SAS). The postintervention surveys were completed on the day of the students’ written exams. Results. A total of thirteen
women and fourteen men participated. Median age was 28 (24 yrs–32 yrs). 48.1% were Caucasian, 7.4% Black, 11.1% Hispanic, 11.1%
Asian, and 22.2% other. Paired 𝑡-tests showed a statistically significant reduction in perceived stress (18.44 versus 14.52; 𝑝 = 0.004)
after the six-week yoga and meditation program. After the yoga intervention, self-assessment survey results showed a significant
improvement in feelings of peace, focus, and endurance. Improvements in happiness, positivity, personal satisfaction, and self-
confidence were also seen. An improvement in unsubstantiated parameters such as patience and fatigue was observed. Conclusion.
Yoga and meditation may be effective in reducing stress levels and improving aspects of personal wellbeing in medical students.

1. Introduction [3, 4]. Perpetual distress adversely affects the development

of students’ knowledge, skills, and professionalism. Students’
Stress amongst medical students is experienced in response ability to establish good relationships with patients has been
to a range of occupational stimuli. These include sacrificing compromised resulting in feelings of inadequacy. This has
time spent with loved ones, acquiring sizable financial debt, been associated with dissatisfaction which continues into
and experiencing sexual harassment or professional abuse. residency and future clinical practice [5].
Dealing with issues of human suffering and mortality can be Mind body interventions are increasingly being used in
emotionally challenging. Finally, working to master increas- the general population to assist with stress reduction. Mental
ing amounts of information in limited time periods can silence-oriented meditation has been shown to be a safe and
contribute to academic stress [1]. Investigators have reported effective strategy for dealing with work stress and depressive
that the need to perform well on exams and preparing for feelings in full time workers [6]. Patients undergoing IVF
and taking exams were the most stressful situations that report high levels of depressive symptoms, anxiety, and
students experienced in medical school [2]. Beyond certain distress. Yoga has been found to improve the overall quality
levels, however, continuous exposure to stress may negatively of life related to infertility and to reduce general anxiety and
impact the physical and mental health of students. depression over time [7]. Yoga and meditation techniques
It has been shown that medical students have a high rate have also been found to reduce performance anxiety and
of deterioration in quality of life due to work hours and haz- mood disturbance in young professional musicians [8]. There
ardous work related behavior patterns. In the United States, is evidence which suggests that meditation-based stress
approximately 50% of medical students experience burnout, management practices reduce stress and enhance forgiveness
25% have depression, and many suffer from chronic anxiety among college undergraduates [9].
 4747, 2016, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2016/9251849, Wiley Online Library on [21/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 Evidence-Based Complementary and Alternative Medicine

Our study focuses on yoga, an ancient Indian system and/or that you should only do physical activity
of philosophy and practice. Modern yoga practice has been recommended by a doctor?
influenced by the “Eight-Limbed Path” of yoga, as described
by Patanjali in The Yoga Sutras in 200 CE [10]. This text Yes: —
along with the Hatha Yoga Pradipika written in the 15th No: —
century CE suggests that one may gain physical, emotional,
(2) Do you feel pain in your chest when you do physical
and spiritual health through the practices of yoga [11]. Hatha
activity?
yoga practice incorporates breath awareness with bodily
postures requiring focus and improving strength, flexibility, Yes: —
and balance. Other aspects of yoga include pranayama or No: —
“breath control” exercises which intentionally alter one’s
breathing pattern to help achieve mindful concentration. (3) In the past month, have you had chest pain when you
Meditation is a state which enables one to focus on the were not doing physical activity?
present moment, leading to a state of thoughtless awareness
[12]. Yes: —
There are limited reports of structured yoga programs No: —
used in medical schools to promote students’ wellbeing and (4) Do you lose your balance because of dizziness or do
reduce stress levels. A mindfulness based stress reduction you ever lose consciousness?
(MBSR) intervention has been shown to improve perceived
stress and self-compassion and promote self-awareness, self- Yes: —
reflection, and self-care in first-year medical students [13, No: —
14]. Similar to our focus on yoga, a pilot study done in
Montreal showed that a sixteen-week yoga intervention may (5) Have you ever been told by a doctor that you have
be effective in decreasing stress and improving general well- bone, joint or muscle problems that could be made
being in first-year medical students [15]. Also, a randomized worse by physical activity?
controlled trial conducted in India showed that a yoga
Yes: —
intervention reduced levels of anxiety in first-year medical
students prior to taking exams [16]. The primary aim of our No: —
study was to determine whether incorporating the practice (6) Do you have a diagnosed illness that could be made
of yoga into the first-through-third-year medical school worse by physical activity?
curriculum for a six-week period would enable students to
reduce perceived stress and experience an improvement in Yes: —
personal wellbeing prior to taking their exams. No: —
(7) Is your doctor currently prescribing medication for
2. Materials and Methods your blood pressure or heart condition?
This was a prospective case-control study undertaken be- Yes: —
tween October 2013 and June 2015 at New York Presbyterian No: —
Hospital, Weill Cornell Medical School, in New York. The
study was approved by the Weill Cornell Medicine Research (8) Are you pregnant?
and Ethics Committee. First-through-third-year medical stu-
dents regardless of age, gender, or ethnicity were recruited Yes: —
by email prior to beginning either their six-week biological No: —
sciences course (first and second years) or clinical rotation
(9) Do you know of any other reason why you should not
(third years). Upon response, they were asked to complete
do physical activity?
an intake form and physical activity readiness questionnaire
(PAR-Q) as follows: Yes: —
No: —
Physical Activity Questionnaire (PAR-Q)
Identifier Code: —
Fitness Participation Agreement. I have answered the ques-
Age: — tions above to the best of my ability and affirm that my
Date: — physical condition is good and I have no known conditions
that would prevent me from participation. I acknowledge that
Please read the following questions carefully and check
participation is at my own pace and comfort level and that I
(X) the appropriate answer. Answer all questions honestly
may discontinue my participation at any time. Furthermore, I
and to the best of your ability.
agree to self-determine my exertion through good judgement
(1) Has your doctor ever said that you have a heart and to discontinue any activity that exceeds my personal
condition (had a stroke, heart attack, or heart surgery) limitations.
 4747, 2016, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2016/9251849, Wiley Online Library on [21/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Evidence-Based Complementary and Alternative Medicine 3

Signature of Participant: — 0
Date: — 1
2
Participants were excluded if they had engaged in greater than 3
one year of weekly yoga and if they had practiced weekly
in the three months preceding the start date of the study. 4
They had to meet wellness criteria determined by the physical
(3) In the last month, how often have you felt nervous and
activity readiness questionnaire and be able to attend and
stressed
participate in the classes. Consent was obtained on initial
contact. 0
All participants were required to attend one hour
1
biweekly Hatha yoga classes for six weeks consisting of forty
minutes of asanas (postures), ten minutes of pranayama 2
(breathing exercises), and ten minutes of meditation. Stu- 3
dents participated for twelve hours in total. Classes took place 4
in the medical students’ lounge, in the evenings on campus.
Each session was conducted by a 500-hour certified yoga (4) In the last month, how often have you felt confident
instructor with over fifteen years of experience. Classes were about your ability to handle your personal problems?
taught at an open level providing options for modifications
based on the individual’s requirements. 0
Data was obtained from participant self-reported ques- 1
tionnaires, specifically the perceived stress scale (PSS) and 2
self-assessment surveys (SAS), respectively, as follows: 3
Perceived Stress Scale Survey. The questions in this scale ask 4
you about your feelings and thoughts during the last month.
(5) In the last month, how often have you felt that things
In each case, you will be asked to indicate by circling how
were going your way?
often you feel or thought a certain way.
Identifier Code: — 0
1
Date: —
2
Age: —
3
Gender (Circle): 4
M (6) In the last month, how often have you found that you
F could not cope with all the things that you had to do?

Other: — 0
0 = Never 1
2
1 = Almost Never
3
2 = Sometimes 4
3 = Fairly Often
(7) In the last month, how often have you been able to
4 = Very Often
control irritations in your life?
(1) In the last month, how often have you been upset
because of something that happened unexpectedly? 0
1
0 2
1 3
2 4
3
4 (8) In the last month, how often have you felt that you
were on top of things?
(2) In the last month, how often have you felt that you
were unable to control the important things in your 0
life? 1
 4747, 2016, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2016/9251849, Wiley Online Library on [21/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 Evidence-Based Complementary and Alternative Medicine

2 “global” measurement of stress. Questions are based on a five-

3 point Likert scale. Scores range from zero to forty with higher
4 scores indicating higher levels of perceived stress. Score
points around thirteen are average. Twenty or higher is an
(9) In the last month, how often have you been angered indicator of moderate to high stress [17]. We created the self-
because of things that were outside of your control? assessment survey. This is a nine-item questionnaire using
a five-point Likert scale to assess medical students’ general
0 sense of wellbeing. Questions included in the self-assessment
1 survey measured happiness, peace, focus, endurance, pos-
itivity, personal satisfaction, self-confidence, patience, and
2
fatigue. The first seven of these components are synonymous
3 with those incorporated as part of the established fourteen-
4 item Warwick-Edinburgh mental wellbeing scale validated
on a student population [18]. The latter scale includes cor-
(10) In the last month, how often have you felt difficulties relating phrases such as “I’ve been feeling cheerful,” “I’ve
were piling up so high that you could not overcome been relaxed,” “I’ve been thinking clearly,” “I’ve had energy
them? to spare,” “I’ve been feeling optimistic about the future,”
“I’ve been feeling good about myself,” and “I’ve been feeling
0 confident.” Although the other two components, patience
1 and fatigue, are not used as part of the Warwick-Edinburgh
2 mental wellbeing scale, we chose to include these parameters
3 as part of our self-assessment survey with the interest of
4 increasing our scope of comparison understanding that these
characteristics are relevant to performance in medical school.
Similar items have been previously incorporated into a
Self Assessment Survey subjective assessment tool used in an Indian randomized
controlled yoga trial. In this study, anxiety levels and general
Identifier Code: — wellbeing were measured in first-year medical students before
Date: — and after a yoga intervention prior to taking their exams.
Survey parameters to gain students’ feedback included rating
I have: sense of wellbeing, feeling of relaxation, ability to concentrate,
feeling refreshed, level of self-confidence, task efficiency,
(1) a sense of happiness (Strongly Disagree/Disagree/
irritability levels, stamina, exhaustion, appetite, optimistic
Neither Agree or Disagree/Agree/Strongly Agree)
outlook, headache/body ache, and interpersonal relation-
(2) a peaceful feeling (Strongly Disagree/Disagree/Nei- ships [16]. Irritability levels and exhaustion are comparable
ther Agree or Disagree/Agree/Strongly Agree) descriptive terms to patience and fatigue. The latter were
(3) the ability to be focused (Strongly Disagree/Disagree/ included as part of our self-assessment survey and have
Neither Agree or Disagree/Agree/Strongly Agree) been displayed in our graph; however, we acknowledge that
these are not substantiated parameters. In order to main-
(4) increased endurance (Strongly Disagree/Disagree/
tain a consistent and validated measurement, only scores
Neither Agree or Disagree/Agree/Strongly Agree)
for items synonymous with those used in the Warwick-
(5) a positive outlook (Strongly Disagree/Disagree/Nei- Edinburgh mental wellbeing scale, that is, happiness, peace,
ther Agree or Disagree/Agree/Strongly Agree) focus, endurance, positivity, personal satisfaction, and self-
(6) personal satisfaction (Strongly Disagree/Disagree/ confidence, are reliable in our analysis. Scores of our self-
Neither Agree or Disagree/Agree/Strongly Agree) assessment survey including these seven items ranged from
zero to 28 with higher numbers indicating a greater sense of
(7) self confidence (Strongly Disagree/Disagree/Neither wellbeing.
Agree or Disagree/Agree/Strongly Agree) The Statistical Program for the Social Sciences (SPSS),
(8) patience (Strongly Disagree/Disagree/Neither Agree version 22.0 (IBM), was used for data analysis. The normality
or Disagree/Agree/Strongly Agree) of the data was checked with the Shapiro-Wilk test. Paired
(9) fatigue (Strongly Disagree/Disagree/Neither Agree or samples 𝑡-test comparisons were performed on the perceived
Disagree/Agree/Strongly Agree) stress scale survey scores before and after the yoga interven-
tion.
These were completed at baseline prior to commencing their
academic and clinical rotations and at six weeks after the 3. Results
yoga intervention, just before taking their end of rotation
written exams. The perceived stress scale is a ten-item A total of 34 medical students volunteered to participate in
questionnaire that poses general questions allowing users to the study. One was excluded because of her regular yoga
respond according to their personal stressors. This results in a practice. Six dropped out before completing the six-week
 4747, 2016, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2016/9251849, Wiley Online Library on [21/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Evidence-Based Complementary and Alternative Medicine 5

4
30

25 3

20

SAS scores
2
PSS score

15

10 1

5
0

Endurance
Peace

Focus

Self-confidence
Fatigue

Happiness

Patience
Pers. Satisfaction
Positivity
0

PSS score before PSS score after

the intervention the intervention
Figure 1: Perceived stress scale (PSS) graph.
Pre
Post
yoga program. The reasons given included being too busy
with medical school responsibilities or unwell. Twenty-seven Figure 2: Self-assessment survey (SAS) graph.
medical students completed the six-week yoga program,
answered all the questionnaires, and therefore were included
in the analyses. A total of thirteen women and fourteen helps improve my focus”. . . “I am more relaxed because I have
men participated. The median age was 28 years (24–32). become more aware of my breath”. . . “I feel more grounded
Eight (29.6%) were in their third year. Other participants and have noticed my posture has improved!”.
included fifteen (55.5%) second-year and four (14.8%) first-
year students. Forty-eight percent of the study sample were 4. Discussion
Caucasian, 7.4% were Black, 11.1% were Hispanic, 11.1% were
Asian, and 22% identified themselves as other. Twenty (74%) Our study showed that six weeks of yoga including physical
students had previous experience with yoga, but none had postures, breathing exercises, and meditation may be effective
practiced regularly. in reducing stress levels and improving aspects of personal
Eleven (41%) students had previous experience with med- wellbeing in medical students prior to taking their exams.
itation. Twenty-three (85%) reported involvement between Paired 𝑡-tests showed a statistically significant reduction in
one and five hours of physical exercise per week at the onset perceived stress (18.44 versus 14.52; 𝑝 = 0.004) after the
of the yoga study. Five (18.5%) participants reported taking six-week intervention. Similar results have been reported. A
medications. pilot study carried out in Montreal evaluated the efficacy of a
The perceived stress scale showed a statistically significant yoga intervention in first-year female medical students with
reduction in stress levels from baseline compared to six a mean age of 22 and showed a significant reduction in PSS
weeks after the yoga intervention (18.44 versus 14.52; 𝑝 = scores from baseline to the end of the intervention (22.15
0.004) (Figure 1). The mean baseline perceived stress score versus 13.38) [15].
in our study population was 18.44 which is less than the The results of our self-assessment survey showed a
scores documented in the literature for student populations significant improvement in participants’ levels of peace,
(23.7 and 23.2) [17]. However, twelve of the 27 (44.4%) focus, and endurance with an increase in points ranging
students were considered to be moderately to highly stressed between one and four from baseline to after six weeks of
at baseline with a score ≥20. Results of the self-assessment yoga and meditation. Improvements in happiness, positivity,
survey showed that there were significant improvements personal satisfaction, and self-confidence were also seen after
in feelings of peace, focus, and endurance. The increase the intervention. Although not validated by the Warwick-
in survey scores ranged between one and four points for Edinburgh mental wellbeing scale, the parameters of patience
each of these parameters from baseline to after the six-week and fatigue also showed improvements after the six-week
yoga program. An improvement in scores was also seen for yoga program. A randomized control study conducted in
feelings of happiness, positivity, personal satisfaction, and India observed the effects of a yoga intervention on stress
self-confidence from baseline to the end of the intervention. levels in first-year medical students aged eighteen to nineteen
Improvements in the unsubstantiated parameters of patience prior to taking exams and showed comparable results to our
and fatigue were also observed after the yoga intervention findings. A subjective assessment form incorporating well-
(Figure 2). ness parameters was used as part of their evaluation. Their
Students described favorable effects. Comments received participants showed a statistically significant improvement in
after the study included “I look forward to these evenings relaxation and calmness, in the ability to concentrate, and in
because I leave feeling relaxed”. . . “It clears my mind and stamina and exhaustion. These findings directly correlated
 4747, 2016, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2016/9251849, Wiley Online Library on [21/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6 Evidence-Based Complementary and Alternative Medicine

with a greater number of yoga classes attended over time to the yoga instructors, Rebecca Cheeks Soule and Cynthia
(𝑝 < 0.01) [16]. Despite similarities, neither of these studies Moss, for their valuable time and teaching.
may be generalizable to the American population because of
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Evidence-Based Complementary and Alternative Medicine 7

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