Stress among Portuguese medical students: A national cross-sectional study

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2019/2020

Maria João Sá Trovão Oura

Stress among Portuguese medical students:

A national cross-sectional study

Stress nos estudantes de medicina portugueses:

Um estudo transversal nacional

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Mestrado Integrado em Medicina

Área: Ciências Médicas e da Saúde – Medicina Clínica

Tipologia: Dissertação

Trabalho efetuado sob a Orientação de:

Professor Doutor Paulo Alexandre Azevedo Pereira Santos

Trabalho organizado de acordo com as normas da revista:

Journal of Epidemiology and Global Health

Maria João Sá Trovão Oura

Stress among Portuguese medical students:

A national cross-sectional study

Stress nos estudantes de medicina portugueses:

Um estudo transversal nacional

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Para os meus pais, pelo amor, força, sabedoria, apoio incondicional e por serem

sempre o meu porto seguro.

Para o meu irmão, pela paciência e por ser o meu maior companheiro de vida que me

faz sorrir até dos meus próprios medos.

Para os meus amigos, por todas as gargalhadas e lágrimas, por me ensinarem tanto e

serem o pilar que sustenta a minha felicidade.

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Stress among Portuguese medical students: A national

cross-sectional study

Maria João Sá Trovão Ouraa_{, Ana Raquel Alves Moreira}a_{, Paulo Alexandre Azevedo Pereira}

Santosa,b

a_{Department of Medicine of Community, Information and Health Decision Sciences (MEDCIDS),}

Faculty of Medicine, University of Porto, Portugal.

b_{Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University}

of Porto, Portugal.

Correspondence to: Maria João Sá Trovão Oura; Department of Medicine of Community, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, Porto, Portugal, 4200-319; E-mail address: mariajoao.oura@hotmail.com; Full postal address: Praça dos Combatentes, 83, 3B, 4490-439, Póvoa de Varzim, Portugal; Telephone number: +351910917832.

Word count: 3338 words.

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ABSTRACT

Introduction: The medical course is extremely stimulating but also demanding, and it can interfere with students’ mental health. Stress leads to lower life quality, academic performance and ultimately to a lower quality of patient care delivered.

Objective: To characterize stress levels of sixth-year medical students who attend Portuguese colleges.

Methodology: This observational cross-sectional study involved Portuguese medical students attending the sixth year of all Portuguese faculties. We applied an online self-response questionnaire, including the 10 items Perceived Stress Scale (PSS) to assess stress levels, and sociodemographic variables. Logistic regression was used to estimate the weight of the studied determinants on stress levels.

Results: A total of 501 participants were included for analysis (69.5% females), with a median age of 24 years old. We found significant levels of stress in 49.9% (95%CI: 45.5-54.3%), with 20.8% of total students presenting extremely high levels, irrespective of age, gender and faculty. Stress was higher when students presented bad sleeping and eating habits, lack of ability to manage time, unsatisfaction with social life and academic experience, and low family support. Also, these students are more worried about their future and present a higher degree of concern about their graduation test performance.

Conclusion: Stress is very common in medical students, concerning social determinants as well as the intrinsic complexity of the course. Coping strategies are crucial to make students deal with stress and be healthier, currently and in the future.

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RESUMO

Introdução: O curso de Medicina é extremamente enriquecedor. No entanto, os desafios e exigências inerentes podem afetar a saúde mental dos estudantes. O stress leva a uma diminuição da qualidade de vida, do desempenho académico e, em última instância, da qualidade da prática clínica futura.

Objetivo: Caracterizar os níveis de stress presentes nos estudantes a frequentar o sexto ano nas Faculdades de Medicina em Portugal.

Métodos: Neste estudo transversal foram envolvidos os estudantes do sexto ano de todas as Faculdades de Medicina Portuguesas. Foi aplicado um questionário online, que incluiu uma escala para avaliar os níveis de stress (Perceived Stress Scale, PSS) e uma avaliação de variáveis sociodemográficas. Através de regressão logística, foi estimado o peso de cada determinante estudado nos níveis de stress.

Resultados: Um total de 501 respostas foram incluídas para análise (69.5% feminino), tendo os respondedores uma idade média de 24 anos. Foram encontrados níveis significativos de stress em 49.9% (95%CI: 45.5-54.3%), com 20.8% do total de estudantes a apresentar níveis extremamente elevados, independentemente da idade, género e faculdade. Os estudantes apresentam mais stress quando possuem maus hábitos de sono, alimentação e gestão do tempo, insatisfação com a vida académica ou social, e menor apoio familiar. Para além disso, estes têm também maiores preocupações com o seu futuro e apresentam uma pior perceção relativamente à sua Prova Nacional de Acesso.

Conclusão: O stress é relativamente comum nos estudantes de Medicina, estando bastante associado a determinantes sociais e não unicamente à complexidade intrínseca do curso. Conclui-se que é fundamental instituir medidas de coping e apoio aos estudantes, de forma a contribuir para a sua saúde atual e futura.

Palavras-chave: Stress; Saúde Mental; Estudantes de Medicina; Faculdade de Medicina; Educação Médica.

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1. INTRODUCTION

“Stress” is a widely used word in everyday life, which meaning varies according to the circumstances. Nevertheless, it can be explained by the general adaptation syndrome described by Hans Selye (1930) [1]. The different organisms have a similar cognitively mediated emotional response pattern to sensory/psychological stimuli. Selye differentiated two types of stress: the distress (negative stress) and the eustress (positive stress), that are physiologically experienced in a similar way. The cause of stress is not in the objective event itself, but in the physiological response to it. Therefore, stress effects become evident when the situation is appraised as threatening and the resources to cope with it are insufficient [2].

There are several strategies to handle stress when it takes over. Coping refers to cognitive, emotional, and/or behavioral efforts to tolerate or reduce a troubled person-environment relationship[3]. Lazarus and Folkman suggested two different perspectives as they focus on the problem or on the emotions. Emotion-focused coping aims to reduce the negative emotions associated with stress and the emotional reaction to the stressors, including measures such as drug therapy, meditation, drinking, reframing, and positive thinking. On the other hand, problem-focused coping attempts to remove or reduce the cause of the stressor. This includes identifying the problem, evaluating possible solutions and choosing one of them[4].

Stress is a natural feeling and an inevitable part of life. It emerges from the combination of a triggering event with the lack of ability to cope with it. Stressors may be linked to work, financial struggles, conflicts in relationships or major life events. Even though youngsters cope with concerns and anxiety that surround them through optimistic attitudes and a relative positive perception of their future, stress is still common among them. University is an astonishing and challenging experience, both personally and academically. However, it is a period that can exacerbate emotional vulnerabilities. College admission causes significant changes in the students' daily life: entering a new environment, leaving parent’s home and accustoming to academic demands may condition stress[5], affecting their physical and emotional welfare, quality of life and leading to lower academic success. They also face concentration difficulties, memory problems, behavior changes, constant worry, self-defeating thoughts, and social withdrawal.

Several studies have demonstrated that medical students suffer more from depression and other mental issues than the general population[6–8] and it may extend even after graduation, into their high emotional demand professional life[9]. This psychological morbidity appears to arise from training process, as medical students show better mental health at admission than age-matched college graduates [10]. This implies the need to provide students

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better mental health support since medical school, to prepare them to a deep emotional medical career.

Medical students may present certain common personality traits. They are generally more perfectionists, more obsessive-compulsive and have higher expectations regarding themselves[11], which might contribute to the higher prevalence of mental disorders among them. Nevertheless, it is also these traits that enable them to overcome the adversities throughout those years, and the driving force that helps them to attain their goals.

In Portugal, the medicine course lasts six years and it requires students to have remarkable dedication, strong emotional capacities and good time management skills. After graduation, a global test determines the rating for access to future specialty: Prova Nacional de

Acesso (PNA). The decisive character of this exam to the near future of students provokes a lot

of concern during 6th_{year corresponding to the need to study and prepare the evaluation.}

Recently, a new model for the exam was introduced, closer to clinical skills but significantly different from the previous model. Despite commonly considered a positive change, it may be perceived as frightening and stressful.

This study aims to assess stress levels of medical students attending sixth year of Portuguese Universities, to better understand this problem and draw possible prevention and support measures.

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2. MATERIALS AND METHODS

We conducted an observational cross-sectional study in the 6th_{year grade medical}

students of Portuguese Universities, by survey.

In Portugal, there are currently eight Medical Schools. Two of them in Porto (Faculdade

de Medicina da Universidade do Porto, FMUP, and Instituto de Ciências Biomédicas Abel Salazar,

ICBAS), two in Lisbon (Faculdade de Medicina da Universidade de Lisboa, FML, and NOVA

Medical School Lisboa), one in Braga (Escola de Medicina da Universidade do Minho, EM), one

in Coimbra (Faculdade de Medicina da Universidade de Coimbra, FMUC), one in Covilhã (Faculdade de Ciências da Saúde da Universidade da Beira Interior, UBI) and one in Faro (Universidade do Algarve, UAlg). Although some differences among them, all curricula are quite similar, granting the integrated master grade in Medicine at the end of 6 years, with the exception of Ualg, which targets complementary clinical learning to previous graduate students. The total number of students attending the 6th_{year comprises approximately 1.200 individuals,}

all of them eligible for participation.

The data collection occurred from September 2019 to the end of January 2020. All eligible students were invited to participate in the survey on four different occasions through the institutional email system and via contact with college’s academic administrations and student’s associations. The sample size considering a margin of error of 3.5% for a confidence interval of 95%, for an unknown expectant result, was established in 475 participants.

We measured stress using the Perceived Stress Scale (PSS) developed by Sheldon Cohen and colleagues[2], translated and validated to Portuguese by Pais Ribeiro and Marques[12]. This version has 10 items pointing how often participants have found their lives unpredictable, uncontrollable and overloaded in the last month, classified by a Likert scale from 0 (never) to 4 (very often). The final score ranges from 0 to 40 and the higher the score, the greater the stress. It has an internal consistency (Cronbach's α) of 0.87 and an item total correlation ranging from 0.32 to 0.82, with the majority above 0.60. The dichotomic categorization classifies pathological stress above 22 in the females and 20 in the males [12]. We also used a polynomial categorization of low stress levels when PSS score ranged from 0 to 13, moderate when it varied from 14 to 26 and high when the score obtained was equal or higher than 27[13].

We also evaluated social and demographic variables: age, gender, enough sleeping hours, eating habits, spirituality, ability to manage time, social life satisfaction, satisfaction with academic experience, presence of financial problems, family support, displacement from home, frequency of home visits (if applicable), worries about the future and the degree of concern about the new exam.

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The Ethical Committee of Hospital de São João / Faculty of Medicine of University of Porto assessed and approved the study protocol. We followed the principles of the Helsinki Declaration and the Oviedo Convention about the protection of human rights in the biomedical investigation in this investigation. The first page of the web-form, before the questionnaire itself, included information for participants, and asked for their explicit consent, allowing the refusal with automatically drop out of study.

We used descriptive and inferential statistics. Data were encoded and registered in a Microsoft Office Excel 2013 ® database and analyzed using IBM SPSS Statistics ®, version 25.0 (IBM Corp., Armonk, NY, USA ®). We used descriptive measures to describe our sample. The main outcome “stress” was dichotomized in low or high. Odds ratio for determinants were calculated by logistic regression. A multivariate model, adjusted for age, gender and faculty of study, was constructed using backward (Ward) logistic regression and significant factors in univariate analysis. The significance level was set at 0.05.

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3. RESULTS

We register 501 valid participants, out of 559 total answers (89.6%). Invalid questionnaires are related to answers from students from other years than the 6th_{(n=58). As}

expected by the demography of medical students in Portugal, female respondents are the main group (69.5%) and the mean age is 24 years old (±2.5). The most represented college is FMUP (29.7%), followed by FMUC and FML (19.6% and 13.2%, respectively), which was predictable since these three present the highest attending number of students. Table 1 shows the demographic characteristics of our sample.

Table 1 - Sociodemographic characteristics of medical students.

Characteristics N (%) Gender Male Female 153 (30.5%) 348 (69.5%)

Mean age in years (SD) 24,0 (±2.5)

Medical school FMUP ICBAS EM UBI FMUC FMUL NOVA UAlg 149 (29.7%) 57 (11.4%) 37 (7.4%) 48 (9.6%) 98 (19.6%) 66 (13.2%) 30 (6.0%) 16 (3.2%)

Lives away from home 319 (63.7%)

Visits home frequently (in those living away from home) 248 (78.0%)

Sleeps enough hours 248 (49.5%)

Maintains a balanced diet 370 (73.9%)

Able to manage time 283 (56.5%)

Social life satisfaction 216 (43.1%)

Satisfaction with academic experience 208 (41.5%)

Financial problems 57 (11.4%)

Good family support 481 (96.0%)

Feelings of worry about the future 375 (74.9%)

Spirituality feelings 231 (46.1%)

New exam model perception Less intimidating Equally intimidating More intimidating 181 (36.1%) 121 (24.2%) 199 (39.7%)

Had/has mental illness 17 (23.4%)

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FMUC: Faculdade de Medicina da Universidade de Coimbra; FMUL: Faculdade de Medicina da Universidade de Lisboa; FMUP: Faculdade de Medicina da Universidade do Porto; ICBAS: Instituto de Ciências Biomédicas Abel Salazar; NOVA: NOVA Medical School; SD: standard deviation; UAlg: Universidade do Algarve; UBI: Faculdade de Ciências da Saúde da Universidade da Beira Interio; UM: Escola de Medicina da Universidade do Minho.

The mean perceived stress score is 20.2 (95%CI: 19.6- 20.9). Pathological stress is present in 250 students (49.9%; 95%CI: 45.5-54.3%), using the dichotomic categorization, with no differences between gender, age or faculty of origin. The polynomial scale shows 89 students present low stress (17.8%; 95%CI: 14.7-21.4%), 308 moderate and 104 (20.8%:17.4-24.5%).

In a univariate analysis, pathological stress is associated with bad sleeping habits, lack of ability to manage time and unsatisfaction with social life and academic experience. These students are more worried about their future and present a worst perception about the graduation test. Besides, 30% of students with stress levels considered pathological have or had a mental disease. It has been found a statistically significant association between stress and psychiatric illness. Figure 1 shows stress determinants and its association with PSS score. Figure 1 – Association of stress determinants with pathological stress (by Perceived Stress Scale score).

0,1 1 10

Less intimidating More intimidating New exam model perception (comparison with…

Worries about the future Able to manage time Spirituality feelings Satisfaction with social life Satisfaction with academic experience Sleeps enough hours Maintains a balanced diet Finnancial difficulties Visits home frequently Lives away from home Family support Had/has family with mental illness Had/has mental illness Age Male vs Female

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The multivariate analysis using logistic regression adjusted for age, gender and faculty shows that males are less prone to present stress than females, as those who sleep well, eat well, who are satisfied with social life and friends’ support and have a good ability to manage their time (table 2). Stress is more common among those who have mental illness, currently or in the past, and those who are worried about their future.

Table 2 – Factors related with stress in medical students.

Determinants OR (95%CI) p value

Male vs Female 0.194 (0.115 – 0.328) <0.001

Sleeps enough hours 0.586 (0.362 – 0.951) 0.030

Had/has mental illness 2.982 (1.717 – 5.192) <0.001

Maintains a balanced diet 0.450 (0.259 – 0.783) 0.005

Able to manage time 0.391 (0.243 – 0.627) <0.001

Social life satisfaction 0.471 (0.282 – 0.789) 0.004

Satisfaction with academic experience 0.535 (0.320 – 0.897) 0.018

Worries about the future 3.092 (1.794 – 5.329) <0.001

Multivariate analysis, using logistic regression adjusted for age, gender and college. (CI: confidence interval; OR: odds ratio; p value was set at <0.05).

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4. DISCUSSION

Almost half of the students attending the sixth year of Portuguese medical Schools present pathological stress (49.9%), with 20.8% revealing extremely high levels. They are more vulnerable to the development of mental disease, such as anxiety and depression[14]. This is extremely worrying for several reasons. First, youth is supposed to be one of the healthiest and happiest phases in the cycle of life. High stress levels reduce their perceived happiness[15]. Second, it can interfere with study skills, such as concentration and memory capacities, eventually leading to a reduction on academic performance[16]. Finally, there is a risk of persistence throughout life, negatively affecting medical performance and the patient’s care and the health-care systems.

Higher stress levels are associated with more worries regarding the future and the graduation test performance. This group of students is the second round of the new model of test. They will do the exam in November 2020. Currently, there is a lack of vacancies for the all candidates, exerting pressure in the performance to achieve the admission for the desired specialty. This is surely a cause of stress, potentially leading to an exacerbation of mental health problems.

Our results also show a relation between stress and several social determinants. Difficulties in maintaining healthy eating and sleeping habits, financial problems, lack of ability to manage their time, low family support and female gender are associated with pathological stress. In addition, unsatisfaction with social life, academic experience and the presence of a mental disease make students more prone to high stress levels. All of these factors can be the cause but also be the consequence of a stressful situation. Identification and support of students with these risk factors can either prevent the onset and the progression of stress.

These findings are in line with recent studies that also applied PSS to medical students. Samanta et al (2017), in India, found a mean PSS score of 18.41 (±6.22) in medical students [17], and Tavolacci et al (2015), in France, found a mean value of 19.4 (±6.9) in sixth-year students[18]. Rahimi et al (Canada, 2014) described higher levels of perceived stress in medical students comparing to the general population, matched by age and gender[19]. Even using different methods, Galán (2011), in Spain, found high burnout prevalence in sixth-year students by the Maslach Burnout Inventory[20]. Moreover, several works associate the studied determinants with stress. Hill (2018) described the stressors facing medical students in the millennial generation: medical school workload, performance pressure, financial problems, time constraints and lack of balance [21]. Several other American[22,23], European[24,25] and Asian[26–28] studies have also noted these as stressors among medical students.

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In our study, although family support isn’t associated to pathological stress, it is protective from high stress (OR=0.211; 95%CI: 0.07-0.64), making us to think that family has a relevant role in preventing the extremely high stress in our students. Additionally, feelings of spirituality and displacement from home don’t have an impact on stress, unlike some literature showing lack of spirituality [29] and accommodation away from home [30,31] as severe stressors.

To our knowledge, this is the first nation-wide study measuring and characterizing perceived stress in the pre-graduated medical students and using a high reliable scale for measuring the perceived stress. Nevertheless, our results must be adjusted considering the limitations of our study. First of all, the cross-sectional design lacks temporality. A longitudinal design would have evaluated temporal relationships. The self-response questionnaire may condition some information bias, in which respondents provide what they believe to be socially acceptable answers rather than their own truth, even using a Likert scale to prevent the tendency for the correct answer. Finally, since the participation in the study was optional, there could be a self-selecting bias, in which the students who decided to answer may present different characteristics in comparison to the non-answering community, although the distribution by age and gender is under the expected.

This study emphasizes the high number of medical students presenting pathological stress. However, few students actually seek help[32], which may lead to a persistence of this problem into the medical practice. It is then of extreme importance to identify and implement prevention and management measures since it might prevent students from getting into a vicious cycle of stress and related diseases. A wide range of strategies can be used to cope with stress. Several extracurricular activities have been correlated with the reduction of stress and burnout, such as physical exercise or music [33]. Music-related activities may have positive effects on the emotions and the body. Besides, physical activity has been associated with lower stress levels in other health students[34]. Thus, a study has shown that medical students’ perceived stress decreased after a six weeks program of yoga and meditation, which also improved self-confidence, happiness, and endurance[35]. Mindfulness practices have been increasingly incorporated into medical students’ mental health interventions. Mindfulness has its roots in Buddhism, but it has extended into western contemporary culture. The main goal of mindfulness-based interventions is to enable individuals to cultivate and incorporate its practice into daily life[36]. Mindfulness-based stress reduction (MBSR) is a well-established training that has been associated with lower stress levels, anxiety and depression in health professional students[37]. It highlights the importance of observing situations and thinking in a nonjudgmental, nonreactive and accepting manner[38]. Most of the medical students’ programs follow the traditional MBSR format, requiring the presence of qualified trainers. A

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recent study reported UK medical student’s experience of an eight-week course of mindfulness training carried by a trained teacher[39]. The participants had a two-hour session each week and thirty-minute daily home practice between. It consisted of “formal and informal meditation practices, including guided body scans, sitting and walking meditations, mindful movement based on Hatha yoga, three-minute breathing spaces, and focused awareness on routine daily activities”. This eight-week program was found helpful, efficient and it positively influenced students’ approach on their well-being. Furthermore, the Medical University of Graz (Austria) implemented the “Peer2Peer” program [40]. It gives students the knowledge to become tutors and mentor younger colleagues. First, there is an elective course that addresses psychological stress, relaxation techniques and coping mechanisms, psychiatric diseases (such as anxiety and depression). Afterwards, students become tutors, mentoring peers through consultation services one to three hours per week, and organizing lectures and workshops about the topic. This enables not only student tutors to acquire stress coping skills, but also to teach them to their colleagues. However, there are programs that do not require a qualified trainer, which might make it more accessible. In fact, some electronic interventions have proved to be effective. A study used the Mindful Gym course, a DVD-delivered program consisting of a five-week audio-video intervention with two-to-three-hour sessions per five-week[41]. There were no individual sessions, group meetings or online discussions. After the intervention, there was a reduction in perceived stress, anxiety and depression, with an absolute risk reduction of 0.158, 0.132 and 0.211, respectively. Besides, the “Computer Assisted Learning for the Mind” (CALM) is a New Zealand website with audio files addressing stress-management and positive thinking[42]. It may be listened directly from the computer or downloaded and played in any mp3 device. In the USA, there is a resource for college mental health called “ULifeLine”. It includes information regarding mental/emotional disorders and how to obtain help for oneself or others. It also has a self-evaluator tool that screens the most common mental health conditions that college students face, identifying problems that could be affecting thoughts, feelings and behaviors. Both of these last programs provide an affordable and anonymous way of helping the group of students with high levels of stress. Substance abuse should also be addressed since it has been established that alcohol abuse is associated with higher stress levels[43,44]. This is worrying as several works have found a high prevalence of alcohol abuse in medical students[45]. A study among them found that 74.3% of alcohol users and 90% of cigarette smokers had severe stress symptoms[46]. In Portugal, alcoholic drinks is a relevant problem between youngers and illicit substances’ consumption is increasing[47]. It is then important to take this into consideration when implementing a stress-management program since it is crucial to warn and prevent students from acquiring these habits and help those who

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already face this problem to develop strategies towards the reduction of substances’ consumption. Moreover, real time monitoring through electronic devices is a new way to make students taking sense of their current state, by assessing heart rate, for instance, sending an alert able to remind the need to change attitudes to decrease stress levels [48]. Also, the information should be easily available in accessible sources, with scientific rigor and topicality[49].

There is a wide range of coping and intervention measures useful for medical students. Several studies explain the different methods but there is a lack of interventional studies that measure their efficacy. In the future, it would be of extreme importance to conduct those studies to assess these strategies’ efficacy. Besides, it is imperative to evaluate how these measures should be implemented. They could be part of the core medical school curriculum or an optional component. Furthermore, they could be part of a large nation-wide program or an intensive course with a few weeks’ duration. More studies are required to explore and compare these. A study found that UK undergraduate and graduate-entry medical students cope with stress differently, despite having similar profiles of stress symptoms[50]. This needs to be enlightened in future studies as it means that coping mechanisms should be adapted according to the students’ situation. Upcoming studies should also assess the temporal relationship between perceived stress among the six years of medical school, as the literature is controversial. A recent study suggests that stress levels don’t vary significantly over training years, remaining moderately high[51], but this is not well established yet. Finally, since saliva or blood cortisol levels are objective stress measures, it could be interesting to complement stress studies with them.

5. CONCLUSION

The medical career is an extremely demanding and never-ending path. These demands already commence in college and increase as time goes by since responsibilities only grow stronger. While in college, medical students face certain difficulties, such as time management, the overwhelming pressure to succeed, the uncertainty of the future, financial concerns, struggles to maintain healthy lifestyle habits and social environment [52]. All of these factors may lead to an exacerbation of stress and, ultimately, to burnout. The medical education trajectory is accompanied by several major transitions. It is a challenging process and a possible source of additional stress that surmounts throughout the daily practice of physicians. Stress levels found in this study are worrying, and it should warn us to the urgent need for the

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development of prevention and support measures in order to strike this problem early instead of allowing it to progress into the medical practice.

6. CONFLICTS OF INTEREST

The authors declare they have no conflicts of interest.

7. CONTRIBUTORS

All named authors made substantial contributions to the conception, design, analysis and interpretation of data for the work and to its draft. Final approval of the version was provided by all authors, agreeing to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

8. FUNDING

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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23/04/2020 Journal of Epidemiology and Global Health - author guidelines | Atlantis Press

https://www.atlantis-press.com/journals/jegh/author-guidelines 1/23

Search

Journal of Epidemiology and Global Health

Author Guidelines

Introduction

Manuscript Submission Checklist

Article Types

Submission Process

Open Researcher and Contributor ID (ORCID)

Manuscript Preparation

Article Structure and Organization

Artwork

Journal Editorial Standards

Journal Ethical Standards

Open Access & CC License

Post-Acceptance Rights

Article Proofs

Articles in Press

Responsible Sharing

Author Inquiries

Introduction

The

Journal of Epidemiology and Global Health

(JEGH) is an open access,

peer-reviewed, multidisciplinary journal which aims to impact global

epidemiology and international health with articles focused on innovative

scholarship and strategies to advance global health policy. The journal seeks

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to improve regional and global health by informing efforts to reduce the risk

of communicable and non-communicable diseases and takes special interest

in publishing rigorous assessments of policies which have been implemented

based on epidemiological and public health research. We welcome original

studies (laboratory, epidemiological or clinical), reviews, perspectives and

commentaries from all aspects of communicable and non-communicable

diseases, in particular those identi ed as priorities by the World Health

Assembly. The journal does not accept case reports and submissions purely

focused on basic (bench) science.

Manuscript Submission Checklist

Before you submit your manuscript to the journal for review, please ensure

that all the items listed below have been checked and uploaded with your

submission. In case you require more information about any of the items in

this list, please refer to the relevant section in these Author Guidelines or

contact the Publisher directly at

author-support@atlantis-press.com

.

A title page which shows: (i) a concise and informative article title; (ii) the

name(s) of the Author(s); (iii) the af liation(s) and complete permanent

address(es) of the Author(s) – the address at which the research was

conducted must be kept as the main af liation address; any current

address (if different) can be included as a footnote to the Author’s name;

(iv) clear indication of the designated Corresponding Author with contact

details including email address, full postal address and telephone number

(including country code); (v) a total word count for the article; and (vi) a

total table and gure count for the article.

• Keywords have been included in the manuscript.

• All gures (including relevant captions).

• All tables (including title, description, footnotes).

• All gure and table citations in the text match the les provided.

• References are in accordance with the journal reference style.

• All references mentioned in the reference list are cited in the text and vice

versa.

• Author Declaration of Potential Con ict form.

Note that this competing

interest declaration needs to be provided, even if the Author(s) have no

competing interests to declare

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Article Types

The

Journal of Epidemiology and Global Health

(JEGH) publishes a range of

article types with the following speci cations:

competing interests to declare.

Data Availability Statement.

• Any supplementary les/materials (where applicable).

• Manuscript has been “spell checked” and “grammar checked” in the word

processor tool used.

• Permission has been sought and obtained for the use of copyrighted

materials from other sources (including the Internet).

• Referee suggestions and contact details have been provided as per the

journal’s requirements.

• Journal policies detailed in these Author Guidelines have been reviewed.

• Research Article. A research article describes an original study which is of

interest to the readership of the journal.

Speci cations: unstructured

abstract required of max. 250 words, main body of text (i.e. excluding

abstract, tables, gures and references) not to exceed 4,000 words, max. 8

tables and/or gures, max. 100 references.

• Review Article. A review article is a comprehensive and balanced survey

of recent developments in a given eld which is of interest to the

readership of the journal. Review articles are often commissioned,

although pre-submission enquiries for reviews are also welcome.

Speci cations: unstructured abstract required of max. 250 words, main

body of text (i.e. excluding abstract, tables, gures and references) not to

exceed 6,000 words, max. 12 tables and/or gures, max. 150 references.

• Perspective. A perspective is intended to provide a forward-looking and/or

speculative approach to a given research topic which is of interest to the

readership of the journal. Perspectives should always remain balanced and

aim to stimulate discussion within the relevant research community.

Pre-submission enquiries for perspectives are encouraged.

Speci cations:

unstructured abstract required of max. 150 words, main body of text (i.e.

excluding tables, gures and references) not to exceed 2,000 words, max. 2

tables and/or gures, max. 15 references.

• Correspondence A correspondence is a concise communication which

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Submission Process

Manuscripts are submitted to the

Journal of Epidemiology and Global Health

using the Editorial Manager online submission and peer review system.

Please click on the

Submit your Paper

button in the left-hand menu on the

journal homepage for a link to access this system. Instructions will be

provided on screen for uploading all the relevant information and les

associated with your submission. All manuscripts must be in the English

language and Authors are advised to ensure clarity, brevity and accuracy of

the information provided.

Note that the submission of a manuscript means that the research described

has not been published previously in other journals, that it is not under

consideration for publication elsewhere, that its publication is approved by all

Authors – either tacitly or explicitly – and by the responsible authorities

Correspondence. A correspondence is a concise communication which

provides a forum to address new or hot issues which are relevant to the

readership of the journal.

Speci cations: no abstract required, main body of

text (i.e. excluding tables, gures and references) not to exceed 1,200 words,

max. 2 tables and/or gures, max. 20 references.

• Commentary. A commentary is a short manuscript that provides

information about a recent development or innovation in the eld or

opinions on unresolved and timely issues. The nature of such an article

lends itself to opinion, thus appropriate evidence should be provided,

excessive speculation should be avoided and the topic should be of interest

to the readership of the journal.

Speci cations: no abstract required, main

body of text (i.e. excluding tables, gures and references) not to exceed

1,500 words, max. 2 tables and/or gures, max. 10 references.

• Letter to the Editor. This is a letter addressed to the Editor which is related

to an article published in the journal. It must be submitted within 6 weeks

of online publication (under no circumstances will exceptions be made).

The Editor may choose to invite the Authors of the article in question to

write a correspondence reply. Such letters are not appropriate for

publishing new data without peer review.

Speci cations: no abstract

required, main body of text (i.e. excluding tables, gures and references)

not to exceed 1,000 words, max. 2 tables and/or gures, max. 10 references.

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where the work was carried out, and that upon acceptance the article will not

be published elsewhere in the same form, either in English or in any other

language, including in any electronic medium, without the written

permission of the journal owner. The editorial team of the

Journal of

Epidemiology and Global Health

veri es the originality of submitted

manuscripts using similarity detection software.

Submission to the journal proceeds in an online environment only where

Authors will be stepwise guided through the process of entering article details

and uploading submission les. The online submission system automatically

converts all source les into a single PDF le which is used in the peer review

process. Please note that even though source les are converted to PDF at

submission, the original editable les (e.g. in Word or LaTeX) are still needed

for further processing and typesetting after acceptance. All correspondence,

including noti cation of the Editor’s decision and requests for revision, is sent

via email.

Open Researcher and Contributor ID (ORCID)

The

Journal of Epidemiology and Global Health

supports

ORCID

in its

publication work ow, enabling researchers to apply for a unique ID which is

connected to their work. Similar to DOIs for articles, ORCID for Authors will

help researchers to distinguish their research from others, to get appropriate

recognition and to enhance the discovery of their work. Corresponding

Authors are required to register for an

ORCID

identi er (free of charge) and to

link this identi er to their submission. Any co-Authors are encouraged to do

the same.

If you have registered with

ORCID

, you can link your personal ID to your

existing Editorial Manager account by going to your account details and

entering your ORCID identi er. After you validate and con rm your details,

you will be directed to the ORCID website to sign in (make sure you have your

username and password ready). You will then be requested to agree to attach

your ORCID details to your Editorial Manager account. In the event that the

number is invalid (you will see a red cross next to the ORCID identi er) you

can click on the link to “Update ORCID iD” and follow the instructions to

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j

y

Manuscript Preparation

Use of Word Processing Software

It is important that your manuscript text le is saved in the native format of

the word processor used. The text should be in a single-column format and

the layout should be kept as simple as possible. Most formatting codes will be

removed and replaced on processing the article. In particular, do not use the

word processor’s options to justify text or to hyphenate words. However, you

can use bold face, italics, subscripts, superscripts, etc. When preparing tables,

if you are using a table grid, use only one grid for each individual table and not

a grid for each row. If no grid is used, use tabs and not spaces to align

columns. Note that source les of gures, tables and text graphics will be

required regardless of whether you embed your gures in the text or not. To

avoid unnecessary errors you are strongly advised to use the “spell-check”

and “grammar-check” functions of your word processor.

LaTeX Submissions

Manuscripts, for example those which contain a lot of mathematical formulas,

can also be submitted in LaTeX. All source les that are uploaded to the

submission system will be automatically compiled into a single PDF le to be

approved by the Author at the end of the submission process. While the

compiled PDF will be used during peer review, the uploaded source les will

be sent to the Publisher for publication upon acceptance. Please do not use

subfolders for your LaTeX submission, e.g. for gures or bibliographic les.

Should you require additional technical information for uploading and

compiling your LaTeX submission, please refer to the following resource:

http://www.editorialmanager.de/pdf/latex

.

Article Structure and Organization

Cover Letter

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Including a cover letter with your submission gives you a chance to convince

the Editors that your article is suitable for publication in the journal and of

importance to its readership. A cover letter should be no more than two pages

long and should include all the standard elements which are to be expected in

an of cial letter (for example, the date and the address of the recipient, etc.).

The Author(s) should con rm that the submission is original (include the title

of the manuscript and the journal name) and not under consideration for

publication in another journal. Furthermore, you should brie y mention the

focus of the manuscript (no more than 4-5 sentences). Note that while we ask

the Author(s) to provide competing interest information separately, you are

welcome to also include this information in the cover letter.

Abstract

The abstract of your article should brie y state the purpose of the research,

the main results and the major conclusions. An abstract is often presented

separately from the article, so it must be able to stand alone. It should

therefore not contain any unde ned abbreviations or unspeci ed references. If

references are still deemed essential, then cite the Author(s) and year(s). Also,

if non-standard or uncommon abbreviations cannot be avoided they must be

de ned at their rst mention in the abstract itself.

Keywords

Immediately after the abstract, provide a maximum of 7 keywords, using

American-English spelling and avoiding general and plural terms and

multiple concepts (for example, avoid “and”, “of”, etc.). Also avoid using

abbreviations unless they are rmly established in the eld. Note that these

keywords will be used for indexing purposes.

Subdivision – Numbered Sections

Divide your article into clearly de ned and numbered sections. Subsections

should be numbered 1.1 (then 1.1.1, 1.1.2, ...), 1.2, etc. Note that the abstract

should not be included in the section numbering. Use the section numbering

also for internal cross-referencing: do not just refer to 'the text'. Any

subsection may be given a brief heading. Each heading should appear on its

own separate line.

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Abbreviations

Abbreviations which are non-standard in the eld should be de ned at their

rst mention in the text and used consistently thereafter. De nitions can be

placed in a footnote on the rst page of the article.

Introduction

An introduction should state the objectives of the work and provide an

adequate background. Make sure you explain the nature of the problem and

provide the context of why the work is important. Avoid a detailed literature

survey or a summary of the results and make sure you include all the relevant

references.

Materials and Methods

This section is important to allow reproducibility of your work by an

independent researcher. You should therefore provide suf cient details and a

description of the techniques and equipment used. Standard techniques and

methods used during the work should just be mentioned at the beginning of

the section and descriptions of these are not needed. Methods that are already

published should be summarized and indicated by a reference. If quoting

directly from a previously published method, use quotation marks and cite the

source. Any modi cations to existing methods should also be described. If

lengthy descriptions of experimental procedures are required, the Authors are

encouraged to include them in a supplementary le. Where applicable,

Authors must con rm whether all ethical approvals for a procedure have been

obtained. For clinical trials, Authors have to clarify the study design

(prospective, retrospective or other).

Results

Present your results and experimental data in a clear, consistent and concise

manner. Only essential results should be included in the text and only points

which are important for the discussion should be highlighted. Do not attempt

to hide data; any secondary data can be included in a supplementary le.

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Discussion

This section should contain an interpretation of what the results mean and

explore their signi cance. Highlight the impact of your results compared with

recent work and relate it back to the problem or original question in your

study. Do not repeat the results in this section and avoid extensive citations or

a discussion of published literature.

Conclusion

The main conclusions of the study may be presented in a short Conclusions

section. Recommendations or plans for future studies can be included in this

section as well.

Competing Interests

All Authors must disclose any nancial and personal relationships with other

people or organizations that could inappropriately in uence or bias their

work. Examples of potential con icts of interest include employment,

consultancies, stock ownership, honoraria, paid expert testimony, patent

applications or registrations, and grants or other funding. The

Journal of

Epidemiology and Global Health

follows the

recommendations of the

In-ternational Committee of Medical Journal Editors

(ICMJE) with regard to

Authors’ responsibilities for reporting con icts of interest. Authors submitting

to the journal are required to complete an

Author Declaration of Potential

Con ict

form and upload it as a mandatory submission item together with

their manuscript. Any potential competing interests must also be mentioned

in an explicit statement within the manuscript itself: this statement should

describe all potential con icts of interest (or lack thereof) for each

contributing Author.

Contributors

Each Author is encouraged to declare his/her individual contribution to the

work submitted: all Authors should have materially participated in the

research and/or article preparation and as such the roles of each Author

should be clearly described. The statement that all Authors have approved the

nal article should be true and included in the disclosure. For more

information, please refer to the

Author Statement of Contribution

section in

the Atlantis Press

Submission & Author Guidelines

policy.

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Role of Funding Source

Authors are required to disclose and list any parties which have made a

nancial contribution to the research and/or the preparation of the article and

to brie y describe the role that such party may have had in the work (if any).

If the funding source(s) had no involvement in the work beyond providing a

nancial contribution, then this should be explicitly stated as well.

Acknowledgements

Where applicable, Authors can collate a list of grants, funds and/or

individuals who provided help during the research or writing of the

manuscript in a separate Acknowledgements section at the end of the article

before the references. Names of funding organizations should be written in

full. Do not include acknowledgements on the title page, as a footnote to the

title or otherwise.

Research Data

The

Journal of Epidemiology and Global Health

encourages Authors to deposit

their research data in a relevant data repository and to cite and link to this

dataset in their article. In cases where data sharing is not possible for some

reason, Authors are requested to make a statement to explain why the

research data cannot be shared. Authors are required to provide a

Data

Availability Statement

along these lines as a mandatory item in the

submission process. For more information, please refer to the

Research Data

Policy

section in the Atlantis Press

Transparency & Research Data

policy.

Figure Captions

Authors must ensure that each illustration has a caption. Captions must be

supplied separately and not attached to the gure itself. A caption should

comprise a brief title (not on the gure itself) and a description of the

illustration. Keep text in the illustrations themselves to a minimum, but

explain all symbols and abbreviations used. Note that captions should contain

the gure number as cited in the text.

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