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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 112-117

Effect of pedometer-based walking on depression, anxiety, and insomnia among medical students in a government medical college


1 Jhalawar Medical College and Associated Hospital, Jhalawar, Rajasthan, India
2 Department Pharmacology, S.M.S. Medical College, Jaipur, Rajasthan, India
3 Department of Forensic Medicine, Jhalawar Medical College and Associated Hospital, Jhalawar, Rajasthan, India

Date of Submission24-Feb-2021
Date of Acceptance17-Dec-2021
Date of Web Publication10-Feb-2022

Correspondence Address:
Dr. Lokendra Sharma
Department of Pharmacology, S.M.S. Medical College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmgims.jmgims_19_21

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  Abstract 


Context: Pedometer is a popular tool to measure physical activity and it is easy to use. Objectives: The impact of pedometer-based walking on insomnia, anxiety, and depression among medical students was evaluated in this study. Methods: A total of 120 2nd-year MBBS students were randomly assigned to two groups (n = 60 in each group). Anxiety, insomnia, and depression levels were assessed using Beck's depression inventory, Beck's anxiety inventory, and Likert sleep scale questionnaire at different time durations. Data were analyzed using the independent t-test, Chi-square, and repeated measures tests. Results: We noticed 22.1% reduction in depression score in the intervention group (P = 0.009). Anxiety score was reduced to 19% among the intervention group students (P = 0.03). Sleep quality improved in students of the intervention group as compared to the control group (P < 0.001). Conclusion: A walking training programme can be considered to manage depression, anxiety, and insomnia in medical students.

Keywords: Anxiety, depression, pedometer, stress


How to cite this article:
Sharma S, Rani M, Jain S, Sharma L. Effect of pedometer-based walking on depression, anxiety, and insomnia among medical students in a government medical college. J Mahatma Gandhi Inst Med Sci 2021;26:112-7

How to cite this URL:
Sharma S, Rani M, Jain S, Sharma L. Effect of pedometer-based walking on depression, anxiety, and insomnia among medical students in a government medical college. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2022 Oct 3];26:112-7. Available from: https://www.jmgims.co.in/text.asp?2021/26/2/112/337432




  Introduction Top


Psychological disorders are often neglected due to their indefinite clinical diagnosis, social taboos, and long-term treatment.[1] Approximately 20% of adults and children have some type of mental problems or disorders.[2] Medical colleges have a very stressful environment which affects students' psychosocial well-being, physical health, and academic performance.[3] More than half the medical students have some form of depression, anxiety, and insomnia.[4] In the medical profession, students experience many difficulties such as the burden of the syllabus and very high level of competition. All these factors create stress in students which has a negative effect on their mental health. This leads to reduced concentration, lack of confidence, sleep deprivation, depression, anxiety, and substance abuse.

Physical activity helps students remain healthy and improves physical function, quality of life, and emotional well-being.[5] Walking is a very common physical activity among adults.[6] Walking is safe because both its intensity and frequency can be managed easily.[6] Walking is used as an intervention to decrease the risks of many chronic diseases such as hypertension, obesity, and psychiatric disorders.[7] Regular physical activity protects against the development of anxiety disorders and depression and reduces their symptoms. It has been reported to increase the quality of life among people diagnosed with anxiety disorders or depression.[8]

A pedometer is a popular tool for measuring physical activity interventions in different settings and it is easy to use. A pedometer can be used as motivational tool to encourage walking.[6] Previous studies have shown that pedometer-based walking interventions with a step goal increased the physical activity[6],[9] and mental health of patients.

A recently published meta-analysis has reported that one-third of medical students suffer from depression worldwide.[10] The prevalence of depression is higher among medical students as compared to the general population. Other psychological symptoms such as insomnia, anxiety, burnout, and substance abuse are also common among medical students.[11] According to published research, the mental health of medical students deteriorates during school years and continuously declines when they enter the workforce. Published research studies also show that physical activity such as walking and exercise can reduce the symptoms of anxiety and stress. Abedi et al.[12] conducted a study among postmenopausal women to show the effects of pedometer-based walking on depression, anxiety, and insomnia and found that pedometer-based walking positively affects depression, insomnia, and anxiety.

This study was conducted to explore the effect of walking on depression, anxiety, and insomnia among medical students in a government medical college using a pedometer. We also explored whether increase in step counts have any impact on depression, anxiety, and insomnia levels.


  Methods Top


This randomized and controlled interventional study was conducted among second-year MBBS students of a government medical college. The study was granted approval from the institutional ethics committee. Prospective students' consent was taken in writing. A total of 120 students participated in the study. Selected students were randomly divided into Group 1 (intervention group) and Group 2 (control group). Randomization was done by flipping a coin, where heads indicated the intervention group and tails indicated the control group. The duration of the study was 3 months.

Inclusion criteria were male or female students, above 18 years of age, able to follow the instructions, and with reasonable fluency in the English language. Exclusion criteria included having any type of physical or mental condition that limited motor, sensory, or cognitive abilities, having contraindications for physical activity, or suffering from any confounding conditions such as a neurologic, medical, or surgical disorder.

Estimation of sample size

The evaluated mean difference and standard deviation[6] before and after intervention were 7.2 and 13.46. Two-tailed group comparison equation for evaluating the sample size is given by Eq. 1.

(1)

where Zα/2 is 1.96, Zβ is 0.84, μ1– μ2 is–7.2, and S is 13.46.

To maintain 80% power and 0.5 type 1 error, a minimum of 55 participants were needed for the intervention and control group. A total of 120 participants were enrolled in the present study.

In this study, a total of 120 students were randomly allotted to the two groups. In Group 1, (intervention group): 60 MBBS 2nd-year medical students and in Group 2 (control group): 60 students of the same class were included in the pedometer-based walking programme.

The participants of both the groups were enrolled during the mid-semester so as to avoid the immediate pre-examination period. Participants of Group 1 were advised to walk at different places using a smart phone with a pedometer application. The pedometer app (Pedometer–Free Step Counter App and Step Tracker of ITO Technologies, Inc) used in the study is free and independent of the hardware used. For the smart phone pedometer application, the researcher guided the participants to download the pedometer application in smart phones. The participants were instructed to carry the same mobile phone in their pocket from the moment they got up to the end of the day, just before they went to bed (except when bathing).[13] In addition, they told how to record and reset the number of steps aggregate at the end of each day and document the step count in a logbook (record form). They then mailed the screen shot of the logbook each day to the researcher. Data of the study were evaluated after 10 days (P0 baseline) and then after 25-day gap for two sessions (P1, P2) to complete a 2-month duration. At the end of the 2nd month, all students were assessed using Beck's depression inventory (BDI),[14] Beck's anxiety inventory (BAI),[15] and Likert Sleep Scale.[16] For all three scales (BDI, BAI, and Likert Sleep Scale), reduction in the score shows that there is improvement in mental health. To observe the effect of enhanced physical activity on depression, anxiety, and sleep at the end of 2nd month, students of Group 1 were encouraged to enhance their physical activity by the pedometer steps count and maintain their logbook. Participation and compliance were ensured by providing completion certificates and prizes to the students. Participants of Group 2 were instructed not to install the pedometer app and keep their physical activities to a minimum.

Analysis of data

The IBM SPSS software, version 17.0 (Chicago, USA) was used for analysis. Before evaluation, all records were checked for normal distribution, missing values, outliers, and extreme values. Continuous data were denoted as mean and standard deviation and categorical data were represented in the form of frequency and percentage at baseline. It may be noted that data of age and body mass index at baseline were not distributed normally. Therefore, a nonparametric test (Mann–Whitney U test) was used to evaluate its characteristics. The remaining data at baseline were evaluated and compared using the Chi-square test. Data of BDI, BAI, and Likert sleep scale of both groups were compared by applying Student's t-test at each time. The effects of intervention over time in both groups were analyzed by performing repeated measures analysis of variance. Intention-to-treat design was used. The significance level was set at P < 0.05.


  Results Top


A total of 120 medical students were included in the study. The majority of students (68%) were in the age group of 17–20 years and 51.79% were females. Nearly 41.12% of students were involved in moderate physical activities. Nearly 46.76% of students were satisfied with the choice of medicine as their career. Prevalence of a family history of depression, anxiety, and insomnia was 24.65%, 26.78%, and 35.7%, respectively. The demographic characteristics of students have been tabulated in [Table 1].
Table 1: Demographic characteristics of study participants (n=120)

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Anxiety, depression, and insomnia scores were significantly higher at the baseline. During the study, it was to be found that students of age group of 17–20 years had more symptoms of depression than students of age group ≥20 years. The majority (62.5%) of students of age group 17–20 years had mild symptoms of depression. The majority of girls (68.1%) had a mild form of depression. Although anxiety was reported to be significantly more (64.2%) among students of age group ≥20 years. It is important to note here that 52.3% of girls had poor sleep quality as compared to the boys.

The comparison between BDI, BAI, and sleep Likert scale scores for Group 1 (intervention group) and Group 2 (control group) is shown in [Table 2]. Baseline scores of depression, anxiety, and insomnia were found to be comparable (p>0.05). A reduction of 22.1% was found in the BDI score (14.56 ± 7.45 at baseline and 11.34 ± 5.89 after completion of study) among the students of Group 1 which is higher compared to Group 2 (P = 0.009). Anxiety score (BAI) of Group 1 students reduced more significantly (19% reduction) as compared to Group 2 students (P = 0.03). The group of students who used the pedometer had 37% improvement in sleep quality than students of control group (P ≤ 0.001). When compared, we noticed that the scores of depression, anxiety, and sleep of Group 1 students significantly improved over time (P < 0.05).
Table 2: Comparison of mean scores of Beck's depression inventory, Beck's anxiety inventory and Sleep Likert Scale of Group 1 and Group 2 at different duration for intention to treat analysis

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Steps covered, distance covered, and calories burnt at the different times during the study are depicted in [Table 3]. These are the conclusion lines of table 3 in simple form. In [Table 3] all the data has been provided in median. At the end of the study, the maximum step cont was increased to 9856 (median) and significantly more distance and calories were burned among participants of intervention group.
Table 3: Steps covered, distance covered, and calories burned by students during pedometer intervention (n=60)

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  Discussion Top


Depression, anxiety, and insomnia are very common in medical students. However, persistent high depression and anxiety can lead to deterioration of the physical and psychological health of students. We observed high anxiety and depression scores at baseline in medical students. Similarly, Puthran et al.[10] reported higher prevalence of depression among medical students at baseline. In our study, approximately 32.5% of students were found to have some symptoms of depression from mild to moderate. These findings of the current study are higher than figures from Western countries and closer to the records reported by Eastern countries. A study conducted among 2000 medical students in the USA showed that only 9.2% of students had mild or moderate symptoms of depression.[17] A study conducted in Sweden reported that only 13% of the students had depression.[18] Studies from Eastern countries observed a higher rate of depression in medical students as compared to Western countries. A study from India found that 21.9% of students had symptoms of some form of depression,[19] while studies from Pakistan and Iran have also reported high rates of depression (35.1% and 52.6%, respectively).[20],[21] Reasons for this higher rate of depression could be due to cultural and lifestyle factors. Students from the age group of 17–20 years (younger students) had more depressive symptoms than those of the age group ≥20 years. Similar findings have been found in some previously published studies.[22],[23] However, a study from Turkey observed a higher rate of depression among older medical students.[24] The results of the present study found that female students were at higher risk of depression than male students, and this result was consistent with previous studies.[18],[19],[25]

The magnitude of anxiety among students in our study was 35.8%. This finding was in line with another published study from Brazil who reported a figure of 33.7%.[26] However, the rate of anxiety was higher than a study conducted in Nepal (5%).[27] but lower than studies published in Bahrain (51%)[28] and Egypt (73%).[29] Reasons of the high rate of anxiety could be due to high course load and sociocultural differences among various countries. Female students had 1.4 times more symptoms of anxiety as compared to boys. Our results were similar to the study conducted in Northeast Brazil.[26]

Our study found that 38.1% of medical students had some kind of sleep problem. This finding was in congruence with results obtained from the study conducted in Brazil.[30] We found a higher prevalence of insomnia among female students than male students. Lind et al. conducted a longitudinal study and observed that adult females were more likely to be affected by insomnia.[31]

Physical activities positively affect many aspects of mental health such as depression, anxiety, and insomnia.[32] The pedometer app in smart phones is an acceptable and feasible instrument to improve physical activity (walking) in medical students. We observed a significant improvement in depression, anxiety, and insomnia among students of pedometer group at the end of the second month. Limited studies have been conducted among students to check the effect of pedometer walking on psychological traits. A study conducted in postmenopausal women to assess the effect pedometer walk on depression, anxiety, and insomnia found results similar to our study.[12]

Physical activities directly affect psychological symptoms (depression, anxiety, and insomnia) in medical students. In our study, students of the active subgroup had better improvement in psychological symptoms. A strong correlation was observed between increased step counts and improvement in scores of BDI, BAI, and sleep Likert scale. At the end of the 2nd month of the study, students increased their step counts, and it was observed that this led to improvement in scores of depression, anxiety, and insomnia.

The pedometer provided a practical and objective measure of physical activity and simultaneously provided possible beneficial psychological impact in the students on positive improvement. One of the limitations of this study is that it was not a blinded study it cannot be blinded by its nature) and there is a risk of conscious and unconscious bias. The intervention group quite likely understands what the aim of the study is, based on the questionnaires given to them, and this may bias their responses. Another limitation is that it was a single center study with limited generalizability. The present study was conducted among 2nd-year students only and they had a rather high baseline level of mental health disorders.

Distress among medical students may influence the development of students. Therefore there is a need to improve this condition by introducing physical activities among medical students. Pedometer based walking was found to have a significant effect on depression, anxiety and insomnia among medical students. Walking training programmes (using pedometer) may be considered for medical students in colleges. Longer follow-up studies are required to assess the correlation between increased step counts and mental symptoms.

Financial support and sponsorship

This study was conducted with funding from an ICMR-short term studentship

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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