SYNOPSIS

Research Title:
Factors leading to increase in aggression at campus in undergraduate medical
students of University College of Medicine, University of Lahore.

Supervisor

● Dr. Wardah Kafeel

Participants

● Javeria Usman ( Leader )

● Ch Ahmad Shahid
● Zain Ali
● Tooba Aslam
● Muhammad Abdullah
● Sara Khalil
● Dua Aziz
● Muhammad Waqas Nadeem
● Umama Hani
● Rabia Sarfraz
● Muhammad Nauman Zahid
● Fakhar Un Nisa Safdar
● Muhammad Adnan

Session 2018-2023
 Department of Community Medicine
University College of Medicine and Dentistry
Lahore

1. INTRODUCTION

Human aggression has newly been defined as "any behavior leveled at another
person that is carried out with the immediate motive to inflict harm" (1). The different
levels of aggression are physical, verbal, anger, and hostile.(2) Aggressive behavior
or aggression can exist at different levels ranging from just having a thought to hurt
another person’s feelings, abusing, pushing, and even killing.

Aggression is observed in medical students on a daily basis especially at campus.

Aggression at campus is usually observed at micro level. Medical students are
usually under pressure due to their study stress, competition among peers,(3) and a
difficult grading system. Moreover interpersonal conflicts, minority background and
gender biasness are also proven to be contributing factor.(3)

Aggression is not only limited to daily basis outcomes, rather it has long-lasting
outcomes. It is proven that students with high aggressive behaviors tend to have
low skill set in their respective field.(4) This eventually will affect the patients seen
by the future doctor, as well their career success

A study conducted on university students in Kermanshah University of Medical

Sciences in the western Iran determined the Prevalence and socio-demographic
factors of aggression among medical college students. About 11.6%, 1.2% and 7.7
% of the respondents had a history of cigarette smoking, opium use, and alcohol
drinking respectively. 15.3% of the participants were found to be aggressive. It was
shown that socio-demographic features, marital status, and smoking were the most
significant prognostic factors for aggression among participants.(5)

In another study the damage caused by excessive negative aggression in

adolescents and adults, included physical injury, psychological and emotional
trauma, and financial costs. The consequences for the perpetrator of aggression
included financial loss, imprisonment and execution.(6)
 Although much work has been done on aggression and the factors that lead to it
among different age groups, there is a lack of identification of factors of aggression
among medical students particularly in our country.

Therefore, our study aims to highlight the factors that trigger aggression among
medical students at campus. A better understanding of the factors precipitating
aggression among medical students is essential for learning how to address these
factors and produce socially and mentally healthy doctors.

2. LITERATURE REVIEW:
 Account Title Objective Study Sample Results Conclusi
Design Size ons

1 Linking Emotional The aim of Research sample of The Principal

Intelligence, this was 932 findings findings
Physical Activity and research is conducted students highlight showed
Aggression among to analyze following a from the how how
Undergraduates the descriptive, universities emotional physical
relationship cross- of Almeria, intelligence activity and
Yr of Publication: 26 established sectional, Cádiz, and EI help
November 2021 between and non- Córdoba, physical reduce
emotional experiment Granada, activity aggressive
Author name: intelligence al design Huelva, practice behaviors.
using Jaen, decrease it was
José Luis Ubago-
TMMS-24, Malaga, violent found that
Jiménez
physical and Sevilla behavior in the higher
https://www.mdpi.co activity, (Spain) university the
m/1378106 using IPAQ, using students. In physical
and convenienc addition, activity
aggression e sampling men tend intensity,
behaviors in to have the lower
university more the
students aggressive aggressive
behaviors ness
than indexes.
women, as
well as the
relation
between
physical
activity and
emotional
intelligence
is stronger
in all its
dimensions
.
2 Violent Video Some The survey This study We found This study
Games and scholars came in the sampled a that thus
Aggression Among claim that form of QR total of increased provides
Young Adults: The VVG codes, 3,219 exposure to strong
Moderating Effects promotes URLs with young VVG is support for
of Adverse aggression, few hard adults associated the
Environmental reduces copies for between with frequently
Factors. empathy, some cafés the ages of reduced debated
increases in Ghana. 18 and 35 empathy adverse
Yr. of Publication: 11 self-injury, Descriptive years from concerns, effects of
Jan, 2021. and Study. China and aggression- playing
externalizati Ghana. related VVG
Author name: Prince on, whereas thoughts, among
Clement Addo others claim and young
that a increased adults with
https://www.liebertpu minimal or, aggressive a particular
b.com/doi/full/10.108 in some behavior. reference
9/cyber.2020.0018 cases, no to
traits as environmen
reported by tal factors
the former is and will
associated hence aid
with playing in
VVGs. communica
ting a more
representat
ive
viewpoint
on the
effects of
VVG.
3 The Epidemiology of This survey Cross 10,957 The overall A majority
Aggression and was Sectional participants mean (SD) of the
Associated Factors conducted Study from 23 out score of population
among Iranian Adult to determine of 31 aggression has some
Population: A the level of provinces was 77.10 degree of
National Survey aggression (22.53). aggression.
among the Based on Aggression
Yr. of Publication: 25 Iranian adult the severity is a
Nov, 20220 population of multifactori
and aggression, al behavior
underlying the correspondi
Author name: predisposing participants ng with
Jalal Poorolajal factors. were several
categorized demograph
https://www.ncbi.nlm into four ical, social,
.nih.gov/pmc/articles groups as cultural,
/PMC8695783/ follows: and
2,464 religious
(23.1%) factors,
nonaggress some of
ive, 4,692 which back
(43.9%) to early
mild, 3,071 childhood
(28.8%) events.
moderate,
and 454
(4.2%)
severe
aggressive.
4 Sleep pattern, A perception Cross 739 Only 56.2% Around
aggressive behavior of having sectional students of of the two-fifth of
and substance use been study Class VII students the
among school mistreated and VIII in had adolescent
students of Manipur: in medical both adequate s were not
A cross-sectional school is governmen sleep. The getting
study. related to t and proportion enough
students' private of sleep. The
Yr. of publication: career schools in adolescent association
Jul-sep 2019 choices, a Impala s using between
finding that West and alcohol, aggressive
Author name: may be Kangpokpi tobacco, behavior
Markordor Lyngdoh useful to districts of cigarettes, and
medical Manipur and Ganja substance
https://pubmed.ncbi. school between was 4.6%, use was
nlm.nih.gov/3155285 administrato August 27 9.5%, found but
5/ rs/faculty and 5.7%, and needs
and September 1.6%, further
students as 25, 2017 respectivel investigatio
mistreatmen y. n for its
t is Aggressive temporal
addressed behavior relationship
in program was shown .
planning, by 35.3%.
counseling, Male
and faculty students
recruitment. were
getting
more sleep,
were more
aggressive,
and were
using
tobacco
and
cigarettes
more than
female
students.
5 An exploratory study This study The Out of 545 The Micro
on micro reports the authors students at response aggression
aggressions in prevalence used UFCOM,35 rate was s are
medical school: and simple 1 agreed to 64%. Fifty- prevalent
What are they and understandi statistics participate four on a day-
why should we ng of and chi-test percent to-day
care? macroaggre to analyze reported basis
ssions the experiencin among
Yr. of Publication :8 among demograph g micro medical
June 2019 medical ic data and aggression students
students at an s, of those with female
Author name: Andre the inductive the majority students
Espaillat University of thematic were from a
Florida qualitative female minority
College of analysis students background
https://pubmed.ncbi. Medicine was 73% as well as
nlm.nih.gov/3116147 (UFCOM), performed compared white
9/ while on the with 51% female
gaining open- among students
insights into ended male experiencin
experiences responses students; g more
of medical to study for female micro
students medical students aggression
dealing with students. from s. Further
micro minority research is
aggressions. background needed to
s this was explore
68% and intervention
for white s to counter
female micro
students aggression
76%. Micro s in order
aggression to ensure a
s are more healthy
common in learning
the second environmen
year of t.
medical
school
(30%),
followed by
the third
year (23%).
6 Association of To explore 1024 Stratified The AQ The lower
aggressive behavior the questionnai random score and the
with separation from relationship res were sampling other factor frequency
parents and social between solved by was used scores of parental
anxiety in grade four separation students to collect were higher contact, the
to six of rural senior from parents 1126 in boy longer time
primary school and social students of students. to work and
students in Anhui anxiety with the fourth, The the higher
Province in 2014. aggressive fifth and children the social
behaviors, sixth grade whose anxiety
Yr. of publication: to provide from three parents go score of
march 2018 scientific primary out one children,
basis for the schools in year ago, the more
Author name: Qin prevention Dangshan whose serious the
Zhang of County and parents attack
aggression. two primary don't go behavior of
schools in home in left-behind
https://pubmed.ncbi. Guzhen one year, children.
nlm.nih.gov/2990327 County. and who
0/ hardly
contact
parents,
these
children'
AQ score
and each
factor
points are
the highest.
The
frequency
of parent-
child links
and
children's
social
society
influences
the
aggressive
behavior of
students (P
< 0. 05).
7 Factors Affecting The study A The Aggression Findings
Aggression in South was descriptive participants had indicate
Korean Middle undertaken study was were 340 significant that
School Students. to assess conducted girls and correlations depression,
levels of using self- boys from with academic
Yr. of Publication: aggression, report two middle academic stress, and
Dec 2014 and to questionnai schools stress, grade
determine res and 302 depression, (second
Author name: factors questionnai self- grade)
MiJeongParkPhD, affecting res were esteem, influence
RN aggression used for decision- aggression.
among the final making Additionally
https://www.science South data competenc ,
direct.com/science/a Korean analysis. y, and developme
rticle/pii/S19761317 middle happiness. nt of
14000723#bib2 school Mean score positive
students. for factors
aggression such as
was 2.49 self-
out of 5. esteem,
Significant decision-
explanatory making
variables skills, and
for happiness
aggression in middle
were school
grade, students is
academic important
stress, and to reduce
depression. aggression.
The
explanatory
power of
these
factors was
26.9%, and
this was
statistically
significant
8 Bullying among This survey A cross- group of Results Bullying
medical students in aims to sectional 542 clinical revealed among
a Saudi medical ascertain questionnai years' that more Saudi
school. the extent of re survey medical than one medical
bulling and was students in quarter students is
Yr. of publication: 2 sexual conducted a Saudi (28.0%) of an existing
July 2012 harassment medical the problem. A
among school surveyed policy
Author name: students in a students against
Hasan Ali Alzahrani Saudi reported bullying
medical exposure to and
https://pubmed.ncbi. school. some sort harassment
nlm.nih.gov/2274807 of bullying should be
4/ during their adopted in
clinical all medical
studies. colleges to
Ninety monitor this
percent of phenomen
the on and
reported support
insults students
were who have
verbal, 6% been
sexual and bullied.
4%
physical.
Males were
more
exposed
but the
difference
was not
statistically
significant.
9 Student The purpose Using Not clearly At medical A
mistreatment in of this study Association mentioned schools perception
medical school and was to of where of having
planning a career in determine American relatively been
academic medicine. whether a Medical high mistreated
perception Colleges' percentage in medical
Yr. of publication: of having 2000-2004 s of school is
Jul-sep 2011 been Medical graduating related to
mistreated School seniors students'
Author name: Mark in medical Graduation were career
G Haviland school had Questionna planning choices, a
an ire data, we academic finding that
https://pubmed.ncbi. association evaluated careers, may be
nlm.nih.gov/2174505 with the students useful to
7/ planning a relationship reporting medical
full-time between mistreatme school
career in students' nt administrat
academic mistreatme experience ors / faculty
medicine. nt s were less and
experience likely at students as
and their graduation mistreatme
career to be nt is
choice planning addressed
careers in in program
academic planning,
medicine. counseling,
and faculty
recruitment
.
1 Family conflict and the present Questions 50 children The study The
0 childhood study asked by aged 7 to proposed hypothesis
aggression: the role examined their 13 years. that family was
of child anxiety. the role of parents via conflict partially
anxiety in interviews would be supported
Yr. of publication: moderating and positively as family
Nov 2010 the Questionna related to conflict was
relationship ires. aggression related to
Author name: Akiho between in the increased
Tanaka family context of proactive
conflict and higher but not
https://pubmed.ncbi. childhood levels of reactive
nlm.nih.gov/2004071 aggression child aggression
0/ anxiety. in children
Parents with high
completed levels of
self-report anxiety.
instruments Implication
examining s of these
family findings are
conflict and discussed.
aggressive
behavior
exhibited
by their
children.
Children
completed
a self-
report
measure of
anxiety.
1 Sex Differences in They cover Compariso Males and Findings Anger
1 Aggression in Real- self-reports, n Study females at are related showed no
World Settings: A observations all ages to sexual sex
Meta-Analytic , peer sampled. selection differences.
Review reports, and Not more theory and Higher
teacher clearly social role female
Yr. of Publication:
reports of mentioned . theory. indirect
1 Dec, 2004
overall Physical aggression
Author name: direct, aggression was limited
John Archer physical, was more to later
verbal, and common in childhood
indirect males and and
https://journals.sage forms of females at adolescenc
pub.com/doi/10.103 aggression, all ages e and
7/1089-2680.8.4.291 as well as sampled. varied with
trait anger. method of
measurem
ent. The
overall
pattern
indicated
males’
greater use
of costly
methods of
aggression
rather than
a threshold
difference
in anger.
3. RESEARCH QUESTION:

What are the factors leading to Aggressiveness among Medical students in University
College of Medicine, University of Lahore?

4. RESEARCH OBJECTIVES:
● To assess the factors affecting aggression among undergraduate students of
UCM
● How to address the factors that are leading to aggression?

5. MATERIALS AND METHODS:

(1) Study type: Descriptive Cross Sectional Study

(2) Study setting: University College of Medicine (UCM), The University of Lahore
(UOL)

(3) Duration of Study: 6-8 month

(4) Sampling Technique:

▪ Phase 1: Stratified Random Sampling
▪ Phase 2: Non-probability purposive sampling

(5) Sample size: Sample size calculated is 385 with 50% prevalence and 5% margin
of error.

(6) Sample selection:

▪ Inclusion criteria
▪ First Year to Final Year MBBS students of University College of
Medicine, UOL
 ▪ Exclusion criteria
▪ Students that are active smokers.
▪ Students diagnosed with any mental disorder.

6. DATA COLLECTION TOOL

● Phase 1: Buss-Perry Aggression Questionnaire (7)

● Phase 2: Self-administered Questionnaire

7. DATA COLLECTION PROCEDURE

A written consent will be taken from the study participants. In phase one Data will be
collected through a pre designed and pre tested aggression scale questionnaire; Buss
Perry Aggression scale using stratified random sampling. Two strata will be made, 1 st on
the bases of their MBBS class and second on their gender. Data will be collected
depending on their respective representation in each strata. i.e. sample size will be
divided into 5 classes first and from each class data will be collected from both genders
according to their percentage in each class. In phase 2, Participants with positive
aggression score will be given a self-designed questionnaire. The Questionnaire is
developed after a thorough literature review. The Questionnaire contains questions to
collect socio-demographic information of the participants and data regarding the factors
contributing to aggression, and it will be pilot tested on 35 MBBS students. The
questionnaire will require approximately 15 minutes to be filled. The data will be collected
over a period of one week.

8. DATA ANALYSIS PROCEDURE

The data collected will be analyzed using SPSS (Statistical Package for Social
Sciences, version 25). The results will be presented using frequencies, percentages and
tables.

9. OPERATIONAL DEFINITION:
Aggression:
Any behavior leveled at another person that is carried out with the immediate
motive to inflict harm" ranging from just having a thought to hurt another person’s
feelings, abusing, pushing, and even killing.
The different types of aggression are physical aggression, verbal aggression, anger
and hostile aggression.

7. ETHICAL CONSIDERATIONS:

● The study will be reviewed by the Ethical Committee of UCMD-UOL, Lahore.

● All participants will sign a written informed consent and the information gathered
will be kept confidential.

● Voluntary participation will be encouraged.

● The participants will be made aware of the option to decline or withdrawal at any
time.

● Participants will remain anonymous.

● Privacy of participants will be ensured.

9. WORK PLAN

TASK START DATE DAYS TO COMPLETE

Literature Review 10-Oct-22 10

Proposal Making 20-Oct-22 20

Ethical Approval 30-Nov-22 30

 Data Collection 20-Feb-22 60

Data Processing 15-Mar-23 20

Data Analysis 20-Mar-23 20

Report Writing 30-March-23 15

Review 5-April-23 15

Consent form:
This is Group B of Batch 2, Fourth year M.B.B.S student of University College of
Medicine and Dentistry, University of Lahore. As a part of our Research Clerkship
module, we are conducting this research. We are inviting you to participate in our
study. The purpose of this study is to assess the “Factors leading to aggression
among the Medical Students in University College of Medicine, University of
Lahore”. All information obtained in this study will be kept strictly confidential
and entry into the computer will be anonymous. The results of this study will be
presented collectively and no individual participant will be identified without their
permission. In case the study results are published, participant name will not
appear on any publication or reports. There will be no financial help provided to
the participants for participation in study. There are no direct personal benefits
from your participation in the study. However, your participation will help us
identify and address the factors causing aggression among medical students.

I _____________________________ S/O or D/O _________________________

have been informed about the details of this study. I have gone through the
contents of the consent form. I understand that the data will be kept confidential
and will only be used for research outcomes. I will not be paid for my
participation. I may withdraw and discontinue at any time without penalty. It will
take approximately 10 to 15 minutes. All my queries regarding this study are
answered to satisfaction, and I voluntarily agree to participate in this study. I am
giving my consent to participate in this research.

10. REFERENCES
(1) Allen JJ, Anderson CA. Aggression and Violence: Definitions and Distinctions. In:
The Wiley Handbook of Violence and Aggression [Internet]. Chichester, UK: John
Wiley & Sons, Ltd; 2017. p. 1–14. Available
from:https://onlinelibrary.wiley.com/doi/10.1002/9781119057574.whbva001

(2) Website [Internet]. Available from: IJSER © 2016 http://www.ijser.org

(3) Espaillat A, Panna DK, Goede DL, Gurka MJ, Novak MA, Zaidi Z. An exploratory
study on microaggressions in medical school: What are they and why should we
care? Perspect Med Educ. 2019 Jun 3;8(3):143–51.

(4) Orpinas P, Raczynski K, Hsieh HL, Nahapetyan L, Horne AM. Longitudinal

Examination of Aggression and Study Skills From Middle to High School:
Implications for Dropout Prevention. J Sch Health. 2018 Mar;88(3):246–52.

(5) Moradi M. Epidemiology of Drug Abuse and Drug Dependence in Individuals Visiting
Drug Abuse Treatment Centers in Kermanshah Province in 20 [Internet]. [cited 2022
Oct 15]. Available from:
https://scholar.googleusercontent.com/scholar?q=cache:6XGpJpDQT7IJ:scholar.go
ogle.com/+prevalence+aggression+among+medical+student&hl=en&as_sdt=0,5

(6) Liu J. Concept analysis: aggression. Issues Ment Health Nurs. 2004 Oct;25(7):693–
714.
(7) Buss AH, Perry M. The aggression questionnaire. J Pers Soc Psychol. 1992
Sep;63(3):452–9.

(8) Ubago-Jiménez JL, Cepero-González M, Martínez-Martínez A, Chacón-Borrego F.

Linking Emotional Intelligence, Physical Activity and Aggression among

Undergraduates. International Journal of Environmental Research and Public

Health. 2021 Nov 26;18(23):12477.

(9) Addo PC, Fang J, Kulbo NB, Gumah B, Dagadu JC, Li L. Violent Video Games and

Aggression Among Young Adults: The Moderating Effects of Adverse Environmental

Factors. Cyberpsychology, Behavior, and Social Networking. 2021 Jan 1;24(1):17–

23.

(10) Poorolajal J, Ebrahimi B, Rezapur-Shahkolai F, Doosti-Irani A, Alizadeh M,

Ahmadpoor J, et al. The Epidemiology of Aggression and Associated Factors among

Iranian Adult Population: A National Survey. Journal of Research in Health

Sciences.

(11) Akoijam B, Lyngdoh M, S. Agui R, Sonarjit Singh K. Sleep pattern, aggressive

behavior and substance use among school students of Manipur: A cross-sectional

study. Indian Journal of Public Health. 2019;63(3):239.

(12) Espaillat A, Panna DK, Goede DL, Gurka MJ, Novak MA, Zaidi Z. An exploratory

study on microaggressions in medical school: What are they and why should we

care? Perspectives on Medical Education. 2019 Jun;8(3):143–51.

(13) Zhang Q, Meng Y, Wu L, Yao R, Fu L. [Association of aggressive behavior with

separation from parents and social anxiety in grade four to six of rural senior primary

school students in Anhui Province in 2014]. Wei Sheng Yan Jiu = Journal of Hygiene

Research [Internet]. 2018 Mar 1;47(2):206–17.

(14) Park M, Choi J, Lim S-J. Factors Affecting Aggression in South Korean Middle

School Students. Asian Nursing Research. 2014 Dec;8(4):247–53.

(15) Alzahrani HA. Bullying among medical students in a Saudi medical school. BMC

Research Notes. 2012 Jul 2;5(1).

(16) Haviland MG, Yamagata H, Werner LS, Zhang K, Dial TH, Sonne JL. Student

Mistreatment in Medical School and Planning a Career in Academic Medicine.

Teaching and Learning in Medicine. 2011 Jul;23(3):231–7.

(17) Tanaka A, Raishevich N, Scarpa A. Family Conflict and Childhood Aggression:

The Role of Child Anxiety. Journal of Interpersonal Violence. 2009 Dec

29;25(11):2127–43.

(18) Archer J. Sex Differences in Aggression in Real-World Settings: A Meta-Analytic

Review. Review of General Psychology. 2004;8(4):291–322.

QUESTIONNAIRE: Form Number: ______

Section 1: Socio-demographic Characteristics

1: Student Name: (Optional) ___________________

2: Age (years): ______________

3: Gender: Male Female

4: Year of MBBS:

5: Hostel lite / Day Scholar

 Section 2: Factors leading to increase in aggression at campus
(Please tick the option/s where applicable)

1. Do you feel stressed by being a medical student?

a. Yes
b. No

If YES, which of these lead to an increase in your stress?

a) Grading system
b) Competition
c) Attendance
d) Frequent Assessments

2. Have you ever experienced any kind of bullying at campus?

a. Yes
b. No

If YES, what was your response?

a. Reacted
b. Did not react

3. Does the political instability of our country affect your mood?

a. Yes
b. No

If YES, how?

----------------------------------------------------------------------------

4. Have you ever faced discrimination due to caste/sect?

a. Yes
 b. No

If YES, did it lead to any fight or conflict?

a. Yes
b. No

5. Have you ever been/are in a relationship?

a. Yes
b. No
If YES, how does it affect your mood on daily basis?

a) No impact
b) Happy
c) Angry
d) Depressed

6. What do you like to do in your free time?

----------------------------------------------------------------------

7. Do you like to watch movies?

a. Yes
b. No
If YES, which genre do you prefer?
a) Horror
b) Action
c) Comedy
d) Drama
e) Other specify ------

8. What is your average screen time?

a. 0-3 hours
b. 3-6 hours
c. 6-9 hours
d. >9 hours
 9. Which social media application do you use the most?

-------------------------------------------------------------------------------
10. Do you drive to campus?
a. Yes
b. No

If yes, have you ever been involved in a roadside clash?

a. Yes
b. No

11. Do you think your friend’s circle is getting smaller gradually?

a. Yes
b. No

12. What kind of relationship does your parents have with each
Other?
a. Living together and happy
b. Living together but unhappy
c. Separated / Divorced