Symptoms and Health Complaints and Their Association with Perceived Stressors among Students at Nine Libyan Universities

University students are exposed to many stressors. We assessed the associations between two stressors (educational related and general overall), socio-demographic characteristics (five variables), health behaviours/lifestyle factors (six variables), as well as religiosity and quality of life as independent variables, with self-reported symptoms/health complaints as dependent variables (eight health complaints). A sample of 2100 undergraduate students from nine institutions (six universities, three colleges) located in seven cities in Libya completed a general health questionnaire. The most prevalent symptoms were headaches, depressive mood, difficulties to concentrate and sleep disorder/insomnia that have been reported by 50%–60% of the students. The majority of students (62%) reported having had three or more symptoms sometimes or very often in the last 12 months. There was a positive association between perceived stressors and health symptoms, which remained significant after adjustment for gender and many other relevant factors for headache (OR 1.52; 95% CI 1.15–2.02), depressive mood (OR 2.20; 95% CI 1.64–2.94) and sleep disorder/ insomnia (OR 1.55, 95% CI 1.19–2.03). Other factors independently associated with most health symptoms were female gender and poor self-perceived health. Stress management programmes and a reduction of educational related stressors might help to prevent stress-related symptoms and health complaints in this student population.

The stressors that students face and the accompanying health symptoms are an increasing problem that adversely affect their health. We investigated two types of stressors: college-related stressors; and general life stressors [19]. Better understanding of students' symptoms (health complaints) and (educational or general) stressors and their frequencies, along with the associations between health complaints and students' demographics and health behaviours, and the associations between individual symptoms and stressors are important to tailor effective interventions. Few studies of stressors and associated symptoms of university students have been conducted in some Eastern Mediterranean countries, and no such research has been implemented in Libya. Given this scarcity, together with challenges/ barriers imposed by the previous political regime in terms of accessing universities within Libya, such young adult college populations are hard-to-reach. The current research bridges these knowledge gaps, attaching high significance to the study' contributions and findings.

Aim of the Study
This cross-sectional survey of a representative sample of undergraduate students across nine Libyan universities/ colleges (2008)(2009) assessed the frequencies of self-reported students' symptoms (eight health complaints) and two stressors (educational related and general overall). We also examined the associations between the health complaints and students' socio-demographics (five variables-age, marital status, year of study, living arrangement during semester, income sufficiency) and health behaviours/lifestyle features (six variables-smoking, illicit drug/s, alcohol, subjective health, health awareness, BMI), as well as religiosity and quality of life. The study also explored the associations between the four most prevalent symptoms and stressors. The four specific objectives were to:  Describe the sample's general characteristics;  Assess the prevalence of eight symptoms, and the number of symptoms reported in the last 12 months;  Assess the association between the frequency of the four most prevalent symptoms and students' demographic characteristics and health behaviours; and  Explore the frequency of symptoms by extent of perceived stressors (burdens); and the association between the four most prevalent symptoms and perceived stressors while controlling for all other symptom groups.

Sample, Data Collection and Ethics
The study was approved by research/ethics committees at the participating institutions. A representative sample of students was sought at the universities by selecting courses that represented the different departments/faculties. Questionnaires (self-administered) were distributed to students attending the selected sessions, and collected after completion. Participation was voluntary and anonymous, and data were confidential and protected. All data were computer-entered by the second author for quality assurance. The questionnaire was provided to 2100 students, and 1567 completed questionnaires were returned (response rate ≈ 74.6%), of which 267 questionnaires were excluded (missing data), leaving 1300 questionnaires for analysis (439 males, 33.8%; 861 females, 66.2%; M age 20.9 years, SD 2.4). Nine institutions (six universities, three colleges) in seven cities (Misurata, Sabha, Zawea, Sirt, Al Bida, Benghazi, Tripoli) participated, thus the sample was representative of Libyan higher education institutions and of many scientific/academic disciplines: e.g., Agriculture, Business, Education, Law, Mechanical Engineering, Medical Science, Medical Technology, and others. In Libya (academic year 2010/2011), more than 90% of the university students were enrolled in public universities (59% females). Thus the current study included most public universities in order to ensure representativeness of the study sample to the greater population of university students in Libya. In addition, geographically, the universities that were included in the study were situated across Libya, in the north, west, east and south, also ensuring representativeness of the study sample.
Generally in Libya, Higher Education is completely financed by the state, except for private universities. All high school students have the access to higher education institutions. Every year, the Cabinet determines the regulations for students' admission to higher education institutions by considering the results of the "Secondary School Leaving Certificate", the needs of society, and institutions' capacities. Students' fees are very small; students pay only registration fees at the beginning of the academic year or semester. In terms of the economic situation, until recently Libya was classified as a high-income country, but has lately moved to low-income country status.
Perceived Stressors (burdens) (two items): one item focused on students' educational/university related burdens (course work, exams): "To what extent do you feel burdened in the following areas?".
Living arrangements during semester time: "Where do you live (during university/college term time)?" with two options based on whether the participant was living with parents or not.
Illicit drug/s use: "Have you ever use/used drugs?" ("Yes, regularly", "Yes, but only a few times", "Never"), recoded into two options based on whether the participant ever used illicit drug/s or not [24].
Alcohol consumption frequency: "Over the past three months how often have you drunk alcohol, e.g., beer?" (six options: "never", "once a week or less", "once a week", "a few times each week", "every day", and "a few times each day").
Importance of religion/personal faith (religiosity: "My religion is very important for my life?" (1= "strongly disagree", 5= "strongly agree"), recoded into two options based on whether the participant agreed or not.
Income sufficiency (subjective economic situation): how sufficient students considered the amount of money they have at their disposal (4-point scale: "always sufficient", "mostly sufficient", "mostly insufficient", "always insufficient").
Quality of one's life: "If you consider the quality of your life: How did things go for you in the last four weeks?" (1 = "very badly", 5 = "very well") [33], later recoded into three categories.

Statistical Analysis
The Statistical Package SPSS v19.0 was used for the statistical analyses (p set at <0.05). For descriptive analyses, categorical data were expressed as frequencies and percentages, and score data presented as means and standard deviations. Chi-Square tests compared the categorical variables between males and females. For each symptom, two-sample t-test or ANOVA compared the mean levels of symptoms across variables of interest (e.g., year of study, age, marital status etc.). We employed Bonferroni adjustment for multiple testing for the statistical comparisons (p-value set at p ≤ 0.001). Linear regression assessed the association between increasing levels of feeling burdened overall and increasing frequency of symptoms (p set at <0.05). Multifactorial logistic regression analysed the relationship between general stressor (feeling burdened overall strongly/very strongly), other students' general characteristics as independent variables, and each of the four most prevalent symptoms, each as a dependent variable. Only the variables significant in initial bivariate tests were included in the final model. Odds ratios were adjusted for all variables in the models.

General Characteristics
The sample comprised 66% females, 65% were 20-24 years old, 97% not married, 82% living with their parents, and 98% reported that religion was of high importance in their life, while 73% regarded their income as mostly or always sufficient (Table 1). Most respondents (80%) watched their health to some extent or very much (health awareness), 53% perceived their health as very good or excellent, 59% rated their quality of life as quite well or very well, but 28% were overweight or obese based on their BMI. There was a low proportion of smokers (9%), those who had ever used illicit drug/s (2%) or reported occasional/daily alcohol (3%) use. More than half (56%) the sample felt strongly/very strongly burdened by exams, and one quarter felt strongly/ very strongly burdened overall. Compared with males, female students were younger, more often married, had more often insufficient income, were enrolled in higher years study, lived more often with parents, consumed alcohol or other illict drug/s less frequently, were less often overweight or obese, and felt more burdened by exams.

Prevalence and Number of Symptoms in Last 12 Months
About 50%-60% of the sample had headaches, depressive mood, difficulties to concentrate or sleep disorder/insomnia sometimes/very often during the last year ( Table 2). The prevalence of these four symptoms was highest, followed by back pain and shoulder and neck pain. Less than one third of students had circulatory problems or stomach trouble/heartburn sometimes or very often. All percentages are row percentages rounded to one decimal point. Table 3 depicts the proportion of students with no symptoms, 1-2 or 3 or more symptoms. A majority of students (62%) and significantly more females than males reported having had ≥3 symptoms, while only 8% had no symptom (sometimes or very often) during the last year.  Table 4 depicts the frequency of the four most prevalent symptoms expressed as mean rating (1 = "never", 4 = "very often") by students' general characteristics and health behaviours. After Bonferroni adjustment, some associations were significant. Participants perceiving their health as fair/poor, those who were strongly/very strongly burdened by exams, and those who were strongly/very strongly burdened overall had consistently significantly higher ratings across all the four most prevalent symptoms when compared with those reporting very good/excellent health or feeling less burdened.   Across all four symptoms (except for difficulties to concentrate), females had higher ratings of complaints than males. For quality of life, those feeling bad/very bad quality of life had consistently significantly higher ratings of symptoms (except for headache). Students who watched their health not much/not at all (lower health awareness) had significantly higher ratings of depressive mood and difficulties to concentrate.

Frequency of Symptoms by General Characteristics
Students reported increasing frequency of insomnia with older age, and increasing frequency of depressive mood and insomnia with higher year of study. Those with insufficient income had significantly higher difficulties to concentrate than students who had always/ mostly sufficient income. The associations between symptoms and all the remaining variables did not reach statistical significance (according to the Bonferroni adjusted level of p = 0.001). Table 5 shows the frequency of the four most prevalent symptoms expressed as mean rating (from 1= "never", 4 = "very often") by increasing level of feeling generally burdened overall (6-point Likert scale from "not at all" to "very much"). A significant linear regression between the frequency of symptoms and the level of feeling burdened overall was observed for all four symptoms, but the regression coefficient was highest for depressive mood. Figure 1 depicts a positive relationship of increasing frequency of symptoms with increasing levels of feeling generally burdened overall. Table 5. Mean frequency of symptoms by level of feeling burdened overall.  Symptoms measured on a four-point response scale (1 = "never"; 4 = "very often"); β coefficients and p-values based on linear regression. Figure. 1. Mean frequency of headache, insomnia, difficulties to concentrate and headache by level of feeling burdened overall. Table 6 shows the associations between feeling generally burdened overall (strongly/very strongly) and having experienced each of the four most prevalent symptoms sometimes or very often as Sleep disorder/Insomnia dependent variables while adjusting for a number of general characteristics. After adjustment, students feeling burdened strongly or very strongly were significantly more likely to suffer headache, depressive mood and sleeping disorder/insomnia, but not difficulty to concentrate. Across all symptoms, perceived (subjective) poor health was consistently associated with higher frequency of all four symptoms. Students who watched their health not much/not at all (lower health awareness) were more likely to report depressive mood. Better quality of life was associated with lower frequency of depressive mood. Females were more likely to have headache, depressive mood, and sleeping problems/insomnia than the males. Students were more likely to have difficulty to concentrate when their income was always/mostly insufficient. Older students had more sleep disorder/insomnia, and students in higher study year had more depressive mood.

Discussion
University students are subjected to stressors and they respond to it on daily basis. Researchers have also acknowledged the stressful nature of the students' roles and expectations [34]. The current study bridges the knowledge gaps to assess, across a representative sample of students at nine different universities in Libya, students' self-reported symptoms (health complaints) and (college-related and general) stressors, and their frequencies. We also scrutinized the associations between the health complaints and students' demographic characteristics and health behaviours, as well as the associations between each symptom and stressors adjusting for a number of other relevant factors. To the best of our knowledge, this is the first published in depth examination of such issues in Libya.
As for the study's first objective, there were more females, and the majority of students were single, living with their parents, and religion was of high importance in their lives. These features need to be considered within a range of issues of Libya's geopolitical situation, prevalent cultural norms, and prevailing religious Islamic faith. Across most Arabic Eastern Mediterranean countries generally, it is quite traditional for unmarried individuals/ students to live with their parents, particularly for females. Likewise, our finding of the high importance to religiosity needs to be viewed in the context that Libya is of predominantly Muslim faith, where it is customary to pray five times each day, and for public modesty, many/most women might wear loose traditional dress (abayas) covering the body and not revealing the silhouette, or at least a Hijab for their heads concealing the hair and neck. Similarly, the higher proportion of females in the Libyan sample reflects what seems to be a reality at higher education institutions globally, and is in agreement with the gender distributions of university student samples from other higher income countries e.g., England, Wales and Northern Ireland, Sweden, Ireland, Korea [27,[35][36][37], or lower income countries e.g., Colombia or Egypt [2,38]. We also agree with Iran, where across 300 students, 91% were single 71% lived in dormitories, 26% lived at home with their families and only 3% lived alone in rental properties [17].
In terms of objective two, our sample reported headaches (60.6%), difficulties to concentrate (56.8%), depressive mood (57.6%), sleep disorder/ insomnia (49.9%) as the four symptoms that most often occurred sometimes/very often in the last year. The other remaining symptoms appeared to various extents, and were reported as sometimes/ very often by about one third to one quarter of the students. The array of symptoms across our sample agrees with findings of students from seven European countries [29], where headache, back ache, and neck/shoulder pain were often reported complaints, suggesting a prevailing role of headache among self reported symptoms of college students. Our findings also agree with and are quite similar to levels of health complaints reported by students across seven universities in England, Northern Ireland and Wales, where symptoms that occurred sometimes/very often in the last year included headache (59.5%) and difficulties to concentrate (54.4%) [6]. The UK study [6] also reported back pain (43.3%) and neck/shoulder pain (39.4%), both of which were comparable to our Libyan sample (45.4% back pain; 37.5% neck/shoulder pain). However, the Libyan levels were lower than those of Egypt, where the health complaints that occurred sometimes/very often in the last year included difficulties to concentrate (78.1%), headache (77.9%), and sleep disorders (63.7%) [2]. It is unlikely that the higher health complaints levels in Egypt [2] than those in Libya were related to methodological issues, as the same research instrument was employed in both countries (although the symptoms list used in Libya had slightly less items). It remains speculative why the levels in Egypt were higher than in Libya, although both these eastern Mediterranean neighbouring countries share similarities (history, traditions, culture, religion and context), as well as contrasts. Other similarities between Libya and Egypt, as observed in Oman, is that most students in these Middle Eastern countries who join university leave their homes for the first time (loss of the traditional social support and supervision), cohabite with other students (peer relationships), and face alterations in the learning styles from what students were acquainted with at school [39]. Hence, it is unclear if these observed differences actually reflect real differences in the prevalence of complaints, or if specific cultural factors might contribute to higher "readiness" to report health complaints among Egyptian students compared to their Libyan peers.
As for the number of symptoms reported in the last year, ≈62% of the Libyan sample and significantly more females than males reported having had ≥3 symptoms, while only 8% had no symptom (sometimes/very often) during the last year. One might conclude that experiencing at least one health complaint can be considered as a normal condition in this population of young adults, a finding that is in line with research in Egypt [2].
In connection with objective three, females generally reported significantly higher frequency across all four symptoms, in agreement with the higher levels of health complaints among female university students [28,40]. In Jordan, there were statistical differences between male and female students regarding their perception and reactions to stressors [18]. Women might report higher levels of health problems because of reduced access to resources and social conditions of life that foster health, and because of the greater stressors associated with their gender and marital/societal roles [41]. Hamaideh et al. [18] suggested that, generally, in the Arab countries, including Jordan, women might be given a "lower status" than men, which, along with culturally derived expectations, often determines their perception of and reactions to stress. However, among students in Korea, there were no significant gender differences in gastrointestinal symptoms over the past three months [37], perhaps because the proportion of males in the Korean sample was low (<10% of the sample); and across students in Ireland, there was no association between gender and lower back pain [36].
In terms of the stressors/burdens (whether educational related and general overall), we found a positive significant relationship between each of the amount of perceived educational related and general overall stressors on the one hand, and all four most prevalent symptoms on the other. We agree with Saudi Arabia, where the most frequently occurring stressors among students were related to academic and psychological domains [42]; and a review of students' stress reported that the sources of stress (stressors) included educational environment factors and academic factors [11]. In support, at the level of adolescent students, studies have pointed out the links between examination related stressors and somatic complaints, e.g., gastrointestinal symptoms or physical pain in Sri Lanka or Taiwan [43,44]. These features raise two points: The first is that is that stressors could also have beneficial effects, and little research considered those stressors expected to improve students' well-being/educational process [45]. The second point is that it is useful for educators to debate ways to decrease the educational related stressors, where emphasis on formative versus summative assessments, elimination of quotas, problem-based learning, and reflective portfolios are some promising strategies [46,47].
As for the socio-demographic features, across our sample, females were associated with three of the four most prevalent symptoms, in contrast to other studies (discussed above). For age/year of study, our younger students had more sleep disorder/insomnia than their older colleagues. In Canada, the sources of stress in dental students and first-year residents varied according to their stage in the program and the period of the year [15]. It also seems that final year students (older) might have learnt ways to "harness" the stressors they encounter and turn them into positive actions for their w ell-being/educational process, as their long experience could had probably influenced the given stress responses compared to those students in the earlier stages of their studies [45]. For income sufficiency, we found a significant inverse relationship between income and difficulties to concentrate, (increasing income insufficiency was associated with more difficulties to concentrate), in agreement with others where the most frequently mentioned personal factors in countries where students support themselves financially were financial problems [13,48]. Specific stressors seem to differ in different parts of the world, where stressors e.g., related to fear of parents were more significant in India, whilst stressors related to students' financial situation were more significant in western countries [11].
As regards to health behaviours/lifestyle factors, for subjective health we found that compared to students with excellent health, those with good, fair or poor health were more likely to have higher levels of three of the four most prevalent symptoms. We agree with Jordan, where both male and female students with excellent/very good health reported lower stress levels [18]. It is noteworthy to note that in contrast to the UK where students with higher alcohol consumption were more likely to report symptoms [27], smoking, alcohol or illicit drug/s use did not play a relevant role among Libyan students due to its very low prevalence in this population.
Both health awareness and quality of life had an inverse significant relationship with depressive symptoms, but not with any other symptom. Poorer quality of life and a lower level of health consciousness/ awareness among depressed students have also been described in other countries [8].
As for objective four, our results showed that the positive association between feeling burdened with a higher frequency of symptoms remained significant for three out of the fours symptoms even when controlled for gender and self-perceived health. This agrees with other research showing that stress is an independent predictor for symptoms and health complaints among university students [2,3].
The study has limitations. One variable measured each of the college related stressors and general stressor (burdens) overall, when college related stressors are many (lack of practical relevance of studies, anonymity/isolation at university, bad job prospects, problems with peers, lack of time for studies), and general stressors are many (problems with parents, friends or significant other, housing, health problems). Due to respondent burden and the study being a general health survey, we were unable to explore each variable employing many items. The study is cross sectional, no cause-effect relationships can be deduced. Females were slightly over-represented (a reality at higher education institutions in many countries). Selection bias, as students with health problems would have been less probable attend at university during the data collection is possible. Self-reports estimated the symptoms (no objective validation was conducted). Nevertheless, no valid external measurement of health complaints exists since physicians' ratings also rely heavily on patients' descriptions. Future research could address these limitations. The study has notable strengths. The large sample size (and representativeness), and the relatively high response rate enabled the calculation of accurate estimates across students at many Libyan higher education institutions. We mobilized many students' demographic characteristics and health behaviour variables. No previous study had investigated in detail, the health complaints, and their associations with perceived stressors, and with students' demographic features and health behaviours at Libyan universities.

Conclusions
The study indicates that education related and general stress play an important role in the life's of students in Libya and that at the same time the fast majority of students is experiencing one or more health complaints. The strong relationship between perceived stressors and health complaints calls for preventive action. Stress management and relaxation programmes offered on campus may be an option to prevent stress-related symptoms. However, although it is important to help students cope with stress borne out of overall life circumstances, interventions by universities aimed at reducing the impact of academic stressors on students may also be of great importance.