Depression and stress among the first year medical students in university of medicine and pharmacy at hochiminh city, vietnam

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DEPRESSION AND STRESS AMONG THE FIRST YEAR MEDICAL STUDENTS IN UNVERSITY OF MEDICINE AND PHARMACY HOCHIMINH CITY, VIETNAM Ms. Quyen Dinh Do A Thesis Submitted in Partial fulfillment of the Requirements for the Degree of Master of Public Health Program in Health Systems Development College of Public Health Sciences, Chulalongkorn University Academic Year 2007 Copyright of Chulalongkorn University Thesis Title DEPRESSION AND STRESS AMONG THE FIRST YEAR MEDICAL STUDENTS IN UNIVERSITY OF MEDICINE AND PHARMACY AT HOCHIMINH CITY, VIETNAM By Quyen Dinh Do Field of Study Health Systems Development Thesis Advisor Associate Professor Prida Tasanapradit, M.D., M.Sc. Accepted by The College of Public Health Sciences, Chulalongkorn University, in Partial Fulfillment of the Requirement for the Master’s Degree …………….………………..Dean of College of Public Health Sciences (Professor Surasak Taneepanichsakul, M.D.) THESIS COMMITTEE ……………………………………………….Chairperson (Prathurng Hongsranagon, Ph.D.) ………………………………………………..Thesis Advisor (Associate Professor Prida Tasanapradit, M.D., M.Sc) ………………………………………………..External Member (Rasmon Kalayasiri,M.D.) iii PH: 072464 : MAJOR HEALTH SYSTEMS DEVELOPMENT KEY WORDS : CES-D/ DEPRESSION/ MEDICAL STUDENT STRESS QUYEN DINH DO: DEPRESSION AND STRESS AMONG THE FIRST YEAR MEDICAL STUDENTS IN UNIVERSITY OF MEDICINE AND PHARMACY AT HOCHIMINH CITY, VIETNAM. THESIS ADVISOR: ASSOCIATE PROFESSOR PRIDA TASANAPRADIT. M.D., 95 pp. Objectives: 1) to assess the prevalence of depression by using the Center for Epidemiologic studies depression scale (CES-D). 2) to determine sources of stress. 3) to find out the relationship between the main sources of stress, the general characteristics, potential personal consequences and depression among the first year Medical students in February, 2008. Methods: in cross-sectional descriptive study design, CES-D with cut-off point 22 and Students Stress Survey questions were used as self-administrated to 351 first year Medical students in Hochiminh city. Chi-squared test, Spearman correlation were analyzed in bivariate analysis, binary Logistic regression used in multivariate analysis. Results: the prevalence of depression was 39.6%. The top five of stress was prone intrapersonal factors, academic environment and environmental factors. Stress scores and depression scores had positive linear relationship with r = 0.272. There were significant different between depressive symptom group and ethnicity, type of accommodation, whom the students living with, exercise practice, perception of financial status, satisfaction of relationship with parents and friends. Working with un-acquainted people, decline in personal health, increased class workload, and put on hold for extended period of time as stressors were differentiated significantly with depressive group. Among those variables, quality of relationship, and stressors as decline in personal health, fight with friend and put on hold for long time increased the risk to get depression; in contrast, living with family, practice exercise, working with un-acquainted people reduced the risk of depression with p-value<0.05 in multivariate analysis. For further study, qualitative and quantitative as longitudinal study should be conducted to determine consequences of daily hassles, level of stress and its relationship with depression in duration of Medical learning as well as in different faculty for a broader picture about depression in Medical University in Vietnam. Field of Study Heath Systems Development Student’s signature Academic year 2007 Advisor’s signature iv ACKNOWLEDGEMENTS I would like to express my deep appreciation to Associate Professor Prida Tasanapradit, my thesis advisor, for his guidance and supervision throughout this study. His invaluable advices have motivated me on doing research. Most importantly, I am very grateful to Dr Ratana Somrongthong, for her encouragement and valuable suggestions that I was able to accomplish my study. I also would like to thank my committee members: Dr. Prathurng Hongsranagon, my Chairman and Dr. Rasmon Kalayasiri, my external thesis examiner, for providing me valuable suggestions and comments on my proposal and thesis as well. Special appreciations are extended to Dr. Robert Sedgwick Chapman, Arj. Piyalamporn Havanont and Arj. Venus Udomprasertgul, for their teaching, providing valuable knowledge and advice about Statistics and Epidemiology. My sincere gratefulness goes to all my teachers and staff of the College of Public Health Sciences, Chulalongkorn University for, their kindness and support for my study. Most of all, the deepest gratitude goes to my family for their love and care which have been a tremendous encouragement to me in my study. I also want to thank my friends, classmates, for being my friends and supporting me in their kindly and friendly way. Last but not the least; I am grateful to Thailand International Cooperation Agency – Colombo Plan scholarship for my study grant. v TABLE OF CONTENTS Page ABSTRACT...……..…...………………………………………………………………i ACKNOWLEDGEMENTS ..…………..……………………………………………ii TABLE OF CONTENT....……………..……………………………………………..v LIST OF TABLES.....………………..……………………………………………..viii LIST OF FIGURES ...……………..…………………………………………………x ABBREVIATIONS.....…………………………..…………………………………...xi CHAPTER I INTRODUCTION ...………………………………………………….1 . 1.1 Background ..................................................................................................1 1.2 Research questions.......................................................................................3 1.3 Study hypotheses .........................................................................................3 1.4 Objectives …………………………………………………………………3 1.4.1 General objectives............................................................................3 1.4.2 Specific objectives ...........................................................................4 1.5 Variables in this study..................................................................................4 1.6 Operational definition ..................................................................................5 1.7 Conceptual framework.................................................................................8 CHAPTER II LITERATURE REVIEW………………………………………...9 2.1 Stress and Students Stress survey questions ................................................9 2.2 Depression and CES-D ..............................................................................11 2.3 Review of related studies ...........................................................................14 2.4 Site of study ...............................................................................................22 vi Page CHAPTER III METHODOLOGY...………………………………………………24 3.1 Research design .........................................................................................24 3.2 Study population ........................................................................................24 3.3 Sample size ................................................................................................24 3.4 Sampling technique....................................................................................25 3.4.1 Inclusion criteria ............................................................................25 3.4.2 Exclusion criteria ...........................................................................25 3.5 Data collection tool ....................................................................................25 3.6 Data collection procedure ..........................................................................26 3.7 Data analysis ..............................................................................................26 3.8 Reliability and Validity..............................................................................28 3.9 Ethical consideration..................................................................................29 CHAPTER IV RESULTS.………….………………………………………………30 4.1 Description of General characteristics .......................................................30 4.2 Potential personal consequence factors .....................................................35 4. 3 Student stress factors.................................................................................38 4. 4 Prevalence of depression...........................................................................42 4.5 Relationship between depression and related factors ................................42 4.5.1 Relationship between depression and general characteristics .......43 4.5.2 Relationship between depression and potential personal consequence ...................................................................................47 4.5.3 Relationship between depression and student stress......................50 vii Page CHAPTER V DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS…………………………………………...63 5.1 Discussion ..................................................................................................63 5.2 Conclusions................................................................................................70 5.3 Recommendations......................................................................................72 REFERENCES ……………………………………………………………………..74 APPENDICES ………….…………………………………………………………..79 APPENDIX A: The relationship between depression and related factors …..80 APPENDIX B: CES-D Reliability Statistics ………………………………...81 APPENDIX C: Questionnaire (English version) ……………………………82 APPENDIX D: Questionnaire (Vietnamese version) ……………………….87 APPENDIX E: Schedule Activities …………………………………………93 APPENDIX F: Administration Cost ………………………………………...94 CIRRICULUM VITAE ……………………………………………………………95 viii LIST OF TABLE Page Table 1: University of Medicine and Pharmacy ..........................................................23 Table 2: Variables, measurement scale and statistic inference....................................28 Table 3: Description of general characteristics............................................................32 Table 4: The student's religion and their religious practice .........................................33 Table 5: Financial status ..............................................................................................34 Table 6: Coping with problems....................................................................................35 Table 7: Quality of friendship......................................................................................36 Table 8: Quality of relationship with parents ..............................................................37 Table 9: Leisure activities and exercise practice .........................................................38 Table 10: Student stress factors ...................................................................................40 Table 11: Prevalence of depression among the first year Medical students ................42 Table 12: The relationship between depression and general characteristics ...............45 Table 13: The relationship between depression and religion practice.........................46 Table 14: The relationship between depression and perception of financial status.....46 Table 15: The relationship between depression and coping with problems ................47 Table 16: The relationship between depression and quality of relationship................48 Table 17: The satisfaction with friendship among students who have no close friend and lower......................................................................................................................48 Table 18: The relationship between depression and exercise practice ........................49 Table 19: The relationship between leisure activities and depression.........................50 Table 20: The relationship between stress and depression ..........................................50 ix Page Table 21: The relationship between depression and interpersonal sources .................52 Table 22: The relationship between depression and intrapersonal sources .................53 Table 23: The relationship between depression and academic sources.......................56 Table 24: The relationship between depression and environmental stress factors ......58 Table 25: The relationship between depression and related factors in Logistic regression model ........................................................................................61 x LIST OF FIGURES Page Figure 1: Conceptual framework ...................................................................................8 Figure 2: Proposed model of causes and consequences of student distress.................18 xi ABBREVIATIONS B : Regression coefficient CES-D : The Center for Epidemiologic Studies Depression Scale C.I : Confident interval df : degree of freedom HCM : HoChiMinh SD : Standard Deviation WHO : The World Health Organization χ2 : Chi-square CHAPTER Ι INTRODUCTION 1.1 Background Depressive disorders, causing a very high rate of diseases' burden, are expected to show a rising trend during the coming 20 years. It is a significant public health problem with relatively common, high prevalence and its recurrent nature profoundly disrupts patients' lives. General population surveys conducted in many parts of the world, including some South-East Asian Region countries, constituting 18 to 25% of the population in member countries region, in which, 15 to 20% children and adolescents suffered from it that are almost similar to that of adult populations (The World Health Organization [WHO]-Regional Office for South-East Asia, 2001). Inability to cope with intense emotions in healthy ways may lead adolescents to express their pain and frustration through violence or self-injury, or to attempt to numb themselves of emotions through isolation, reckless behaviors, and alcohol or illicit drug use. Furthermore, other behaviors and attitudes are also linked to adolescent mental health: aggressiveness and disregard for laws or the rights of others; isolation from peers, family, and other emotional relationships; or the inability to keep one's disappointments in perspective and academic stress. Medical university is responsible for ensuring that graduates are knowledgeable, skillful, and professional (Liaison Committee on Medical Education [LCME], 2003). Since the field of medical knowledge is immense and particularly science in training programs for specialist medical undergraduate and its education is 2 characterized by many psychological changes in students. Many studies have explored high prevalence of psychological morbidity in medical students at different stage of their training (Aktekin et al., 2001). Unfortunately, some aspects of the training process have unintended negative consequences on students' personal health. It may, in fact, produce stress at levels which are hazardous to the physical and psychological wellbeing of students. Although a moderate degree of stress can promote student creativity and achievement, the intense pressures and relentless demands of medical education may impair students' behavior, diminish learning, destroy personal relationships, and ultimately, affect patient care. In addition, according to study of Marie Dahlin, Medical students are more distressed than the general population, especially in freshmen that face transitional nature of university life (Dahlin et al., 2005; Seyedfatemi et al., 2007) In Vietnam, a national community-based study in 2005 of 5,584 young people aged 14-25 years found that a quarter report feeling so sad or helpless that they could no longer engage in their normal activities and they found it difficult to function (Ministry of Health [MOH]-Vietnam, 2005). Somehow, there is a few published evidence and concern to solve the burden of mental health problem. In medical university, it has also no study about stress, depression among students who will become future doctors with responsibility and capacity for caring health's community. University of Medicine and Pharmacy at Hochiminh city, the biggest city of the South Vietnam, is the main university educating the health professions for the South region. This study wanted to explore what are the main sources of medical stress, screen the level of depression, and find their relationship between depression 3 and the main source of stress among the first year students by using the student stress survey tool and the Center for Epidemiologic Studies’ Depression Scales tool. The finding would be a significant evidence to prevent mental disorder and improve the qualitative of education for this university as well. 1.2 Research questions − What is the prevalence of depression among the first year Medical students? − What are the sources of stress among the first year Medical students? − Is there any relationship between sources of stress, potential consequence factors and depression among the first year Medical students in University of Medicine and Pharmacy, Hochiminh city, 2008? 1.3 Study hypotheses − There is a relationship between depression and sources of stress (interpersonal, intrapersonal, academic and environmental sources). − There is a relationship between depression and individual characteristics. − There is a relationship between depression and potential personal consequences 1.4 Objectives 1.4.1 General objectives The general objectives of this study are to measure the prevalence of depression; to determine the sources of stress; and the factors related to depression among the first students in University of Medicine and Pharmacy, Hochiminh city, 2008. 4 1.4.2 Specific objectives − To assess the prevalence of depression among the first year Medical students by using the Center for Epidemiologic studies depression scale. − To determine the sources of stress among the first year medical students. − To find out the relationship between the main sources of stress, the individual characteristics, potential personal consequences and depression. 1.5 Variables in this study Background variables (general characteristics) − Gender − Age − Ethnicity − Living status − Perception of financial status − Coping with problem Independent variables Potential personal consequences − Parents' marital status − Quality of relationship with parents and friends − Leisure activity − Exercise practice Student stress − Interpersonal factors 5 − Intrapersonal factors − Academic factors − Environment factors Dependent variable Depression 1.6 Operational definition Depression: in this study, adolescent depression is a disorder occurring during the teenage years marked by persistent sadness, discouragement, loss of self-worth, and loss of interest in usual activities (Voorhees, 2007). The Center for Epidemiologic studies Depression scale (Radloff, 1991) will be used to measure depression An overall CES-D score, the scores on the twenty above questions were combined. The minimum and maximum score are 0 and 60, range from 0 to 60. With cut – off point 22, the following classification is defined for depressions. • Scores less than 22 = Non- depressive symptoms group • Scores are 22 or more = Depressive symptoms group CES-D emphasis on affective components: depressed mood, feelings of guilt, worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disorders. CES-D question composed four factors: • Depressed affect: blues, depressed, lonely, cry, sad • Positive affect: good, hopeful, happy, enjoy • Interpersonal affect: unfriendly, dislike • Somatic and retarded activity: bothered, appetite, effort, sleep, going 6 The Student Stress was measured by students stress survey questionnaires. The questionnaire concludes 40 items divided 4 categories of potential sources of stress. Respondents will be provided a “Yes” or “No” answer to each item for experience students had during the academic year (since September, 2007 to February, 2008). • Interpersonal sources: 6 items • Intrapersonal sources: 16 items • Academic sources: 8 items • Environmental sources: 10 items Age is a continuous variable Gender is a nominal variable with female and male values. Ethnicity is nominal variable with 5 values: Vietnamese, Hoa (Chinese), Khmer, Chăm and other. Living status compose 4 nominal variables with following values: • Hometown: HoChiMinh and Non- HoChiMinh • Living location: Inner city and Suburban district • Type of accommodation: Dormitory, Rented room/house and Own home, Relative's home and others. • Whom students lived with: Alone, Friend, Relative, and Family Perception of financial status is an ordinal variable about students' feeling on their financial status using Likert scale with values: not enough for tuition fee, not enough for living spending, nearly sufficient, sufficient, and comfortable. 7 Living spending referred for spending on shopping or for rent a good quality room/house, allowance, etc, excluding money for food. Practice of religion is an ordinal variable about participation in religious services and activities as going to church or pagoda or fasting and following other religious regulations, by using Likert scale with values: rarely, sometime (≥ twice/year & < once/4 week), often (≥ one/4 week & < one/week) and always (≥ once/week). Coping with problem is a nominal variable about the way student coping with problems including talking with parents, talking with friends, solving by yourself, praying, smoking/drinking, and others. Potential personal consequences Parents' marital status is a nominal variable about marital status of parents' students including live together, separated, divorce and parental loss. Exercise practice is an ordinal variable about regularity in exercise practice using Likert scales as never, seldom (< 1 time/month), sometime (≥ 1 & ≤ 3 times/month), often (> 3 & < 12 times/month), and always (≥ 12 times/moth). Leisure activity is a nominal variable about activities that students often do in their free time with values such as going out with friends, listening to music/reading book/watching TV/playing game, playing sport, sleeping, others. Quality of relationship with friends and parents are an ordinal variable reflecting through satisfaction of students about their relationship with parents and friends by Likert scales: very satisfy, satisfy, not satisfy and not satisfy at all. 8 1.7 Conceptual framework The outcome variable is prevalence of depression that related to general characteristics, potential personal consequences and student stress. General characteristics conclude age, gender, ethnicity, living status, practice of religion, perception of financial status and coping with problems. The potential personal consequences consist of parents' marital status, quality of relationship, and leisure/excise activity. These factors change differently and influence on prevalence depression in medical students. Independent variables Dependent variable General characteristics Age Gender Ethnic Living status Practice of religion Perception of financial status Coping with problem Potential personal consequences Parents' marital status Quality of relationship Leisure/Exercise activity Student stress Interpersonal factors Intrapersonal factors Academic factors Environment factors Figure 1: Conceptual framework DEPRESSION CHAPTER II LITERATURE REVIEW In this part, the knowledge about stress, depression, and related factors had been reviewed to introduce an overview about mental status of student in Medical University. Several previous studies in this field also had been reviewed and were used as references. 2.1 Stress and Students Stress survey questions Stress Stress is a term that refers to the sum of the physical, mental, and emotional strains or tensions on a person. Feelings of stress in humans result from interactions between persons and their environment that are perceived as straining or exceeding their adaptive capacities and threatening their well-being. The element of perception indicated that human stress responses reflect differences in personality as well as differences in physical strength or health. A stressor is defined as a stimulus or event that provokes a stress response in an organism. Stressors can be categorized as acute or chronic, and as external or internal to the organism. The Diagnostic and Statistical Manual of Mental Disorders (DAM-IV-TR) defines a psychosocial stressor as "any life event or life change that may be associated temporally (and perhaps causally) with the onset, occurrence, or exacerbation (worsening) of a mental disorder". Stress is also closely associated with depression and can worsen the symptoms of most other disorders. (Rebecca, 2003)
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