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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 105-115

The depression, anxiety, and stress and their sociodemographic correlates among undergraduate medical students of Arsi University, Southeast Ethiopia


Department of Biomedical Sciences, College of Health Sciences, Arsi University, Asella, Oromia, Ethiopia

Date of Submission08-Oct-2019
Date of Decision24-Oct-2019
Date of Acceptance25-Jan-2020
Date of Web Publication9-Apr-2020

Correspondence Address:
Leta Melaku
Department of Biomedical Sciences, College of Health Sciences, Arsi University, Asella, Oromia
Ethiopia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_81_19

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  Abstract 


BACKGROUND: Young adulthood is often marked by beginning of studying in university, in which certain factors contribute to the development of stress and stress-related illness.
OBJECTIVE: We aimed to determine the prevalence of depression, anxiety, and stress and their sociodemographic correlates among undergraduate medical students of Arsi University.
MATERIALS AND METHODS: An institutional-based cross-sectional study was conducted on 265 sampled medical students. Participants were selected by a systematic random sampling technique. Data were collected by a pretested, structured, and self-administrative questionnaire. Afterward, it was double entered into EpiData-3.1 and was analyzed by SPSS-21 software. Logistic regression analysis was employed and statistical significance was accepted atP < 0.05.
RESULT: In the present study, five questionnaires were rejected for incompleteness, giving a response rate of 98.1%. Ages of respondents ranged between 18 and 27 years. Most respondents were male (63.1%), single in marital status (75.4%), living in campus (91.5%), had low monthly income (52.7%), from 6th year (20%), orthodox believers (50%), and Oromo in ethnic (53.9%). The current prevalence rates of depression, anxiety, and stress were 52.3%, 60.8%, and 40.4%, respectively. From all sociodemographic characteristics, depression was specifically associated with monthly income and residency. Moreover, anxiety was significantly associated with residency and educational level. Finally, stress was associated with monthly income, 2nd year educational level, and residency.
CONCLUSION: Generally, overall prevalence rate of depression, anxiety, and stress is alarmingly high among Arsi University medical students. Therefore, implementing a structured orientation program with stress reduction interventions and establishing a student counseling center is highly recommended.

Keywords: Anxiety, depression, medical students and Arsi University, stress


How to cite this article:
Melaku L, Bulcha G. The depression, anxiety, and stress and their sociodemographic correlates among undergraduate medical students of Arsi University, Southeast Ethiopia. Int J Health Allied Sci 2020;9:105-15

How to cite this URL:
Melaku L, Bulcha G. The depression, anxiety, and stress and their sociodemographic correlates among undergraduate medical students of Arsi University, Southeast Ethiopia. Int J Health Allied Sci [serial online] 2020 [cited 2020 May 30];9:105-15. Available from: http://www.ijhas.in/text.asp?2020/9/2/105/282141




  Introduction Top


In fact, transition from childhood to young adulthood is often marked by beginning of studying in university.[1],[2] In undergraduate programs, certain factors either singly or in combination contribute to the development or perpetuation of stress, anxiety, and depression.[3],[4],[5] In psychology, stress is the demand made on an organism to adapt, to cope, or to adjust[6],[7] to disturbing events in the environment. The type of stress that triggers performance and attention of an individual is known as eustress.[8],[9] Conversely, distress is a type of prolonged stress that can overtax our capacity to adjust, dampen our moods, and lead to anxiety and depression.[10],[11] Anxiety is characterized by intense feeling of dread, accompanied by somatic symptoms such as tachycardia, sweating, dry mouth, frequent micturition, and diarrhea.[12] Whereas, major depression is characterized by either a depressed mood or markedly diminished interest in pleasure activity in addition to at least four other symptoms from impaired appetite, disturbed sleep, poor concentration, loss of energy, psychomotor agitation or retardation, feeling of worthlessness or inappropriate guilt, and thoughts of death or recurrent suicidal ideation.[13]

A medical school is a tertiary educational institution that involves a difficult examination system and year-long courses over a long duration.[4],[14],[15],[16],[17],[18],[19] Actually, medical academic atmosphere promotes competition among learners rather than cooperation.[20] Apart from academic constraints, factors such as age, gender, ethnicity, and marital status also influence severity of students' emotional disturbances.[21],[22],[23] Across the globe, medical training causes high incidences of mental illness among undergraduate medical students.[16],[18],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] For instance, the prevalence of stress within undergraduate medical students of United States was 26%,[34] three British universities (31.2%),[35] Malaysia (41.9%),[36] Thailand (61.4%),[37] Saudi Arabia (57%),[38] Nigeria (94.2%),[39] and Jimma University (52.4%)[40] and Bahir Dar University of Ethiopia (37.4%).[41] Systematic reviews have also been conducted on the prevalence of anxiety among undergraduate medical students that showed 43.7% in Pakistan,[42] 54.5% in Malaysia,[43] 65.5% in Greece,[44] 69% in Beirut,[26] 29.4% in Israel,[45] 56% in India,[46] and 60% in Pakistan.[47] Similarly, according to different literatures, there are high incidences of depression among medical students: 17.3% met the criteria for depression and a total of 6.3% reported suicidal ideation within 26 United States universities.[48]

In Sweden, the prevalence of depressive symptoms was also 12.9% and a total of 2.7% of students had made suicidal attempts.[18] Among students of Obafemi Awolowo University, Ile Ife, Nigeria, 84% had depression ranging from mild to severe.[49] Furthermore, in Zimbabwe, 64.5% of first-year medical students were found to be at various levels of stress and/or depression with 12% at risk of suicidal tendencies.[50]

Although series of studies with various methodologies have revealed important findings regarding mental illnesses related to medical students academic life,[51] in Ethiopia, such kinds of studies are quietly few in type. Therefore, the main aim of the present study was to determine the prevalence of depression, anxiety, and stress and their sociodemographic correlates among undergraduate medical students of Arsi University.


  Materials and Methods Top


An institutional-based cross-sectional study was conducted starting from January 10 to 30, 2019, among 265 sampled undergraduate medical students of Arsi University. The sample size was first estimated using single population proportion, with an assumption of 95% confidence interval (CI), 5% margin of error, and prevalence of depression (51.3%), anxiety (66.9%), and stress (53%) which are taken from Iqbal et al.'s study.[52] After that, by taking maximum result, the minimum required sample size for the present study was calculated through correction formula due to the fact that the overall number of Arsi University undergraduate medical students was <10,000. In the present study, after proportional allocation of the calculated sample size to each academic year level, a stratified random sampling method was employed. Through a systematic random sampling method from each stratum with randomly selecting the first student based on his/her ID number, respondents were chosen every four intervals. All medical students undergoing training in Arsi University at the time of the study were eligible to participate with exceptions of severely ill students and that were out of town during the time of data collection. Ethical support letter was obtained from the Ethical Board of Arsi University. Informed consent was taken from all respondents during data collection and participation was totally voluntary. Confidentiality was kept unanimously. Data were collected using manually distributed self-administered questionnaires that comprise the following parts.

  1. Sociodemographic profile: That were collected include age, gender, enrollment year, marital status, residence, income, religion, and ethnicity
  2. Depression, Anxiety, Stress Scale-21 (DASS-21): It is a self-report tool designed to measure the emotional states of depression, anxiety, and stress over the last week.[53] Each of the three DASS-21 scales contains seven items.[54]


The responses are given on a 4-point Likert scale, ranging from 0 if “I strongly disagree” to 3 if “I totally agree.” NB scores on the DASS-21 will need to be multiplied by 2 to calculate the final score, which is according to DASS-21 scoring instructions. As detailed [Table 1], ranges of scores correspond to levels of symptoms, ranging from “normal” to “extremely serious.”[55] However, to determine the prevalence of DAS, DASS-21 scores with normal levels of depression, anxiety, and stress were coded as “0,” whereas those with mild, moderate, severe, or extremely severe levels were coded as “1.” Various studies demonstrated that the DASS-21 was found to have strong internal consistency.[55],[56]
Table 1: Items of depression, anxiety, and stress scale-21 with their respective

Click here to view


The questionnaire was pretested on 13 randomly selected undergraduate medical students of Hawassa University for making questionnaires content, wording, and instructions ease of completion and more understandable for respondents. After checking the collected data for completeness, it was double entered into Epi-data version 3.1 (McGraw-Hill/Irwin ©2009) and exported into SPSS version 21 (IBM Corp., Armonk, NY) for analysis. Incomplete and inconsistent data were excluded from the analysis. The data were processed using descriptive analysis, including frequency distribution, cross tabulation, and summary measures. Bivariate logistic regression was used to measure the association between independent variables with dependent variables. Multivariate logistic regression analysis was carried out to find the role of each significant variable in determining the relevant subscale scores. Statistical significance was accepted at P < 0.05.


  Results Top


Sociodemographic characteristics

Out of 265 sampled undergraduate medical students of Arsi University, five questionnaires were rejected for incompleteness, giving a response rate of 98.1%. The study involved 260 respondents whose age ranged between 18 and 27 years with the mean (standard deviation) of 22.03 (+2.62) years. In the present study, most respondents were male (63.1%), single in marital status (75.4%), living in campus (91.5%), and had monthly income of <700 ETB (52.7%). Regarding their academic year, religion, and ethnicity, 54 (20.8%) were from 6th year, 130 (50%) were orthodox believers, and 139 (53.9%) were Oromo [Table 2].
Table 2: Sociodemographic characteristics of study participants in relation to gender, Arsi University, January 2019

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Prevalence of depression, anxiety, and stress

The present study demonstrated strong internal consistency between depression and anxiety (r = 0.494, P < 0.001), depression and stress (r = 0.456, P < 0.001), and stress and anxiety (r = 0.420, P < 0.001). It was observed that out of 260 respondents, proportion of respondents detected to have depression, anxiety and stress symptoms were 52.3%, 60.8% and 40.4% respectively. Furthermore, percentage of respondents who had extremely severe symptoms of depression, anxiety and stress were 6.2%, 16.2% and 2.3% respectively [Table 3].
Table 3: Severity distribution of depression, anxiety, and stress among study participants in relation to gender, Arsi University, January 2019

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Association of sociodemographic characteristics with depression

A binary logistic regression analysis was applied to evaluate the possible impact of sociodemographic characteristics on respondents' depression level [Table 4]. In the present study, depression had no statistical association with age, educational year, religion, and ethnicity. Conversely, it had statistically significant association with respondents' gender, in which males were 0.59 times less likely depressed than females (95% CI: 0.36–0.99). It was also associated with monthly income, in which respondents who had monthly income of <700 ETB were 1.68 times more depressed than above 700 ETB (95% CI: 1.03–2.74). Depression was also associated with marital status, in which respondents who had not in relationship (single) were 0.53 times less likely depressed than those in relationship (married) (95% CI: 0.30–0.95). Finally, it was also statistically associated with residency, in which nondormitory-living respondents were 10.52 times more likely depressed than those living in dormitory (95% CI: 2.41–46.00).
Table 4: Bivariate logistic regression of sociodemographic risk factors versus depression, n=260, Arsi University, January 2019

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Association of sociodemographic characteristics with anxiety

In a binary logistic regression analysis of the present study, anxiety had no statistically significant association with sociodemographic variables such as monthly income, religion, and ethnicity [Table 5]. Contrariwise, it was statistically associated with age of respondents, i.e., those in the age range of between 20 and 24 years were 1.92 times less likely anxious than respondents >24 years (95% CI: 0.34–0.99). It was also associated with gender of respondents; males were 0.58 times less likely anxious than females (95% CI: 0.34–0.99). Anxiety was also associated with marital status, i.e. respondents who had not relationship (single) were 0.52 times less likely anxious than those in relationship (married) (95% CI: 0.28–0.96). Concerning its association with educational level of respondents, third-year respondents were 4.85 times more likely anxious than sixth-year students (95% CI: 1.93–12.19). Finally, anxiety was also associated with residency; nondormitory-living respondents were 15.48 times more likely anxious than those living in dormitory (95% CI: 2.05–117.00).
Table 5: Bivariate logistic regression of sociodemographic risk factors versus anxiety, n=260, Arsi University, January 2019

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Association of sociodemographic characteristics with stress

In the present study, when impact of sociodemographic characteristics on stress level was evaluated with binary logistic regression analysis, stress had no association with only religion and ethnicity [Table 6]. However, it had a statistically significant association with age of respondents, i.e., respondents in the age range of <20 years were 2.07 times more likely stressed than those in the age range of >24 years (95% CI: 1.01–4.27). It was also associated with sex of respondents, i.e., males were 0.57 times less likely stressed than females (95% CI: 0.34–0.95). Statistically, it was also associated with monthly income, i.e., participants who had monthly income of <700 ETB were 1.87 times more likely stressed than those respondents who had monthly income of above 700 ETB (95% CI: 1.13–3.10). Stress was also associated with marital status, i.e. respondents who had not relationship (single) were 0.55 times less likely stressed than those in relationship (married) (95% CI: 0.31–0.96).
Table 6: Bivariate logistic regression of sociodemographic risk factors versus stress, n=260, Arsi University, January 2019

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Concerning to its association with educational level of respondents, second-year respondents were 4.92 times more likely stressed than those in the sixth year (95% CI: 2.09–11.61). Finally, it was also statistically associated with residency, i.e., nondormitory-living respondents were 3.52 times more likely stressed than those in dormitory (95% CI: 1.38–8.97).

Risk factors for depression

In present study, monthly income and residency were found to be predictors of the depression from all socio-demographic characteristics that were candidate for multivariate logistic regressions [Table 7]. For instance, the odd of being depressed was markedly increases with 1.97 times among respondents who had monthly income of < 700 ETB than < 700 ETB (95% CI: 1.17 – 3.33). Similarly, the odd of being depressed were markedly increases with 12.55 times among respondents living non-dormitory than living in dormitory (95% CI: 2.79 – 56.37).
Table 7: Multivariate logistic regression for sociodemographic factors versus depression level, Arsi University, January, 2019

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Risk factors for anxiety

In present study, educational year and residency were found to be predictors of the anxiety from all socio-demographic characteristics that were candidate for multivariate logistic regressions [Table 8]. For instance, the odd of being anxious were markedly decreased as educational level increased after first year. For example, the odd of being anxious were markedly increases with 14.89 times in second year students than sixth years (95% CI: 3.40 - 65.23). The odd of being anxious were also more likely increases with 42.11 times among participants living in non-dormitory than in dormitory (95% CI: 4.88 - 363.36).
Table 8: Multivariate logistic regression for sociodemographic factors versus anxiety, Arsi University, January, 2019

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Predictor risk factors for stress

In the present study, monthly income, educational year, and residency were found to be predictors of the stress from all sociodemographic characteristics that were candidate for multivariate logistic regressions [Table 9].
Table 9: Multivariate logistic regression for sociodemographic factors versus stress, Arsi University, January, 2019

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For instance, the odd of being stressed was markedly increased with 1.99 times among participants who had monthly income of <700 ETB than those who had above 700 ETB (95% CI: 1.00–3.98). Similarly, the odd of being stressed was markedly increased with 1.84 times in the second-year participants than 6th years (95% CI: 1.02–11.21). Furthermore, the odd of being stressed was more likely increased with 4.93 times among respondents living in nondormitory than in dormitory (95% CI: 1.73–14.08).


  Discussion Top


The main goal and objective of medical curriculum is to provide competent and safe doctors to the community. However, burden of information and lots of competition in medical college may have an effect on medical students' mental and emotional health.[57],[58] Therefore, the aim of the present study was to determine the prevalence of depression, anxiety, and stress and their sociodemographic correlates among undergraduate medical students of Arsi University.

In the present study, the overall prevalence rates of depression, anxiety, and stress symptoms were 52.3%, 60.8%, and 40.4%, respectively. The reason might be medical students are exposed to factors such as pressured to succeed, academic overload, separating from family members and adjusting to new living situation and meeting new people especially during preclinical encounters.[18],[23],[59] This greater degree of workload creates feeling of distress and disappointments that predisposes students to have difficulties in solving problems, impaired judgments, absenteeism from class lesson, and break their mental stability.[40],[43],[60],[61],[62] Actually, our present finding is almost similar to the prevalence reported by Basudan et al.,[63] Kulsoom and Afsar,[64] Inam et al.,[47] and Iqbal et al.[52] However, it is higher than the study of Shamsuddin et al.,[65] Fuad et al.,[66] Moutinho et al.,[67] Mehta et al.,[68] and Wong et al.[69] This difference could be due to difference in cultural perception of stressful factors, economic burden, very high tuition fees, lack of family support, and higher or lower “readiness” to report different complaints.[70],[71] In our present setup, academic counseling is not a common practice which may be also a contributor.

In the present study, proportions of respondents who had extremely severe symptoms of depression, anxiety, and stress were 6.2%, 16.2%, and 2.3%, respectively. This prevalence was similar with the finding of Patil et al.[72] However, it is inconsistent with prevalence from other studies that was ranged from 13.9% to 29.3%, 51.5% to 55.0%, and 12.9% to 21.6% for mild-to-severe category.[52],[73],[74] Discrepancies stemming from methodology and type of questionnaire used could account for this high prevalence obtained by the aforementioned authors. The other possible reasons for the variability could be due to certain differences in the curricula, teaching facilities, qualification and experience of the instructors, and levels of care given to the students.

In this cross-sectional study, we correlated sociodemographic risk factors of the student (as independent variables) with the prevalence of depression, anxiety, and stress level among the undergraduate medical students of Arsi University. In the present study, students living in nondormitory have considerably higher degree of depression, anxiety, and stress, which infers living in dormitory, came out to be a protective. This finding is in line with the study reported by Rab et al.[42] and Ajay and Vijay.[75] However, it is inconsistent with the study reported by Kunwar et al.[76] and Liaqat et al.[77] This unequivocal distribution demonstrates that probably depression, anxiety, and stress are associated with a multitude of factors such as poor dormitory conditions, more economic stress, distance from the family, less structured environment, and problems dealing with roommates, which might be different or parallel in the two study groups under consideration.[77]

In the present study, medical students who had lower monthly income were more likely depressed and stressed. Despite the fact that food and dormitory services are provided to the students by the university, students need money for excursions, to print handouts, to buy dressings, and other basic necessities.[40] This indicates that financial constraints could be an additional source of depression, anxiety, and stress besides academic stressors.[78],[79],[80],[81],[82] However, other studies have noted no difference.[83],[84] Again, geographical, racial, and sample size differences may possibly account for these different results.

In the present study, there was a significant association between students' academic year and level of anxiety and stress. There are many associated studies that imply that stress and stress-related illness was highest in the second-year medical students as compared to other academic years.[40],[47],[59],[85] On the other hand, senior students developed skills of how to manage stress and stress-related illness than students in the early years.[86] The possible reason could be the amount and complexity of the material to be learned in the second year with progressive assessments of anatomy, physiology, and biochemistry that they have to pass to join the next higher level. Additional supportive evidence is high level of stress and stress-related illness can be attributed by course workload, lack of leisure time, shortage of learning materials, and frequent examinations.[87],[88]


  Conclusion Top


Healthy medical students are likely to become healthy doctors. However, the overall prevalence of depression, anxiety, and stress is alarmingly high among undergraduate medical students of Arsi University. Furthermore, from all sociodemographic characteristics, monthly income and residency were identified as risk factors of depression. Similarly, residency and educational level were risk factors for anxiety. Finally, monthly income, educational level, and residency were predictors for stress. However, there was no significant difference in depression, anxiety, and stress between age groups, sex, marital status, ethnicity, and religion. Besides stress reduction interventions, implementation of structured orientation program that addresses issues such as expectations for each phase, how students are going to be evaluated, how to cope, and how to get through each phase smoothly were recommended. Establishing a student counseling center in the campus with qualified staff is also highly recommended. Family or close friend problem (recent death or accident), distance from family, frequency of money sent, and being first from home to go far were not assessed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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