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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

Field of Study Health Systems Development Thesis Advisor Associate Professor Prida Tasanapradit, M.D., M.Sc.

Quyen Dinh Do

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)

………………………………………………

(Rasmon Kalayasiri,M.D.)

External Member

iii

:

KEY WORDS:

PH: 072464

MAJOR HEALTH SYSTEMS DEVELOPMENT 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

Academic year 2007

Heath Systems Development

Student’s signature

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

Hongsranagon,

would

like

to

my

Chairman

thank

and

Dr.

my

committee

members:

Rasmon

Kalayasiri,

my

Dr.

Prathurng

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

ABSTRACT

……

Page

………………………………………………………………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

vi

CHAPTER III METHODOLOGY

Page

………………………………………………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

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

Table 1: University of Medicine and Pharmacy

Table 2: Variables, measurement scale and statistic inference

Table 3: Description of general characteristics

Table 4: The student's religion and their religious practice

Table 5: Financial status

Table 6: Coping with problems

Table 7: Quality of friendship

Table 8: Quality of relationship with parents

Table 9: Leisure activities and exercise practice

Table 10: Student stress factors

Table 11: Prevalence of depression among the first year Medical students

Table 12: The relationship between depression and general characteristics

Table 13: The relationship between depression and religion practice

Table 14: The relationship between depression and perception of financial status

Table 15: The relationship between depression and coping with problems

Table 16: The relationship between depression and quality of relationship

Page

23

28

32

33

34

35

36

37

38

40

42

45

46

46

47

48

Table 17: The satisfaction with friendship among students who have no close friend

and lower

Table 18: The relationship between depression and exercise practice

Table 19: The relationship between leisure activities and depression

48

49

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

χ 2

: 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

consequences

1.4 Objectives

a

relationship

between

1.4.1 General objectives

depression

and

potential

personal

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

February, 2008).

had

during

the

academic

Interpersonal sources: 6 items

year

(since

Intrapersonal sources: 16 items

Academic sources: 8 items

Environmental sources: 10 items

Age is a continuous variable

September,

2007

to

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

Age Gender Ethnic Living status Practice of religion Perception of financial status Coping with problem
Age Gender Ethnic Living status Practice of religion Perception of financial status Coping with problem
Age Gender Ethnic Living status Practice of religion Perception of financial status Coping with problem
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

status Quality of relationship Leisure/Exercise activity DEPRESSION Student stress Interpersonal factors

DEPRESSION

Student stress

Interpersonal factors Intrapersonal factors Academic factors Environment factors

Interpersonal factors Intrapersonal factors Academic factors Environment factors
Student stress Interpersonal factors Intrapersonal factors Academic factors Environment factors
Student stress Interpersonal factors Intrapersonal factors Academic factors Environment factors
Student stress Interpersonal factors Intrapersonal factors Academic factors Environment factors

Figure 1: Conceptual framework

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)

10

Richard Lazarus published in 1974 a model dividing stress into eustress and

distress. Where stress enhances function (physical or mental, such as through strength

training or challenging work) it may be considered eustress. Persistent stress that is

not resolved through coping or adaptation, deemed distress, may lead to escape

(anxiety) or withdrawal (depression) behavior. The difference between experiences

which result in eustress or distress is determined by the disparity between an

experience (real or imagined), personal expectations, and resources to cope with the

stress. Alarming experiences, either real or imagined, can trigger a stress response

(Lazarus, 1993)

As "Beyond blue: the national depression initiative" approach that aims to

influence broader social determinants, the settings in which people spend their time,

there are some causes of depression need an attention on the peak incidence in mid-to-

late adolescence:

Cumulative adverse experiences, including negative life events and early

childhood adversity, together with parental depression and/or non-supportive school

of familial environments, place young people at risk for developing depression.

Enhanced life skills and supportive school and family environments can mediate the

effect of stressful life events.

Obviously, school is an important arena for social and emotional development;

however, it can also be a source of negative life events. Poor academic achievement

and beliefs about academic ability, coupled with depression, result in poor school

engagement, enhanced perceptions of school-related stress, and increased problem

behaviors (Burns et al., 2002).

11

The Student Stress Survey

The Student Stress Survey (Insel et al., 1985) will be used to measure sources

of stressors. This survey consists of 40 items divided into 4 categories of potential

sources of stress: 6 items representing interpersonal sources of stress, 16 representing

intrapersonal sources of stress, 8 representing academic sources of stress, and

10 representing environmental sources of stress. Interpersonal sources result from

interactions with other people, such as a fight with a boyfriend or girlfriend or

trouble with

parents;

intrapersonal

sources result from internal sources, such as

changes in eating or sleeping habits. Academic sources arise from school-related

activities and issues, such as increased class workload or transferring between

schools. Environmental sources result from problems in the environment outside of

academics, such as car or computer problems and crowded traffic. Respondents

provided a “Yes” or “No” answer to each item they had experienced during the

current school year (Seyedfatemi et al., 2007).

2.2 Depression and CES-D

Depression is a common mental disorder that presents with depressed mood,

loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or

appetite, low energy, and poor concentration. These problems can become chronic or

recurrent and lead to substantial impairments in an individual's ability to take care of

his or her everyday responsibilities (WHO, 2008).

According to WHO's Global burden of disease 2001, 33% of the years lived

with disability (YLD) are due to neuropsychiatry disorders in which including

depression is one of four neuropsychiatry disorders of the six leading to causes of

12

years lived with disability. More than 150 million persons suffer from depression at

any point in time (WHO, 2003).

Depending on the nature and severity of symptoms, the depressive episode

may be classified as mild, moderate and severe, or with psychotic features. About

15% of severely depressed cases suffer from what is termed as the 'psychotic form' of

depression where they have symptoms which signify their being out of touch with

reality. They have delusions (false fixed ideas not amenable to correction) and

hallucinations (perceiving something through sense organs without anything being

there).

Depression is a complex disorder which can manifest itself under a variety of

circumstances and due to a multiplicity of factors. The bio-psychosocial model is

useful to understand the causation of depression including:

Biological (genetic and biochemical)

Sociological (stressors)

Psychological (development and life experiences)

The following are various risk factors of depression in adolescent (The World

Health Organization [WHO]-Regional Office for South-East Asia, 2001):

Marital status

Family history

Parental deprivation: Parental loss

Social stressors: life events, chronic stress, and daily hassles

Social support

Family type

13

Depression measurement

According

to

Ian

McDowell

in

Measuring

health

book,

depression

measurements are divided into two major groups self-rating methods and clinician-

rating scales, which correspond roughly to their use in clinical versus epidemiological

studies. A formal diagnosis of depression requires the exclusion of other explanations

for the symptoms, and this requires a clinical examination. However, self-assessed

measures of depression that is popular and easy to administer, can identify the

syndrome of depression but, as with dementia, cannot be regarded as diagnostic

devices. This book introduced nine self-rating that have been widely used and tested.

Among several methods, the Center for Epidemiologic studies Depression Scale is a

depression screening instruments designed for adolescent survey use (McDowell,

2006).

CES-D questionnaire

This study adopted the Center for Epidemiologic Studies’ Depression Scales

(CES-D) to measure the levels of adolescent depression. The CES-D was designed to

cover the major symptoms of depression identified in the literature, with an emphasis

on affective components: depressed mood, feelings of guilt and worthlessness,

feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite,

and sleeping disorders.

It composes of 20 questions asking about adolescents’

feelings or behaviors related to depressive symptoms. It has been extensively used in

large studies and norms are available. It is applicable across age and general groups. It

has often been used in cross-cultural research (Iwata et al., 2002; McDowell, 2006).

14

Items in CES-D were selected from many other scales as Beck’s depression

inventory (BDI), Zung’s self-rating depression scale, Raskin’s depression scale, and

the Minnesota Multiphasic personality inventory. It performs comparably with other

self-report scales and CES-D is better than BDI’s where there is a relatively high

prevalence of depression (McDowell, 2006).

Moreover, this instrument used for Thai adolescents which its results show the

Cronbach alpha coefficient of the CES-D was 0.86, that the validity was significant

with Mean = 25.6, SD = 8.8, compared with non-depressed subjects with Mean =

15.4, SD = 6.7, that the sensitivity was 72%, the specificity was 85% and the accuracy

was 82%; the cutting point = 22 scores. The report shown that the sample was

diagnosed for depression at the significant p-value < 0.001 (Trangkasombat et al.,

1997)

2.3 Review of related studies

Studies used CES-D

In adolescent depression and risk factors study by Tiffany, seventy nine high

school seniors from suburban Florida were administered the CES-D as well as a

questionnaire of parent/peer relationships, suicidal thoughts, academic performance,

exercise, and drug use. The extremely high incidence of adolescents who scored

above the cut-off >19 for depressed mood (37%) had poorer relations with parents.

The depressed adolescents also had less optimal peer relationships, fewer friends, less

popular, less happiness, and more frequents suicidal thoughts. They spent less time

doing homework, had a lower grade point average, and less time exercising. (Field et

al., 2001).

15

A study in Thai done by Ratana in 2003, she measured depressive prevalence

by using CES-D (with cut-off point 22) in 871 adolescents aged 12-22 years. One

third (34.9%) of the subjects having depressive symptoms, late adolescents (18-22

years)

suffered

with

high

percentage

at

33.1%,

gender

differences

existed

in

depressive symptoms in all subjects with p-value < 0.001, female were more likely

than males to have depressive symptoms (Somrongthong, 2004).

The Black women's health study in 35,224 women ages 21 to 69 in African

American

measured

depressive

symptoms

in

which

CES-D

was

used

and

its

association with physical activity. Adult vigorous physical activity was inversely

associated with depressive symptoms. Women who reported vigorous exercise both in

high school (5 hr per week) and adulthood (2 hr per week) had the lowest odds of

depressive symptoms (OR=0.76, 95%CI=0.71-0.82) relative to never active women;

the OR was 0.90 for women who were active in high school but not adulthood (95%

CI=0.85-0.96) and 0.83 for women who were inactive in high school but became

actives in adulthood (95% CI=0.77-0.91) (Wise et al., 2006)

A nearest study in 2008 conducted to investigate the 2-week prevalence of

depressive symptoms in 802 Hong Kong and 988 Beijing Chinese college freshmen.

Approximately 8.9% of Beijing had scores on the CES-D of 25 or higher, whereas,

17.6% of freshmen in Hong Kong reported scores of 25 or higher. There was no sex

difference in prevalence in Beijing. The prevalence is significantly different between

sexes in Hong Kong in which 13.4% of men having scores of 25 or higher and 21.3%

of women having scores of 25 or higher (Yuqing et al., 2008).

16

Studies on Medical students

According to the study done by Liselotte N.Dyrbye's, their special articled

summarized the central themes of exploring the prevalence, causes, and consequences

as well as strategies to reduce student medical distress by reaching MEDLINE and

Pubmed for English article published between 1966 and 2004. Medical student

distress, medication, educational environment contain risks element for students'

mental health and its specific consequences. The various manifestations of medical

students that were recorded increasingly and differently for each stage of academic

year include stress, depression and burnout. Potential causes of student distress

mentioned

as

adjustment

to

the

medical

school

environment, ethical

conflicts,

exposure

to

death

and

human

suffering,

student

abuse,

personal

life

events,

educational debt. Obviously, many effects on students involve impaired academic

performance, cynicism, academic dishonesty, substance abuse, and suicide. The

overview analysis is shown following on next page as a model of cause and

consequence of medical student distress (Dyerbye et al., 2005).

Some terminologies that closely related to depression and stress as anxiety and

burnout that was distinguished follow:

Anxiety

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defined

anxiety as "apprehensive anticipation of future danger of misfortune accompanied by

a feeling of dysphoria or somatic symptoms of tension.

Anxiety and depression share common symptoms and can result from similar

circumstances, but in theory, at least these two distinguishable. Probably, they are

17

linked, but anxiety suggests arousal and an attempt to cope with the situation;

depression suggests lack of arousal and withdrawal. A 1991 paper by Clark and

Watson proposed a tripartite hierarchical model that holds that anxiety and depression

have common, but also unique, features. Depression is uniquely characterized by

anhedonia and low levels of positive affect referring to loss of pleasure and interest in

life, lack of enthusiasm, sluggishness, apathy, social withdrawal, and disinterest.

Anxiety,

meanwhile,

is

uniquely

characterized

by

physiological

hyper

arousal,

exhibited in racing heart sweating, shakiness, trembling, shortness of breath, and

feelings of panic (McDowell, 2006).

Burnout

Burnout is a state emotional and physical exhaustion caused by excessive and

prolonged stress. It can occur when you feel overwhelmed and unable to meet

constant demands. As the stress contuse, you begin to lose the interest or motivation

that led you to take on a certain role in the first place. Burnout reduces your

productivity and saps your energy, leaving you feeling increasingly hopeless, cynical,

and resentful. The unhappiness burnout causes can eventually threaten your job, your

relationships, and your health. Burnout usually has its roots in stress and its sign tend

to be more mental than physical. They can include feelings of powerlessness,

hopelessness, emotional exhaustion, detachment, isolation, irritability, frustration,

being trapped, failure, despair, cynicism, and apathy (Smith et al., 2007).

Students are subjected to different kinds of stressors, such as the pressure of

academics with an obligation to succeed, an uncertain future and difficulties of

18

integrating into the system. The students also face social, emotional, physical, and

family problems which may affect their learning ability and academic performance.

PERSONAL FACTORS Life events (birth of child, death in family, etc) Personality Coping strategies Personal responsibilities (married, children, etc) Consumer debt Learning style Motivation

POTETIAL PERSONAL CONSEQUENCES Broken relationships Substance abuse Poor self-care (lack of exercise, poor diet, etc) Decline in physical health Suicide

poor diet, etc) Decline in physical health Suicide STUDENT DISTRESS Stress Anxiety Burnout Depression
poor diet, etc) Decline in physical health Suicide STUDENT DISTRESS Stress Anxiety Burnout Depression
poor diet, etc) Decline in physical health Suicide STUDENT DISTRESS Stress Anxiety Burnout Depression

STUDENT DISTRESS Stress Anxiety Burnout Depression

STUDENT DISTRESS Stress Anxiety Burnout Depression FACTORS RELATED TO MEDICAL SCHOOL TRAINING Workload

FACTORS RELATED TO MEDICAL SCHOOL TRAINING Workload Curriculum Exposure to patient death/suffering Student's loan debt System of performance evaluation (letter grade, pass/fail, etc) Ethical conflicts Student abuse (verbal, emotional, etc) Institutional culture hidden/informal curriculum

POTENTIAL PROFESSIONAL CONSEQUENCES Impaired academic performance Cynicism/decline in empathy Academic dishonestly Impaired competency Influence specialty choice Attrition from medical school Medical errors

Figure 2: Proposed model of causes and consequences of student distress (Dyerbye et al., 2005).

Study

about

experienced

stressors

and

coping

strategies

among

Iranian

Nursing students by Naiemeh consisted 440 undergraduate nursing students between

18 and 24 year olds enroll in Iran Medical Science in 2004-2005 academic year by

using Student Stress Scale. The most common sources of stress were interpersonal as

"finding new friend" (76.2%), the intrapersonal sources as "new responsibilities

(72.1%) and "started college (65.8%), that this factor and "change in sleeping habits"

were significantly greater stressors in first year students than in students of other

years. The other prevalence was academic stressor as "increased class workload"

19

(66.9%), environment sources as "being placed in unfamiliar situations" (64.2%), and

"waiting long line", "change living environment" that were significantly greater in

first year students. The most commonly used coping strategies are going along with

parent, praying, making one's own decisions, apologizing, helping other people to

solve problems, keeping friendships and daydreaming (Seyedfatemi et al., 2007).

According

to

Marie

at

el,

a

cross-sectional

study

in

Institute

Medical

University, Stockholm, Sweden gave high ratings to the workload and lack of

feedback stressors in the first year, female students gave higher ratings than male on

many factors. (Stress measured by the Perceived Medical School Stress Scale and

depression

measured

by

the

Major

depression

inventory).

The

prevalence

of

depressive symptoms among students was 12.9%, significantly higher than in the

general population, 16.1% among female versus 8.1 among males. (Dahlin et al.,

2005)

In Nepal, psychological morbidity sources of stress and coping strategy among

undergraduate

medical

students

studying

2005,

the

overall

prevalence

of

psychological morbidity was 20.9%. The General health questionnaire, 24 items to

assess sources of stress showed that the most important and severe sources of stress

were staying in hostel, high parental expectation, vastness of syllabus, test/exam, lack

of time and facilities for entertainment (Screeramareddy et al., 2007).

Kaohsiung Medical University, Taiwan, 2005, correlations between academic

achievement and anxiety and depression in medical students experiencing integrated

curriculum reform (four blocks in the first semester of the new curriculum) study

20

approved that there were both positive and negative correlations between academic

achievement and anxiety and depression in medical students, regarding differing

levels of severity of anxiety or depression, used the Zung’s Anxiety and Depression

scale. Among the medical students who were in the high depression level group in the

second psychological assessment, those who had more severe depression had poorer

academic achievement in the fourth learning block differing levels of severity of

anxiety or depression. (Yeh et al., 2007)

Majority of medical students (175 of 283, approximately 73%) perceived

stress publishing by a study of stress in medical students at Seth G.S. Medical College

and King Edward Memorial Hospital, Parel, Mumbai, India. Academic factors were

greater perceived case of stress in medical students. Emotional factors were found to

be significantly more in first year students as compared to second & third students.

The Zung's Self – Rating Scale for depression was used to assess the perceived feeling

of the students regarding their emotional status counted score more than or equal to 40

as stress definition (Supe, 1998).

Students mentioned that their overwhelming amounts of information were

expected during their first and second year of medical training. Moreover, they had

difficulty relaxing and engaging in activities normally associated with personal

wellbeing. The realizably on future was the most stressful of all. Questionnaires were

mailed to students whose essays were reviewed in a quality study about students'

perception of medical school stress and their evaluation of a wellness elective which

focused on stress reduction and personal wellness done by Jungkwon Lee and

Antonnette V Graham (J. Lee et al., 2001).

21

Female medical students from the general Sweden population in the thesis of

Marie Dahlin were more depressed (16.1%), more affected by study stress than their

male peers (7.8%). They were also more depressed than women of the same age in the

general population (12.9% for common among medical students, 7.8% for general

population controls). Study stress was examined by The Higher Education Stress

Inventory, prevalence of self-rated depression and suicide ideation/attempts were

compared with controls matched by age and sex (Dahlin, 2007).

Using the General Health Questionnaire, it was found that 49.6 percentage

encountered significant stress and 64.6 percentages reported that more than 60

percentage of their total life stress was due to medical school. The most important

psychosocial stressors were: too much work and difficulty in coping. That is

demonstrated in a cross-sectional study to understanding the psychosocial and

physical work environment in a Singapore medical school, 2003-2004 (Chan et al.,

2007).

A considerable majority (>90%) think that they had been stressful. Females

reported more symptoms. Academics and exams were the most powerful stressors.

More leisure time activities, better interaction with the faculty and proper guidance,

advisory services and peer counseling at the campus, could do a lot to reduce the

stress from study a by Shaikh in Pakistani Medical School, 2004 (Shaikh et al., 2004).

22

2.4 Site of study

There are two public Medical universities in HMC city. Pham Ngoc Thach

Medical University is only for students who are residents of HCM city and this

university assigns working place for the students after graduate. University of

Medicine and Pharmacy which is bigger than the other in terms of amount of students

and its history is for all students who come from many other provinces. The students

take the same entrance exam for these universities but each University has different

standard grade for recruitment.

University of Medicine and Pharmacy at Hochiminh city is the main Medical

University for the South of Vietnam locating in HCM city. Its responsibility is to train

health profession in under graduate to post graduate level, to conduct research, to care

for community health as well as to link with international cooperation. This public

university consists of 982 officers and 659 lecturers of which 7 faculties for 84

departments.This study population chose students in Medical Faculty that is the

biggest Faculty containing the most number of students.

The University has a hospital in three different locations, one Pharmaceutics

Technical Science Centre, six Medical Specialize Centers that apply high technique in

treatment as well as medical research. In addition, four dormitories serve for 1,500

students each year. More than 2,000 students enroll for various health science courses

in technical, college, undergraduate and post graduate degree each year.

23

Table 1: University of Medicine and Pharmacy

Faculty

Number of Department

Fundamental science

8 Departments

Medical Faculty

28 Departments

Traditional Medicine Faculty

5 Departments

Odontology Faculty

14 Departments

Pharmacy Faculty

14 Departments

Nurse and Medical Technique Faculty

6 Departments

Public Health Faculty

9 Departments

In two first years, student are learnt the basic sciences and some medical

subjects.

Their

curriculum

includes

42

credits

of

physics,

chemistry,

biology,

language, physical exercise, advance mathematics, anatomy and military education in

the first term of the first year. Each subject takes around more than 11 weeks, then

after final exam students starting new subject. Generally, students spend 48 hours per

week for attending theoretical and practical class.

CHAPTER III

METHODOLOGY

3.1 Research design

This study was a cross-sectional descriptive study that is used to measure the

prevalence of depression, stress and related factors among the first year Medical

students.

3.2 Study population

Target population of this study was the first year students in Medical

Universities at HoChiMinh city, Vietnam

Study population composed 404 first year students in Medical Faculty in

University Medicine and Pharmacy, Hochiminh city, Vietnam

3.3 Sample size

Sampling formula for estimating a population proportion with specified

absolute precision was calculated for this study:

Z 2 1 - α/2

P (1 - P)

n = ----------------------------

d 2

Z 1 - α/2 = 1.96 : critical value for 95% confidence level

α = 0.05

: level of significant

25

P = 0.20 : anticipated population (according to previous study, prevalence of

mental health problem in the Vietnamese youth) (Ministry of Health

[MOH]-Vietnam, 2005)

n = 246 : minimum sample size

3.4 Sampling technique

Using above formulation for result of 246 subjects and to predict number of

absent students or refusing to join this study, sample was added more 10% (24

students) so the total sample included 270 students.

Sampling technique: this study was the first study in order to measure the

prevalence of depression and related factor among Medical students so a census

investigation was conducted with total population of 387 students, though, collected

sample was 351 students.

3.4.1 Inclusion criteria

The entire 404 first year Medical student in Medical Faculty in

University Medicine and Pharmacy, Hochiminh city, Vietnam were chosen in this

study.

3.4.2 Exclusion criteria

17 repeat students were sort out this study population

3.5 Data collection tool

The questionnaire consisted of 3 parts with 79 questions; the first part was 19

questions about general information, the second part was depression measurement in

20 items of the CES-D questionnaire, and the third was 40 questions about Student

stress.

26

The questionnaire was translated into Vietnamese language and versus to

make sure the accurateness.

3.6 Data collection procedure

Data collection method: self – administrated

Pre-test (pilot) was implemented prior data collection in first year students in

other medical university at HoChiMinh city.

In the field, data were collected in classrooms with the approval by the Dean

of Medical Faculty. The purpose of study was explained to students before delivering

questionnaire

3.7 Data analysis

Questionnaire

was

coded

before

entering

the

data

to

computer

by

the

researcher. The sample database was checked by double entry.

For data analysis, the Statistical Package for the Social Sciences (SPSS

version 13) was used. The analysis part composed 2 parts, descriptive and analytical

statistic. In analytical statistic, data were tested in bivariate and multivariate analysis.

Descriptive statistics such as frequency, percentage, mean, and standard

deviation was applied for general characteristics, prevalence depression, sources of

medical stress description.

Analytical statistics

Bivariate analysis: Chi-square test and Fisher’s Exact test were used

to test the relationship between depression and the students stress sources, and also for

relationship between depression and living condition, perception of financial status,

27

practice of religion, parent's marital status, and exercise/leisure activity, coping with

problems, quality of friendship.

Non-parametric Spearman correlation was used to find association

between 2 continuous variables: depression and age; also between depression scores

and total stress scores.

 

Testing

of

the

hypothesis

will

be

performed

at

5%

level

of

significances.

 

Multivariate

analysis:

Logistic

regression

was

applied

to

find

predictors

of

effect

of

multivariable

in

dichotomous

depression

variable

after

controlling confounding factors. Level of significant was set at 5%.

For depression variable, question scores were summed to provide an

overall score ranging from 0 to 60. Four positive questions 4, 8, 12 and 16 were

reversed by subtracting the score from 3. If more than 5 items on the scale are

missing, a score is generally not calculated.

If one to five items on the scale were missing,

sum x 20 Score = number items answered

Depression score was categorized by cut-off point into 2 groups below:

Scores less than 22 = Non- depressive symptoms group

Scores are 22 or more = Depressive symptoms group

About

students

stress

sources

including

40

questions,

in

non-

parametric spearman correlation, students stress scores were summed up as a

28

continuous variable with non normality distribution. In chi-square test, then, students

stress was used separately in each 40 sources to find relationship with depression.

Table 2: Variables, measurement scale and statistic inference

Variables

Measurement scale

Statistic inference

Age Gender Ethnic Living status Perception of financial status Religious practice Parents' marital status Excise practice Leisure activity Coping problems Quality of relationship Depression group Depression scores Student stress sources Student stress scores

Ratio scale Nominal scale Nominal scale Nominal scale Ordinal scale Ordinal scale Nominal scale Ordinal scale Nominal scale Nominal scale Ordinal scale Nominal scale Continuous variable Binary variable Continuous variable

Mean, max, min, S.D Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Mean, Min, Max, S.D Number, Percentage Mean, Min, Max, S.D

3.8 Reliability and Validity

Validity

The content and face validity was checked by experts after constructing the

draft questionnaire, special focus on some terms and explanation in translation

English to Vietnamese.

29

Reliability

The reliability was done in pre test on 30 first year students in other Medical

university at Hochiminh city. Cronbach's alpha coefficient was used to measure

reliability of the CES-D questions. Cronbach's alpha coefficient for CES-D = 0.775

3.9 Ethical consideration

The questionnaire will be administered anonymously to the student in their

classrooms. Then, verbally consent information was explained to students before

delivering questionnaire. They can refuse to join this study without any effects on

their study's result and no need to explain the reason. Data were used for research's

purpose only. Their information will be kept confidentially.

CHAPTER IV

This

descriptive

RESULT

cross-sectional

study

was

conducted

in

University

of

Medicine and Pharmacy at HoChiMinh city, VietNam. The study determined the

prevalence of depression, sources of stress and factors related to depression among

351 first year Medical students. Total study population was 382 subjects but at last

total sample was 351 students with 91.0% of respond rate. The results are presented in

four parts as follows:

General characteristics including general and potential personal consequence

factors

Prevalence of depression among the first year Medical students

Sources of stress among the first year Medical students.

Relationship between general

characteristics,

potential

personal

factors, sources of stress and depression.

4.1 Description of General characteristics

Gender

consequence

There were 351 first year Medical students that consisted of male more than

female (58.1% vs 41.9%).

Age

The students' age ranged from 18 to 25 years, with a mean age of 19.37 and

31

Ethnicity

The main ethnicity group was Vietnamese accounting for 85.2%; the Khmer

group was 5.7%; others groups were Chinese, Cham and Cambodian with 8.1%.

Living status

Living status included 4 variables as hometown, living location, type of

accommodation, and whom student lived with.

Hometown and living location

Most of the students' hometown was not from HoChiMinh city

(77.8%). They were mainly located in inner-city with 90.9%, only 9.1% of them

stayed in sub-urban area.

Type of accommodation and whom student lived with

They mainly lived in rented-room or house with 35%, in dormitory

with 32.5%; 23.4% of them lived in their own home and some of them lived in their

relative's house by 6%. They lived with their friend (46.4%), their relative (21.1%),

their family (20.8 %) and stay alone (11.7%).

32

Table 3: Description of general characteristics

Variables

Frequency

Percentage

Gender (n=351)

Male

204

58.1

Female

147

41.9

Age (n=351)

Mean = 19.37 SD = 0.845

Range: 18-25

Ethnicity (n=351)

Vietnamese

299

85.2

Chinese

10

2.8

Khmer

20

5.7

Cham

22

6.3

Hometown (n=351)

Non-HCM city

273

77.8

HCM city

78

22.2

Living Location (n=351)

Inner city

319

90.9

Sub-urban

32

9.1

Type of accommodation (n=351)

Dormitory

114

32.5

Rented

room/house

123

35.0

One's home

82

23.4

Relative's home

21

6.0

Others

11

3.1

Whom students live with (n=351)

Alone

41

11.7

Friend

163

46.4

Relative

74

21.1

Family

73

20.8

Religion

About religion, more than half (66.4%) of the students said they had no

religion which actually it was Ancestor worship (a traditional belief may not be

strictly considered as a religion) or they were Buddhist but they did not practice

strictly as a follower. Buddhist was proclaimed as their religion by 21.1%, Christian

was rated with 10.8% and the rest was answered with 1.7% of others as Cao Dai.

33

Religion practice

Religion practice was defined as participation in services and activities of the

religion, particularly going to church or pagoda and fasting.

Among students that

have religion, those who sometime participate (twice/year & < once/4 week) was

37.3%, 33.1% of them always do their religious activities Always (once/week),

rarely practice were 16.9%; while only 12.7% of them followed often (one/4 week

& < one/week).

Table 4: The student's religion and their religious practice

Frequency

Percentage

Religion (n=351)

Buddhist

74

21.1

Christian

38

10.8

Others

6

1.7

Non

233

66.4

Religious practice (n=118)

Rarely

20

16.9

Sometime (twice/year & < once/4 week)

44

37.3

Often (one/4 week & < one/week)

15

12.7

Always (once/week)

39

33.1

Finance support

Most of the students were fully supported by their family with 92.9% (from

parents or sister/bother, and their relatives), some of them (5.1%) were partially

supported by their parents and the rest was earned by themselves, the others (2%)

loaned or were sponsored by government.

34

Part-time job

Among the students, some of them had part-time job with 10.8%, the

remaining (89.2%) had no part-time job.

Perception of financial status

38% of students felt their finance status was nearly sufficient, 33.9% felt that

it was sufficient and 4.3% answered that it was not enough for tuition. 12% of the

students said that their finance was comfortable, 11.7% reported that finance was not

enough for their living cost, 4.3% was responded not enough for tuition.

Table 5: Financial status

Variables

Frequency

Percentage

Financial support (n=351)

Fully support

326

92.9

Partialy support

18

5.1

Others

7

2.0

Part-time job (n=351)

No

313

89.2

Yes

38

10.8

Perception of financial status (n=351)

Not enough for tuition

15

4.3

Not enough for living

41

11.7

Nearly sufficient

134

38.2

Sufficient

119

33.9

Comfortable

42

12.0

35

Coping with problems

When facing the problems, 54.1 % of students talked with their friend, 24.2%

talked to parents, 19.1% solved by themselves, 13.1 % of them prayed, and others

chose traveling, solving by themselves with 8%.

Table 6: Coping with problems

Coping with problems *

Frequency

Percentage

1. Talk to friend (n=351)

190

54.1

2. Talk to parents (n=351)

85

24.2

3. Solve by oneself (n=351)

67

19.1

4. Praying (n=351)

46

13.1

5. Others (n=351)

28

8.0

6. Smoke/drink (n=351)

5

1.4

* Multiple choice question. More than one choice can be chosen

4.2 Potential personal consequence factors

Potential personal consequence factors concluded quality of relationship with

friends and with parents, parents' marital status, leisure, and exercise activities

variables.

Satisfaction with friendship

The table 7 presented 18.5% of students did not have close friend and only

20% had lover. Regarding satisfaction of relationship, 60.7% satisfied, 28.2% very

satisfied, 10.3% of student did not satisfy, only nearly 1% did not satisfy with their

friend at all.

36

Table 7: Quality of friendship

Quality of friendship

Frequency

Percentage

Having Close friend (n=351)

Yes

286

81.5

Having lover (n=351)

Yes

71

20.2

Satisfaction with friendship (n=351)

Very satisfy Satisfy Not satisfy Not satisfy at all

99

28.2

213

60.7

36

10.3

3

0.9

Parents' marital status

Almost parents of students lived together (92.9%), remaining percentages with

3.1% of students lost their father or mother, 2.6% their parent divorced and 1.4% for

separated parent.

Quality of relationship with parents

About the satisfaction of relationship with parents, the percentage of students

very satisfied more than percentage of satisfied (63% vs 32.5%), only 4.3% of them

did not satisfy and 0.3% for not satisfy at all.

37

Table 8: Quality of relationship with parents

Frequency

Percentage

Parents' marital status (n=351)

Together

326

92.9

Separated

5

1.4

Divorce

9

2.6

Loss

11

3.1

Satisfaction of relationship with parents (n=351)

Very satisfy

221

63.0

Satisfy

114

32.5

Not satisfy

15

4.3

Not satisfy at all

1

.3

Leisure activities

The percentage of students who chose listening to music of reading book,

watching television and playing games for leisure in free time was 74.4%. Following

that was 29.6% of students who went out with friends and only 14.5% of play sports;

Besides, 3.4% student chose sleeping and 8.8% for others such as nothing, some

complained that they did not have free time and others choices as went back their

home town, did homework.

Exercise practice

The highest percentage did it sometime (1 & 3 times/month) by 28.2%;

26.5% of them did exercise seldom (< 1 time/month), 12.3% of students answered

never doing. Doing exercise often (> 3 & < 12 times/month) was responded by 21.4%

and only 11.7% for practice always (12 times/moth).

38

Table 9: Leisure activities and exercise practice

 

Frequency

Percentage

Leisure activities*

1. Listen to music/read book/TV/game (n=351)

261

74.4

2. Go out with friend (n=351)

104

29.6

3. Sport (n=351)

51

14.5

4. Others (n=351)

31

8.8

5. Sleeping (n=351)

12

3.4

Exercise activities (n=351) Never Seldom (< 1 time/month) Sometime (1 & 3 times/month) Often (> 3 & < 12 times/month) Always (12 times/moth)

43

12.3

93

26.5

99

28.2

75

21.4

41

11.7

* Multiple choice question. More than one choice can be chosen

4.3 Student stress factors

Generally, students responded whole 40 items student stress factors that

focused on four main sources, including interpersonal, intrapersonal, and academic

sources. Students were asked about their experiences those events during this

academic year (from September, 2007 until February, 2008).

Interpersonal factors

In interpersonal sources, among six factors, the highest percentage (62.7%) of

students was stressed of working with un-acquainted people, followed by 51.3% of

change in social activities. The remaining with finding new friends experience was

responded 36.8%, 26.5% of trouble with parent, and 22.8% for conflicted with

roommate.

39

Intrapersonal s factors

In sixteen intrapersonal sources, most of the students (91.7%) had started

college and they had to deal with new responsibilities (88.6%); moreover, they

changed their sleeping, eating habits (76.1% & 70.7%) and declined their health

obviously (60.1%). In additional, many students (64.1%) found difficulty in speaking

in public and nearly half of the students (47.9%) admitted to violate the minor law

such as the laws of safe traffic, then a little lower percentage of student (44.4) faced

financial difficulties.

Academic factors

Being a student, increased class workload and lower grader than anticipated

were 2 problems that most of Medical students experienced with 88% and 82.3%;

they also reported that missed too many classes by 55% and anticipated of graduation

by 47.3% in eight academic sources.

Environmental factors

According to environmental sources, approximately 72% of students had to

change in living environment and placed in unfamiliar situation; they were put on

hold for extended period of time (67%) and their vacation or break time were not

enough (61.8%); car troubles (56.1%), wait in long line (55%), and computer

problems (49.3%).

40

Table 10: Student stress factors

Student stress factors (n=351)

Frequency

Percentage

Interpersonal factors

1. Working with unacquainted people

220

62.7

2. Change in social activities

180

51.3

3. Trouble in finding new friend

129

36.8

4. Trouble with parents

93

26.5

5. Roommate's conflict

80

22.8

6. Fight with friend

(quarrel or cannot get along with friend)

31

8.8

Intrapersonal factors

1. Started college

322

91.7

2. New responsibilities

311

88.6

3. Change in sleeping habits

267

76.1

4. Change in eating habits

248

70.7

5. Problem in spoke in public

225

64.1

6. Decline in personal health

211

60.1

7. Minor law violation (such as traffic law…)

168

47.9

8. Financial difficulties

156

44.4

9. Outstanding personal achievement (excellent study performance)

72

20.5

10. Holding a job

64

18.2

11. Death of a family member

54

15.4

12. Change in religious beliefs

30

8.5

13. Change in use of alcohol or drugs

30

8.5

14. Death of a friend

18

5.1

15. Severe injury

17

4.8

16. Engagement/Marriage

10

2.8

41

Table 10: Student stress factors (continued)

Stude