Depression and Stress Among First Year Medical Students

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 Masters 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 Students signature
Academic year 2007
Advisors 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.
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
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
: Chi-square
CHAPTER
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, Chm 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.
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.
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
Coping with problem

Quality of relationship
Leisure/Exercise activity
Student stress
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)
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-tolate 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 clinicianrating 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 Becks depression
inventory (BDI), Zungs self-rating depression scale, Raskins depression scale, and
the Minnesota Multiphasic personality inventory. It performs comparably with other
self-report scales and CES-D is better than BDIs 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
STUDENT DISTRESS
Stress
Anxiety
Burnout
Depression
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 Zungs 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:
Z2 1 - /2 P (1 - P)
n = ---------------------------d2
Z 1 - /2 = 1.96 : critical value for 95% confidence level
= 0.05
: level of significant
d = 0.05
: absolute precision required
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 Fishers 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,
Score =
sum x 20
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 nonparametric 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
Ratio scale
Mean, max, min, S.D
Gender
Nominal scale
Frequency, Percentage
Ethnic
Nominal scale
Living status
Nominal scale
Ordinal scale
Religious practice
Ordinal scale
Nominal scale
Excise practice
Ordinal scale
Leisure activity
Nominal scale
Coping problems
Nominal scale
Quality of relationship
Ordinal scale
Depression group
Nominal scale
Depression scores
Continuous variable
Mean, Min, Max, S.D
Student stress sources
Binary variable
Number, Percentage
Student stress scores
Continuous variable
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
RESULT
This descriptive 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 consequence
factors, sources of stress and depression.

4.1 Description of General characteristics
Gender
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
standard deviation of 0.845.
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
Female
204
147
58.1
41.9
Age (n=351)
Mean = 19.37
SD = 0.845
Range: 18-25
Ethnicity (n=351)
Vietnamese
Chinese
Khmer
Cham
Hometown (n=351)
Non-HCM city
HCM city
Living Location (n=351)
Inner city
Sub-urban
Type of accommodation (n=351)
Dormitory
Rented
room/house
One's home
Relative's home
Others
Whom students live with (n=351)
Alone
Friend
Relative
Family
299
10
20
22
85.2
2.8
5.7
6.3
273
78
77.8
22.2
319
32
90.9
9.1
114
32.5
123
35.0
82
21
11
23.4
6.0
3.1
41
163
74
73
11.7
46.4
21.1
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
1.7
233
66.4
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
Others
Non
Religious practice (n=118)
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.
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
18
5.1
2.0
No
313
89.2
Yes
38
10.8
Not enough for tuition
15
4.3
Not enough for living
41
11.7
Nearly sufficient
134
38.2
Sufficient
119
33.9
42
12.0
Partialy support
Others
Part-time job (n=351)
Perception of financial status (n=351)
Comfortable
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
1.4
6. Smoke/drink (n=351)
* 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
Yes
71
20.2
99
28.2
213
60.7
36
10.3
0.9
Having lover (n=351)

Satisfaction with friendship (n=351)
Very satisfy
Satisfy
Not satisfy
Not satisfy at all
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
1.4
Divorce
2.6
11
3.1
Very satisfy
221
63.0
Satisfy
114
32.5
15
4.3
.3
Loss
Satisfaction of relationship with parents (n=351)
Not satisfy
Not satisfy at all
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
Never
43
12.3
Seldom (< 1 time/month)
93
26.5
Sometime ( 1 & 3 times/month)
99
28.2
Often (> 3 & < 12 times/month)
75
21.4
Always ( 12 times/moth)
41
11.7
Exercise activities (n=351)
* 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).
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
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
31
8.8
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
6. Fight with friend

(quarrel or cannot get along with friend)
41
Table 10: Student stress factors (continued)

Student stress factors (n=351)
Frequency Percentage
Academic factors
1. Increased class workload
309
88.0
2. Lower grade than anticipated
289
82.3
3. Missed too many classes
193
55.0
4. Anticipation of graduation (expectation after graduation)
166
47.3
5. Search for graduate school/job (prepare for after graduation)
97
27.6
6. Change of Major
44
12.5
7. Transferred schools
35
10.0
8. Serious argument with instructor
29
8.3
1. Change in living environment
254
72.4
2. Placed in unfamiliar situation
251
71.5
235
67.0
217
61.8
5. Car trouble
197
56.1
6. Waited in long line
193
55.0
7. Computer problems
173
49.3
8. Messy living conditions
116
33.0
24
6.8
1.7
Environmental factors
3. Put on hold for extended period of time

(waiting for something for uncertainty time)
4. Vacations/breaks
(no vacations/break or it was too short or not enough)
9. Quit job
10. Divorce between parents
42
4.4 Prevalence of depression
Using CES-D question for asking the feeling or behaviors that the responder
had during last week, twenty scale questions scored from 0 to 3 as 0 for never or
rarely, 1 for sometime, 2 for occasionally, 3 for mostly level were summed up of 20
questions. The minimum score and maximum was 4 and 50, the range was 4-50. The
mean and standard deviation was 19.6 and 8.5.
According to previous study done by Ratana that using CES-D tool and cut-off
point of 22, with the screening approach, the found out that 39.6% of the first year
Medical students were having depressive symptom (more than 22 scores), 60.4% of
them had no depressive symptom (less than 22 scores).
Table 11: Prevalence of depression among the first year Medical students
Prevalence of depression (n=351)
Frequency
Percentage
No Depressive symptom
212
60.4
Depressive symptom
139
39.6
Mean = 19.6, SD = 8.5, Range: 4 50
4.5 Relationship between depression and related factors
In the analytical part, firstly, depression variable was used as a binary variable
with two values, have depressive symptom and have no depressive symptom. The
relationship between general characteristics, potential personal consequence factors,
source of stress and depression were determined by Chi-square test, Spearman
correlation and the level of significance for relationship between these variables was
43
set at P-value = 0.05. Secondly, Logistic regression was used in multivariate analysis
with odds ratio, coefficient and p-value.
Bivariate analysis
4.5.1 Relationship between depression and general characteristics
Age
Using non-parametric spearman correlation to find relationship

between ages as a continuous variable with non-normality distribution and depression
as continuous variable, the relationship was not significant difference at P-value =
0.081 (>0.05).
Gender
There was no significantly difference between percentage of male and

female who get depression with P-value = .201
Ethnicity
After combination of Khmer, Cham, Chinese and others become one

group because expected values were less than 5%, there were highly significantly
differences between depression and ethnicity (P-value = 0.01). 55.8% of other ethnic
students had depression that compared with 36.8% percentage of Vietnamese
students.
Hometown
Students who had hometown in other provinces and in HCM city were
not significant difference in prevalence of depression with P-value = .307
44
Living location
There was no significantly difference between percentage of students

that live in inner city and sub-urban get depression with P-value = 0.377
Type of accommodation
The differences between types of accommodation and depression was

highly significantly (P-value = 0.014). Students lived in dormitory were likely get
depression with highest percentage (51.8%) comparing with other places.
Religion
There was no significantly difference between depression and religion

variable with P-Value = 0.147
Whom students live with
Students lived with friends and alone get depression higher (46.6%)
than the other students who lived with family or their relative at P-value = 0.015.
45
Table 12: The relationship between depression and general characteristics

Depression
Non Depressive
symptoms
n (%)
Depressive
symptoms
n (%)
2 (df)
P-value
Gender (n=351)
129 (63.2)
75 (36.8)
Female
83 (56.5)
64 (43.5)
Ethnicity (n=351)
Vietnamese
Others
189 (63.2)
23 (44.2)
Hometown (n=351)
HoChiMinh
Non-HoChiMinh
51 (65.4)
161 (59.0)
Male
1.638(1)
.201
110 (36.8)
29 (55.8)
6.671(1)
.010
27 (34.6)
112 (41.0)
1.042(1)
.307
124 (38.9)
15 (46.9)
0.779(1)
.377
55 (48.2)
82 (66.7)
55 (67.1)
20 (62.5)
59 (51.8)
41 (33.3)
27 (32.9)
12 (37.5)
10.646(3)
.014
38 (51.4)
30 (68.2)
144 (61.8)
36 (48.6)
14 (31.8)
89 (38.2)
3.839(2)
.147
Whom students lived with (n=351)

Alone
22 (53.7)
Friends
87 (53.4)
Relative
54 (73.0)
Family
49 (67.1)
19 (46.3)
76 (46.6)
20 (27.0)
24 (32.9)
10.413(3)
.015
Living location (n=351)

Inner city
Sub-urban
195 (61.1)
17 (53.1)
Type of accommodation (n=351)

Dormitory
Rented room/house
One's own
Relative's + Others
Religion (n=351)
Buddhist
Christian + others
Non-religion
Religious practice
There was not significantly difference between depression and the

level of religious practice of students at P-value = 0.615
46
Table 13: The relationship between depression and religion practice
Religion practice
(n=351)
Rarely
Sometime
Often
Always
Depression
Non Depressive
Depressive
symptoms
symptoms
n (%)
n (%)
12 (60.0)
8 (40.0)
22 (50.0)
22 (50.0)
9 (60.0)
6 (40.0)
25 (64.1)
14 (35.9)
2 (df)
P-value
1.799(3)
.615
As shown in table 14, the difference between depression and

perception of financial status was significant with 0.044 of P-value. The students who
had not enough finance for tuition fee get depressive symptom at highest percentage
at 73.3% comparing with lower depression of other higher financial status.
Table 14: The relationship between depression and perception of financial status
Not enough for tuition

Not enough for living cost
Nearly enough
Sufficient
Comfortable
Depression
Non Depressive Depressive
symptoms
symptoms
n (%)
n (%)
4 (26.7)
11 (73.3)
21 (51.2)
20 (48.8)
86 (64.2)
48 (35.8)
74 (62.2)
45 (37.8)
27 (64.3)
15 (35.7)
2 (df)
9.805(4)
Pvalue
.044
Coping with problem
There were many ways that students chose to cope with their problems
like talking to friends, talking to parent, praying, smoking/drinking, solving by
themselves, etc. Among those ways, there were no differences between depression
and each of above way significantly (P-value>.05). In multiple choices, there were no
significant differences in combination many choices and depression.
47
Table 15: The relationship between depression and coping with problems
Coping with problem*
Talk to friends
Depression (n=351)
Non Depressive
Depressive
symptoms
symptoms
n (%)
n (%)
121 (63.7)
69 (36.3)
2 (df)
P-value
1.869(1)
.172
Talk to parents
58 (68.2)
27 (31.8)
2.880(1)
.090
Pray
25 (54.3)
21 (45.7)
.810(1)
.368
4 (80.0)
1 (20.0)
**
.652
Solve by yourself
43 (64.2)
24 (35.8)
.495(1)
.482
Others
14 (50.0)
14 (50.0)
1.376(1)
.241
Smoke/drink
* Multiple choices question. More than one choice can be chosen.

** Fisher's exact test
4.5.2 Relationship between depression and potential personal consequence
Potential personal consequence factors were satisfaction of relationship

with their friends in general and parents. Satisfaction was a scale variable with 4
values as very satisfy, satisfy, not satisfy and not satisfy at all, but in Chi-square test 2
last values (not satisfy and not satisfy at all) was combined to become one value that
was showed in table 16.
Quality of friendship with friends
There was a highly significantly differences between depression and

satisfaction of students with their friend at P-value < .0001. Percentage of students did
not satisfy with their friend get depressive symptom with highest percentage (64.1).
Among students who had no close friends and lower, percentage of
depressive symptom in not satisfy group (80%) was likely more higher significant
than not satisfy group (37.2%) with p-value =0.031.
48
Quality of relationship with parents
Among students whose parents divorced or separated, 100% of them

were not satisfy with their relationship with parents. The difference between
depression and satisfaction with their parents was highly significant with P-value =
.005, by the highest percentage of students in not satisfy group (75.0) get depressive
symptom compared with the others group.
Table 16: The relationship between depression and quality of relationship
Depression
symptoms
symptoms
n (%)
n (%)
Satisfaction with friendship (n=351)
Very satisfy
Satisfy
Not satisfy + not satisfy at all
73 (73.7)
26 (26.3)
125 (58.7)
88 (41.3)
14 (35.9)
25 (64.1)
2 (df)
Pvalue
17.414(2)
<.001
10.641(2)
.005
Satisfaction of relationship with parents (n=351)
Very satisfy
Satisfy
Not satisfy + not satisfy at all
143 (64.7)
78 (35.3)
65 (57.0)
49 (43.0)
4 (25.0)
12 (75.0)
Table 17: The satisfaction with friendship among students who have no close friend
and lower
Satisfaction with
friend (n=53)
Satisfy
Not satisfy
* Fisher's exact test
Depression
Non Depressive
Depressive
symptoms
symptoms
n (%)
n (%)
27 (62.8)
16(37.2)
2 (20.0)
8 (80.0)
2 (df)
P-value
.031
49
Exercise practice
The difference between those who did exercise regularly and those
who did not exercise had high significant relationship with depression by P-value =
.006. Those who did not exercise had depressive symptom with highest percentage
(53.5) comparing with remaining groups.
Table 18: The relationship between depression and exercise practice
Exercise activity
Never
Depression
symptoms
symptoms
n (%)
n (%)
20 (46.5)
23 (53.5)
Seldom (< 1 time/month)
48 (51.6)
45 (48.4)
Sometime ( 1 & 3 times/month)
61(61.6)
38 (38.4)
Often (> 3 & < 12 times/month)
57 (76.0)
18 (24.0)
Always ( 12 times/moth)
26 (63.4)
15 (36.6)
2 (df)
14.31(4)
Pvalue
.006
Leisure activities
Leisure activities including going out with friends, listening to

music/reading book/watching TV/playing games, playing sports, sleeping, and others
were checked separately the relationship with depression. Within each separate
choice, there were no significantly differences in any relationship with P-value > 0.05
(shown in appendix A)
For more than one choice that shown in table 20, students who chose
going out with friend and listening to music/read book/TV/game get less depressive
symptom than the students who had one leisure activity. This different was significant
with P-value = 0.032. Only 25 students chose play sport and listen to music/read
book/TV/game, 25 students chose to play sport and go out with friends, the chi-square
50
test for relationship among those choice and depression showed insignificant
difference with p-value>0.05.
Table 19: The relationship between leisure activities and depression
Depression
Leisure* (n=351)
symptoms
symptoms
n (%)
n (%)
Go out with friend and listen to music/ book/ TV/game
Yes
43 (72.9)
16 (27.1)
No
169 (57.9)
123 (41.2)
2 (df)
P-value
4.620
0.032
* Multiple choices question. More than choice can be chosen

4.5.3 Relationship between depression and student stress
Firstly, stress was considered as continuous data by sum total score that
students responded their experience during this academic year (since September, 2007
until February, 2008). The range of stress score was from 1 to 29, with mean of 16.42
and SD = 4.72. Then the relationship between depression and stress was analyzed in
Spearman Correlation for non parametric statistics. Generally, stress and depression
had a positive linear relationship highly significant with correlation coefficient r =
0.272 and p-value < 0.001.
Table 20: The relationship between stress and depression
Coefficient
P-value
Spearman correlation (n=351)

Stress score and depressive score
.272
< .001
51
As Students stress survey approach, the student stress source focus on
sources of stress so the relationship between depression and 40 student stress sources
was characterized specifically in table 21, 22, 23 and 24.
Interpersonal stress sources
In table 21, among 6 factors in interpersonal sources, only relationship

between depression and trouble with parent, change in social activities was not
significant differences with P-value > 0.05. The 4 remaining sources that consisting
finding new friend; working with un-known people, roommate conflict and fight with
friend was significant differences.
Finding new friend
There were significant differences between depression and experiences

in finding new friend at P-value = 0.025. Percentage of students who had finding new
friend experience get depression higher than students who had no that experience with
4 7.3% vs 35.1%.
Working with un-acquainted people
Students who had to work with un-acquainted people had lower

depressive symptom at comparing with students who had no experience in work with
un-acquainted people with 35.0% and 47.3% respectively at P-value = 0.022.
Roommate conflict
The difference between depression and roommate conflict of among

students was significantly at P-value = 0.03. Half of students (50%) who had
roommate conflict get depression while only 36.5% of students that had not conflict
get depression.
52
Fight with friend
Nearly 58% of students that fought with friend get depression while
37.8% of students had no fighting had depression. This different was significant at Pvalue = 0.028.
Table 21: The relationship between depression and interpersonal sources
Depression
Non Depressive
Depressive
symptoms
symptoms
n (%)
n (%)
Interpersonal sources (n=351)
2 (df)
Pvalue
1. Finding new friend

Yes
68 (52.7)
No
144 (64.9)
61 (47.3) 5.037 (1)
.025
78 (35.1)
2. Working with un-acquainted people

Yes
143 (65.0)
77 (35.0)
No
69 (52.7)
62 (47.3)
Yes
40 (50.0)
40 (50.0)
No
172 (63.5)
99 (36.5)
Yes
107 (59.4)
73 (40.6)
No
105 (61.4)
66 (38.6)
Yes
13 (41.9)
18 (58.1)
No
199 (62.2)
121 (37.8)
Yes
57 (61.3)
36 (38.7)
No
155 (60.1)
103 (39.9)
5.217(1)
.022
4.684(1)
.030
.141(1)
.708
4.846(1)
.028
.042(1)
.838
3. Roommate's conflict?
4. Change in social activities
5. Fight with friend
6. Trouble with parents
53
Intrapersonal stress sources
Among 17 intrapersonal sources, there were only 2 sources as minor

law violation and decline in personal health had significantly differences.
Minor law violation
There was significant difference between minor law violation and

depression in which the percentage of students that violated minor law had higher
percentage than those who did not violate by 45.2% vs 34.4% at P-value = 0.039.
Decline in personal health
There was highly significantly difference between depression and

decline in personal health by P-value = 0.001. Among students who declined in their
health with 46.4% responded depressive symptom, a lower percentage of depression
in group did not decline in their health with 29.3%.
Table 22: The relationship between depression and intrapersonal sources
Depression
Non
Depressive
Depressive
symptoms
symptoms
n (%)
n (%)
2 (df)
P-value
Intrapersonal Sources
7. New responsibilities
Yes
185 (59.5)
126 (40.5)
No
27 (67.5)
13 (32.5)
Yes
16 (55.2)
13 (44.8)
No
196 (60.9)
126 (39.1)
.952(1)
.329
.361(1)
.548
8. Started college
54
Table 22: (continued) The relationship between depression and intrapersonal sources
Depression
Non
Depressive
Depressive
symptoms
symptoms
n (%)
n (%)
2 (df)
P-value
9. Change in sleeping habits

Yes
155 (58.1)
112 (41.9)
No
57 (67.9)
27 (32.1)
Yes
147 (59.3)
101 (40.7)
No
65 (63.1)
38 (36.9)
2.568(1)
.109
.447(1)
.504
11. Outstanding personal achievement (excellent study performance)

Yes
43 (59.7)
29 (40.3)
No
169 (60.6)
110 (39.4)
Yes
90 (57.7)
66 (42.3)
No
122 (62.6)
73 (37.4)
Yes
132 (58.7)
93 (41.3)
No
80 (63.5)
46 (36.5)
Yes
16 (53.3)
14 (46.7)
No
196 (61.1)
125 (38.9)
Yes
92 (54.8)
76 (45.2)
No
120 (65.6)
63 (34.4)
Yes
113 (53.6)
98 (46.4)
No
99 (70.7)
41 (29.3)
.017(1)
.895
.860(1)
.354
.786(1)
.375
.685(1)
.408
4.281(1)
.039
10.361(1)
.001
13. Spoke in public
15. Minor law violation
55
Table 22: (Continued) The relationship between depression and intrapersonal sources
17. Held a job
Yes
40 (62.5)
24 (37.5)
No
172 (59.9)
115 (40.1)
.144(1)
.704
1.483(1)
.223
.203
1.949(1)
.163
.004(1)
.949
1.329(1)
.249

Yes
15 (50.0)
15 (50.0)
No
197 (61.4)
124 (38.6)
4 (40.0)
6 (60.0)
208 (61.0)
133 (39.0)
Yes
28 (51.9)
26 (48.1)
No
184 (62.0)
113 (38.0)
8 (47.1)
9 (52.9)
201 (60.4)
132 (39.6)
Yes
11 (61.1)
7 (38.9)
No
204 (61.1)
130 (38.9)
Yes
No

Yes
No
22. Severe injury
Academic stress sources
According to table 22, in comparison between depression toward 8

academic stress sources, only increased workload and depression relationship had
significantly differences, the 7 rest sources had no significant of P-value > 0.05.
Increased workload: Among students who answered that increased
class working had depressive symptom with 41.7%, unlike this, students did not
increase their class workload with 23.8% get depression at P-value = 0.026 for very
significantly difference.
56
Table 23: The relationship between depression and academic sources
Depression
symptoms
symptoms
n (%)
n (%)
2 (df)
P-value
Academic sources

Yes
180 (58.3)
129 (41.7)
No
32 (76.2)
10 (23.8)
Yes
168 (58.1)
121 (41.9)
No
44 (71.0)
18 (29.0)
Yes
27 (61.4)
17 (38.6)
No
185 (60.3)
122 (39.7)
Yes
51 (52.6)
46 (47.4)
No
161 (63.4)
93 (36.6)
Yes
113 (58.5)
80 (41.5)
No
99 (62.7)
59 (37.3)
4.974(1)
.026
3.517(1)
.061
.020(1)
.889
3.428(1)
.064
.613(1)
.434
2.520(1)
.112
.346(1)
.556
.459(1)
.498
25. Change of Major
26. Search for graduate school/job
28. Anticipation of graduation (expectation after graduation)

Yes
93 (56.0)
73 (44.0)
No
119 (64.3)
66 (35.7)

Yes
19 (65.5)
10 (34.5)
No
193 (59.9)
129 (40.1)
Yes
23 (65.7)
12 (34.3)
No
189 (59.8)
127 (40.2)
57
Environmental stress sources
Among 10 environmental stress sources, the test to find relationship

between those source and depression found that only 3 differences significant with Pvalue, including messy living conditions, put on hold for extended period of time, and
quit job (in table 24).
Messy living conditions
Among students that had messy living conditions, the percentage of

students get depression was 48.3% while 35.3% of students that did not have those
factors with significantly at P-value = 0.02.
Put on hold for extended period of time
Putting on hold for extended period of time (waiting for something for
uncertainty time) as a source of stress was get depression with 46% while those who
did not wait for something for uncertainty time get depression only 26.7%. These
difference was highly significant at P-value = 0.001.
Quit job
For students that had to quit their job, depressive symptom in them
responded at 58.3%, otherwise the percentage of depression in group that had not
quite job was 38.2%. There was close to significantly difference at P-value = 0.052
58
Table 24: The relationship between depression and environmental stress factors
Depression
symptoms
symptoms
n (%)
n (%)
2 (df)
P-value
Environmental sources
31. Vacations/breaks
Yes
126 (58.1)
91 (41.9)
No
86 (64.2)
48 (35.8)
Yes
108 (56.0)
85 (44.0)
No
104 (65.8)
54 (34.2)
Yes
154 (61.4)
97 (38.6)
No
58 (58.0)
42 (42.0)
Yes
146 (57.5)
108 (42.5)
No
66 (68.0)
31 (32.0)
Yes
112 (56.9)
85 (43.1)
No
100 (64.9)
54 (35.1)
Yes
107 (61.8)
66 (38.2)
No
105 (59.0)
73 (41.0)
1.295(1)
.255
3.534(1)
.060
.336(1)
.562
3.273(1)
.070
2.361(1)
.124
.300(1)
.584
35. Car trouble
59
Table 24: (continued) The relationship between depression environmental stress

factors
Depression
symptoms
symptoms
n (%)
n (%)
2 (df)
P-value

Yes
60 (51.7)
56 (48.3)
No
152 (64.7)
83 (35.3)
5.451(1)
.020
38. Put on hold for extended period of time (waiting for something for uncertainty time)
Yes
127 (54.0)
108 (46.0)
No
85 (73.3)
31 (26.7)
Yes
10 (41.7)
14 (58.3)
No
202 (61.8)
125 (38.2)
4 (66.7)
2 (33.3)
208 (60.3)
137 (39.7)
12.011(1)
.001
3.779(1)
.052
.100(1)
.752
39. Quit job

Yes
No
* Fisher's exact test
Multivariate analysis
Multivariate analysis was used to describe relationship between depression

and stressors, depression and potential personal consequence factors under influences
of general characteristics. All variables have significant difference in relationship with
depression in bivariate analysis was checked inter-relationship before put in logistic
model concluding ethnicity, type of accommodation, perception of financial status,
whom the student lived with, satisfaction with friend and parents, exercise practice,
and stress factors as working with un-acquainted people, roommate conflict, fight
60
with friend, minor law violation, decline in personal health, increased class work load,
messy living conditions, and put on hold for extended period of time.
Among many different people that students lived with, those who lived their
relative and family get less depressive symptoms than the other did not so whom the
student lived variable was re-coded as living with family with yes and no values.
Similarly, type of accommodation was re-classified as living in dormitory variables
with yes and no value based on the highest percentage of students get depressive
symptoms was lived in dormitory comparing with other type of accommodations.
In term of inter-relationship, each variable among 16 independent variables
was taken out of Logistic model, and then compared chi-squared value, coefficient,
and p-value as well in test of model coefficient. If the change was significant, the
relationship was checked by chi-square (shown in appendix A) and this variable was
not put in logistic model. There were 3 variables shown the inter-relationship
including out living in dormitory, living with family and ethnicity. The variable had
lower chi-square in Logistic model was chosen in model, the others was taken out of
the final model.
The change in chi-square value of model of coefficient of Logistic regression
when took out living in dormitory, living with family and ethnicity was presented
following:
Took living in dormitory out of model:
2 = 86.526
Took living with ethnicity out of model:
2 = 86.106
Took living with family out of model :
2 = 85.106
61
With p-value < 0.001, living with family with smaller chi-square value was
remained in model, 2 others was rejected.
After controlling all variables and checking inter-relationship, the final model
consisted of 8 variables which contributed to depressive out-come significantly with
p-value < 0.05.
Table 25: The relationship between depression and related factors in Logistic
regression model
Logistic regression model (n=351)
Lived with family

Satisfaction of relationship with
parents
Satisfaction with friendship
Exercise practice
Fight with friend
Decline in personal health
Put on hold for extended period of
time
95.0% C.I.
B
OR
Pvalue
Lower
Upper
-.989
.372
<.001
.224
.618
.570
1.769
.010
1.149
2.724
.613
1.845
.004
1.211
2.810
-.314
.730
.003
.593
.899
-.638
.528
.013
.319
.874
1.032
2.806
.015
1.223
6.436
.696
2.007
.007
1.206
3.340
.717
2.049
.009
1.199
3.501
When Students who lived with their family and their relative, the risk to get
depressive symptoms reduced 0.372 times at p-value < 0.001 and coefficient = 0.989.
Satisfaction of relationship with parents also had positive (B=0.570) effect on
depression. When students change their feeling such as from satisfy to not satisfy, the
risk to get depressive symptom increased by odds ratio = 1.769 significantly by p-
62
value 0.010. Similarly, satisfaction with friendship was significant positive effect on
depression with odds ratio = 1.845 and p-value = 0.004.
In terms of potential personal consequence factors, exercise practice effects
negatively on group had depressive symptoms. At p-value = 0.003, the risk of
depression likely increases 0.7 times when student reduces frequency of doing
exercise one level.
As a stressor, with negative effect of coefficient, students who worked with
un-acquainted people reduced risk of depression 0.493 at p-value=0.009.
Students who fought with their friends increased risk to get depressive
symptoms with odd ratio = 2.806 at p-value = 0.015 and coefficient = 1.032.
Regarding intrapersonal stress factors, students decline in personal increased
risk of depression 2 times with p-value = 0.007 at coefficient = 0. 696.
Students who had to wait for something so long increased risk to get
depression 2.049 times with coefficient B = 0. 717 and p-value= 0.09.
CHAPTER V
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
5.1 Discussion
A cross-sectional study was carried out in 351 first year Medical students to
find out the prevalence of depression and its relationship with related factors in
University of Pharmacy and Medicine at HoChiMinh city, Vietnam, in February,
2008.
The first year students were the subject that has some special characteristics
related to their mental health status specifically stress and depression consequently.
Most of them were in the age of 19, some of them were more than 21 years old
because they took entrance exam for more than two times. For the freshman
university, they had to face to the transition from a personal to an impersonal
academic environment, very structure of academic experience at college level and
Medical major in particular was high pressure and requirement. According to
Education and training management Department of University of Medicine and
Pharmacy at HoChiMinh city, in the first term of the first Medical academic year, the
students had to attend class 48 hours per week and finish their homework,
assignments and final exam at the same time without break time after finish subject.
Additional, a huge and broad information and knowledge in very specific major of
Medical increase pressure of overload working for students, presenting in high
prevalence of stress in increased class workload (88%) and lower grade than
anticipated (82.3%). This result was consistency with a study conducted by Shield
64
(Shields, 2001).In addition 76.1% of students changed their sleeping habit which
might be a result from not only too many class works but also from lack of time
management skills and learning strategy (Misra et al., 2000). It is evident that
necessary information and skills were not available for freshmen students in this
university. Moreover, most of them (77.8%) lived far from home for the first time,
they majority had lived in rented room or rented house and dormitory with their
friends. However, among 118 students lived in dormitory, there were 20 students
(17.0%) responded that they lived alone. Spending more than 4 months (since
September to February) but still could not make any friends, thus they felt lonely.
This characteristic was reflected in high percentage of stress in "troubles in finding
new friends" (36.8%).
Prevalence of depression among the first year Medical students was quite high
by 39.6%. This finding was higher than the result in the study done by Ratana in Thai
adolescents aging between 18 to 21 with 33.1% (Somrongthong, 2004) and also
higher than depressive prevalence in freshman college in Hong Kong and Beijing
(Yuqing et al., 2008). With very strict and tough requirement of Medical academic
environment, in addition to the fact that data collection of this study was at the end of
the first term, the students were spending time for many exams so they might respond
with high percentage of poor feeling.
In bivariate analysis, regarding gender, female students seem to be higher in
prevalence of depressive symptom insignificant than male. This finding was similar
with study in Beijing (Yuqing et al., 2008) and also found in metropolitan China study
(S. Lee et al., 2007). However, it is contrasted with study did in adult women whose
65
had higher significantly depressive prevalence than male in Korean (Cho et al., 1998).
Being a first year student, female and male faced to similar changes in the transition
stage of life and they also learnt in the same conditions in this university life (similar
in distribution of general characteristics). Moreover, recently years the socialeconomic in Vietnam and particular in HoChiMinh city have changed and developing
so fast as well as additional changes in gender role in society might be explained for
non-difference in gender and depressive symptom.
There were significant associations between depression and general
characteristics in bivariate analysis. Those students who were an ethnic students had
higher prevalence of depressive symptoms than the Vietnamese students with p-value
= 0.01 was shown by 57% of ethnic students felt their finance was not enough. They
might be faced many difficulties in medical learning and adaptation many changes in
culture of the city life as well. In agreement, a study done in California found out that
depression was twice as high as among Latinos ethnic comparing with non-Latino
(10.5% versus 5.5%,p<0.001). Low acculturation was associated with an increased
risk of depressive symptoms (OR=1.54, p=0.007). Additionally, perception of
financial status related to depression that revealed sufficient and comfortable feeling
had likely less depressive symptoms than not enough perception by p-value = 0.044.
This was nearly similar meaning indirectly of higher risk factor for depressive
symptoms among the low income Latino ethnicity in study carried out at California
(Mikolajczyk et al., 2007). There were differences between depression and type of
accommodation where dormitory seemed to got higher percentage of depressive
symptoms.
66
Satisfaction of relationship revealed the quality of relationship with parents
and friends which were considered as very important support systems for students.
There were highly significant difference between those potential personal
consequences and depression, presenting with p-value < 0.01 for more satisfaction
with friends less depressive symptom and p-value = 0.05 also for higher in
dissatisfaction of relationship with parents higher prevalence of depressive
symptomatology. There was consistency with finding of peer and parents relationship
were associated with depressive symptom in Chinese American college students
(Ying et al., 2007). Furthermore, among the students who had no close friends and
lower, the percentage of depressive symptom in group "not satisfy with friends"
(80%) was likely more higher significant than "satisfy" group (37.2%) with p-value =
0.031. In agreement, poor interpersonal skills can create difficulties for adolescents in
changing relationship with peers (Burns et al., 2002).
Furthermore, exercise activity represented for personal self-care also belong to
potential personal consequence in which less exercise practice was likely get high
percentage of depressive symptom with p-value = 0.006. A study in Black women at
United State also found that exercise activity associated with a reduced odds of
depressive symptoms (Wise et al., 2006). The other study in high school senior
differentiated in the depressed and non depressed group, showing depressed group
was found to engage in less physical activity (Field et al., 2001). Regular physical
exercise has been shown to decrease the level of stress hormones the body releases in
response to stress. Experts recommend performing about 20 minutes of aerobic
exercise three times a week. Stretching is a form of exercise that relieves muscle
67
tension. A brisk walk is a healthy way to clear the mind and relieve tension (Paul
Ballas, 2006).
In view of using leisure time effectively, going out with friend or listening to
music/read book/TV/game or playing sport had positive meaning. Those students who
chose more than 2 positive choices get less depressive symptom than the students had
one leisure choice. This different was significant with P-value = 0.040 (shown in
Appendix A)
University students, especially freshmen, were risk subjects of stress due to
the transitional nature of university life (Aktekin et al., 2001; Dahlin et al., 2005;
Morrison et al., 2001). In terms of stress, intrapersonal sources of stress resulted from
internal factors and academic factors that caused by university-related activities and
issues were the most common source of stress. There were 2 factors of intrapersonal,
2 factors of academic sources and 1 factor from environment sources that listed in the
top five sources of stress, including new responsibilities (88.6%), increased class
workload (88%), lower grade than anticipated (82.3%), change in sleeping habits
(76.1%), and change in living environment (72.4%). Furthermore, interpersonal stress
factors raised from interaction with other people, such as friends, parents, etc was
responded with highest percentage of stress caused by working with unacquainted
people (62.7%). Those finding consisted with stressors among Iranian nursing
students (Seyedfatemi et al., 2007) and in Midwestern University, intrapersonal
sources were the most common source of stress (Ross et al., 1999).
68
Stressful life events was powerful predictor of depression in longitudinal study
(David et al., 2006). The association between depression and stress was analyzed in
Spearman Correlation for non parametric statistics test. Obviously, stress and
depression had a positive linear correlation highly significant with correlation
coefficient r = 0.272 and p-value < 0.001. This measurement approved a little positive
linear correlation between stress and depression. The students experienced more stress
they get more risk of depression. Specifically, in relationship between each stress
factor and depression, the finding showed significant differences between depression
and intrapersonal stress sources (decline in personal health with p-value = 0.001),
academic sources (increased class workload with p-value = 0.026), environment
sources (put on hold for extended period of time with p-value = 0.001), and
interpersonal sources (working with un-acquainted people with p-value = 0.022).
Depression obviously was caused by a large number of factors that can be
approved in multivariate analysis. In binary logistic regression equation, multivariable
including ethnicity, type of accommodation, perception of financial status, whom the
student lived with, satisfaction with friend and parents, exercise practice, working
with un-acquainted people, roommate conflict, fight with friend, minor law violation,
decline in personal health, increased class work load, messy living conditions, and put
on hold for extended period of time that differentiated in relationship with depression
in bivariate analysis was retested simultaneously predicting multiple depression
outcome.
Regarding inter-relationship among 16 independent variables, living in
dormitory, living with family, and ethnicity had relationship which shown highly
69
significant in chi-square test for bivariate analysis (p-value < 0.001). Obviously, in
addition to the fact that these were very closely relationships that most of ethnic
students lived in dormitory and those lived in dormitory often lived with their friends.
Among three variables, when took out of logistic model, chi-square for change of
living with family was smallest comparing with 2 other variables.
After controlling all 16 variables and checking inter-relationship, the finding
sorted out 8 confounding factors and revealed the multifaceted nature of risk factors
and their relative contribution to outcome variable. In term of positive effect, students
who did not satisfy with relationship with parents and friends, decline in personal
health, fight with friends, waiting something for long time, the risk of depression
increased significantly. In contrast, regarding negative effect, living with family,
practice exercise and working with un-acquainted contributed to reduce the risk of
depression.
The result in the final logistic model revealed that the support system from
parents and friends was very important. Good relationship reduced depression and
versus poor relationship leaded to more troubles, stress and depressive symptoms.
However, the result in logistic model shown the contribution of potential
personal consequences and stress to depressive out-come; the causation could not
confidently approve in cross-sectional study design that was unable to measure
exposure factors whether come first or not.
70
Limitation
The Student Stress Survey question explores only stressors; therefore, it could
not reveal the level of each stress factor. Test for trend was not used to show the trend
of stress associated with depressive continuous score which was used as binary
variable and were not significant the bivariate analysis.
The CES-D as a tool for screening only was limit in depressive measurement
that requires a strictly clinical diagnosis and related to many factors as family and
personal history which could not determine accurately in this cross-sectional study
design.
Data collection procedure carried out in the class by gathering all students
together at the same time. While filling self-administrated questionnaire, students
respond can be influenced by the others.
There are some limitations to use reference data as the base line, the previous
study about mental health problems are not available so the finding could not compare
with the national data or some other different depression measurement.
Because of time and budget constrain, this study can only assess the first year
Medical students that can not be the representation of all the first year students in this
University so there was limit comparison with other academic years and in
generalized for the first year.
5.2 Conclusions
Being a Medical student, it is an honor and achievement not for oneself and
their family but also an expectation for University in their education and training
progress. That motivation was pay more attention on students since they start their
71
University life, a transition time of natural of life consisting of many changes in social
life and academic environment exposure. This study explored prevalence of
depression and related factors among 351 first year Medical students in HoChiMinh.
Data were collected in first year Medical student with 91% of respondent rate.
The population of this study was in the age of 18 to 25 and most of students were 19
year olds with 41.9% of male and 58.1% of female. The majority of ethnicity was
Vietnamese group with 85.2% and the mainly religion was Ancestor Worship. Their
hometown mainly were in other provinces with 77.8% and students lived rent room or
house with 35%, dormitory with 32.5% and lived with friends by 46.4%. More than
half of students with 54.2% felt that their finance was not enough. The percentage of
students sometime do exercise was 28.2%, often do with 21.4%, always do with
11.7%.
Potential personal consequence factor including satisfaction of their
relationship, very satisfy with parents was responded by 63%, satisfy with friends was
answered by 60.7%. Leisure activities that most of choices for immobility relax
activities as listening to music of reading book or watching television of playing game
with 74.4% were others factor in potential personal consequences; but 8.8% of
students responded that they did not have free time. More than half of students chose
talking to friend as a way to coping with problems; the second choice was talking to
parents.
About students stress, top five of stress that students faced was prone
intrapersonal factors, academic environment and environmental factors. There were
new responsibilities by 88.6%, increased class workload by 88%, lower grade than
72
anticipated by 82.3%, change in sleeping habits with 76.1%, and change in living
environment 72.4%. In addition, the highest percentage of interpersonal factors was
working with un-acquainted people. Most of those stressors were daily hassles.
Prevalence of depressive symptom among first year Medical students was
quite high with 39.6% by using the CES-D tool for screening depression with cut-off
point = 22.
In bivariate analysis, this study found out that there were significant
differences
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. Stress scores and
depression scores had positive linear relationship with r = 0.272. Many stressors as
working with un-acquainted people, decline in personal health, increased class
workload, and put on hold for extended period of time were differentiated
significantly with depressive group.
In multivariate analysis, in logistic regression model after controlling
confounder factors, satisfaction with parents and friends, and stressors as decline in
personal health, fight with friend and put on hold for long time increased the risk to
get depression; additionally, living with family, practice exercise and working with
un-acquainted people reduced the risk of depression with p-value<0.05.
5.3 Recommendations
It is suggested that for further study, qualitative study should be conducted in

combination with quantitative study to explore the perception of responding with
73
stress, causes and level of stress in association with depression. Regarding
quantitative study, longitudinal study should be carried out to determine consequences
of daily hassles and life events that related to depression during students' learning
time stages.
In terms of depressive prevention, freshmen students need to be orientated
about learning skill, time management skill and communication skill in order to meet
academic requirement, arrange their time effectively for learning and leisure
activities, and overcome difficulties in working in new environment through
foundation workshop at the beginning time of the first term or cooperate with The
youth Union activities. Moreover, stress management information should be provided
in high pressure environment like Medical University.
Maintaining and enhancing support systems from friends, peers should be
promoted for students in coping with problems in learning and life skills as well
through supporting from seniors. The other factor released stress and reducing
depression as exercise and sports should be encourage to practice regularly combining
with extra activities in University.
Reducing stress like class works, messy living condition, expectation for
grades, conflicting with friends should be implemented to prevent suffering from
stress and its more severe consequences. Additionally, dormitory environment where
one third of students lived in should be improved in terms of friendly and neat
environment.
74
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Corrected Proof)
APPENDICES
80
APPENDIX A
RELATIONSHIP BETWEEN DEPRESSION AND RELATED FACTORS
The relationship between depression and leisure activities
Leisure*
Go out with friend
Depression (n=351)
symptoms
symptoms n
n (%)
(%)
69 (66.3)
35 (33.7)
2 (df)
P-value
2.185(1)
.139
Listen to music/ book/

TV/game
161 (61.7)
100 (38.3)
.705(1)
.401
Sport
35 (68.6)
16 (31.4)
1.689(1)
.194
Sleep
8 (66.7)
4 (33.3)
**
.770
Others
18 (58.1)
13 (41.9)
.077(1)
.781
* Multiple choices question. More than choice can be chosen

** Fisher's exact test
The relationship between depression and leisure (Combinational choices)
Leisure
Less than one choice

More than 2 choices
Depression (n=351)
symptoms
symptoms
n (%)
n (%)
159 (57.6)
117 (42.4)
53 (70.7)
22 (29.3)
2 (df)
4.204(1)
P-value
.040
* Multiple choices question. More than choice can be chosen. This combination was gathered by Go
out with friend and Listen to music/ book/ TV/game and play sport and others
81
APPENDIX B
CES-D Reliability Statistics
Cronbach's Alpha
N of Items
.775
20
Item-Total Statistics
d1
Scale
Scale Mean if
Variance if
Item Deleted Item Deleted
25.4667
48.326
Corrected
Cronbach's
Item-Total Alpha if Item
Correlation
Deleted
.476
.760
d2
25.2667
51.030
.057
.788
d3
24.9333
44.823
.612
.746
d4
23.8000
50.166
.137
.781
d5
24.5333
48.051
.364
.764
d6
25.2000
46.993
.561
.753
d7
24.1333
49.223
.179
.779
d8
23.2000
52.028
.126
.776
d9
25.3667
47.689
.360
.764
d10
25.1000
46.576
.467
.757
d11
25.1000
48.645
.268
.771
d12
23.7667
50.806
.105
.782
d13
25.0333
43.206
.645
.740
d14
25.1000
49.748
.179
.777
d15
25.2333
48.668
.340
.766
d16
23.7000
50.838
.121
.779
d17
24.7333
44.616
.638
.744
d18
24.5333
47.292
.501
.756
d19
25.0667
47.926
.382
.763
d20
25.3667
48.792
.437
.762
82
APPENDIX C
University of Medicine & Pharmacy
ID: ----/----/----/
QUESTIONNAIRE
Dear students, being a lecturer in our University, we conduct a study to measure prevalence of
depressive symptoms and related factors in learning environment. Your information will be
managed confidentially, only for research purpose and contributed to improve quality of academic
environment and your well-being as well. Please fill this questionnaire in 15 minutes.
Fill this box
with your suitable choice
Part I: General information

1. Gender: Female/Male
2. Birth year: 19...
3. Ethnic
Khmer
Kinh
Chm
Hoa (Chinnes)
Other...
5. Living status:
Suburban
Dormitory
Your own house
inner city
Room/house rent
Other: ...
6. Religion:
4. Resident of Hochiminh city

Non Hochiminh's resident
7. How often do you practice your religion?

Buddhist
Rarely
Christian
Sometime
Other
Often
Non-religion
Always
(if non-religion, move to question 8 )

8. Live with whom?
9. Parents' status
Alone
Live together
Friend
Separated
Relative
Divorce
Family
Parental loss
83
10. Who financially support for your study?
11. How do you feel about your finance status?
My parents
Not enough for tuition fee
My relative
Not enough for living condition
Brother/sister
Nearly sufficient
Parents & yourself
Sufficient
Other:
More than enough
12. Do you have a part-time job?
13.Do you have close friends?
No
Yes
Yes, It is .
No
14. Do you have boyfriend/girlfriend (lover)?
15.How do you feel about your relationship with
Yes
friends?
No
Very satisfy
Satisfy
Not satisfy
Not satisfy at all
16.How do you feel about your relationship with
17.How often do you do excises?
parents/family? (in case of parents loss, answer
Never
for family relationship)
Seldom
Very satisfy
Sometime
Satisfy
Often
Not satisfy
Always
Not satisfy at all

18. What do you often do in your free time?
19. What do you do when facing problems?
(can chose more than once choice)
(can chose more than one choice)
Go out with friends
Talk with parents
Listening
to
music/
Reading/watching
Talk with friend
TV/playing game
Praying
Playing sport
Smoking/drinking
Nothing
Other ..
Other:
84
Part II: CES-D questionnaire

Below is a list of the ways you might have felt or behaved. Please tell me how often you felt this way
during the past week (circle your suitable choice)
During the past week
Mostly
or
all of the time
(5-7 days)
Occasionally
or
moderate
amount of
the time (3-4
days)
2
6. I felt depressed
7. I felt that everything I did was an effort
8. I felt hopeful about the future
9. I thought my life had been a failure
10.I felt fearful
11.My sleep was restless
12.I was happy
13.I talked less than usual
14.I felt lonely
15.people were unfriendly
1. I was bothered by things that usually
Never
or
Rarely
(< 1 day)
Sometime
or
a little of
the time (12 days)
dont bother me
2. I did not feel like eating; my appetite
was poor
3. I felt that I could not shake off the
blues even with help from my family or
friends
4. I felt that I was just as good as other
people
5. I had trouble keeping my mind on what
I was doing
85
16.I enjoyed life
17.I had crying spells
18.I felt sad
19.I felt that people dislike me
20.I could not get going
Part III: Student stress survey questions

Instruction: please check (X) the following items if you had experienced during current this academic year (
9/2007- 1/2008)
Items
1.
Finding new friend
2.
3.
Roommate's conflict?
4.
Change in social activities
5.
Fight with friend
6.
Trouble with parents
7.
New responsibilities
8.
Started college
9.
Change in sleeping habits

11. Outstanding personal achievement
(excellent study performance)
13. Spoke in public
15. Minor law violation
17. Held a job
Yes
No
86
(if yes: please write your change here...)
22. Severe injury
25. Change of Major
26. Search for graduate school/job
28. Anticipation of graduation
(expectation after graduation)
31. Vacations/breaks
35. Car trouble
38. Put on hold for extended period of time
(waiting for something for uncertainty time)
39. Quit job
Thank you so much for your cooperation!
87
APPENDIX D
QUESTIONNAIRE (VIETNAMESE VERSION)
M S:----/----/----
I HC Y DC TP.HCM
B CU HI
Bn thn mn! l ging vin ti i hc Y Dc Tp.HCM, chng ti tin hnh nghin cu
nhm tm hiu cm nhn ca bn v nhng yu t lin quan n mi trng hc tp ti i
hc Y Dc Tp.HCM. Thng tin ca bn s c bo mt v s dng vo mc ch nghin
cu cng nh gp phn nng cao cht lng mi trng hc tp. Xin bn vui lng dnh
khong 15 pht tr li b cu hi sau
Hng dn tr li: Xin vui lng t en
hoc khoanh trn la chn thch hp vi bn
Phn I: Thng tin c nhn

1. Gii tnh:
3. Dn tc
Nam
2. Nm sinh : 19...
Khme
Kinh
Chm
Hoa
Other.
5. Hin ti bn ang sng u?

Ngoi thnh
Ni thnh
6. Tn gio:
4. Thng tr (h khu) ti thnh ph

Tm tr ti thnh ph
K tc x
Phng/nh thu
Nh ca bn
Khc : ...........................
7. Mc bn thc hnh tn gio ca mnh nh

Pht gio
Ki t gio (Cng gio, Tin lnh)
Khc
Khng tn gio
(nu khng tn gio, chuyn n cu 8 )
7. Hin ti bn sng vi ai?
th no? (nh i cha hay i nh th v tun gi cc

qui nh khc ca tn gio)
Him khi
Thnh thong (2 ln/nm)
Thng xuyn ( 2 ln/thng)
Lun lun, rt u n (1 tun/ln)
8. Hin ti b m bn?
Mt mnh
Sng chung
Bn
Ly thn
Ngi thn
Ly d
Gia nh
Ba hoc m mt
88
9.
Ai h tr ti chnh cho vic hc ca bn?
10. Bn cm thy nh th no tnh trng ti
Ba m
chnh ca bn ?
Ngi thn
Khng tin ng hc ph
Anh/ch
Khng chi ph sinh hot
Gia nh, nhng bn phi t lm b sung thm
Gn , phi n o khi tiu xi
Khc:
Cm thy thoi mi
2.
Bn c vic lm thm khng ?
Khng
C ( xin vui lng vit r vic ca bn...)
4.
3. Bn c bn thn khng?
C
Khng
Bn c bn trai/bn gi (ngi yu) khng?
C
Khng
5. Bn cm thy mi quan h ca mnh vi bn
b nh th no?
Rt hi lng
(nu tr li khng cu 13 v cu 14, chuyn n
Hi lng
cu.16)
Khng hi lng
Rt khng hi lng
15. Bn cm thy mi quan h ca bn vi ba m/gia nh
16.Mc thng xuyn ca vic tp th dc?
nh th no? (nu ba m mt, ngh v gia nh ca bn)
Khng bao gi
Rt hi lng
Him khi (< 1 ln/thng)
Hi lng
Khng hi lng
Rt khng hi lng
Thnh thong (3 ln/thng)
Thng xuyn (< 3 ln/tun)
Lun lun, rt u n ( 3 ln/tun)
17. Bn thng lm g trong lc rnh?
18. Bn thng lm g khi gp kh khn?
(C th chn nhiu la chn)
(C th chn nhiu la chn)
i chi vi bn b
Tm s vi bn b
Nghe nhc/c sch/coi tivi/chi game
Tm s vi ba m
Chi th thao
Cu nguyn
Ng
Ht thuc/ung ru-bia
Khc (xin ghi r)
Khc (xin ghi r)
89
Phn II: cu hi v sc khe tinh thn
Xin vui lng cho bit mc thng xuyn m bn cm nhn hoc mt s thi quen bn c th c
trong tun qua: (khoanh trn s im mi cu)
Trong tun qua
1. Ti cm thy kh chu, bc mnh vi nhng
Khng bao
gi
hoc
Him khi
< 1 ngy
Mt vi khi
hoc
Thnh thong,
i khi hoc
Rt hay xy ra
hoc
t 1-2 ngy
Trung bnh
khong t 3-4
ngy
Hu ht thi
gian t -7 ngy
iu m trc y bnh thng i vi ti

2.
Ti cm thy thy khng thm n. n
khng thy ngon ming.

3.
Ti cm thy khng th thot khi ni bun
d gia nh hoc bn b gip

4.
Ti cm thy mnh tt/bnh thng nh bao
ngi khc
5.
Ti cm thy kh khn khi kim sot suy
ngh ca mnh (kh tp trung)

6.
Ti cm thy chn nn, tht vng
7.
Ti cm thy mnh phi c gng hon
tt mi vic
8.
Ti hi vng v tng lai
9.
Ti ngh cuc sng mnh ch ton l tht bi
10. Ti cm thy lo lng, s hi

11. Ti ng khng yn gic
12. Ti cm thy mnh hnh phc
90
0
13. Ti cm thy mnh ni t hn bnh thng

14. Ti cm thy c n
15. Mi ngi khng thn thin vi ti
16. Ti c tn hng cuc sng
17. Ti c lc khc lc
18. Ti cm thy bun
19. Ti cm thy mi ngi khng thch mnh
20. Ti khng th tip tc iu g, hay chn
nn (b vic gia chng)
Phn III: cu hi v mi trng hc

Xin vui lng nh du cho (X) vo ct "c" nu bn tng tri qua nhng kinh nghim hoc
cm nhn sau trong nm hc qua (t thng 9/200 n nay)
Ni dung
1. Kh khn trong vic tm bn mi
2. Lm vic vi khng quen bit
3. Mu thun vi bn cng phng
4. Thay i hot ng x hi
5. nh nhau vi bn
6. Gp rc ri vi ba m
7. Nhiu trch nhim mi
8. Bt u kha hc i hc
9. Thay i thi quen ng
Khng
91
10. Thay i thi quen n
11. t thnh tch xut sc (vic hc, )
12. Kh khn ti chnh
13. Pht biu trc cng chng
14. Thay i nim tin tn gio
15. Vi phm li nh ca bt k lut (v d lut an ton giao thng,)
16. Gim st sc khe
17. C vic lm
18. Thay i vic s dng ru (nu c, xin vui lng vit r, bt u
s dng hay gim hay tng s dng ..........)
19. nh hn hoc kt hn
20. Ngi thn trong gia nh qua i
21. Bn thn qua i
22. Chn thng nng
23. Tng p lc hc hnh
24. im thp hn mong i
25. Thay i chuyn ngnh
26. Tm cng vic hoc trng hc (chun b cho sau khi tt nghip)
27. B nhiu tit hc
28. Chun b, mong i tt nghip
29. Tranh ci (bt ng, xch mch) vi thy/c gio
30. Chuyn trng
31. Ngy ngh, ngy l qu ngn hoc khng
32. Xp hng ch i (ch i ci g rt lu mi n lt ca
mnh)
92
33. c t vo nhiu tnh hung khc nhau
34. Thay i mi trng sng
35. Vn rc ri v xe c
36. Vn rc ri v my tnh
37. Mi trng sng ln xn, ba bi
38. Ch i iu g m khng bit bao gi xy ra (lu hn thi
gian mong i )
39. B vic lm
40. Ba m ly d
Chn thnh cm n s hp tc ca bn!
APPENDIX E
SCHEDULE ACTIVITIES
No Activities
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
November
December
January
February
March
April
May
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Writing proposal
Submit first draft
Revise first draft
Submit for proposal exam
Proposal exam
Revise proposal
Pretest questionnaire
Revise questionnaire
Conduct
structured
interview
Data management
Data analysis
Report writing
Submit for final defense
Thesis exam
Revision
Submit as the final product
93
94
APPENDIX F
ADMINISTRATION COST
No
Activities
Unit
Price
Unit
Total
(baht)
(number)
Budget
(Baht)
1.
Pre-testing
- Photocopy
Quest.
30
210
- Stationery
Set
300/set
300
Air fare : BKK - HCM - BKK
Trip
7.000/tr
2 x Trip
14,000
Data Collection
- Photocopy
Quest.
0.5
7 x 100
350
- Interviewers per diem
Person
300/p/d
2 pr x 20day
12,000
- Transportation cost
Trip/day
200/p
2 pr x 20day
8,000
- Data Processing
Person
200/p
2 pr x 10day
4,000
DATA COLLECTING PROCESS
38,860
Document Printing
- Paper + Printing
Page
5/page
600 pages
3,000
- Photocopy
Page
0.5/pag
10 x 300
1,500
- Stationery
Set
300/set
1 set
300
- Binding Paper (exam)
Set
100/set
5 set
500
- Binding Paper (submit)
Set
200/set
5 set
1,000
THESIS DOCUMENT PROCESS

TOTAL
6,300
45,160
Note: a half of this expenditure will be provided by Comlombo Plan-Thailand International Cooperation Agency Scholarship.
95
CURRICULUM VITAE
Name
: Ms. Quyen Dinh Do
Date of Birth
: 6 September 1980
Place of Birth
: Vietnam
Education
: Bachelor of Public Health, University of Medicine and

Pharmacy at Hochiminh, Vietnam (1999-2003 academic years)
Experience
: 2003 until now, assistant lecture in Health Management

Department, Faculty of Public Health, University of Medicine
and Pharmacy at Hochiminh, Vietnam

Depression and Stress Among First Year Medical Students

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Depression and Stress Among First Year Medical Students

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DEPRESSION AND STRESS AMONG THE FIRST YEAR MEDICAL

STUDENTS IN UNVERSITY OF MEDICINE AND PHARMACY

Ms. Quyen Dinh Do

A Thesis Submitted in Partial fulfillment of the Requirements

DEPRESSION AND STRESS AMONG THE FIRST YEAR

Health Systems Development

Associate Professor Prida Tasanapradit, M.D., M.Sc.

Accepted by The College of Public Health Sciences, Chulalongkorn University,

...Dean of College of Public Health Sciences

Heath Systems Development Students signature

Academic year 2007

1.1 Background ..................................................................................................1

: The Center for Epidemiologic Studies Depression Scale

: The World Health Organization

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,

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

Interpersonal sources: 6 items

Intrapersonal sources: 16 items

Academic sources: 8 items

Environmental sources: 10 items

Age is a continuous variable

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

1.7 Conceptual framework

Potential personal consequences

Figure 1: Conceptual framework

Biological (genetic and biochemical)

Psychological (development and life experiences)

Parental deprivation: Parental loss

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

It composes of 20 questions asking about adolescents

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

POTETIAL PERSONAL CONSEQUENCES

FACTORS RELATED TO MEDICAL SCHOOL TRAINING

Figure 2: Proposed model of causes and consequences of student distress

2.4 Site of study

Table 1: University of Medicine and Pharmacy

Traditional Medicine Faculty

Nurse and Medical Technique Faculty

Public Health Faculty

: absolute precision required

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

Mean, max, min, S.D

Perception of financial status

Parents' marital status

Mean, Min, Max, S.D

Student stress sources

Student stress scores

Mean, Min, Max, S.D

3.8 Reliability and Validity

The questionnaire will be administered anonymously to the student in their

factors, sources of stress and depression.

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

Most of the students' hometown was not from HoChiMinh city