Introduction & Ross, 2003). The significant level of psychological



of the Problem

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According to WHO, health is define
as a state of complete physical, mental and social wellbeing and not merely the
absence of disease or infirmity (World
Health Organization, 2013). Many people perceived health as generally being
physically well and free from any disease, however they neglect the importance
of mental health. Poor physical health can lead to an increased risk of developing
mental health problems; poor mental health can negatively impact on physical health
such as death from heart disease, external causes, and risk of death from
cancer, which have been linked to high level of psychological distress (Russ,
et al., 2013)


Psychological distress is a one of
the fundamental component of mental illness, characterized by absence of the
emotional and social wellbeing (Mirowsky & Ross, 2003). The significant
level of psychological distress have been reported in university students
worldwide (Vazquez, Otero & Diaz, 2012; Stallman, 2010; Verger, et al.,
2009) who experience greater psychological distress than the general population
(Stallman, 2010). It is reported
that the most common psychological distresses found among university students
are depression, anxiety and stress (Bayram & Bilgel, 2008)



Globally, the prevalence of
psychological distress in Norway, Ethiopia and Ireland among undergraduate
students ranged from 21% to 41.4% respectively (Nerdrum, Rustøen & Rønnestad,
2006; Dachew, Bisetegn
& Gebremariam, 2015; Deasy, et al., 2014). In Hong Kong,
a web based survey of stress among the first year tertiary education students
found 27% of the respondents were reported having stress with moderate,
severity or above (Wong, Cheung, Chan, Ma & Wa Tang, 2006). Likewise, in
Malaysia the prevalence of psychological distress among undergraduate students
was ranging from 29.6% to 49.3%. (Yusoff, Rahim & Yaacob, 2010; Zaid, Chan
& Ho,  2007; Phang, et al., 2014).


This is due to the fact that
university students face multiple stressors such as academic workload, constant
pressure to succeed, financial burden as well as concern about their future career
(Vaez, de Leon & Laflamme, 2006). Furthermore, being away from home and
having to make decisions for the first time can cause some students to feel
overwhelmed that they are unable to cope well which may later lead to
psychological distress (Vaez & Laflamme, 2008).








of the Problem


University students are a group of
people that is undergoing a critical transitory period from adolescence to
adulthood. This can be a stressful period for the university students (Mahmoud,
Staten, Hall & Lennie, 2012). This highly stressful period can affect
negatively on the psychological and physical wellbeing of the university
students such as depression, tiredness, anxiety and poor academic performance (Vaez
& Laflamme, 2008) especially for the first year students (Dyrbye, Thomas
& Shanafelt, 2006. They can become vulnerable to psychological distress as they
have to adjusting to a new life and new environment in university (Dyrbye, et
al., 2006).


In Malaysia, there have been many studies
of psychological distress on university students conducted among undergraduate
students or medical students in general. However, there is still a paucity of
information about prevalence of psychological distress specifically among first
year university students. Therefore, identifying the prevalence of psychological
distress and factors with it among this gap of students will provide essential
information in order to find a proper and generalized solution suitable for the









This study will be guided by the
following questions:


What is the prevalence of psychological
distress among first year UNIMAS students?

What are the socio-demographic variables
that contribute to elevation of psychological distress among first year UNIMAS


            Research Objectives

To determine the prevalence of
psychological distress among first year UNIMAS students.

To identify the socio-demographic
variables that influence to elevation of psychological distress among first
year UNIMAS students.








of the Research


Understanding the prevalence of
psychological distress and the possible associated factors that influence psychological
distress would help increase awareness especially among students themselves for
the early detection and prevention (Costello, 2016). Besides that, the health care educators or staff will understand
more about student’s level of psychological distress and identify those who are
at risk of psychological distress so proper counseling and preventive mental
health services can be provided. Health education related to this problem will
also be provided to encourage the university students to seek help on exposure
to psychological distress. In addition, the university health center can offer
programs related to depression, anxiety and stress reduction and wellness for
the students to cope with psychological distress. This would definitely help
the university to achieve its mission to produce high quality graduates who can
contribute effectively to the community and nation building










of Terms


Psychological Distress

distress is defined as a nonspecific term that encompasses sadness,
frustration, anxiety, depression and a number of other negative mood states
(Mirowsky & Ross, 2003). In this study, psychological distress is defined
as emotional discomfort in the form of depression, anxiety and stress that will
be measure using the Depression, Anxiety and Stress Scale (Lovibond &
Lovibond, 1995).















of Literature


Psychological distress is defined
as a disturbance of mood state characterized by features of depression and anxiety
(Mirowsky & Ross, 2002). It is commonly associated with poor academic
performance (Kudachi, et al., 2008), depression, anxiety, stress and suicide (Compton,
et al., 2008)


Prevalence of psychological
distress among undergraduate student is significantly high. In Ireland, 41.9%
of respondents from the undergraduate nursing and teacher education students
from one of the university in Ireland were psychologically distressed (Deasy,
et al., 2014). It was suggested that study course, financial, living
satisfaction and social pressures are the factors that contributed to their
distress. Another study by Dachew (2015) in Northwest Ethiopia was done to
determine the prevalence of psychological distress. A significant percentage
(40.9%) of from 826 students of University of Gondar reported psychologically
distressed. Female students (44.6%) were found likely to have psychological
distressed than males (38.8%) (Dachew, et al., 2015). Nerdrum (2006) study showed
that level of psychological distress was 21% among 1750 first year
undergraduate students in Norway.


The prevalence of psychological
distress is still in worrying state in this country as it can associated with
substance abuse, co-morbidity, personality changes, suicide attempts (Dahlin, Joneborg & Runeson,
2005) . The local studies on psychological distress on university students were
mainly conducted among undergraduate students or medical students generally (Mohd
Sidik, Rampal & Kaneson, 2003; Zaid, et al., 2007; Al-Naggar &
Al-Naggar, 2012). Little is known about the study on the first year university
students. Among the studies on medical students, the prevalence of
psychological distress was found to be 29.6% (Yusoff, et al., 2010) and 46.2% (Zaid,
et al., 2007). While for the undergraduate students generally, it is can be
seen in recent study by Al-Naggar (2012), who found 48.3% reported having psychological distress among 338 university
students from Management and Science University (MSU). Gender, residency and
smoking showed a significant influence to this problem. Another local study on
prevalence of psychological distress among 306 undergraduate students attending
a health program in a Malaysian university indicates 49.3% of the respondents
had psychological distress (Phang, 2014).


As common psychological distresses
is depression, anxiety and stress (Dyrbye,et al., 2006), some of the studies
conducted the prevalence of psychologically distress specifically in
depression, anxiety and stress. One of the studies is Teh (2015), who found
30.7%, 55.5% and 16.6% of depression, anxiety and stress respectively among 397
undergraduate medical students in Melaka Manipal Medical College using the DASS
21 Questionnaire. The outcome of this study showed the significant association
between relationship status, social life and total family income per month for
depression and stress. Meanwhile, only ethnicity has been shown to be
significantly associated with anxiety. Similarly, Cheung (2016) conducted a
study among the 661 baccalaureate nursing students using DASS 21 questionnaire
at Hong Kong to find the prevalence of psychological distress in terms of
depression, anxiety and stress. The study indicates the prevalence of depression,
anxiety and stress were 35.8%, 37.3% and 41.1% respectively. The study had
proven that clinical specialty, financial difficulties and lifestyle factors
can increase nursing student’s level of depression, anxiety and stress.  Another researches conducted by Gan (2011)
and Al-Ani (2015) showed that the prevalence of moderate to extremely severe
level of depression, anxiety and stress among undergraduate students was
ranging from 13.9% to 29.3%, 51.5% to 55.0% and 12.9% to 21.6% respectively. In
addition, the analysis of the cross sectional study conducted among 506
university students between the ages of 18 and 24 years from four public
universities in Malaysia showed severity distribution with 27.5% having
moderate and 9.7% with severe or extremely severe depression; while 34% had
moderate anxiety and 29% of all students had severe or extremely severe
anxiety. As for stress about 18.6% had moderate scores and 5.1% had severe or
extremely severe stress (Shamsuddin, 2013).


Psychological distress in
undergraduate students is associated with several factors. In Iran, a study
done by Dahlin (2005) showed that
females (16.1%) had significantly higher level of psychological distress than
males (8.1%). This is consistent with the study conducted by Verger (2009) with
the level of psychological distress 33.0% among females and 15.7% among males.
This cross-sectional study was done on first year university students with
range age between 18-24 years, enrolled in the 6 universities of southeastern
France. In addition, this finding can also be supported by several studies from
Turkey, Egypt, Australia and Norway which also found that female had higher
levels of emotional disorder compared to male (Bayram & Bilgel, 2008; Wahed
& Hassan, 2017; Stallman, 2010; Nerdrum, et al., 2006). The same results
were also obtained from the study by Wong (2006). In local study, Al-Naggar
(2012) stated in his study that gender was significantly influenced the
psychological distress among university students as female students has higher
self-expectations and a feeling of lack of competence. However, there are also
studies that found no differences according to gender in terms of depression,
anxiety and stress (Grant, et al.,


Regarding ethnicity, only the
stress scores demonstrated that there was significant relationship where Malay
had highest mean scores (Shamsuddin, 2013). However, another study indicated
that psychological distress was the highest among Chinese, followed by Malays
and Indians (Nordin, Talib
& Yaacob, 2009)


In term of type of faculty, Al-Naggar
(2012) indicates no significant associations with the psychological distress.
Nevertheless, the depression, anxiety and stress score were found to be higher
among students who studying social and political science than those who were
studying basic sciences and engineering or medicine (Bayram & Bilgel, 2008).
Meanwhile, some of other study found higher scores of depression, anxiety and
stress among medical students (Verger, et al., 2009). This is consistent with
study by Abiola
(2015) that medical students have been shown to be more inclined to emotional
disorders especially stress and depression as compared to their non-medical


Moreover, Everson, Maty, Lynch
& Kaplan (2002) found that financial distress was strongly associated with
psychological distress. This finding were supported by other studies in
Australia (Cvetkovski, Reavley & Jorm, 2012) and United States of America
(Eisenberg, Gollust, Golberstein
& Hefner, 2007) which found that financial hardship was
independently associated with psychological distress. However, no significant
association were found between financial problem and psychological distress in
study done by Dachew (2015).


Despite the increased burden of
psychological distress with moderate and severe symptoms from previous study, there
is still a paucity of information about prevalence of psychological distress among
first year university students in Malaysia. Thus, this study will be conducted
in order to fill in the gap to determine the prevalence of psychological
distress among first year students and the socio-demographic variables that
contribute to psychological distress.

















This study is a quantitative study
and the data will be collected from the first year of UNIMAS students using a
cross sectional approach. Cross sectional approach is carried out by collecting
the data on a population at a single point of time (Levin, 2006). It is useful
to use this type of approach in this study as it is can obtain the overall
picture of the population as it stands at the time of study.


and Sampling


This study will be conducted in
University Malaysia Sarawak which the Malaysia’s eighth university that was
officially incorporated on 24 December 1992. It is situated at Kota Samarahan, one
of the districts in Sarawak. Population for this study will be the UNIMAS students
and sampling will be the first year UNIMAS students. By using the Sample Size
Calculator (Creative Research System, 2012) with 95% of confidence level and 5%
of confidence interval and estimated size of population 14427 of UNIMAS
students, the sample size needed will be 374. The sample size obtained will
also include the 10% of estimated missing data (Naing, Winn & Rusli, 2006),
so the total sample size needed is 411.




The inclusion criteria for the
respondent in this study are:

First year student

Enrolled their study at University
Malaysia Sarawak

exclusion criteria for the respondent in this study are:

Post-graduate students

Not enrolled their study at University
Malaysia Sarawak.


The sampling technique that will be
used in this study is the simple random sampling method. Using this technique,
all the first year UNIMAS students will has an equal chance of being selected
to become subject in this study. The list name of first year UNIMAS students
from the two of randomly selected faculty (between Art and Science faculty)
will be obtained from the Academic office. Then, all the student’s data will be
entered in the Excel to get randomized. 
Student’s matric number will be used as student’s ID and it will be
sorted in ascending order before it get generate randomly. After the data get
randomized, the respondents for the study will be chose from the first 411 in
the random sample data.









The study will be conducted by using
21 items of Depression, Anxiety and Stress Scale (DASS 21) (Lovibond &
Lovibond, 1995). The questionnaire will be in English and consists two sections
which are:


Section one is about socio-demographic data.
There are 10 questions that consists of age, ethnicity, gender, study course,
religion,  relationship status, academic
performance, social life satisfaction, parental marital status and monthly
parental income

Section two will be focusing on measuring
the psychological distress level in the form of depression, anxiety and stress.
The item that will be using in this study is Depression, Anxiety Stress Scale
21 (DASS 21). DASS 21 consists of 21 questions in total which was designated to
measure and assesses the severity of range of symptoms common to depression,
anxiety and stress. The participants are required to indicate the presence of a
symptom over the previous week when completed the 21 questions that specially
designated for participants to specify their emotional level for each
statement. In total, there are 7 questions for each depression, anxiety and
stress assessment. Likert scale are used for the scoring system scored from 0
(did not apply to me at all) to 3 (applied to me very much or most of the time
over the past one week) Because DASS 21 is a short form version of the DASS (original
form have 42 questions), the final score of each groups (depression, anxiety
and stress) must be multiplied by two (x2). The below scoring system are the
final score of DASS:


DASS Severity Score





















Extremely Severe




Source: Lovibond
and Lovibond, 1995





In this study, the ethical approval
(refer Appendix 1) will be obtained from the Research Ethics Committee, Faculty
of Medicine and Health Sciences, Universiti Malaysia Sarawak. Explanation
regarding the purpose of the study, respondent consent and confidentiality of
the respondent’s information will be given to each eligible respondent prior
answering the questionnaire. Respondent that agree to participate in the study
will be asked to sign the informed consent form (Appendix 2).





Data collection will be started after
getting the approval from the Research Ethics Committee (Appendix 1)
approximately on January 2017. A set of questionnaire consists two sections
will be used in this study for the data collection (Appendix 3).  The screening will be conducted after the
pilot study has been done. Pilot study will be carried out on at least 10 first
year students prior to data collection in order to test the validity of the
items in the questionnaire. 10 first year students will include male and female
that study in UNIMAS. The person whom will be participated for the pilot study
will be excluded from the actual study. Cronbach Alpha is used to test the
reliability of each domain in the questionnaire before it is used to collect data
(Tavakol & Dennick, 2011). According to Nunnally and Bernstein (1994), a
Cronbach Alpha’s value of more than 0.7 is acceptable.


After the pilot study, the
questionnaires will be distributed to the all selected subject at the place of their
own faculty such as class, student lounge or hall. Respondents will be given
some time to complete the questionnaires and to return back the questionnaire
right after completed it.








Statistical Package for Social
Science Programme (SPSS) version 22 will be used to analyze the data. For the
socio-demographic data, all the data obtained will be described using
descriptive statistic using statistical presentation such as means or standard
deviation for continuous data (age, DASS score, monthly parental income) and
frequency or percentages for categorical data (ethnicity, relationship status,
parental marital status, study course) .

Statistical significance for the
comparison of psychological distress and the socio-demographic data will be
examined whether it is normally distributed or not. For the normally distributed,
comparison of differences on depression, anxiety and stress score between two
different groups will be done by using parametric test, T-test. While for more
than two different groups will be using ANOVA test. Whereas, for not normally
distributed data, non-parametric test such as Mann-Whitney (independent variables
with two groups) or Kruskal – Wallis H (for more than two groups) will be used.
P-value of < 0.05 will be considered as statistically significant.               Limitation   The potential limitations for this study will be time constrain since only a few months will be given to conduct this study. Next, this study only focused on psychological distress in Universiti Malaysia Sarawak, thus the result might not be applicable to the other students, whereby there might be differences in the determinants of psychological distress level and it associated factors.