Introduction Backgroundof the Problem According to WHO, health is defineas a state of complete physical, mental and social wellbeing and not merely theabsence of disease or infirmity (WorldHealth Organization, 2013). Many people perceived health as generally beingphysically well and free from any disease, however they neglect the importanceof mental health. Poor physical health can lead to an increased risk of developingmental health problems; poor mental health can negatively impact on physical healthsuch as death from heart disease, external causes, and risk of death fromcancer, which have been linked to high level of psychological distress (Russ,et al.
, 2013) Psychological distress is a one ofthe fundamental component of mental illness, characterized by absence of theemotional and social wellbeing (Mirowsky & Ross, 2003). The significantlevel of psychological distress have been reported in university studentsworldwide (Vazquez, Otero & Diaz, 2012; Stallman, 2010; Verger, et al.,2009) who experience greater psychological distress than the general population(Stallman, 2010). It is reportedthat the most common psychological distresses found among university studentsare depression, anxiety and stress (Bayram & Bilgel, 2008) Globally, the prevalence ofpsychological distress in Norway, Ethiopia and Ireland among undergraduatestudents 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 studentsfound 27% of the respondents were reported having stress with moderate,severity or above (Wong, Cheung, Chan, Ma & Wa Tang, 2006). Likewise, inMalaysia the prevalence of psychological distress among undergraduate studentswas 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 thatuniversity students face multiple stressors such as academic workload, constantpressure to succeed, financial burden as well as concern about their future career(Vaez, de Leon & Laflamme, 2006). Furthermore, being away from home andhaving to make decisions for the first time can cause some students to feeloverwhelmed that they are unable to cope well which may later lead topsychological distress (Vaez & Laflamme, 2008). Statementof the Problem University students are a group ofpeople that is undergoing a critical transitory period from adolescence toadulthood. This can be a stressful period for the university students (Mahmoud,Staten, Hall & Lennie, 2012). This highly stressful period can affectnegatively on the psychological and physical wellbeing of the universitystudents 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 theyhave to adjusting to a new life and new environment in university (Dyrbye, etal., 2006).
In Malaysia, there have been many studiesof psychological distress on university students conducted among undergraduatestudents or medical students in general. However, there is still a paucity ofinformation about prevalence of psychological distress specifically among firstyear university students. Therefore, identifying the prevalence of psychologicaldistress and factors with it among this gap of students will provide essentialinformation in order to find a proper and generalized solution suitable for thestudents. ResearchQuestions This study will be guided by thefollowing questions: · What is the prevalence of psychologicaldistress among first year UNIMAS students?· What are the socio-demographic variablesthat contribute to elevation of psychological distress among first year UNIMASstudents? Research Objectives· To determine the prevalence ofpsychological distress among first year UNIMAS students.
· To identify the socio-demographicvariables that influence to elevation of psychological distress among firstyear UNIMAS students. Significanceof the Research Understanding the prevalence ofpsychological distress and the possible associated factors that influence psychologicaldistress would help increase awareness especially among students themselves forthe early detection and prevention (Costello, 2016). Besides that, the health care educators or staff will understandmore about student’s level of psychological distress and identify those who areat risk of psychological distress so proper counseling and preventive mentalhealth services can be provided. Health education related to this problem willalso be provided to encourage the university students to seek help on exposureto psychological distress. In addition, the university health center can offerprograms related to depression, anxiety and stress reduction and wellness forthe students to cope with psychological distress. This would definitely helpthe university to achieve its mission to produce high quality graduates who cancontribute effectively to the community and nation building Definitionof Terms · Psychological DistressPsychologicaldistress 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 definedas emotional discomfort in the form of depression, anxiety and stress that willbe measure using the Depression, Anxiety and Stress Scale (Lovibond , 1995). Reviewof Literature Psychological distress is definedas a disturbance of mood state characterized by features of depression and anxiety(Mirowsky & Ross, 2002).
It is commonly associated with poor academicperformance (Kudachi, et al., 2008), depression, anxiety, stress and suicide (Compton,et al., 2008) Prevalence of psychologicaldistress among undergraduate student is significantly high. In Ireland, 41.9%of respondents from the undergraduate nursing and teacher education studentsfrom one of the university in Ireland were psychologically distressed (Deasy,et al., 2014).
It was suggested that study course, financial, livingsatisfaction and social pressures are the factors that contributed to theirdistress. Another study by Dachew (2015) in Northwest Ethiopia was done todetermine the prevalence of psychological distress. A significant percentage(40.
9%) of from 826 students of University of Gondar reported psychologicallydistressed. Female students (44.6%) were found likely to have psychologicaldistressed than males (38.8%) (Dachew, et al., 2015). Nerdrum (2006) study showedthat level of psychological distress was 21% among 1750 first yearundergraduate students in Norway.
The prevalence of psychologicaldistress is still in worrying state in this country as it can associated withsubstance abuse, co-morbidity, personality changes, suicide attempts (Dahlin, Joneborg & Runeson,2005) . The local studies on psychological distress on university students weremainly conducted among undergraduate students or medical students generally (MohdSidik, Rampal & Kaneson, 2003; Zaid, et al., 2007; Al-Naggar -Naggar, 2012). Little is known about the study on the first year universitystudents. Among the studies on medical students, the prevalence ofpsychological 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 beseen in recent study by Al-Naggar (2012), who found 48.3% reported having psychological distress among 338 universitystudents from Management and Science University (MSU). Gender, residency andsmoking showed a significant influence to this problem. Another local study onprevalence of psychological distress among 306 undergraduate students attendinga health program in a Malaysian university indicates 49.3% of the respondentshad psychological distress (Phang, 2014). As common psychological distressesis depression, anxiety and stress (Dyrbye,et al.
, 2006), some of the studiesconducted the prevalence of psychologically distress specifically indepression, anxiety and stress. One of the studies is Teh (2015), who found30.7%, 55.
5% and 16.6% of depression, anxiety and stress respectively among 397undergraduate medical students in Melaka Manipal Medical College using the DASS21 Questionnaire. The outcome of this study showed the significant associationbetween relationship status, social life and total family income per month fordepression and stress. Meanwhile, only ethnicity has been shown to besignificantly associated with anxiety. Similarly, Cheung (2016) conducted astudy among the 661 baccalaureate nursing students using DASS 21 questionnaireat Hong Kong to find the prevalence of psychological distress in terms ofdepression, anxiety and stress.
The study indicates the prevalence of depression,anxiety and stress were 35.8%, 37.3% and 41.1% respectively. The study hadproven that clinical specialty, financial difficulties and lifestyle factorscan 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 severelevel of depression, anxiety and stress among undergraduate students wasranging from 13.9% to 29.3%, 51.
5% to 55.0% and 12.9% to 21.6% respectively. Inaddition, the analysis of the cross sectional study conducted among 506university students between the ages of 18 and 24 years from four publicuniversities in Malaysia showed severity distribution with 27.5% havingmoderate and 9.
7% with severe or extremely severe depression; while 34% hadmoderate anxiety and 29% of all students had severe or extremely severeanxiety. As for stress about 18.6% had moderate scores and 5.
1% had severe orextremely severe stress (Shamsuddin, 2013). Psychological distress inundergraduate students is associated with several factors. In Iran, a studydone by Dahlin (2005) showed thatfemales (16.1%) had significantly higher level of psychological distress thanmales (8.1%). This is consistent with the study conducted by Verger (2009) withthe level of psychological distress 33.0% among females and 15.
7% among males.This cross-sectional study was done on first year university students withrange age between 18-24 years, enrolled in the 6 universities of southeasternFrance. In addition, this finding can also be supported by several studies fromTurkey, Egypt, Australia and Norway which also found that female had higherlevels of emotional disorder compared to male (Bayram & Bilgel, 2008; Wahed& Hassan, 2017; Stallman, 2010; Nerdrum, et al., 2006). The same resultswere also obtained from the study by Wong (2006). In local study, Al-Naggar(2012) stated in his study that gender was significantly influenced thepsychological distress among university students as female students has higherself-expectations and a feeling of lack of competence.
However, there are alsostudies that found no differences according to gender in terms of depression,anxiety and stress (Grant, et al.,2002). Regarding ethnicity, only thestress scores demonstrated that there was significant relationship where Malayhad highest mean scores (Shamsuddin, 2013). However, another study indicatedthat psychological distress was the highest among Chinese, followed by Malaysand 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 higheramong students who studying social and political science than those who werestudying basic sciences and engineering or medicine (Bayram & Bilgel, 2008).Meanwhile, some of other study found higher scores of depression, anxiety andstress among medical students (Verger, et al., 2009). This is consistent withstudy by Abiola(2015) that medical students have been shown to be more inclined to emotionaldisorders especially stress and depression as compared to their non-medicalpeers. Moreover, Everson, Maty, Lynch& Kaplan (2002) found that financial distress was strongly associated withpsychological distress. This finding were supported by other studies inAustralia (Cvetkovski, Reavley & Jorm, 2012) and United States of America(Eisenberg, Gollust, Golberstein& Hefner, 2007) which found that financial hardship wasindependently associated with psychological distress. However, no significantassociation were found between financial problem and psychological distress instudy done by Dachew (2015).
Despite the increased burden ofpsychological distress with moderate and severe symptoms from previous study, thereis still a paucity of information about prevalence of psychological distress amongfirst year university students in Malaysia. Thus, this study will be conductedin order to fill in the gap to determine the prevalence of psychologicaldistress among first year students and the socio-demographic variables thatcontribute to psychological distress. Methodology ResearchDesign This study is a quantitative studyand the data will be collected from the first year of UNIMAS students using across sectional approach. Cross sectional approach is carried out by collectingthe data on a population at a single point of time (Levin, 2006).
It is usefulto use this type of approach in this study as it is can obtain the overallpicture of the population as it stands at the time of study. Populationand Sampling This study will be conducted inUniversity Malaysia Sarawak which the Malaysia’s eighth university that wasofficially incorporated on 24 December 1992. It is situated at Kota Samarahan, oneof the districts in Sarawak.
Population for this study will be the UNIMAS studentsand sampling will be the first year UNIMAS students. By using the Sample SizeCalculator (Creative Research System, 2012) with 95% of confidence level and 5%of confidence interval and estimated size of population 14427 of UNIMASstudents, the sample size needed will be 374. The sample size obtained willalso include the 10% of estimated missing data (Naing, Winn & Rusli, 2006),so the total sample size needed is 411.
The inclusion criteria for therespondent in this study are:· First year student· Enrolled their study at UniversityMalaysia Sarawak Theexclusion criteria for the respondent in this study are:· Post-graduate students· Not enrolled their study at UniversityMalaysia Sarawak. The sampling technique that will beused 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 selectedto become subject in this study.
The list name of first year UNIMAS studentsfrom 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 beentered in the Excel to get randomized. Student’s matric number will be used as student’s ID and it will besorted in ascending order before it get generate randomly. After the data getrandomized, the respondents for the study will be chose from the first 411 inthe random sample data. Instruments The study will be conducted by using21 items of Depression, Anxiety and Stress Scale (DASS 21) (Lovibond &Lovibond, 1995). The questionnaire will be in English and consists two sectionswhich are: · Section one is about socio-demographic data.There are 10 questions that consists of age, ethnicity, gender, study course,religion, relationship status, academicperformance, social life satisfaction, parental marital status and monthlyparental income· Section two will be focusing on measuringthe psychological distress level in the form of depression, anxiety and stress.
The item that will be using in this study is Depression, Anxiety Stress Scale21 (DASS 21). DASS 21 consists of 21 questions in total which was designated tomeasure and assesses the severity of range of symptoms common to depression,anxiety and stress. The participants are required to indicate the presence of asymptom over the previous week when completed the 21 questions that speciallydesignated for participants to specify their emotional level for eachstatement. In total, there are 7 questions for each depression, anxiety andstress 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 timeover the past one week) Because DASS 21 is a short form version of the DASS (originalform have 42 questions), the final score of each groups (depression, anxietyand stress) must be multiplied by two (x2). The below scoring system are thefinal score of DASS: Table1DASS Severity Score Rating Depression Anxiety Stress Normal 0-9 0-7 0-14 Mild 10-13 8-9 15-18 Moderate 14-20 10-14 19-25 Severe 21-27 15-19 26-33 Extremely Severe 28+ 20+ 37+ Source: Lovibondand Lovibond, 1995 EthicalIssue In this study, the ethical approval(refer Appendix 1) will be obtained from the Research Ethics Committee, Facultyof Medicine and Health Sciences, Universiti Malaysia Sarawak. Explanationregarding the purpose of the study, respondent consent and confidentiality ofthe respondent’s information will be given to each eligible respondent prioranswering the questionnaire.
Respondent that agree to participate in the studywill be asked to sign the informed consent form (Appendix 2). DataCollection Data collection will be started aftergetting the approval from the Research Ethics Committee (Appendix 1)approximately on January 2017. A set of questionnaire consists two sectionswill be used in this study for the data collection (Appendix 3). The screening will be conducted after thepilot study has been done.
Pilot study will be carried out on at least 10 firstyear students prior to data collection in order to test the validity of theitems in the questionnaire. 10 first year students will include male and femalethat study in UNIMAS. The person whom will be participated for the pilot studywill be excluded from the actual study.
Cronbach Alpha is used to test thereliability of each domain in the questionnaire before it is used to collect data(Tavakol & Dennick, 2011). According to Nunnally and Bernstein (1994), aCronbach Alpha’s value of more than 0.7 is acceptable. After the pilot study, thequestionnaires will be distributed to the all selected subject at the place of theirown faculty such as class, student lounge or hall. Respondents will be givensome time to complete the questionnaires and to return back the questionnaireright after completed it. DataAnalysis Statistical Package for SocialScience Programme (SPSS) version 22 will be used to analyze the data.
For thesocio-demographic data, all the data obtained will be described usingdescriptive statistic using statistical presentation such as means or standarddeviation for continuous data (age, DASS score, monthly parental income) andfrequency or percentages for categorical data (ethnicity, relationship status,parental marital status, study course) . Statistical significance for thecomparison of psychological distress and the socio-demographic data will beexamined whether it is normally distributed or not. For the normally distributed,comparison of differences on depression, anxiety and stress score between twodifferent groups will be done by using parametric test, T-test.
While for morethan two different groups will be using ANOVA test. Whereas, for not normallydistributed data, non-parametric test such as Mann-Whitney (independent variableswith 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 thisstudy will be time constrain since only a few months will be given to conductthis study. Next, this study only focused on psychological distress inUniversiti Malaysia Sarawak, thus the result might not be applicable to theother students, whereby there might be differences in the determinants ofpsychological distress level and it associated factors.