DEPRESSIVE SYMPTOMS AND RELATED FACTORS OF THE GENERAL MEDICAL STUDENT AT HAI PHONG UNIVERSITY OF MEDICINE AND PHARMACY IN 2016

NGUYEN THI MODEPRESSIVE SYMPTOMS AND RELATED FACTORS OF THE GENERAL MEDICAL STUDENT AT HAI PHONG UNIVERSITY OF MEDICINE AND PHARMACY IN 2016 GRADUATE THESIS OF PREVENTIVE MEDICINE DOCT

NGUYEN THI MO

DEPRESSIVE SYMPTOMS AND RELATED FACTORS

OF THE GENERAL MEDICAL STUDENT

AT HAI PHONG UNIVERSITY OF MEDICINE AND

PHARMACY IN 2016

GRADUATE THESIS OF PREVENTIVE MEDICINE DOCTOR

HAI PHONG 6/2016

NGUYEN THI MO

DEPRESSIVE SYMPTOMS AND RELATED FACTORS

OF THE GENERAL MEDICAL STUDENT

AT HAI PHONG UNIVERSITY OF MEDICINE AND

published in other research projects.

NGUYEN THI MO

Phong University of Medicine and Pharmacy

The Chairmen Board and lecturers of the Department of Public Health

at Hai Phong University of Medicine and Pharmacy dedicatedly instructed

me to study and complete my thesis

Meanwhile, the training University department assists me to collectaccurate and reliable data particularly

I would like to express my faithful thanks to Master Nguyen Thi MinhNgoc and Nguyen Thi Thu Thao, who spent a lot of their time oninstructing me for my thesis

I sincerely thank Mr Ha Van Truong, the lecturer at the Ha TruongEnglish center guided, instructed and prompted me in English language

My family and friends always encourage and support me to study andcomplete my thesis

Hai Phong, 25/5/2016

Author Nguyen Thi Mo

C.I Confidence interval

CONTENT

1.1.1 Concepts 3

1.1.2 History of depression 4

1.1.3 Causes and risk factors of depression 5

1.1.4 Influence and consequences of depression 7

1.2 The situation of depression in the world and Vietnam 8

1.2.1 The situation of depression in the world 8 1.2.2 The situation of depression in Vietnam 9 1.2.3 The situation of depression in medical students 10 1.3 Risk factors and consequences of depression in medical students 11

1.3.1 Risk factors leading to depression in medical students 11 1.3.2 The consequences of depression for medical students 13 1.4 Depression measurement 15

1.4.1 The Center for Epidemiologic studies Depression Scale (CESD)15 1.4.2 The studies used CES D 16 CHAPTER 2: METHODOLOGY 18

2.1 Study subjects 18

2.2 Study location 18

2.3 Study time 18

2.4 Methodology 18

2.4.1 Study Design 18 2.4.2 Sample size and sampling 18 2.4.3 Variable and index measurement 20 2.4.4 Method and data collecting 22 2.4.5 Error control methods, limiting potential conformity 23 2.5 Data processing and analyze data 24

3.2 Students have depressive symptoms based on the CES-D scale 28 3.3 Depressive symptom and related factors 31

3.3.1 The relationship between depressive symptom and generalcharacteristics 31

3.3.2 Relationship between depressive symptom and stressful life events

35

3.3.3 Relationship between depressive symptom and personal factors 37CHAPTER 4: DISCUSSION 41CONCLUSION 55RECOMMENDATION 57

Table 3.2: Distribution of subject by parents’ education 27

Table 3.5: Difficulty in communication signs based on the CES-D 29

Table 3.8: The relationship between depressive symptom and grade 33Table 3.9: The relationship between depressive symptom and gender 34Table 3.10: The relationship between depressive symptom and religion 34Table 3.11: The relationship between depressive symptom and current

Depression is now becoming one of the most serious mental healthissues and social problems in many countries and trending to increase in thenext 20 years [31] Depressive symptoms are widely distributed in thepopulation and disrupt people’s normal life

According to World Health Organization (2012), depression is asignificant contributor to the global burden of disease with an estimated 350million people in all communities across the world affected [37] Moreover,every year, approximately 5% of the world population have depression[36] WHO predicts that by 2020 depression will be the second cause of loss

of working second in the world [37] Depression results from a complexinteraction of social psychological and biological factors Especially, whenlong-lasting and with moderate or severe intensity, depression can lead to lead

to more stress and dysfunction, worsen the affected person’s life situation Atits worst, depression can lead to suicide Within about 1 million cases die peryear in the world, the suicide is the second leading cause of death in the 15-29age-group [37]

However, in Vietnam, a scientific awareness about depression is stilllimited "Feeling sad" has been seen as a normal shape of mood, not to beconsidered as criteria for evaluating early signs of depression The earlyevaluation of depressive signs is an extremely important thing to prevent theoccurrence as well as to have effective treatment process for depression

So far there have been few types of research on depressive symptoms inVietnamese people as well as students, especially on medicalstudents Students have to experience numerous challenges includingexploring or developing their identity, navigating the transition from a state of

full dependence on a state of semi-dependence on parents, creating the socialrelationship, managing the finance, leaving their primary support system Inaddition, medical students have to spend a long time on training with hugeknowledge and high pressure to become good doctors Previous studies havesuggested that medical students have many high-risk factors of depression[24, 33, 13] The prevalence of depressive symptoms in American andCanadian medical students was 15% and 19% [8] Seriously, as aconsequence, the rate of medical students with suicidal intention is increasingrapidly Blum R showed 20% of medical students in Asia had thought ofsuicide, including 8,4% of students with deliberate suicide in a study[8] They are evidence of the burden of mental health, problems of youngpeople, especially medical students It will lead to long-term consequenceswith the impact on a future career Therefore, early detection of depressivesymptoms in medical students will help to make efficacious and cost-effective treatment as well as to prevent the serious consequences caused by

depression Because of this reason we conducted the study: "Depressive

symptoms and related factors of general medical students at Hai Phong University of Medicine and Pharmacy, 2016" with two objectives:

1 To examine the percentage of depressive symptom of generalmedical students at Hai Phong University of Medicine and pharmacy,academic year 2015-2016

2 To determine some related factors to depressive symptoms of generalmedical students at Hai Phong University of Medicine and Pharmacy,academic year 2015-2016

CHAPTER 1 LITERATURE REVIEW 1.1 Concepts of depression

1.1.1 Concepts

Based on the World Health Organization (WHO): "Depression is acommon mental disorder, characterized by sadness, loss of interest andpleasure, feelings of guilt, underestimate the value itself, sleeplessness, loss ofappetite, fatigue and poor concentration" [36]

Depression may persist or recur, weaken the ability to activate at work,school or daily life The most severe, depression can lead to suicide If thedisease is mild, people can be treated without medication, if moderate orsevere depression, the patient needs medication and treatments withpsychological [36]

According to Nguyen Minh Tuan [10], depression is a state ofemotional turmoil, it has the following characteristics:

- Sadness organisms (boundless mental suffering)

- Inhibition of thinking and working (slowly, dementia)

- Sleep disturbances and the biological functions

- The prognosis relates to suicide risk This risk is present throughout thecourse of the disease Therefore, the patients should be monitored closely

Regarding the formation of the depressive episode, the situation canoccur include:

- Usually the insidious progression

- Sometimes a sudden (start by suicide)

- Maybe after the next episode of mania

- After a trauma, mental or body (illness, retirement, mourning)

- Perhaps because of medicinal disadvantage causes depression

At the onset, the disease progresses slowly with the first signs ofinsomnia, headaches, fatigue After a few weeks or a few months, ability towork, loss of self-worth, hesitation, indifference to work and family can beseen working, in this way, patients are anxious about the health and future,may have come to tendency to suicide.

During the entire development phase, symptoms can include:motionless face, signs of suffering "depression Omega" (wrinkle whenfrowning two eyebrows) Patients do not care about their appearance aswell Patients almost are motionless, sitting in one place for severalhours Not necessarily talking, being asked is answered reluctantly,interspersed moans, sighing More severe is not talking

Some cases of patients try to hide disorders (fake smile) In this case,suicide risk is high because of those around him not guard From naturaldisease may average 6-7 months later (short attacks are just a few weeks, longattacks last many years) When being treated, episodes of illness may shortenthe average one month after hospitalization The symptoms graduallyimproved and sleep recovery Patients are considered cured when the joycomes back

environment, body, and emotions He described that a mania involvinglactation was better than delirium cooperating puerperal sepsis.

- Four centuries after Hippocrates, Areteus described explicitly moodcycle, he said that the depression appeared before the mania (humoral theory)

- Galen, a Greek physician practice for profession in Rome in the secondcentury AD, continued the tradition of humoral theory perspective, given thatdepression was caused by excess black bile (to be activated from melankholy,Melan means black, khole is bile liquid), although he also began consideringthe psychological factors, emotional

- 1896 depression was separated into an independent disease by EmilKraepelin-German psychologist, based consensus on the clinicalmanifestations and character progression

1.1.3 Causes and risk factors of depression

Depression is a complex disorder and can manifest in many differentstates, because of a lot of factors The causes of depression include biologicalfactors: genetic and biochemical elements of social, psychological factors:including the experiences of life and psychological life

Genetic factors: Children of depressive parents are high risk, up to 70% of children are likely to get depressed if both parents are suffering fromdepression [17]

50-Biological factors: The fall of the neurotransmitter can lead todepression

Psychological factors: Depression is a psychological disorder; allhuman thoughts can start to depression If people have distorted thinkingabout everything around, about themselves and their future, then their moodbecomes sad, completing the picture of depression

Risk factors for depression:

- Gender: Women are twice as likely as men to experience depression, it

is explained by women have important positions such as housewives, theparenting role and obligations wife [17] Also, related to the reduction of theconcentration of Omega 3 postpartum women, is one of the causes ofdepression [20]

- Age: The average age for the onset of depression is between 20 and 40years [17] However, many studies have confirmed that depression can alsooccur in childhood [17]

- Marital status: Separated and divorced people have the highest risk,while single and married people carry the lowest risk [17]

- Living conditions: People living with family members suffering fromdepression are at risk for higher depression Most studies suggest that geneticfactors are mainly, but the family environment contributes to increase the risk

of depression Early lost his parent is a risk factor for depression Someresearchers have noted that the separation from their parents early in life canaffect a child's personality The children do not learn to tolerate the negativefeelings and adapt to every situation so easily lead to depression

- Social stressor: The risk factors for depression for any age Includingthe stressful events in life, such as bereavement, serious traumatized ,prolonged stress like living in war / conflict zones, the disease

- Family status: Asian countries have an extended family However, withincreasing urbanization and industrialization rapidly, nuclear families areincreasing Many surveys in India have shown an increased rate of occurrence

of psychiatric problems, including depression in families with fewergenerations living together The members live together being increasedresistance to depression [17]

1.1.4 Influence and consequences of depression

1.1.4.1 Patients

Depression is a disease of mental health for everyone, regardless of theelderly, children, adults Depression affects about consciousness, feeling,thinking, memory, language, emotion of patients The disease makes thepatient insensible, emotionless, the world in their eyes is narrow, physicalhealth deteriorates seriously, down to eat and sleep, reduce weight, reduceinterest all social activities and all other activities for them are becominginsensitive Depression is the main reasons to cause psychosis and otherillnesses related to mental health The worst, depression leads easily to suicideacts [1]

1.1.4.2 Society

Depression combined with other chronic diseases causes the mostnegative consequences of the loss of health, it is a matter of public healthwhich is very interested in the key programs of national health (2- 15%incidence) [1] Depression tends to become chronic, increased disability in theworkforce, especially young workers

- Depressive patients are a burden to family and society, in fact, familiesmust put effort, money, and wealth in the treatment for a long time, societyhas to spend expensive studies, prediction, treatment and prevention ofdisease Depression makes social backwardness, retardation and economicdifficulties

- Depression is the fundamental cause which raises many otherdangerous illnesses related to mental health, such as Schizophrenia, paranoid,other disorders and losing of work ability in 2020 [1]

1.2 The situation of depression in the world and Vietnam

1.2.1 The situation of depression in the world

Depression is a pathological status that gets higher rates in countriesaround the world Based on many authors, a depressive proportion is from 3%

to 5% of the population [20] Some statistics from a number of Europeancountries, depressive disorders ranges from 3-4% of the population [4]

Levitan (1997) studied 8116 patients at aged 15-64 years old anddetermined the rate of depressive disorders typical 8% and tended to increase2-3 times in the next 25 years, females were higher than males 2 times,increased at age 40 [1]

N.A.Satorious and A.S.Jablenski 1984 announced about 3% - 5% of thepopulation of our planet that is nearly 200 million people, has entered a state

of apparent depression Many new studies in the UK, France, the US and theEurozone raised the incidence of depression (lifetime Incidence) from 15% -24% [8]

Approximately 18.8 million American adults or about 9,5% of the USpopulation at the age of 18 and older have the depressive disorder in a year,while the proportion of women was higher than men twice times (12% and6,6%) In 1997, 30.535 people died from suicide in the United States Thesuicide rate in young people increased a lot in the past few decades In 1997,suicide was the 3rd cause leading to death in the age group of 15 to 24 [32].Based on research published in 2010 in the Journal of the American MedicalAssociation, the percentage of teen suicide in 2004 rose to 18% To newresearch, the rate went down in 2005, but not much, the rate was about 4,5%per 100.000 people [6]

In the Asia - Pacific region, according to the author Chiu E (2004), theincidence of depression within 1 month was from 1,3% to 5,5%, within 1 year

from 1,7% to 6,7% and the incidence of depression in a lifetime was from1,1% to 19,9%, lower than many regions of the world In Australia, the rate ofdepression was higher than in some other countries (20-30% of thepopulation), of which 3-4% was moderate and severe depression In someAsian countries such as China, according to the author Chen R, the rate ofdepression in the elderly over 60 years in rural areas was 6%, yet 3,6% in theurban areas [4].

1.2.2 The situation of depression in Vietnam

In Vietnam, various studies on the epidemiology of depression showedthat the incidence of depressive disorder in the community ranged from 3 to8% For the study of special subjects such as the elderly, postpartum womenindicated that the incidence of depression was much higher [7]

According to Tran Van Cuong study and collaborator (2002)Depression was 13,2% of the population Based on Nguyen Van Siem (2010)studied at Quat Dong Commune, Thuong Tin District, Ha Tay showed theincidence of depressive disorders was 8,35% of the population aged over

15 The proportion of female patients / male was 5/1 The incidence at the age

of 30-59 was 58,21%, this about 60 years and above was 36,9% Most of thepatients (94,24%) infected for more 1 year, some infected over 4 years was70,3% Chronic depression progressed significantly, 93,6% as recurrentdepression The lonely depressive episode accounted for 6,3% of anycases The recurrent depression with psychotic rated 2,3% and bipolardisorder was 3,46% [7]

Based on a survey about Vietnamese adolescent reported secondly in

2009 (SAVY II) said, among 10.044 adolescents and young people aged

14-25 living in all 63 provinces / cities around nationwide, there was a significant

proportion also sometimes feeling inferior (29,9%), feeling frustrated,depressed about the future (14,3%) [3].

1.2.3 The situation of depression in medical students

Based on the global study has shown that medical students sufferhigher stress, so easily lead to depression The symptoms of depression,anxiety of medical students are higher than others in different fields andgeneral population [13] The estimated incidence of health problems ofmental medical students in the US and European countries was 8-15%, in theMiddle East was 45-67%, in other countries from 21-38% Particularly, thetendency for suicide of medical students in the US rated 11,2%, those inNorthern Europe were 14% and in China was 12% [11]

According to researchers at the Medical University in Saudi Arabia, therate of the freshmen stressed accounted for approximately 74,2%, 69,8% withthe second form, the third form took 48.6%, 30.4% the fourth grade and thefifth grade was 49% [5]

The study of a middle medical school in Thailand showed 2,4% to bevery tense, 61,4% students have a stress [12]

Currently in Vietnam, there are some studies on the mental health ofmedical students, but small-scale survey, in 1 or 2 schools [11] As many as39,6% of students with symptoms of depression in the study of the freshmen

at the Ho Chi Minh University of Medicine and Pharmacy [31] At HanoiMedical University, some students of the general block getting depressionrisk are high, with the ratio of the block of the 2nd form, the 4th form, the 6th

form was 51%, 50% and 40%, respectively [3] A study was conducted for2,099 students enrolled in the general doctors the first form, the third form,the fifth form at 8 schools: Hanoi Medical University, Thai NguyenUniversity of Medicine and Pharmacy, Hai Phong University of Medicine and

Pharmacy, Thai Binh University of Medicine and Pharmacy, Hue University

of Medicine and Pharmacy, Tay Ninh University (Faculty of Medicine), HoChi Minh University of Medicine and Pharmacy and Can Tho University ofMedicine and Pharmacy from 1-4/2013 [11] Results showed that 43% of the2.099 students who had signs of depression Of these, 23% was milddepression and 20% could be severe depression Especially about suicidalbehavior: 8,7% of students was suicidal ideation, 3,9% of students deliberatedsuicide and 0,9% of students committed suicide The students were all signs

of depression and suicidal ideation was 5,8% (119 students), this was risk groups should be warned

high-According to professor Michael P Dunne, estimated percentageVietnam medical students for signs of depression was significantly highercompared to studies in adults in Vietnam (according to research by DoanVuong Diem Khanh, 2011), and higher than the study of medical students inthe United States (the study of Goebert 2009) [11]

1.3 Risk factors and consequences of depression in medical students

1.3.1 Risk factors leading to depression in medical students

The curriculum in medical school aims to train students to have theknowledge, expertise However, some aspects of training can impactimpaired to the mental health of medical students The study found that themental health becomes worse after students began going to medical schooland still continues to worsen in the training process The medical studentsgetting depression proportion range from 21% to 56%, depending on theircountry and their school [39] Considering the degree of personal influence,healthy problems can push students to abuse stimulants, disorientateoccupation, and seriously, to suicide On a professional level, the study found

that students with problems of mental health affect the care, treatment, theability to work and break the moral medicinal values [18].

The change in the learning environment: Medical students need to learn

a large amount of knowledge However, the knowledge gained is notsufficient to work, but only for the exams, causing feelings of depression [39].Moreover, academic workload and pressure of academic achievement lead todepression Trying to master a large work volume also puts pressure onmedical students These challenges are increasing in preclinical academic yeardue to the pressure to pass exams During the school year clinical studentsmust become familiar with the new learning environment that is at thehospital, facing the patient has different symptoms It requires students tomastes the knowledge learned in the preclinical year and skills to applyknowledge Students are exposed to the patient's pain, so it changes themental students

There is a conflict between theory and practice The medical professionrequires high moral both in training and working During studying at thehospital, the morality is misleading In a study about the student in the 3rd andthe 4th grade, 98% of student responded that they saw doctors insultingpatients 60% of students had seen a physician violating professionalmoral More two thirds of the students had a feeling they did not completetheir responsibilities for patients and for their future [18]

Learning environment exposes to the suffering and the death Medicalstudents in the clinical years regularly face with death But the curriculumusually focuses on diagnosis and treatment, less interest in palliative care inthe final stages of life The medical students often learn lessons about thetheoretical exposure of patients and relative’s patients in critical cases, but nottrained in skills of patient care in the final stages of life So students feel

frightened, nervous, confused, sad, vulnerable and hesitant when they see thepatients died.

The personal life event of students Students face with the medicaltraining program, experience much stressful personal life, as well In a study

of more 1000 medical students, many students witness a member of theirfamily died (15%), besides, they are ill or injury (25%), changing in the health(42%), in addition, they are engaged or get married and have children In

1995, the Association of American Medical Colleges surveyed graduatedmedical student, 30% of those was married, and 14% was engaged or had achild Married was less stressful than the single [18]

Marriage is common among medical students, students have childrenbefore graduation accounted for 10% [18], and therefore, it will greatly affectthe lives of students In fact, based on one study of medical students secondyear, female students were more likely to be depressed if they had children[18]

1.3.2 The consequences of depression for medical students

Poor academic performance: Stress, anxiety and academic performanceare closely related to each other Poor academic performance leads to thestudents are not satisfied with their studying result All of them cause stressand depression However, the influence of these factors depends on theindividual's personality

The insensitivity of medical students: Although the noble obligation ofthe medical student is to be interested in helping people The Reducingempathy in medical students starts to do from the pre-clinical, especially,adversely decline in the clinical years Emotionless attitude can be developed

to require learning at university, to help them to combat the anxiety and thefear when exposing the suffering of patients and patients' relatives The

consequences of insensitive are that doctors do not care about a mentality ofpatients and the relative’s patients They only think about how to cure,without thinking about the cost and whether patients can afford ornot Finally, they lose the humanitarian ideals of medicine.

Deception in the process of learning is taking examples, such ascheating during examinations and finding all the tricks to achieve high scores

in exams Cheating in patient care activities is such as taking care of patientsthoughtlessly, increasing the unnecessary tests for patients,

The use of stimulants such as alcohol, drug and neuroleptic drug

Suicide: Although suicidal ideation and deliberate suicidal of medicalstudents have not been studied, but the risk of suicide in students during theclinical year are seriously high The research from the Norwegian medicalstudents, 14% of students have suicidal thoughts, 6% of the studentsdeliberate suicide to commit suicide [18] Depression, stress in personal life,the personality characteristics are factors affecting the process from idea to bedeliberated suicide and suicidal action

Figure 1.1: Proposed model of causes and consequences of student distress [18]

1.4 Depression measurement

1.4.1 The Center for Epidemiologic studies Depression Scale (CESD)

According to Ian Mc Dowell, depressive assessment is divided into twomajor groups, including: self-evaluation methods and diagnostic methods byclinicians, corresponding how to use in clinical and epidemiologicalstudies A formal diagnosis of depression requires clinicalexamination However, self-assessment measures of depression is commonand easy to use, can identify symptoms of depression but cannot beconsidered diagnostic equipment In some methods, the depression scale ofthe Centre of Epidemiological Studies Depression Scale - CESD is a tooldesigned for using surveys depression in adolescent [28] CESD scale wascreated in 1977 The advantage of this rating scale is used in the community

to determine the cases with signs of depression required furtherintervention This scale evaluates about value and reliability for those

adolescents in Vietnam [5] The question in the scale is short and easy touse Rating scale consists of 20 questions ask about feelings of youth orbehavior related to depression [32] The scale is used widely in largestudies Each question rates on a score of 0, 1, 2, 3 according to the followinglevels:

- 0 point: never or rarely (<1 day / week)

- 1 point: Sometimes (1-2 days / week)

- 2 points: Occasionally (3-4 days / week)

- 3 points: Most of the time (5-7 days / week)

CES-D designs to include the main symptoms of depression with theattention to the emotional part: depressed mood, guilt and worthlessness,feeling helpless and hopeless, mental retardation, loss of appetite and sleepdisturbances The questions of scale are selected from a variety of differentscales such as the Beck Depression Scale, a self-assessment scale of Zungdepression, Raskin depression scale CESD scales are compared with manyother self-assessment scale and CESD is considered better than the Beckdepression scale if there are used in the evaluation of depression cases in thecommunity [28]

CES-D is widely used in many studies in the community Based on theevaluation of international standards, 16 points (cut - off point) is the symbol

to arrange between with and without signs of depression [32, 15]

1.4.2 The studies used CES D

In adolescents depression and risk factors by Tiffany research, students

of seventy-nine high school from suburb Florida used the CES-D as well as aquestionnaire of parents’ relationships, suicidal thoughts, learning result,exercise and drug use The extremely high incidence of adolescents withdepressed mood (37%) had a poor relation with parents Teenagers suffering

from depression also had a fewer relationship, fewer friends, less happy, andoften had suicidal thoughts They spent less time doinghomework, have lower grade point average, and less time to exercise [19].

A study in Thailand was performed by Ratana in 2003, to determine therate of depression using the CES-D (with a cut-off point 22) in 871adolescents aged 12-22 One third (34,9%) subjects had depressivesymptoms, the age of 18-22 adolescents with depression had a higher rate33,1%, the gender differences that affect depressive symptoms in all subjects,with p-value <0,001, women were more likely than men to have symptoms ofdepression [34]

A study in 2008 conducted surveys to determine the rate of depressivesymptoms, in 802 new students in Hong Kong and 988 the college freshmen

in Beijing China Approximately 8,9% of the freshmen Beijing had 25 orhigher score on CES-D, while 17,6% of the freshman in Hong Kong reached

25 points or higher There was no difference between gender and the ratio ofdepressive symptom in Beijing This proportion was considerably differentbetween the gender in Hong Kong, in which 13,4% of men had 25 or higherscores, and 21,3% of women had 25 or higher scores [38]

CHAPTER 2 METHODOLOGY 2.1 Study subjects

The general medical student of Haiphong University of Medicine andPharmacy, 2015-2016

Exclusion criteria: Students who do not agree to participate in research

2.2 Study location

The study is conducted at Hai Phong University of Medicine andPharmacy, Nguyen Binh Khiem Street, No 72A, Ngo Quyen District, HaiPhong City

2.3 Study time

From January to June 2016

2.4 Methodology

2.4.1 Study design

A cross-sectional descriptive study

2.4.2 Sample size and sampling

a) The sample size: Using the formula for estimating sample sizeproportions:

Z  : confidence coefficients, with = 0,05, Z = 1,96

p : the percentage of students shows depressive symptom,

p = 0,396 (depressive symptom prevalence of the freshman students of HoChi Minh University of Medicine and Pharmacy,) [31]

From which n= 368

Then apply the formula for calculating the sample size for the stratum:

ni= n

Inside:

ni : sample size of i stratum

n : total sample size

Ni : the subjects of i stratum

N : total subjects

Table 2.1: Distribution of the sample size in grade

Number Grade Subjects

size

The minimum sample size

The actual investigative number

of 1st grade, 9 classes of 2nd grade, 9 classes of 3rd grade, 8 classes of 4th grade,

9 classes of 5th grade, 9 classes of 6th grade

Two classes of each grade are randomly chosen from the list in order toconduct control chart

2.4.3 Variable and index measurement

Table 2.2: Variables and index measurement

Variable

General characteristics: The characteristics of the general medical students

at Hai Phong University of Medicine and Pharmacy, 2015 – 2016

General

characteristics

Parents’ marital status Qualitative (Nominal)

Objective 1: To examine the percentage of depressive symptoms of generalmedical students at Hai Phong University of Medicine and Pharmacy,

Prevalence of active selves signs Prevalence of depression symptoms

Objective 2: To determine some related factors to depressive symptoms of general medical students at Hai Phong University of Medicine and

Pharmacy, academic year 2015-2016

Variable

Stressful life

events

Difficulties in accommodation Qualitative (Binary)

Death of a close family member Qualitative (Binary)

Troubles with parents Qualitative (Binary)Troubles in finding new friends Qualitative (Binary)Troubles in making social activities Qualitative (Binary)Finished the relationship with love Qualitative (Binary)

Personal

factors

Study-related

Factors

Academic grade point average Qualitative (Binary)

Choosing the study major again Qualitative (Binary)Breaking university regulation Qualitative (Binary)

2.4.4 Method and data collecting

a) Data collecting

Information was collected by self- completed questionnaire

The questionnaire are conducted to have general information ofparticipants and possible information related to depressive symptoms such asstressful life events, personal factors, study-related factors

To assess depression signs of students, we used the CES-D scale ofthe Research Centre for the Epidemiology designed by Radloff and validated

on Ho Chi Minh University of Medicine and Pharmacy freshman students[31]

b) Assess depressive symptoms using the CES-D scale

CES-D Scale consists of 20 questions to evaluate the commonsymptoms in one week Each question has marked with 4 points, from 0-3,with the following levels:

- 0: never or rarely (<1 day / week)

- 1: sometimes (1-2 days / week)

- 2: occasionally (3-4 days / week)

- 3: mostly, all of the time (5-7 days / week)

CES-D 4, 8, 12, 16 questions are as follows:

- 3: never or rarely (<1 day / week)

- 2: sometimes (1-2 days / week)

- 1: occasionally (3-4 days / week)

- 0: mostly, all of the time (5-7 days / week)

The total point of each 20 questions is calculated; Depressive symptom

is defined due to the overall points:

- Total score <16 points: Non depressive symptoms

- Total score ≥ 16 points: Depressive symptoms

Evaluation criteria: for each question: the behavior is considered as

“yes” if the answers names as “sometimes” to “mostly, all of the time”

c) Method of collecting data

The questionnaire is developed based on research variables, indexesand using the CES-D scale of Radoloff After having completedquestionnaire, the primarily survey was done to test the logic and relevance ofeach question

After random selecting the students for research, we asked the helpfrom the Undergraduate Training Department to have the schedule of eachclass After that, we chose suitable time to process the research in such a waythat the study did not affect the students

Participants were explained in details about purpose andconfidentiality of the study as well as the required time to complete aquestionnaire before deciding whether to participate in research

The questionnaires were checked to screen all information beforetaking back from the participants.

2.4.5 Error control methods, limiting potential conformity

- Training for the interviewer to understand the question

- Explain carefully the questionnaire to let them understand clearly each

of questions right after giving them the questionnaire

- Conduct a pilot study to complete the questionnaire, monitor the test, then proceed to investigate

pre-2.5 Data processing and analysis

- Cleaning data was done before input: remove absurd questionnaires:torn, uncompleted answer, no/unclear information

- Data were entered into the computer by Epidata 3.1 software andanalyzed using SPSS software

- Depressive signs were described primarily with comparisons betweengroups (having depressive signs and do not have depressive signs) for relatedfactors findings with the use of Chi-square and Fisher’s exact test (thestatistical significance p <0,05)

strictly managed by data administrator of this study and they no one couldaccess those tables.

CHAPTER 3 RESULT 3.1 Description of general characteristics

Figure 3.1: Distribution of subjects by gender

Comment: The number of male who contributed in the research is 68% and

2 nd

Grade N=100 n(%)

3 rd

Grade N=76 n(%)

4 th

Grade N=114 n(%)

5 th

Grade N=75 n(%)

6 th

Grade N=75 n(%)

Total N=511 n(%)

Yes 6 (8,5) 9 (9) 7 (9,2) 8 (7) 3 (4) 3 (4) 36 (7)

(91,5)

91(91)

69(90,8)

106(93)

72(96)

72(96)

475(93)

Comment: 93% of the students are irreligious, and other 7% of students have

their religion

Figure 3.2: Distribution of subjects by ethnicity and course

Comment: The main Kinh ethnic accounts for 89% Among of them, the 6th

grade is the highest (98,7%), followed to the 2nd grade is 96%, next are the5th, 4th, 1st grade with the percentage of 88%, 87,7%, 85,9% , respectivelyand the lowest is the 3rd grade (76,3%)

Table 3.2: Distribution of subjects by parents’ education

Education

Frequency N=511 n(%)

Secondary school and lower 192 (37,6) 212 (41,5)

University degree and higher 89 (17,4) 86 (16,8)

Comment: The table shows the parent’s education, the percentage of fathers

holding a high school diploma, a secondary school and lower diploma anduniversity and higher degree are 45%, 37,6%, and 17,4%, respectively.Mothers have somewhat less educational achievement at 41,7%, 41,5%, and16,8%, respectively.

Figure 3.3: Distribution of subjects by family residence

Comment: The mainly family residence living in rural areas accounted for

85.1%, only 9% of their families living in the city

Table 3.3: Distribution of subjects by current residence and grade

2 nd

Grade N=100 n(%)

3 rd

Grade N=76 n(%)

4 th

Grade N=114 n(%)

5 th

Grade N=75 n(%)

6 th

Grade N=75 n(%)

Total N=511 n(%)

Hall of residence 4

(5,6)

4 (4)

11 (14,5)

15 (13,2)

8 (10,7)

14 (18,7)

56 (11)

(90,1)

76 (76)

62 (81,6)

82 (71,9)

56 (74,7)

56 (74,7)

402 (78,7)

Living with

parents/relatives

3 (4,2)

20 (20)

3 (3,9)

17 (14,9)

5 (6,7)

5 (6,7)

53 (10,3)

Comment: Most of the students living in rent-room accounts for 78.7%, while

an amount of students living in the dormitory is only 11%, similarly, thestudents staying with their parents’ or relatives’ house is 10%, the difference

is not statistically significant, at p-value < 0,001

3.2 Students have depressive symptoms based on the CES-D scale

Table 3.4: Positive signs according to the CES-D

N=511 Percentage CES-D4 Felt just as good as other people 432 84,5

CES-D8 Felt hopeful about the future 383 75

Comment: Most of the students having positive signs according to the

CES-D scale, of which the highest is "Felt just as good as other people" and "Felthappy" (84,5% and 85,5%), followed by "Enjoyed life" (82,4%) and "Felthopeful about the future" (75%)

Table 3.5: Difficulty in communication signs based on the CES-D

Symptom Frequency

N=511 Percentage CES-D15 Felt that people were

CES-D19 Felt that people dislike me 124 24,3

Comment: The percentage of students getting sign "Felt that people were

unfriendly" is 35%, while 24,3% of students has "Felt that people dislike me"

Table 3.6: Depressed signs based on the CES-D

N=511 Percentage

CES-D3: Felt does not shake off the blues 162 31,7

CES-D9: Thought their life had been a

Comment: The student groups that have the highest percentage about having

depression of sign are “Felt sad” and “Felt lonely” at 51,7% and 51,9%,respectively “Felt bothered” takes 40,7%, while “Felt fearful” and “Feltdepressed” nearly have a similar proportion, approximately 31% Besides,the two last groups researched on the CES-D with the lowest percentage are

“Thought their life had been a failure” and “had crying spells” at 29,0% and22,7% respectively