Accepted Manuscript Psychological Distress and its Correlates among University Students: A CrossSectional Study Mahin Delara, Roberta L. Woodgate PII:
S1083-3188(14)00312-X
DOI:
10.1016/j.jpag.2014.08.012
Reference:
PEDADO 1766
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 11 April 2014 Revised Date:
20 August 2014
Accepted Date: 25 August 2014
Please cite this article as: Delara M, Woodgate RL, Psychological Distress and its Correlates among University Students: A Cross-Sectional Study, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.08.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Psychological Distress and its Correlates among University Students: A Cross-Sectional Study Mahin Delara a *, Roberta L. Woodgateb a*
RI PT
Correspondence: Department of Applied Health Sciences, Faculty of graduate studies, University of Manitoba, Winnipeg, Manitoba, Canada, Email:[email protected] b
Structured Abstract
SC
Canadian Institutes of Health Research (CIHR) Applied Chair in Reproductive, Child and Youth Health Services and Policy Research Professor, Child Health and Illness, Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada, Email: [email protected]
M AN U
Study Objective: Mental health disorders are common among university students. In addition to the normal stressors of everyday life, students must deal with stresses related to their education. Our aim was to identify the mental health status of university students and its correlation with socio-demographic, academic performance and menstrual features. Design: A cross sectional study was conducted among undergraduate health students using the Symptoms Checklist-90- Revised (SCL-90-R). The Global Severity Index (GSI), raw scores of SCL-90-R subscales and correlated factors were reported and analyzed.
EP
TE D
Results: A total of 171 health students completed the survey. Psychopathological symptoms were found in 23% of the student. Depression was the most prevalent mental reported symptom (100%). There was no significant association between the symptoms and variables such as age, gender, living in university dormitories, marital status, field of study, academic performance and the day of menstrual cycle while filling the form. GSI scores were significantly related to regular menses. The odds of being identified as a mentally unhealthy individual was 0.37 times lower for those who experienced regular menstrual cycles.
AC C
Conclusion: Psychological distress is prevalent among health students and tends to be reported more by female students with irregular periods and during luteal phase of menstrual cycle. Preventive and treatment programs need to be developed. It is also recommended that SCL-90-R be administered at least seven days after the end of menstrual bleeding. Key words: Mental health; Youth; Health students; SCL-90-R; Menstrual cycle; Premenstrual syndrome
1
ACCEPTED MANUSCRIPT
RI PT
Introduction The demanding nature of studies in health sciences and the growing population of the university students in Iran involve a best screening of psychological distress.1Determining the mental health status of students in health sciences can definitely help to detect mental problems and develop proper treatments prior graduation from university. Several reports indicate that prolonged psychological distress is associated with burnout, reduced academic achievement, unprofessional fieldwork performance and mental disability.1 It is also obvious that promoting mental wellbeing of health students may prevent health-damaging behaviors, improve their quality of life and have a great impact on the quality of care services that they will provide for people as future professionals.2 Furthermore the direct cost of mental health services may represent a considerable amount of total health spending.2
M AN U
SC
While a substantial evidence-base on Iranian students’ well-being exists in medicine, data in the arena of health sciences are relatively sparse. Findings by Nojomi and Gharayee in medical students showed that alarmingly high proportions (19.4%) of them may be in the clinical range of psychological disturbance.3 Other investigators from Germany reported similar findings.4 This rate was 8% reported by Divaris and his colleagues with regard to dental undergraduates’ general health and psychological distress.1 Empirical observations in Iran indicate that even though the majority of health students complete their studies within the eight semesters of the regular curriculum but only a small proportion of them met the professional qualifications as a health care provider prior graduation. It may be deducted that this poor academic performance be related to psychological distress that students undergo during their training courses.
AC C
EP
TE D
Nevertheless, to our knowledge, no investigation has examined the mental well-being in Iranian health students. Moreover, findings on the association of female health students’ psychological distress with the menstrual phase have not been established worldwide. By using Symptom Checklist-90 Revised (SCL-90-R) questionnaire, we aimed at identifying the mental health status of the university students and its correlated factors including academic performance, menstrual characteristics and socio-demographic factors. We also wanted to investigate whether female respondents’ reports of psychological symptoms differ in different phases of menstrual cycle. Our second goal is based on a presumption that adolescents with premenstrual disorders gain higher scores on SCL-90-R than those without premenstrual disorders.5 Symptoms of premenstrual syndrome (PMS) are usually demonstrated during menstruation and premenstrual phase, so if the time when women with PMS report their symptoms be concurrent with their premenstrual phase, it is possible that the psychological symptoms to be over-reported and their scores on SCL-90-R be misleading. Nevertheless, we finally embarked upon this investigation in order to add to the knowledge base of health students’ well-being and psychological distress and subsequently to inform and sensitize educators, researchers and stakeholders about this topic that has received little attention.
2
ACCEPTED MANUSCRIPT
Materials and Methods
SC
RI PT
The study sample and design A cross sectional study was conducted in Sabzevar University of Medical Sciences during 2013 scholastic year. Sabzevar is one of the Khorasan province cities located in the east of Iran. The majority of Iranian students usually enroll in health schools right after high school and admissions are based primarily upon competitive national exams. In Sabzevar University, three major health studies including public, environmental and occupational health are presented with a total of 183 enrolled students. Health studies are structured around a traditional, mostly lecturebased four-year curriculum. The first two years are focused on didactic activities on biomedical and health introductory courses. During the second and third years, students undergo pre-clinical trainings. Year four entails clinical trainings.
M AN U
After obtaining ethical approval, all students from the total three health schools initially contacted and invited to participate in the research from April to June 2013 and 171 students agreed to participate for a response rate of 93.4%. Students were approached during scheduled classes or seminar sessions. The purpose, anonymous nature and voluntary character of the study were explained. The survey was administered in paper and pencil form which required approximately 25 minutes for completion. The participants were asked to voluntarily answer the questions in their classrooms break time.
AC C
EP
TE D
Psychological assessment measure Psychological symptoms were assessed by SCL-90-R which is essentially a psychiatric selfreport instrument. SCL-90-R was introduced by Derogatis and consists of 90 questions in total and is divided into nine symptom dimensions namely somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.6 Respondents rate the 90 symptoms of distress on a 5-point Likert scale (0=" not at all" to 4="extreme"). The mean score of all items are calculated as the Global Severity Index (GSI) and then transformed to T scores. For this study, we used the normative scores and thresholds suggested for young non-patients.6 Moreover it is also important to investigate the properties of self-report questionnaires such as SCL-90-R in each new population since they have specific characteristics that make them sensitive to linguistic and cultural factors. For this reason, the SCL-90-R was translated into the official language of Iran (Persian) and its psychometric properties were supported in an independent study.3 Its reliability proved to be good with a correlation coefficient of 0.97 on pre-test and post-test assessments. Its validity as a measure of general symptom distress was also good since internal consistency for all dimensions of the questionnaire was more than 0.70.3 The sensitivity and specificity of the questionnaire comparing to DSM III-R was 0.94 and 0.98 respectively. 3 Hence, we applied the Iranian version of the SCL-90-R for this study which was shown to perform well in terms of reliability and internal consistency.7
Additional measures A questionnaire for collecting data on demographic, menstrual characteristics and academic performance of the study sample was also designed. This questionnaire consisted of three 3
ACCEPTED MANUSCRIPT
RI PT
sections. Section one included questions about socio-demographic information such as age (years after birth date), marital (single or married), residency (living on or off campus), and economic status (monthly family income).Section two included questions for females about menstrual characteristics such as the regularity of menstrual cycles, the length of menstrual bleeding and duration of menstrual cycle. An additional question was also designed in this section to evaluate the menstrual phase of the students at the time of filling the questionnaires. Section three included questions about educational and academic performance in health schools based on the average score of final grades (ranging from 0 to 20) in previous semesters.
M AN U
SC
Analytical approach Statistical analysis was conducted using the SPSS version 16. All tests were carried out at the 5% level of significance. The data were firstly analyzed in a descriptive fashion. T test was used for comparison. Moreover a Spearman correlation analysis was used to assess any relation between the demographic features, academic performance and menstrual characteristics information provided by the students and the GSI scores. Chi square analysis was also used to determine the correlation between some qualitative variables and the mental health status. We also generated normalized GSI (T) scores centered at 50 separately for males and females used a T score ≥63 definition for a psychological morbidity (cut-off score). Finally, a logistic regression analysis was performed to determine variables that contribute to GSI scores in students. The normal or abnormal mental health status based on the GSI cut-off point was used as dependent variable, and demographic and menstrual characteristics were considered as independent variables.
TE D
Ethical approval The study was approved by the Ethics Committee of Sabzevar University of Medical Sciences. All participants gave their written consent. Results
AC C
EP
In all, 183 undergraduate students were approached from three health schools. One hundred seventy one students returned the self-report questionnaires. The mean age of participants was 21.6±3 years (ranging from 18 to 37 years) with approximately two-thirds being females (79.5%). The majority were first year students (34%), single (74.2%) and accommodated in university dormitories (72.2%). The average monthly family income in 88% of the study sample was less than 1,000,000 Rials (1 US dollar equals 30000 Rials). Regular menstrual cycles were reported in 77.4 % of the female respondents. The socio-demographic characteristics of the participants are illustrated in Table1. The minimum GSI score was 0.04 and the maximum was 2.44 with an overall mean score of 0.91±0.51. The mean score of GSI in female students was 0.95±0.52 and in males was 0.67±0.42. Female students got higher mean scores in all subscales of SCL-90-R. This difference was not statistically significant (P=0.085). Twenty three percent of participants were classified as “suspected to be mentally ill”. These estimates were 26.5% in female and 20% in male respondents. 4
ACCEPTED MANUSCRIPT
RI PT
As demonstrated in Tables 2, the most reported mental symptom was depression with a frequency of 100% both in male and female respondents. Paranoid (76.5%) in female and psychotism (62.9%) in male students were the second major psychological symptoms. The lowest frequent symptom was also reported in somatization domain both for men and women with an approximately 31.5%. No correlation was found between GSI scores and age (P=0.085), monthly income (P= 0.324) and average score of academic performance (P=0.943). T-test analysis also showed no significant correlation between GSI scores and accommodation in dormitories (P= 0.861), marital status (P= 0.118) and field of study (P= 0.814).
SC
The only parameter that was significantly related to GSI scores was the regularity of menstrual cycles in female students. The mean GSI score in women with regular periods was lower than those experiencing irregular periods (P= 0.047).
M AN U
When completing the forms, 80.7% of participants were in luteal phase who reported modest higher psychological symptoms than those in follicular phase but this difference was not statistically significant. In other words there was no association between GSI scores and the date of menstrual cycle at the time of filling out the questionnaires (P=0.849).
TE D
Logistic regression for assessing the impact of regularity of menstrual cycles on GSI score showed that it made a significant contribution (P
S1083-3188(14)00312-X
DOI:
10.1016/j.jpag.2014.08.012
Reference:
PEDADO 1766
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 11 April 2014 Revised Date:
20 August 2014
Accepted Date: 25 August 2014
Please cite this article as: Delara M, Woodgate RL, Psychological Distress and its Correlates among University Students: A Cross-Sectional Study, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.08.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Psychological Distress and its Correlates among University Students: A Cross-Sectional Study Mahin Delara a *, Roberta L. Woodgateb a*
RI PT
Correspondence: Department of Applied Health Sciences, Faculty of graduate studies, University of Manitoba, Winnipeg, Manitoba, Canada, Email:[email protected] b
Structured Abstract
SC
Canadian Institutes of Health Research (CIHR) Applied Chair in Reproductive, Child and Youth Health Services and Policy Research Professor, Child Health and Illness, Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada, Email: [email protected]
M AN U
Study Objective: Mental health disorders are common among university students. In addition to the normal stressors of everyday life, students must deal with stresses related to their education. Our aim was to identify the mental health status of university students and its correlation with socio-demographic, academic performance and menstrual features. Design: A cross sectional study was conducted among undergraduate health students using the Symptoms Checklist-90- Revised (SCL-90-R). The Global Severity Index (GSI), raw scores of SCL-90-R subscales and correlated factors were reported and analyzed.
EP
TE D
Results: A total of 171 health students completed the survey. Psychopathological symptoms were found in 23% of the student. Depression was the most prevalent mental reported symptom (100%). There was no significant association between the symptoms and variables such as age, gender, living in university dormitories, marital status, field of study, academic performance and the day of menstrual cycle while filling the form. GSI scores were significantly related to regular menses. The odds of being identified as a mentally unhealthy individual was 0.37 times lower for those who experienced regular menstrual cycles.
AC C
Conclusion: Psychological distress is prevalent among health students and tends to be reported more by female students with irregular periods and during luteal phase of menstrual cycle. Preventive and treatment programs need to be developed. It is also recommended that SCL-90-R be administered at least seven days after the end of menstrual bleeding. Key words: Mental health; Youth; Health students; SCL-90-R; Menstrual cycle; Premenstrual syndrome
1
ACCEPTED MANUSCRIPT
RI PT
Introduction The demanding nature of studies in health sciences and the growing population of the university students in Iran involve a best screening of psychological distress.1Determining the mental health status of students in health sciences can definitely help to detect mental problems and develop proper treatments prior graduation from university. Several reports indicate that prolonged psychological distress is associated with burnout, reduced academic achievement, unprofessional fieldwork performance and mental disability.1 It is also obvious that promoting mental wellbeing of health students may prevent health-damaging behaviors, improve their quality of life and have a great impact on the quality of care services that they will provide for people as future professionals.2 Furthermore the direct cost of mental health services may represent a considerable amount of total health spending.2
M AN U
SC
While a substantial evidence-base on Iranian students’ well-being exists in medicine, data in the arena of health sciences are relatively sparse. Findings by Nojomi and Gharayee in medical students showed that alarmingly high proportions (19.4%) of them may be in the clinical range of psychological disturbance.3 Other investigators from Germany reported similar findings.4 This rate was 8% reported by Divaris and his colleagues with regard to dental undergraduates’ general health and psychological distress.1 Empirical observations in Iran indicate that even though the majority of health students complete their studies within the eight semesters of the regular curriculum but only a small proportion of them met the professional qualifications as a health care provider prior graduation. It may be deducted that this poor academic performance be related to psychological distress that students undergo during their training courses.
AC C
EP
TE D
Nevertheless, to our knowledge, no investigation has examined the mental well-being in Iranian health students. Moreover, findings on the association of female health students’ psychological distress with the menstrual phase have not been established worldwide. By using Symptom Checklist-90 Revised (SCL-90-R) questionnaire, we aimed at identifying the mental health status of the university students and its correlated factors including academic performance, menstrual characteristics and socio-demographic factors. We also wanted to investigate whether female respondents’ reports of psychological symptoms differ in different phases of menstrual cycle. Our second goal is based on a presumption that adolescents with premenstrual disorders gain higher scores on SCL-90-R than those without premenstrual disorders.5 Symptoms of premenstrual syndrome (PMS) are usually demonstrated during menstruation and premenstrual phase, so if the time when women with PMS report their symptoms be concurrent with their premenstrual phase, it is possible that the psychological symptoms to be over-reported and their scores on SCL-90-R be misleading. Nevertheless, we finally embarked upon this investigation in order to add to the knowledge base of health students’ well-being and psychological distress and subsequently to inform and sensitize educators, researchers and stakeholders about this topic that has received little attention.
2
ACCEPTED MANUSCRIPT
Materials and Methods
SC
RI PT
The study sample and design A cross sectional study was conducted in Sabzevar University of Medical Sciences during 2013 scholastic year. Sabzevar is one of the Khorasan province cities located in the east of Iran. The majority of Iranian students usually enroll in health schools right after high school and admissions are based primarily upon competitive national exams. In Sabzevar University, three major health studies including public, environmental and occupational health are presented with a total of 183 enrolled students. Health studies are structured around a traditional, mostly lecturebased four-year curriculum. The first two years are focused on didactic activities on biomedical and health introductory courses. During the second and third years, students undergo pre-clinical trainings. Year four entails clinical trainings.
M AN U
After obtaining ethical approval, all students from the total three health schools initially contacted and invited to participate in the research from April to June 2013 and 171 students agreed to participate for a response rate of 93.4%. Students were approached during scheduled classes or seminar sessions. The purpose, anonymous nature and voluntary character of the study were explained. The survey was administered in paper and pencil form which required approximately 25 minutes for completion. The participants were asked to voluntarily answer the questions in their classrooms break time.
AC C
EP
TE D
Psychological assessment measure Psychological symptoms were assessed by SCL-90-R which is essentially a psychiatric selfreport instrument. SCL-90-R was introduced by Derogatis and consists of 90 questions in total and is divided into nine symptom dimensions namely somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.6 Respondents rate the 90 symptoms of distress on a 5-point Likert scale (0=" not at all" to 4="extreme"). The mean score of all items are calculated as the Global Severity Index (GSI) and then transformed to T scores. For this study, we used the normative scores and thresholds suggested for young non-patients.6 Moreover it is also important to investigate the properties of self-report questionnaires such as SCL-90-R in each new population since they have specific characteristics that make them sensitive to linguistic and cultural factors. For this reason, the SCL-90-R was translated into the official language of Iran (Persian) and its psychometric properties were supported in an independent study.3 Its reliability proved to be good with a correlation coefficient of 0.97 on pre-test and post-test assessments. Its validity as a measure of general symptom distress was also good since internal consistency for all dimensions of the questionnaire was more than 0.70.3 The sensitivity and specificity of the questionnaire comparing to DSM III-R was 0.94 and 0.98 respectively. 3 Hence, we applied the Iranian version of the SCL-90-R for this study which was shown to perform well in terms of reliability and internal consistency.7
Additional measures A questionnaire for collecting data on demographic, menstrual characteristics and academic performance of the study sample was also designed. This questionnaire consisted of three 3
ACCEPTED MANUSCRIPT
RI PT
sections. Section one included questions about socio-demographic information such as age (years after birth date), marital (single or married), residency (living on or off campus), and economic status (monthly family income).Section two included questions for females about menstrual characteristics such as the regularity of menstrual cycles, the length of menstrual bleeding and duration of menstrual cycle. An additional question was also designed in this section to evaluate the menstrual phase of the students at the time of filling the questionnaires. Section three included questions about educational and academic performance in health schools based on the average score of final grades (ranging from 0 to 20) in previous semesters.
M AN U
SC
Analytical approach Statistical analysis was conducted using the SPSS version 16. All tests were carried out at the 5% level of significance. The data were firstly analyzed in a descriptive fashion. T test was used for comparison. Moreover a Spearman correlation analysis was used to assess any relation between the demographic features, academic performance and menstrual characteristics information provided by the students and the GSI scores. Chi square analysis was also used to determine the correlation between some qualitative variables and the mental health status. We also generated normalized GSI (T) scores centered at 50 separately for males and females used a T score ≥63 definition for a psychological morbidity (cut-off score). Finally, a logistic regression analysis was performed to determine variables that contribute to GSI scores in students. The normal or abnormal mental health status based on the GSI cut-off point was used as dependent variable, and demographic and menstrual characteristics were considered as independent variables.
TE D
Ethical approval The study was approved by the Ethics Committee of Sabzevar University of Medical Sciences. All participants gave their written consent. Results
AC C
EP
In all, 183 undergraduate students were approached from three health schools. One hundred seventy one students returned the self-report questionnaires. The mean age of participants was 21.6±3 years (ranging from 18 to 37 years) with approximately two-thirds being females (79.5%). The majority were first year students (34%), single (74.2%) and accommodated in university dormitories (72.2%). The average monthly family income in 88% of the study sample was less than 1,000,000 Rials (1 US dollar equals 30000 Rials). Regular menstrual cycles were reported in 77.4 % of the female respondents. The socio-demographic characteristics of the participants are illustrated in Table1. The minimum GSI score was 0.04 and the maximum was 2.44 with an overall mean score of 0.91±0.51. The mean score of GSI in female students was 0.95±0.52 and in males was 0.67±0.42. Female students got higher mean scores in all subscales of SCL-90-R. This difference was not statistically significant (P=0.085). Twenty three percent of participants were classified as “suspected to be mentally ill”. These estimates were 26.5% in female and 20% in male respondents. 4
ACCEPTED MANUSCRIPT
RI PT
As demonstrated in Tables 2, the most reported mental symptom was depression with a frequency of 100% both in male and female respondents. Paranoid (76.5%) in female and psychotism (62.9%) in male students were the second major psychological symptoms. The lowest frequent symptom was also reported in somatization domain both for men and women with an approximately 31.5%. No correlation was found between GSI scores and age (P=0.085), monthly income (P= 0.324) and average score of academic performance (P=0.943). T-test analysis also showed no significant correlation between GSI scores and accommodation in dormitories (P= 0.861), marital status (P= 0.118) and field of study (P= 0.814).
SC
The only parameter that was significantly related to GSI scores was the regularity of menstrual cycles in female students. The mean GSI score in women with regular periods was lower than those experiencing irregular periods (P= 0.047).
M AN U
When completing the forms, 80.7% of participants were in luteal phase who reported modest higher psychological symptoms than those in follicular phase but this difference was not statistically significant. In other words there was no association between GSI scores and the date of menstrual cycle at the time of filling out the questionnaires (P=0.849).
TE D
Logistic regression for assessing the impact of regularity of menstrual cycles on GSI score showed that it made a significant contribution (P
