Correlation of Socio-Demographic Variables with levels of Depression, Anxiety and Stress in University Students.

ABSTRACT

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Introduction: Mental health in university students is a topic becoming more and more relevant. It is important to identify factors promoting its appearance, as well as to what extent they influence academic performance.
Method: A non-experimental, descriptive, correlational and cross-sectional quantitative design was used. Chi Square was applied to evaluate the correlation between variables. The sample was non-probabilistic involving 166 students from Nursing, Nutrition and Dietetics, Speech Therapy, and Kinesiology careers. The abbreviated Chilean version of the DASS-21 Depression, Anxiety and Stress Scales was applied, made up of 21 items, with four response alternatives in Likert scale format plus a Sociodemographic Questionnaire. This instrument included personal variables, such as Mapuche Ethnic Group and Schooling Parents’ Level. The research Protocol used was approved by the Scientific Ethics Committee of the Servicio de Salud Del Reloncaví (Reloncaví Health Service).
Results: 54.82% of the sample had some level of alteration or risk of suffering anxiety; 47.59% stress; and 31.33% depression. 42.17% of the students belong to the Mapuche Ethnic group, while 56.02% belong to non-Mapuche ethnicity. Regarding Parents´ Education Level, the highest percentage is Full High school Education (father 37.95%, and mother 36.14%).
Conclusions: There is a correlation between female sex and levels of anxiety, stress and depression. In addition, there is a correlation between belonging to the female gender, studying nursing, Nutrition and dietetics careers with having some level of anxiety. A correlation between anxiety, depression and stress stands out.
Keywords: University Students, Stress, Depression, Anxiety, Sociodemographic Variables.

Introduction

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Mental health of university students has been impacted due to various reasons; among them are adaptation problems, responsibility, lack of autonomy, interpersonal relationships, new challenges, academical demand¹. Such factors cause an increasing prevalence of this type of pathologies². According to the Pan American Health Organization (PAHO), during 2015 the total amount of people who suffered depression -all over the world- exceeded 300 million. The amount of population who suffered depression was 4.4%; and 3.6%³ suffered anxiety. In the Americas, 7.7% of women suffer anxiety disorders; a similar situation is reported in students^{4, 5}, who enter higher education and must adapt themselves to a very demanding system.
Anxiety is caused, due to the expectations created from a situation; and its completion happens when such situation comes true and does not pose a threat⁶. If such situation is extended in time, with no stimuli present, it may become an anxiety disorder^{7, 8}.
The poor articulation between High school and the university causes a big change in students´ life, thus increasing the risk of suffering an anxiety disorder. Among the main causes are psychological/social/academic demands, as well as the high level of stress leading to psycho-emotional disturbances, such as depressive/anxious/suicidal/ disorders, abuse of alcohol and drugs, among others⁹.
In stress, there is a dynamic correlation between the person and the environment and that changes constantly. Facing such situation involves behavioral/cognitive effort, in order to control the demands generated by such stressing situations¹⁰. This picture is the prelude of anxious responses, thus causing students to suffer a stressful personal condition, before a specific threatening event, that becomes acute during the period before exams⁶. In a research made in the “Universidad de los Lagos” College, a high prevalence of stress among Health Areas students was reported, with a higher incidence among women¹¹.
According to World Health Organization (WHO) depression is defined as a frequent mental disorder. People suffering said situation reported sadness, lack of interest/pleasure, guilt feelings, low self-esteem, sleep/eating disorders, fatigue and lack of concentratión³. College students have a higher risk of suffering a depressive/anxious disorder, mainly due to the change in their life styles when they enter college. Depression is reported with a higher prevalence in college students, and a higher frequency during the first years of study¹².
According to our literature review, prevalence of mental health problems is higher in Health Area students, when compared with other college careers. There is a higher prevalence than in general population, which is linked to academical demand, social/economic and social/emotional factors^{5, 13, 14}. Furthermore, the variables career, sex and being a first-year student, would cause a higher prevalence of these psycho-emotional events^{14, 15}. Its symptomatology cloud compromise their future academical/occupational performance^16-17 .According to the data retrieved from the Institutional Analysis Unit of the “Universidad de los Lagos”, Campus Osorno18 students’ failure during the first year of their Health Careers is higher than the institutional average.
According to our literature review, the studies blending psycho-emotional variables with socio-demographic factors in college students are few; therefore, this research will allow to learn if there is a correlation among such variables.
The objective of the research is to determine the correlation between levels of depression, anxiety and stress in college students studying the first year of their careers in Health Areas, with socio-demographic variables.

Method

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This is a quantitative/non experimental/descriptive/correlational/cross cutting research. In order to assess the potential correlation among all the combinations of these variables the Chi square Test of Pearson was applied.
The sample of this study is non-probabilistic. It included 166 subjects belonging to the 2019 cohort who were studying the first year of Nursery, Nutrition and Dietetics, Speech Therapy and Kinesiology careers who completed their academical term, by early 2020. Inclusion criteria were regular students who were willing to participate in this research, prior signature of a written informed; exclusion criteria were non-regular students who rejected to participate in the study.
The instrument applied was the brief Chilean version of the Scales of Depression, Anxiety and Stress (DASS – 21), validated in Chilean College students¹⁹.
Depression deals with the questions^{3, 5, 10, 13, 16, 17, 21}; Anxiety deals with the questions^{2, 4, 7, 9, 15, 19, 20} and stress deals with the questions^{1, 6, 8, 11, 12, 14, 18}. The score of each Sub-scale was calculated with the summation of the scores on the items belonging to that section, and it ranges between 0 to 21 points. The cut score allows to detect the presence of affective states of depression, anxiety and significant stress in Chilean youngsters, whose ages range between 15 to 24 years old. For the Scale of Depression, the cut score was 6; for the Scale of Anxiety, it was 5; and for the Scale of Stress, it was 6. The severity of the alteration is fixed, according to the score of each domain. The higher the score, the higher the severity of depression, anxiety and stress. The score for normality classification, for psycho-emotional pictures are: depression (0-4); anxiety (0-3); stress (0-7). The instrument has a satisfactory level of reliability (Alfa values range between 0.87 to 0.88, for the Scale of Depression; between 0.72 to 0.79, for the Scale of Anxiety; and 0.82 to 0.83, for the Scale of Stress)²⁰.
A socio-demographic questionnaire, created by researchers and validated by experts was applied. It included personal variables, such as: age, sex, origin (urban, rural, or semi-urban), belonging to Mapuche ethnicity (Aboriginal Chilean People) and schooling level of the parents.
Statistical data were processed with the software “SPSS version 25”. We worked with Descriptive Statistical Analysis, and Statistically Significant Correlation Tests provided by the software “IBM SPSS version 25”.

Procedure
The instruments “DASS-21 abbreviated version”, and the Socio-Demographic Questionnaire were applied in the first stage. The information gathered was saved in an encrypted file. Once the required scores were obtained, these were correlated with socio-demographic variables.

Ethical Considerations
The research was subject to the approval of the Scientific Ethics Committee of the Servicio de Salud de Reloncaví (Reloncavi Health Service), Order #27-2019. The Informed Consent was presented to the subjects prior to the introduction of the objectives of the study, by the main Researcher. Signature of the Individual Informed Consent Act was requested.

Results

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The whole set of study had 166 cases. Students belonged to the following careers: Nursery (33.13%); Kinesiology (29.52%); Nutrition and Dietetics (21.08%) and Speech Therapy (16.27%). 71.08 % of all students were women; 28.92 % were men. It is important to highlight that Kinesiology has similar proportions between women (51.02%) and men (48.98%). However, in Speech Therapy, the proportion is uneven, with 85.19% of women and 14.81% of men. Ages ranged between 17 to 31 years old (the average was 18.78 years old). 75.90% of all students come from urban areas; 16.27% come from rural areas; and 7.83% come from semi-urban areas. 42.17% belong to Mapuche ethnicity; while 56.02% do not belong to that ethnicity. From the entire sample, 76.51% of the students have a Free-Education; 22.89% of them do not have such benefit. Regarding father´s and mother´s schooling level, the highest percentage belongs to full High school Category, with 37.95%, and 36.14% respectively. On the other hand, the lowest category is Postgraduate education (father 1.81% and mother 1.20%). Regarding psycho-emotional disorders, 54.82% of the subjects are reported to have some level of alteration or risk to suffer anxiety; 47.59% of them, to suffer stress and 31.33% to suffer depression (Table 1). For correlating the variables with mental health conditions, the levels were grouped as mild, moderate, severe and extremely severe, in a variable named as “some level of alteration “. The classification named as “normal” remained the same. In such a way that when correlating gender with mental health conditions, a significant correlation is reported between feminine sex and some level of anxiety, stress and depression (Table 2). Regarding the correlation of mental health condition and ethnicity, there is no significant correlation (p value: anxiety 0.081, stress 0.066 and depression 0.708). A similar situation is reported when correlating the variable “origin of the student” (p value: anxiety 0.128, stress 0.088, depression 0.336). However, when correlating the variables “Free-Education”, “some level of anxiety” and “feminine sex” a correlation is reported (p value: 0.001). When analyzing some level of depression, anxiety and stress with the careers, there is no correlation reported; however, when correlating the variable sex, some level of mental health disturbance, and the career, in Nutrition and Dietetics, women were reported to suffer more anxiety than men, despite one of the boxes has a very low value (12.50%) the differences are still visible when dealing with the feminine gender. The same situation happens with the career of Nursery, where the value of significance reports that women tend to suffer some level of anxiety, unlike men (Table 3). It is important to highlight that there is no significant correlation between these variables and some level of depression or stress. Regarding Schooling level in both parents and psycho-emotional disturbances; in case of father´s, we obtained 0.494 as a p value for anxiety; 0.065 for stress; and 0.305 for depression. Regarding mother´s schooling level, 0.495 was obtained as a p value for anxiety; 0.088 for stress; and 0.336 for depression. However, there is no significant correlation in such variables. On the other hand, when analyzing the correlation between mental health conditions among them (Table 4), a significant correlation between students who have some level of stress and anxiety is reported (p: 0.000), whose correlation is strong (Cramer´s V: 0.55). Likewise, there is a significant correlation between the students who have some level of stress and depression (p: 0.000), although weak (Cramer´s V: 0.4747). Furthermore, significance was reported between the students who have some level of anxiety and depression (p: 0.000), but this is a weak correlation (Cramer´s V: 0.3783).

DISCUSSION

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This research is aimed to determine the correlation between levels of depression, anxiety and stress among college students of the first year, in careers related to the Health Area, including socio-demographic variables. The main findings of this study report there is a high risk of suffering some kind of mental health problem (anxiety 54.82%; stress 47.59%; depression 31.33%).
According to the results of the first National Survey on College Mental Health in Chile, made in 2019, within three universities, 53.5% of the students reported some symptoms of stress; 46% reported depression; 45.5% reported anxiety; and 29.7% reported symptomatology related to the three variables²¹. These results differ from our findings, as the highest prevalence reported is anxiety, followed by stress and finally depression. However, these tendencies reveal worrying figures, and it is necessary to timely detect mental health problems.
When comparing results obtained against other national studies, where the Scale DASS-21 was used to determine levels of psycho-emotional disturbances in college students of the first year in Health Area careers, a tendency similar than that obtained in this research was reported^13,22 .
Internationally, there is a high prevalence of mental health disturbances in college students; however, different tendencies are reported. In a study made in Colombia, the same scale was used in students of Odontology, thus proving a high prevalence of depression (56.6%); followed by stress (45.4%) and anxiety (37.4%) 16. In another research made in college students from Spain, where the DASS-21 Scale was used, a high prevalence of stress (33.9%), anxiety (23.5%) and depression (18.6%) was reported²³. Furthermore, in a systematic review, aimed to evaluate prevalence of depression, the conclusion was that college students report high rates of depression, against the rates reported in general population. These figures have remained the same from 199013.
Research relating stress, depression and anxiety with social determinants are very few. In a study, aimed to correlate these variables with gender, by using the DASS-21 Scale, reported statistically significant differences between men and women, regarding anxiety and stress symptomatology. Women obtained higher medians than men did. No significant differences were reported between both genders, regarding depression symptoms²⁴. These results turn out to be similar to our findings in variables of gender, anxiety and stress. A different situation was reported between gender and depression. In another study made with a group of college students, significant differences were reported between genders. Women reported a higher general discomfort and depressive/anxious symptomatology, against men. These results are similar to ours15. Other authors²⁵ concluded that belonging to the feminine gender is a risk factor as women report higher anxious/depressive symptomatology. Furthermore, it is important to highlight that a study made in Colombia described that men who had some level of depression, had a more severe condition, compared with females²⁶.
Literature reports that Health Sciences careers have higher levels of stress. Medicine has the highest prevalence²⁷, just as reported in a study²⁸, where 30.1% of all students had depressive symptomatology, and 26.5% suffered anxiety.
When analyzing the variables of mental health and career, no correlation was reported. However, when these are correlated with gender, it was evident that being a woman, and studying Nutrition and Dietetics was correlated with a higher prevalence of anxiety. A Mexican study made in the same career and using the same instrument, concluded that feminine gender has a higher prevalence of psycho-emotional pathologies²⁹. Likewise, our findings report a correlation among these variables and the career of Nursery, as female students tend to have a higher level of anxiety, against men. A national study³⁰ –aimed to determine the levels of anxiety in students of second year of Nursery and Medical Technology– reported that students of Nursery had higher levels of anxiety. This is a similar situation to that reported in an international study where this career also reported a higher prevalence of depression symptoms³¹.
Regarding the correlation between mental health disorders and variables, such as belonging to the Mapuche ethnicity, origin, and Free-Education, no studies on this topic were found that could allow us to compare the results obtained. However, in our sample we have a high percentage (42%) of students who belong to the Mapuche ethnicity, unlike what was reported in a study where only 14% of the subjects reported to belong to this ethnicity. In this case, high levels of psycho-emotional disorders, associated to variables of the regional context, ethnicity, rurality and free-education are identified as risk factors¹⁵. Some authors have described that people belonging to ethnic minorities search for psychological help, only at a more severe stage of their pathology³². In this scenario, it is important to keep making studies about this variable, in order to perform a timely intervention. Furthermore, some autores²⁴ report a high percentage of college students coming from urban zones, just like we did with this research, but they did not have the goal to observe a correlation between this variable and mental disorders which can affect this population.
The literature³³ mentions that parents´ schooling level has an influence on psycho-emotional disorders the students may have. Mother´s schooling level has the highest influence on academical factors. Likewise, father´s schooling level affects in a more discrete manner. Regarding the results of this study, the highest educational level is full high school, with similar proportions between both parents; however, no correlation was reported between these variables.
Another significant finding made in this research is the correlation reported among mental health disturbances. A similar result than that reported²⁹, where a correlation was found among depression-anxiety, stress-anxiety and depression-stress. Furthermore, it is important to highlight that these conditions may arise before common contextual conditions that activate them¹⁹, factor that could explain such correlation.
One of the limitations in our study was that the sample of feminine gender was higher, against the masculine gender. This is important to consider in future research, i.e. including other college education areas.
Another limitation to be considered is to devise an articulation program, in order to timely refer and follow-up the students who had some level of disturbance, in order to provide an integral support.
For future research, a probabilistic sampling could be used, including universities from other regions and other socio-economic contexts, in order to generalize the results for the whole country, apart from including other variables, such as physical activity, sleep hygiene, healthy food, among others.
According to the results obtained in this research, we may infer that considering all the participants from the careers of the Health Department, cohort 2019, there is a higher prevalence of some level of anxiety (54.82%), followed by stress (47.59%), and finally some disorder, associated to depression (31.33%). We may conclude there is a correlation between feminine sex and levels of anxiety, stress and depression. Furthermore, there is a correlation between belonging to the feminine gender, to study the career of Nursery, Nutrition and Dietetics, with having some level of anxiety. A correlation is highlighted among the three mental health conditions, that were studied in this research.
Our suggestion is to implement the Scale DASS-21 for all the careers of the University, as a screening/follow up tool, in order to provide timely support to the students who have some level of psycho-emotional disturbances.

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