The Prevalence and Severity of Depression, Anxiety and Stress as Well as Coping Strategies Used by Medical Undergraduate Students Enrolled in Arsi University: A Cross-Sectional Study

Background Every Objective We aimed to determine the prevalence and severity of depression, anxiety and stress as well as coping strategies used by medical undergraduate students enrolled in Arsi University. Methods Institutional based cross-sectional design was conducted on 265 sampled medical students. Participants were selected by systematic random sampling technique. Data were collected by pre-tested, structured and self-administrated questionnaire. Afterwards, logistic regression analysis was employed and statistical signicance was accepted at p<0.05. Result


Introduction
Stress is a biopsychosocial model that refers to the consequence of failure of an organism to respond adequately to mental, emotional or physical demands 1 . Clinically, anxiety is characterized by intense feeling of dread, accompanied by somatic symptoms that indicate a hyperactive autonomic nervous system 2 . Whereas, depression manifests as loss of interest or pleasure, sadness, feelings of guilt or low self-worth, disturbed sleep or appetite, extreme tiredness, and poor concentration 3 . Studies suggest that mental health worsens after students begin medical school and remains poor throughout training.
Consequently, it is commonly observed that medical students and resident doctors experience high rates of psychological morbidity when compared with students in other disciplines 4 . Previous studies have shown that stress is adversely affecting medical student physical and cognitive capacities. When associated with anxiety and depression, occupational stress, as experienced by the student, can in uence his or her quality of life and decrease his or her academic performance due to anxiety-induced di cult cognitive functioning, such as memory disorders, blockage, incapacity to make decisions, and increased sensitivity to appraisals of others 5 . Similarly, high rates of depression, anxiety, and stress can result in poor quality of life, drug abuse and suicide 6 . Globally, the incidence of depression, anxiety and stress among medical students is increasingly reported. For instance, the prevalence of stress within undergraduate medical students of United States (26%) 7 , Britain (31.2%) 8 , Malaysia (41.9%) 9 , Nigeria (94.2%) 10 and Ethiopia (52.4%) 11 . Sources of increased stress levels experienced by students include overcrowded lecture halls, semester grading system, inadequate resources and facilities, adaptation to the new environment, being away from home for the rst time, and changes in living arrangements, vastness of syllabus, long hours and expectations of rote learning [12][13][14] .
Coping strategies are speci c efforts that individuals employ to manage stress, both behavioral and psychological, so they can tolerate, reduce, or minimize stressful events. Although people differ in the way they think about and react to the stressful situations, coping plays a central role in adaptation to stressful life events 15 . Every individual has a certain number of coping resources, and once these coping resources are challenged or exceeded, stress usually results 10 . The equipping of undergraduates with the skills necessary to recognize personal distress and to develop strategies to promote their own well-being is fundamental to promoting professionalism 16 . Conversely, failure in coping stress may lead students to stop or discontinue further education, suicidal intentions or make students participating in activities like smoking, drinking, aggressive behavior with others, damaging institution's property or involving in violent activities by disrespecting laws and right of others 2,17 . Therefore, the main aim of this study was to determine the prevalence and severity of depression, anxiety and stress as well as coping strategies used by medical undergraduate students enrolled in Arsi University.

Methods
Institutional based cross-sectional design was conducted in Arsi University from January 03-31, 2019 among 265 sampled undergraduate medical students. The sample size was rst estimated by single population proportion, thereafter, through a correction formula since overall numbers of medical students in study area were < 10,000. After proportional allocation of the calculated sample size to each academic year level, strati ed random sampling was employed. The required respondents were chosen from each stratum by randomly selecting the rst respondent based on their id number, and then every 4 intervals through systematic random sampling. All medical students in Arsi University were eligible to participate with exception to severely ill students and that were out of town during the time of data collection. Data were collected by self-administered a questionnaire that comprises the following parts.
1. Sociodemographic pro le: includes age, gender, enrollment year, marital status, residence, income, religion and ethnicity. 2. Depression, Anxiety, Stress Scale -21 (DASS-21): is a self-report tool designed to measure the emotional states of depression, anxiety and stress over the last week 18 . Each of the three DASS-21 scales contains 7 items. The responses are given on a 4-point Likert scale, ranging from zero if "I strongly disagree" to 3 if "I totally agree". According to DASS-21 scoring instructions, the obtained DASS-21 scores need to be multiplied by 2 to have the nal score and the results correspond to levels of symptoms, ranging from "normal" to "extremely serious" (Table 1). However, to determine the prevalence of DAS, DASS-21 scores with normal levels of depression, anxiety, and stress were coded as "0" whereas those with mild, moderate, severe, or extremely severe levels were coded as "1." Various studies have shown the strong internal consistency of the DASS-21 19,20 . 3. Brief COPE scale: is designed to assess a number of different coping behaviors and thoughts after a person's response to a speci c situation among adults with or without clinical conditions 21 . It consists of 28 items and each item is rated on a 4-point Likert scale ranging from "I have not been doing this at all (score 1)" to "I have been doing this a lot (score 4)". The items were scored to produce 14 dimensions (minimum mean score was 2 and maximum score was 8) and each dimension re ects the use of a coping strategy such as active coping, planning, acceptance, denial, self-distraction, use of substance, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, humour, religion, and self-blame 21 . Mean score interpretations were as follows: 2.00 = haven't been doing this at all, 2.01 to 4.00 = have been doing this a little bit, 4.01 to 6.00 = have been doing this a medium amount, 6.01 to 8.00 = have been doing this a lot. The higher score indicates greater coping by the respondents. It is a validated instrument in which the Cronbach's alpha values range 0.50-0.90, with only 3 coping strategies falling below 0.60 21 .

Prevalence of Depression, Anxiety and Stress
The present study demonstrated a strong internal consistency between depression and anxiety (r = 0.494, p < 0.001), depression and stress (r = 0.456, p < 0.001), stress and anxiety (r = 0.420, p < 0.001). From 260 valid analyzed questionnaires, the proportion of respondents detected to have depression, anxiety, and stress symptoms were 52.3%, 60.8%, and 40.4% respectively. Whereas, the percentage of respondents who had extremely severe symptoms of depression, anxiety and stress were 6.2%, 16.2% and 2.3% respectively ( Table 3).

Association of Sociodemographic Characteristics with Depression
A binary logistic regression analysis was applied to evaluate the possible impact of sociodemographic characteristics of respondents' depression level (Table 4). In the present study, depression had no statistical association with age, educational year, religion and ethnicity. Conversely, it had a statistically signi cant association with respondents' gender, in which males were 0.59 times less likely to be depressed than females (95% CI: 0.36-0.99). It was also associated with a monthly income, in which respondents who had monthly income of ≤ 700 ETB were 1.68 times more depressed than above 700 ETB (95% CI: 1.03-2.74). Depression was also associated with marital status, in which respondents who hadn't relationship (single) were 0.53 times less likely depressed than those in a relationship (married) (95%: 0.30-0.95). Finally, it was also statistically associated with residency, in which non-dormitory living respondents were 10.52 more likely depressed than those living in dormitory (95% CI: 2.41-46.00).

Association of Sociodemographic Characteristics with Anxiety
In a binary logistic regression analysis of the present study, anxiety had no signi cant statistical association with sociodemographic variables like monthly income, religion and ethnicity (Table 5). Contrariwise, it was statistically associated with the age of respondents, with individuals in the age range between 20-24 being 1.92 times less likely to be anxious than respondents > 24 years (95% Cl: 0.34-0.99). It was also associated with the gender of respondents; males were 0.58 less likely to be anxious as compared with females (95% Cl: 0.34-0.99). Anxiety was also associated with marital status, respondents who were not in a relationship (single) were 0.52 times less likely to be anxious than those in a relationship (married)(95%: 0.28-0.96). Concerning its association with the educational level of respondents, third-year respondents were 4.85 more likely to be anxious than sixth-year students (95% CI: 1.93-12. 19). Finally, anxiety was also associated with residency, non-dormitory living respondents were 15.48 more likely to be anxious than those living in a dormitory (95% CI: 2.05-117.00).

Association of Sociodemographic Characteristics with Stress
In the present study, when the impact of sociodemographic characteristics on the stress level was evaluated by binary logistic regression analysis, stress had no association with religion and ethnicity ( Table 6). But it had a signi cant statistical association with the age of respondents, with respondents younger than 20 years being 2.07 more likely stressed than those older than 24 years (95% CI: 1.01-4.27). It was also associated with sex of respondents with males were 0.57 times less likely stressed than females (95% CI: 0.34-0.95). Statistically, it was also associated to monthly income, participants who had a monthly income of ≤ 700 ETB were 1.87 times more likely stressed than those respondents who had monthly income of above 700 ETB (95% CI: 1.13-3.10). Stress was also associated with marital status, respondents who hadn't relationship (single) were 0.55 times less likely stressed than those in a relationship (married)(95%: 0.31-0.96).
Concerning to its association with the educational level of respondents, second year respondents were, 4.92 times more likely stressed than those in sixth year (95% CI: 2.09-11.61). Finally, it is also statistically associated with residency, non-dormitory living respondents were 3.52 more likely stressed than those in dormitory (95% CI: 1.38-8.97).

Predictor Risk Factors For Depression
From variables like gender, monthly income, marital status and residency who were candidates for multivariate logistic regressions (P-value < 0.05), predictors of the depression were monthly income and residency (Table 7). In our study, the odd of being depressed was markedly increased with 1.97 times among respondents who had monthly income of ≤ 700 ETB than > 700 ETB (95% CI: 1.17-3.33). Similarly, the odds of being depressed, were markedly increased with 12.55 times among respondents living non-dormitory than living in dormitory (95% CI: 2.79-56.37).

Predictor Risk Factors For Anxiety
Age, sex, marital status, educational year and residency had p < 0.05 that made them candidates for multivariate logistic regressions. Only educational year and residency were found to be predictors of the anxiety (Table 5). In the present study, the odds of being anxious were markedly decreased as educational level increased after the rst year. For example, the odds of being anxious were markedly increased with 14.89 times in the second year students than sixth years (95% CI: 3.40-65.23). The odd of being anxious were also more likely increases with 42.11 times among participants living in nondormitory than in dormitory (95% CI: 4.88-363.36).

Predictor Risk Factors For Stress
In the present study, monthly income, educational year and residency were found to be predictors of the stress from all sociodemographic characteristics that were candidate for multivariate logistic regressions (Table 6). For instance, the odd of being stressed was markedly increased with 1.99 times among participants who had a monthly income of ≤ 700 ETB than those who had above 700 ETB (95% CI: 1.00-3.98). Similarly, the odds of being stressed were markedly increased with 1.84 times in second year, participants than sixth years (95% CI: 1.02-11.21). Furthermore, the odds of being stressed were more likely increases with 4.93 times among respondent living in non-dormitory than in dormitory (95% CI: 1.73-14.08).

Effectiveness of Coping Strategies
The total coping strategies applied by respondents were 28 with the minimum score of 2 and maximum score of 8. Among coping strategies, ''religious coping with mean (± SD) coping score of 5  (Table 7). In the present study, the active coping strategies were the most commonly used strategies than avoidant strategies. However, there was a variation across gender concerning to speci c types of coping strategies used by respondents. Females were more commonly involved in use of emotional support with mean (± SD) coping score of 4 were more commonly used active coping with mean (± SD) coping score of 5.56 (1.71) and substance use with 3.49 (1.75) than females did (Table 7).

Coping Strategies Adopted Under Depressed Situation
A binary logistic regression analysis was done to assess common coping strategies that were utilized by respondents under depressed situation. From total 14 factors of the BC instrument, 7 factors were not statistically associated with respondents' depression level (p < 0.05) (Table 8). However, the coping mechanisms of denial, substance use, use of emotional support, the use of instrumental support, behavioral disengagement, venting, self-blame and humor were signi cant variations among DASdepression distribution.

Coping Strategies Adopted Under Anxious Situation
In the present study, a binary logistic regression analysis was done to assess common coping strategies that were utilized by respondents under anxious situation. Out of 14 factors of the BC instrument, 8 factors were not statistically associated with the scores of respondents' anxiety level (p < 0.05) (Table 9).
Nevertheless, the coping mechanisms of denial, substance use, behavioral disengagement, venting, positive reframing, and self-blame were signi cant variations among DAS-anxious distribution.

Coping Strategies Adopted Under Stressed Situation
A binary logistic regression analysis was also done to assess common coping strategies that were utilized by respondents under stressed situation. Other than humor, acceptance and religion, all other factors of the BC instrument were statistically associated with respondents stress level (p < 0.05) (Table 10).

Discussion
The main goal and objective of medical curriculum is to provide competent and safe doctors to the community. However, mental illness among medical students has often been swept under the carpet and under-recognized, though the rates of these mental illnesses among this vulnerable population are by no means trivial. Therefore, the main aim of the present study was to determine the prevalence and severity of depression, anxiety and stress as well as coping strategies used by medical undergraduate students, enrolled in Arsi University.
The overall prevalence of depression, anxiety and stress symptoms were 52.3%, 60.8% and 40.4% respectively. The reason might be medical students are overloaded with a tremendous amount of information with limited time for internalization, new study environment with obligations to succeed especially during preclinical encounters. This greater degree of workload creates feeling of distress and disappointments that predisposes students to have di culties in solving problems, impaired judgments; absenteeism from class lesson and break their mental stability. Actually, our present nding is almost similar to the prevalence reported by Basudan et al 22 , and Iqbal et al 23 . Conversely, it is higher than study report of Shamsuddin et al 24 , and Moutinho et al 25 . This difference could be due to difference in cultural perception of stressful factors, economic burden, very high tuition fees, lack of family support, and higher or lower 'readiness' to report different complaint. In our present setup, academic counselling is not a common practice which may be also a contributor.
The proportion of respondents who had extremely severe symptoms of depression, anxiety and stress were 6.2%, 16 32 . This unequivocal distribution tells us that probably depression, anxiety and stress are associated with a multitude of factors such as poor dormitory conditions, more economic stress, distance from the family, less structured environment, and problems dealing with roommates, which might be different or parallel in the two study groups under consideration.
Medical students who had lower monthly income were more likely depressed and stressed. Despite the fact that food and dormitory services are provided to the students by the university, students need money for excursions, to print hand outs, to buy dressings, and other basic necessities 11 . This indicates that nancial constraints could be an additional source of depression, anxiety and stress besides academic stressors. However, other studies have noted no difference 33 . Again, sample size differences may possibly account for these different results. The same stressors may be perceived differently by different medical students, depending on their cultural background, personal traits, experience and coping skills 34 .
The educational system also plays an enabling role subsequently leading to increased stress levels experienced by students.
There was a signi cant association between students' academic year and level of anxiety and stress. Many studies have shown higher stress levels and a higher prevalence of stress-related illnesses among 2nd year medical students as compared with other academic years 11,35 . On the other hand, senior students developed skills of how to manage stress and stress-related illness than students in the early years 36 . The possible reason could be the amount and complexity of the material to be learned in the second year with progressive assessments of anatomy, physiology, and biochemistry that they have to pass to join the next higher level. Additional supportive evidence is high level of stress and stress-related illness can be attributed by course workload, lack of leisure time, shortage of learning materials, and frequent examinations.
It has been proven that coping mechanisms are essential for individuals perceiving stress. Coping strategies refer to speci c efforts, both behavioral and psychological, that people employ to master, reduce, tolerate, or minimize stress due to undesired events 37 . Effective and appropriate coping strategies may minimize the impact of encountered stressful situations on one's well-being. The strategies that the students identi ed for coping with stress covered almost all the categories reported previously. 'Active coping' means taking action or exerting efforts to remove or circumvent the stressor, while 'Acceptance' means accepting the stressful event, 'Planning' consists of thinking about how to confront the stressor, 'Positive' reframing means making best of the situation by growing from it and 'Denial' is an attempt to reject the reality of stressful event and 'Behavioral disengagement' means giving up or withdrawing efforts to attain goal 13 .
In the present study, the widely employed original COPE questionnaire containing 14 domains of coping strategies was utilized in order to assess the most common strategies adopted by respondents. The coping strategies most commonly reported by respondents comprise religious coping, active coping, positive reframing and planning strategies. The main coping strategy adopted by respondents was religion, which was similar with the study by Al-Sowygh 38 , and Ahmad et al 39 . This was also reported by Krauss et al 40 , stated that religious people posed higher level self-control thus they are more able to persist in di cult tasks and life situation. However, our result nding was dissimilar with study nding reported in Malaysia 41 , and Jordan 42 . The possible reasons for the variability could be due to certain differences in the curricula, teaching facilities and the levels of care given to the students.
A signi cant correlation between DAS scores and coping mechanisms was found. In particular, the coping mechanisms of denial, substance use, behavioral disengagement, venting, self-blame were signi cantly associated to DAS, which have been reported in studies as very adaptive and hasten the recovery from distress 38 . However, the present study was dissimilar with studies conducted on the United Kingdom and Jordanian medical students, who are using alcohol, tobacco, and drugs as common coping strategies 7,8 . The possible reasons for the variability could be due to geographical and racial differences.

Conclusion
Healthy medical students are likely to become healthy doctors. However, the overall prevalence of depression, anxiety and stress is alarmingly high among undergraduate medical students of Arsi University. Furthermore, monthly income and residency were identi ed as risk factors of depression.
Similarly, residency and educational level were risk factors for anxiety. Lastly, monthly income, educational level and residency were predictors for stress. There was no signi cant difference in depression, anxiety and stress between age groups, sex, marital status, ethnicity and religion. It has been suggested that medical educators should include student-centered academic policies, non-quantitative evaluation of training, feed-back and advisory systems for students and overall improvement of the learning environment. Also, special attention needs to be given to stress reduction. It is noteworthy that, despite positive coping strategies used by the students, the stress prevalence is still higher from the normal population. Perhaps, it will be interesting to explore this matter further in future studies. Further studies are also needed to evaluate the effects of support mechanisms and the strategies provided by the University. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

ETHICAL ISSUE
Ethical approval was obtained from Arsi University Ethical Review Committee. Written informed consent was taken from the students during data collection. The con dentiality was kept anonymous.

FUNDING
Nil support in nancial or other manner

COMPETING INTERESTS
The authors declare that there is no con ict of interests regarding the publication of this paper.