Study-related mental health symptoms and their correlates among allied health professions students

2.1 Design and sample

A cross-sectional design was used in this study, which targeted the faculty of applied medical sciences at Jordan University of Science and Technology (JUST). Students in this institution are mostly Jordanians. Additionally, JUST included students from other Middle Eastern countries such as Kuwait, Saudi Arabia and United Arab Emiratis who speak the same language and share similar cultures and values [25]. Study sample (see Table 1) targeted all students in third and fourth year of all academic majors in host institution. The target institution is a comprehensive facility of AHP that offers nine 4-year AHP undergraduate academic programs. Participants needed to be AHP students undergoing pre-clinical (third year) or clinical (forth year) training. Third- and fourth-year students were chosen to enhance the study sample homogeneity and to study the potential association between MHS and students’ clinical training. The researchers expected to achieve a response rate of 50%, which would create a sample of at least 500 participants. A sample larger than 500 is considered excellent in observational studies [26]. We approached all students at host institution studying physical therapy (PT), occupational therapy (OT), audiology and speech pathology (ASP), radiologic technology (RT), optometry (OPT), paramedics (PA), dental technology (DT), allied dental sciences (ADS), and medical laboratory sciences (MLS). Part-time students and students not registered in preclinical and clinical training were excluded from the study.

The Institutional Review Board (IRB) at JUST approved all of the study procedures (approval number 24/92/2015). Participant recruitment started in November 2015 and ended in March 2016. Study researchers used flyers and cooperated with faculty members at the host institution to facilitate participant recruitment. Targeted students were approached in selected large classes (not during major examination periods) after arrangements were made with their instructors. The study procedures and rationale were described to the students in the classes. Those students who were interested in participating signed the IRB-approved consent forms and received no compensation for their participation. Then, a self-administered questionnaire was handed to students, who anonymously filled it out during a 20-minute break granted by their instructors. Study researchers approached 1038 students. Among the approached students, 838 students agreed to participate and completely filled out the questionnaire, for a response rate of 80.7%.

2.3 Outcome measures

A three-section questionnaire was developed for this study. The first section included a questionnaire to collect socio-demographics data (including gender, age, and nationality), academic-related data (including school major, university GPA, self-evaluation of study difficulty, and satisfaction with academic major), and life style data (including health self-evaluation, diet self-evaluation, exercise habits, and presence of physical and mental dysfunctions). This section was developed through an intensive literature review and series of discussion among the research team members and experienced AHP clinicians to ensure the validity of its content.

Mental stress symptoms were measured using the Depression Anxiety Stress Scale (DASS 21). The DASS 21 is a self-report questionnaire designed to screen the presence of mental stress symptoms over the previous week. The questionnaire measures the severity of depression, anxiety, and stress from normal to extremely severe [27, 28]. DASS 21 normal score cut-offs are 9 for depression, 7 for anxiety, and 14 for stress. Higher scores suggest mild to extremely severe MHS [29]. DASS 21 is a simple and free measure that shows strong validity, reliability, and internal consistency, as its Cronbach alphas ranged between 0.78 and 0.91 for its three subscales [30, 31].

Musculoskeletal pain was measured using the Nordic Musculoskeletal Questionnaire [32]. This is a valid and reliable assessment tool measuring musculoskeletal pain in the neck, shoulders and upper extremities, upper and lower back, and hips and lower extremities as its kappa was documented as 0.63–0.90 [33].

Our study questionnaire was built by an expert panel through discussion and was statistically validated through a pilot study of 39 students excluded from the main study analyses. Students participating in this study were studying physical therapy, occupational therapy, and dental technology. Pilot study participants’ ages ranged between 18 and 23 years, with a mean age of 19.6 years (±0.966). The pilot study participants reported that the questionnaire was clear and easy to follow. Our pilot study DASS 21 scores showed high internal consistency for scores, as Cronbach’s alpha coefficients were 0.88 for the depression domain, 0.91 for the anxiety domain, and 0.87 for the stress domain. The study survey appeared clear to participants and statistically sound; therefore, only minor editorial revisions were implemented on the survey to enhance its readability.

2.4 Statistical analysis

Data were analyzed using SPSS version 20 (IBM Corp., Armonk, NY, USA). Means and standard deviations were used to describe continuous variables and proportions were used to describe categorical variables. A Chi-square test was used to test the differences in the severity levels of depression, anxiety, and stress between male and female students. The general linear model (GLM) multivariate procedure that provides regression analysis and analysis of variance for multiple dependent variables was used to determine predictors of DASS 21 depression, anxiety, and stress scores. A p-value of less than 0.05 was considered statistically significant.

3.1 Participants’ characteristics

Of the 1038 AHP students invited to participate in the study, 838 students agreed to participate and completely filled out the questionnaire, which is a response rate of 80.7%. Students who did not participate did not fulfill the inclusion/exclusion criteria, were absent from class on data collection day, or refused participation. The sample consisted of 77.3% females. The sample numbers (response rates) for each major were 69 (99.7%) PT, 79 (90.0%) OT, 84 (100%) SP, 114 (72.6%) RT, 66 (72.2%) OPT, 92 (72.7%) PA, 103 (100%) DT, 34 (79.8%) ADS, and 197 (71.7%) MLS. Students’ ages ranged between 18 and 41 years, with a mean age of 21.3 (±1.8). Table 1 illustrates participants’ demographics and relevant characteristics.

3.2 Overall severity of depression, anxiety, and stress

Overall, participants’ DASS 21 mean scores were 14.4 (±10.7) for depression, 13.1 (±10) for anxiety, and 17.4 (±11.1) for stress. Table 2 shows the severity levels of depression, anxiety and stress symptoms as measured by the DASS 21 scale according to gender. Mild to extremely severe levels of MHS were found in 62.2% of the participants for depression, 65.3% for anxiety, and 54.2% for stress. Female students had significantly higher stress severity levels than males (p = 0.002). However, males and females did not differ significantly in the severity levels of depression and anxiety.

Table 3 shows the multivariate analysis of factors associated with depression, anxiety, and stress scale scores. Female gender was significantly associated with higher depression (p <  0.01), anxiety (p = 0.004) and stress (p <  0.01) scores. Excellent health self-evaluation was associated with lower depression (p <  0.01), anxiety (p <  0.01) and stress (p <  0.01) scores. On the other hand, having a chronic physical condition was significantly associated with higher depression (p = 0.001), anxiety (p = 0.001), and stress (p = 0.008) scores. Self-evaluation of diet as unhealthy, self-evaluation of study as difficult, and being unconvinced with study major were all associated with higher depression (p = 0.03, p <  0.01, p <  0.01, respectively) and stress (p = 0.011, p <  0.01, p <  0.01, respectively) scores. Self-evaluation of study as difficult was also associated with higher anxiety scores (p <  0.01). Students’ university GPA was significantly and inversely associated with depression (P = 0.018), anxiety (p = 0.02), and stress (p = 0.004) scores. Students from different academic majors reported significantly different stress, anxiety, and depression scores. RT students reported the highest depression (p <  0.01), anxiety (p <  0.01), and stress (p <  0.01) scores compared to other students from other academic majors.

Table 4 demonstrates multivariate analysis of DASS 21 as response variable scores with 12-month body area musculoskeletal pain as predictors. Twelve-month musculoskeletal pain in the neck was significantly associated with student depression (p = 0.02) symptoms. Hand/wrist musculoskeletal pain was significantly associated with student depression (p <  0.01) and stress (p = 0.013) symptoms. Upper back musculoskeletal pain was significantly associated with student depression (p = 0.001), anxiety (p = 0.05) and stress (p = 0.001) symptoms, while lower back musculoskeletal pain was significantly associated with depression symptoms only (p = 0.006). Lower extremity musculoskeletal pain was also significantly associated with MHS, as seen in hip/thigh musculoskeletal pain with anxiety (p <  0.002) and ankle/foot musculoskeletal pain with depression (p <  0.01), anxiety (p <  0.01), and stress (p <  0.01) levels.

4.1 Overall severity of depression, anxiety, and stress symptoms

Consistent with our first hypothesis, our sample from nine undergraduate majors in an allied health profession facility reported moderate levels of depression (14.4) and anxiety (13.1), and a mild level of stress (17.4) [29]. Mild or higher symptom levels were found in 62.2% of the participants for depression, 65.3% for anxiety, and 54.2% for stress.

One study found depression, anxiety and stress levels (measured by DASS) of moderate severity or above in 27.1%, 47.1% and 27% of undergraduate university students, respectively, of various majors, including medicine, science, engineering, veterinary medicine, and agriculture [34]. Researchers in this study found a much higher prevalence of moderate or greater depression, anxiety, and stress (47.1%, 56.7%, and 41.1%, respectively). In another recent study that targeted undergraduate students, using DASS 21, mild or greater MHS was documented in 21.8% of the sample for depression, 28.5% of the sample for anxiety, and 26.5% of the sample for stress [35]. However, compared to these studies, our sample was more homogenous in terms of students’ majors and their academic years (third and fourth). Additionally, reporting mental health symptoms might be affected by cultural aspects [24].

Comparable to our study, high levels of MHS were frequently documented among medical students. For instance, one study documented, similar to our study, the prevalence of mild or greater levels of depression (51.3%), anxiety (66.9%) and stress (53%) among medical students [36]. Another study that targeted medical students cited a high prevalence of depression, anxiety, and stress (43%, 63%, and 41%, respectively) prior to examinations. The prevalence was reduced post-examinations (to 30%, 47%, and 30%, respectively) [37]. Researchers also documented that anxiety, depression and stress prevalences were 37.4%, 56.6% and 45.4%, respectively, among dentistry students [38].

Studies also documented elevated levels of MHS among AHP, including physical therapy, occupational therapy, and communication disorders [21–23]. However, these studies used outcome measures that were different from DASS 21 making results comparisons with our study not applicable. Additionally, none of these studies targeted as many academic majors as the number of majors targeted in this current study.

4.2 Factors associated with depression, anxiety, and stress symptoms

Our study investigated many factors as possible sources of MHS among students. Supporting our second hypothesis, our study documented significant associations between female gender and higher stress and depression scores. This finding is consistent with other studies that documented higher levels of MHS among female healthcare students [10, 34]. As measured by the Student-Life Stress Inventory in one study, undergraduate female students reported higher perception and reactions to stressors than males [39]. In addition, this finding was consistent with findings in the general population, where epidemiological studies demonstrated almost a double prevalence of major depressive disorders among females (21.3%) compared with males (12.7%). The literature indicated that even for minor MHS severities, females articulated more complaints than males [40]. Several factors are thought to contribute to the increased levels of MHS among females, including biological processes, genes, hormonal fluctuations, psychosocial events such as disadvantaged social status, and more vulnerability to stress-induced depression [40–42].

Supporting our second hypothesis, the results of this study suggested an association between increased levels of MHS and compromised physical health and unhealthy habits including diet choices. Studies demonstrated that allied health profession students are at high risk for MHS, which was shown to be associated with unhealthy behaviors [35, 43]. Unhealthy diet and being overweight have been documented to be associated with increased levels of MHS [44]. Physical health [44] status was also reported in the literature as a predictor for MHS presence among college students and among the general population [45, 46]. As found in our study, the presence of MHS among college students might be associated with poor satisfaction with their study major and poor academic performance [34, 47]. Studies demonstrated that students’ concerns related to academic performance and ability to succeed are significantly correlated with MHS levels [8].

Different levels of MHS among different academic majors were reported in the literature [20]. Consistently, our study found different levels of MHS among different targeted AHP academic majors. The highest level of MHS in our study was found among RT students. High levels of physical and mental occupational stressors have been reported by radiographers [48]. Unlike other AHP students, RT students are trained in computerized stressful work environments under a high workload and strict deadlines. Heavy computer using is associated with higher prevalence of musculoskeletal and mental symptoms among undergraduate students [49]. This might explain RT students’ increased MHS levels compared with other AHP students [50]. On the other hand, in this study, PT students showed the lowest MHS levels. School related-stress among PT students across different countries varies in terms of severity [51]. In one study, physical therapy students reported less psychological distress than nursing students [52] but similar levels to communication disorders and nutrition students [23]. Notably, in this current study, PT students at host institution had more faculty members support than the more stressed RT and MLS students. The faculty-to-student ratio in this targeted institution was 0.64 for PT students, while it was 0.22 for RT and 0.21 for MLS students. A high faculty-to-student ratio is considered an influential factor in improving college learning outcomes and choosing an educational program [53, 54]. Studies showed that MHS are significantly related to satisfaction with delivered education and type of faculty [55, 56]. Comprehensive studies that investigated MHS among several AHP students, including RT and PT, are limited, and consequently, it is not easy to discuss why MHS were the highest among RT and the least among PT students. Finding the actual causes of our study results that documented MHS among RT and PT students in the targeted institution needs more focused investigation with different designs.

This study targeted third- and fourth-year students who were undertaking their pre-clinical and field clinical training. Transitioning to clinical training is considered a very difficult period for many AHP students and might deter their academic progress [57]. Many factors might explain this transitional occupational stress, including the extreme increase in students’ workload with limited time available for studying. Students could also find uncertainties related to their expected roles and behaviors in the clinical training settings. Furthermore, these trainees might find difficulties in applying theoretical knowledge in clinical practice. Finally, trainees might find limited opportunities to participate in patient care and lack of clinical supervisors that understand trainee roles during clinical training [58, 59].

Consistent with our second hypothesis and previous literature findings, the MHS of this study were significantly associated with musculoskeletal pain in many body sites. Studies demonstrated that work-related stress, high job demands, psychosocial stress are associated with musculoskeletal pain among allied health students and professionals [60, 61]. Studies also found significant associations between psychosocial stress and upper extremity musculoskeletal disorders in the general population and between stress and musculoskeletal disorders among college students [62–64]. Researchers found in one study that college students’ levels of stress and musculoskeletal pain in both genders were significantly associated [65].

4.3 Clinical implications

Compromised mental health increases the odds of adverse consequences such as hindering the person’s ability to perform daily-life activities. These possible adverse consequences might include a decline in academic performance of university students [66]. One study found a significant negative correlation (0.49 point or half a letter grade) between a confirmed depression diagnosis and students’ GPA [47]. Elevated levels of MHS among undergraduates might lead to burnout, which is a syndrome characterized by emotional exhaustion and a sense of low personal accomplishment. Burnout could be associated with academic dishonesty, substance abuse, and dropouts, and it might hinder the student’s professional development [67].

Elevated levels of MHS among AHP students should be seriously considered. Academic administrators and clinical educators have to acknowledge their students’ potential susceptibility to MHS during classroom teaching and clinical training. Many preventive strategies are suggested in the literature to reduce the possibility of developing MHS. One suggestion is creating a gradual transition between pre-clinical and clinical education in terms of training load. Studies have suggested that cognitive, behavioral and mindfulness interventions are effective in reducing undergraduates’ levels of anxiety and depression [68]. Mindfulness exercises and relaxing exercises, including physical education, might decrease elevated MHS level consequences on the students [69]. College students might adhere well to modern technology-based interventions. There are effective web-based and computer-delivered interventions available to manage college students MHS [70]. Another contemporary suggestion with proven efficacy in reducing MHS is playing Nintendo Wii [71]. AHP colleges administrations are also encouraged to create preventive educational courses for their freshmen to enhance adopting a healthy lifestyle and to improve their mental health status [72]. College students must be encouraged to utilize on-campus counselling centers in order to screen for and treat MHS as early as possible [73]. Support programs can be built to facilitate the education of undergraduate students with significant mental illness [74]. Academic administrators should pay more attention to their female students, as they are more likely to develop MHS.