The magnitude of mental distress and associated factors among a school of medicine and college of health sciences students at Debre Markos University, 2021.

INTRODUCTION: Mental distress is a collection of mental health abnormalities characterized by symptoms of anxiety, depression, insomnia, fatigue, irritability, forgetfulness, difficulty in concentrating, and somatic symptoms. It affects society as a whole and no group is immune to mental distress; however, students have a significantly high level of mental distress than their community peers. The study is aimed to assess the magnitude of mental distress and associated factors among a school of medicine and college of health sciences students.
OBJECTIVE: To assess the magnitude of mental distress and associated factors among a school of medicine and college of health sciences students at Debre Markos University, 2021.
METHODS: Institution-based cross-sectional study design was employed from March 15-29, 2021. A simple random sampling technique was used to select 475 study participants. A binary logistic regression model was used to identify factors associated with mental distress. Variables with a p-value less than 0.25 in the bivariable analysis were entered into multivariable logistic regression analysis and a P-Value of less than 0.05 was considered as having a statistically significant association. RESULT: The magnitude of mental distress among students was found to be 35.4%, 95%CI (31%, 40%). Female sex [AOR = 1.95; 95%CI (1.24-3.06)], financial distress[AOR = 1.64; 95%CI (1.062.54)], feeling of insecurity [AOR = 2.49; 95% CI (1.13-3.54)], lack of interest to department [AOR = 2.00; 95%CI (1.75-4.36)] and cumulative grade point average less than expected [AOR = 2.63; 95%CI (1.59-4.37)]were significant variables with mental distress.
CONCLUSION: The magnitude of mental distress was high. Sex, financial distress, feeling of insecurity, lack of interest in the department, and cumulative grade point average less than expected were significant variables with mental distress, so special attention on mental health promotion is required from policymakers, college officials, parents, and other Non-Governmental organizations.

Introduction

Mental distress is a collection of mental health abnormalities that may not be group into standard diagnostic criteria and characterized by symptoms of anxiety, depression, insomnia, fatigue, irritability, forgetfulness, difficulty in concentrating, and somatic symptoms [1]. Depression, anxiety and stress are the most common forms of mental distress among university students [2]. Stress has been defined as a process in which environmental demands exceed the perceived capability of an individual to cope. Anxiety is characterized by cognitive, physical, emotional, and behavioral components. depression also defined as persistent sad, anxious, feelings of hopelessness, and feelings of guilt [3].

Mental distress is a public health issue explained with variable levels of stress, confused emotions, hallucination, depression, anxiety, panic or somatic symptoms. These symptoms may experience in persons without actually being ill in a medical sense and dominantly interfere students relation with their friends, life events and academic performance [4].

University students are special groups of the communities that are enduring a critical transitory period in which they are going from adolescence to adulthood, from high school to campus and can be one of the most stressful times in their life [5]. Also they represent a unique population with special concerns, obligations and worries that differ from other age and occupational groups [6, 7]. The gap between the need for treatment of mental disorders and its provision is wide all over the world. Many students in colleges and universities today have many different kinds of mental disorders for which they may, or may not, be seeking treatment [8].

The national alliance on mental Illness reports showed that one in five university students encounter mental distress, with 75% of all mental health conditions encounter by the age of 24 [9]. Ronald Kessler from Harvard University found that 37% of people aged 15–24 years have confirmed mental problems. Most of the University students today fit within this age group [10].

In Africa, mental distress is an important public health concern that is considered as a public health problem. Study conducted in South Africa revealed that the prevalence of common mental disorders is 27% [11].

In Ethiopia mental health abnormalities account for 11% of total burden of the disease conditions [12]. Studies examining the magnitude of mental distress in Ethiopia using different cutoffs points of the Self-reporting questionnaire (SRQ-20) have reported magnitude of mental distress ranges from 21.6 to 49.1% among university students [13, 14]. From the total burden of disease mental disorders accounts 25.3% and 33.5% of all years lived with a disability in low- and middle-income countries, respectively [15].

A number of factors including, academic responsibilities, separation from their family and environment, competition with their peers, workload, substance use, exposure to patients suffering and deaths could be reasons why mental distress is very common in students than the general population [8, 16, 17].

Mental distress has overwhelmed negative effect on role functioning like that of many serious chronic conditions [18]. Mental health conditions frequently lead individuals and families into poverty and decrease economic development at the country level [15]. Students with mental distress are at an increased risk of poorer general health [19].

In addition, there is a significant inverse relation between life satisfaction and mental distress among university students [20]. High prevalence, and risk factors of mental distress among clinical students not only affect their health but also affect their academic achievements [21].

Different studies showed that college students torched by their duties, encounter anxiety, depression, poor in academic performance and loosing academic responsibilities [22, 23]. Due to mental distress 55.8% Ethiopian University students had poor sleep quality [24].

The findings of this study will aid in the development of evidence-based mental health promotion programs for students and will be used as a resource to seek remedial action from policymakers, school of medicine and college of health science (SMCHS), non-governmental organizations, and other interested parties, thereby improving students’ academic performance and patient care.

Despite its magnitude, severity and negative consequence, studies on magnitude of mental distress and associated factors among health science students in Ethiopia were limited, particularly in the study area, Debre Markos University (DMU).

Methods

Study design

An institution-based cross-sectional study design was used.

Study area and study period

The study was conducted at DMU, Northwest Ethiopia. DMU is a public university located in the town of Debre Markos, which is located in Northern part of Ethiopia in Amhara region. It is 299 km far from the capital city of Ethiopia, Addis Ababa and 265 km far from the capital city of Amhara Region Bahir Dar. The University has seven Colleges with a total of 11,278 regular students. Under SMCHS there are 10 departments with 1537 (1019 male and 518 female) students [25]. The study was conducted from March 15–29, 2021.

Source populations

The Source populations of the study were all regular undergraduate SMCHS students at DMU.

Study population

The study population consists of all regular undergraduate SMCHS students who were available during the data collection time.

Inclusion criteria

All regular undergraduate students at SMCHS were included in this study.

Exclusion criteria

Critically ill students, students on summer break, and those with a history of mental illness were excluded from the study.

Sample size

The sample size was calculated for both the first (to determine the magnitude of mental distress among undergraduate SMCHS students) and second specific objectives (to identify factors associated with mental distress among undergraduate SMCHS students). Using single population proportion formula with 95% level of confidence, 5% of marginal error, and taking prevalence of mental distress 40.9% which was done in University of Gondar [26] and including10% non-response rate, the sample size was 408.

Where

n- Minimum sample size

P-Estimated proportion of evidence based practice (40.9%)

d-the margin of sampling error tolerated (5%)

Zα/2- is the standard normal distribution at 1-α% confidence level (95% = 1.96)

For the second objective, the sample size was determined using double population proportion formula by considering the following assumptions; power of 80%, 95% Confidence level and 5% level of precision and low grade than expected as a factor variable based on the study done in University of Gondar [26] and including10% non-response rate, the sample size was 475. So, this was selected for final sample size. The calculation was done by using Epi info version 7 statistical package.

Sampling technique and procedure

Simple random sampling technique was used to approach the study participants. The students were stratified into ten strata based on their respective department. Then, the total sample size was calculated for each stratum based on probability of proportion population size in each department. Again the respective sample size from each study year of the department was calculated using proportionate allocation formula. Finally, the samples were selected from each study year of the department using simple random sampling technique (Fig 1).

Fig 1

Schematic presentation of sampling technique for mental distress and associated factors among SMCHS students at DMU, Northwest Ethiopia, 2021.

P = Pharmacy, M = Medicine, HI = health informatics, N = nursing, ML = Medical laboratory, P = Public health, E = enviromental health, N = nutrition, M = Midwifery, A = Anesthesia.

Variables

Dependent variable

Mental distress.

Independent variables

Age, sex, take part in religious practice, having boy or girl friend, conflict with boy or girl friends, family place of residence, educational status of the parents, marital status, number of family members, students monthly income, feeling of insecurity about safety, having financial support, family history of mental illness, having financial distress, exposure to violence, department, department choice, interest to department, vacation time, decrease grade than expected, conflict with instructors, year of study, social support and substance use were independent variables.

Operational definition

Mental distress: Students who were found to have 8 or more symptoms out of the 20 SRQ items in the last 4 weeks were considered as having mental distress [14, 26–28].

Current substance users: when students use specified substance like khat, cigarette, cocaine, alcohol, hashish (for non-medical purposes) in the last one month [29].

Low social support- participants having <3 score in social support scoring scale, Moderate social support- participants having 3–5 score in social support scoring scale, and Strong social support- participants having >5 score in social support scoring scale [30].

Feeling of insecurity- sense of inadequacy and uncertainty in any aspect of academic activities

Financial distress- lack of money for all educational activities

Data collection tools and procedures

Self-Reporting Questionnaire-20 (SRQ-20) is a standardized questionnaire having 20 items was used to indicate magnitude of mental distress. This tool developed by WHO and is validated in Ethiopia and other low socioeconomic countries. Data were collected by four data collectors and two supervisors after getting consent from the study participants. First, the questionnaire was prepared in English language and it was translated to Amharic and back to English by language experts for consistency and to easy of understanding. Amharic version of the questionnaire was used for data collection. Data were collected using structured self-administered questionnaire having five parts. The first part contains socio-demographic characteristics of students. The second part of the questionnaire is a SRQ-20 item to determine the magnitude of mental distress. The rest 3 parts of the questionnaire are questions related to Academics, substance use and social support.

Data quality assurance and control

Training and orientation for the supervisors and data collectors were given. In order to evaluate the clarity of the questions in the questionnaire and to ensure that the reaction of the respondents to the questions, pretest was done on 5% of study subjects at Tropical College of Medicine before one week of the actual data collection period and internal consistency of the measuring tool was checked by Cronbachs alpha (CA = 0.86). Also appropriate modification on the questionnaire was done. The collected data were reviewed and checked for its completeness before data entry and incomplete data were discarded. Epi Data was used for data entry to prevent data entry errors.

Data processing and analysis

The data were checked for its completeness and consistency. Then it were coded and entered in EPI data version 3.02 Software. After that, data were exported to SPSS version 25 for analysis. Model fitness test (Goodness of fit was checked with Hosmer Lemshow model of fit (p = 0.361) and assumption test for multicollinearity problem (VIF≤ 3.35) was done). Descriptive analysis using frequencies, proportions, graphs was performed to describe number and percentage of socio-demographic characteristics. Binary logistic regression analysis model was used to identify associated factors of mental distress. Variables with p-value less than 0.25 in the bivariable logistic regression were entered into the final multivariable logistic regression analysis to control possible confounding and in order to not miss biologically important variables. A p-value of less than 0.05 in multivariable regression analysis was considered as statistical significant with mental distress. The results were presented in text, tables and graphs based on the types of data.

Ethical considerations

Ethical clearance was obtained from Debre Markos University Health Science College Ethical Review Committee. Written consent was used. Also affirmation that they are free to withdraw consent and to discontinue participation was made. Privacy and confidentiality of collected information was ensured throughout the process as no name is written. Privacy and confidentiality of collected information was ensured throughout the process as no name is written. This study was conducted in accordance with the declaration of Helsinki.

Result

Socio-demographic characteristics

Among 475 study participants, 461 students were participated in the study giving a response rate of 97.1%; of these 295(64%) were males. Nearly two-thirds of students (68.5%) were between the ages of 20 and 24, with the median age of the respondents being (21–25 IQR) years. Most of the respondents were Orthodox religion followers (92.6%), 14(3.1%) Muslim and the rest were protestant, 93.9% were from Amhara ethnic group and 88.5% were single. Majority (88.5%) of the participants were married and the rest were single. Among the participants, 88.9% had no family history of mental illness, 50.3% had no financial distress, 84.8% had feeling of insecurity, 93.8% had no exposure to violence, 93.5% had financial support, 23.9% had no conflict with boy or girl friend, 49.7 had financial distress, and 64.6% had no boy or girl friend (Table 1).

Table 1

Socio demographic characteristics of DMU SMCHS students on mental distress, 2021 (N = 461).

Variables	Category	Frequency(n)	Percent (%)
Take part in religious practice	Always	136	29.5
	Usually	112	24.3
	Sometimes	191	41.4
	Never	22	4.8
Educational status of the father	Can’t read and write	142	30.8
	Can read and write	204	44.3
	Primary	40	8.7
	Secondary	34	7.4
	College and above	41	8.9
Educational status of the mother	Can’t read and write	258	56.0
	Can read and write	120	26.0
	Primary	22	4.8
	Secondary	30	6.5
	College and above	31	6.7
Number of family members	<4	25	5.4
	4–7	301	65.3
	>7	135	29.3
Monthly income of the respondent	≤400	193	41.9
	401–700	123	26.7
	≥701	145	31.5

Academic characteristics of students

One hundred thirty one (28.4%) of the respondents were first year and 124 (26.9%) were second year. Among the participants 77(16.7%) were from medicine and 66(14.3%) were from public health department (Fig 2). Almost three forth of the students 345 (74.8%) have entered their department of choice, and 336 (72.9), have expressed interest in their department (Table 2).

Fig 2

Showing department among DMU SMCHS students on mental distress North West, Ethiopia, 2021 (N = 461).

Table 2

Academic related characteristics of DMU SMCHS students on mental distress, North West, Ethiopia, 2021(N = 461).

Variables	Category	Frequency(n)	Percent(%)
Year of study	Year one	131	28.4
	Year two	124	26.9
	Year three	99	21.5
	Year four	81	17.6
	Year five	26	5.6
Department choice	Preferred	345	74.8
	not preferred	116	25.2
Interest to the department	Yes	336	72.9
	No	125	27.1
Conflict with instructors	No	407	88.3
	Yes	54	11.7
Enough vacation time	No	233	50.5
	Yes	228	49.5
CGPA decrease than expected	Yes	323	70.1
	No	138	29.9

Levels of social support

A level of social support is computed from the means of 12 items of multi-dimensional social support questions. Mean of special support, family support, friend support and over all social support become 3.2, 5.55, 4.6, and 4.4 respectively (Fig 3).

Fig 3

Showing social support level among DMU SMCHS students on mental distress North West, Ethiopia, 2021 (N = 461).

Substance use related factors

Among respondents 125(27.11%) of them use alcohol (Fig 4).

Fig 4

Substance use among DMU school SMCHS students on mental distress, North West, Ethiopia, 2021 (N = 461).

Magnitude of mental distress

Over all 35.4%, 95% CI, (31–40%) of students had mental distress (Fig 5).

Fig 5

Showing magnitude of mental distress among DMU school SMCHS students on mental distress, North West, Ethiopia, 2021 (N = 461).

Factors associated with mental distress

In multivariable logistic regression analysis, covariates like sex, financial distress, feeling of insecurity, lack of interest to the department and cumulative grade point average less than expected were statistically significant factors of mental distress among DMU School of medicine and college of health science students.

Being female was about 2 times [AOR = 1.95; 95%CI (1.24–3.06)] more likely to develop mental distress. Students having financial distress were 1.64 times [AOR = 1.64; 95%CI (1.06–2.54)], more likely to develop mental distress as compared to those who didn’t have financial distress. Students who had feeling of insecurity were about 2.5 times [AOR = 2.49; 95% CI (1.13–3.54) more likely to develop mental distress than their counter parts.

Those students who didn’t have interest to the department were 2 times [AOR = 2.00; 95%CI (1.75–4.36)] more likely to develop mental distress as compared to those having interest to their department. Students whose cumulative grade point average less than expected were about 2.6 times [AOR = 2.63; 95%CI (1.59–4.37)]more likely to develop mental distress as compared with their counter parts (Table 3).

Table 3

Bivariable and multivariable logistic regression analysis of factors associated with mental distress those statically associated among DMU SMCHS students on mental distress, North West, Ethiopia, 2021(N = 461).

Variable		Mental distress		COR 95% CI	AOR 95% CI	P value
		Yes	No
Sex	Female	67	99	1.40 (0.94–2.08)	1.95(1.24–3.06)	0.04
	Male	96	199	1	1
Financial distress	Yes	95	134	1.71(1.16–2.51	1.64(1.06–2.54)	0.03
	No	68	164	1	1
Feeling of insecurity	Not secured	37	33	2 (1.41–3.95)	2.49(1.13–3.54)	0.02
	Secured	126	265	1	1
	No	146	285	1	1
	Preferred	106	239	1	1
Interest to the Department	No	69	56	3.17 (2.07–4.85)	2.00 (1.75–4.36)	0.001
	Yes	94	242	1	1
	No	129	278	1	1
Decrease CGPA than Expected	Yes	136	187	2.99 (1.86–2.12)	2.63 (1.59–4.37)	0.001
	No	27	111	1	1
	Moderate	102	180	1.54 (0.98–2.43)	1.36 (0.52–3.54)
	Strong	36	98	1

Discussion

The aim of this study is to assess the magnitude and associated factors of mental distress among DMU School of Medicine and College of Health sciences students. A high prevalence of mental distress among students is a cause of concern as it may alter behavior of students, diminish performance, and ultimately affect patient care and social service after their graduation.

The theoretical values of this finding- it expand body of knowledge for interested readers regarding on mental distress, identifying the possible risk factors and determining the magnitude of mental distress among students.

Practical values of this finding-the university may prepare an action plan for promoting mental health through counseling service, professionals give due attention and assess mental health problems when they assess physical and physiological complains, it is also important for meta-analysis and used as an input for policy making and researchers use this finding as a baseline for future study.

In this study 35.4% (95%CI, 31–40%) of students had mental distress and significantly associated with sex, financial distress, feeling of insecurity, lack of interest to the department, and cumulative grade point average less than expected.

In this study the prevalence of mental distress was 35.4%. This finding was consistent with study conducted in Saudi Arabia (Majmaah) university,35.8% [31] and Saudi Arabia, Jazan, university,31% [32]. This similarity may be due to use of the same measuring tool (SRQ-20).

Studies examining the prevalence of mental distress in Ethiopia using varying cuts off the Self-reporting questionnaire (SRQ-20) have reported prevalence of mental distress ranges from 21.6 to 49.1% among university students [13, 14]. This study result also came up with this range.

This consistency may be due to use of the same measuring tool and similar study subjects in similar setting, Ethiopia.

This study finding was lower as compared with study done at Gondar university 40.9% [26]. This might be due to time variation, difference in study subject, sample size, the improvement of infrastructure and a service option provided by the university from time to time.

Also this study finding was lower as compared with studies conducted in Australia,65.2% [33], Arish,41.9% [34], Nigeria,47.3% [35], and India, Malaysia 48.3% [36] university students. This difference may be contributed to variation in the curriculum, measuring tool, living condition and other constraints.

This study was higher than studies conducted in Mizan Aman health science college students (29.2%) [29] and Hawassa university medical students (30%) [14], Adama University students(21.6%) [37]. This difference might be attributed to slight difference in study subjects (only medical students in Hawassa University, all university students in Adama and college students in Mizan Aman), use of SRQ-20 cut point(11 was used in Mizan Aman Health Science College and Adama) and infrastructures of the institution, time of study (2013 in Adama, before 2016 at Hawassa). Further, this study was done among health science students where the health science education environment is more of stressful and contributes to mental distress, but in Adama it was conducted among all University students.

Also the current study finding was higher as compared with study conducted in Punjab, India (15%) [38] Somaliland, Hargeisa (19.8%) [39] and Egypt, Assiut (17%) [28] university students. This variation may be due to variation in study time (which was at 2015 in India), socioeconomic condition, life style and environmental factors, variation in study subjects (only medical students were studied in India and Hargesia and all college students in Assiut), use of SRQ-20 cutoff point for measurement (India uses 10 and Hargesia uses 11).

The likelihood of mental distress was about 2 times higher among female students (AOR = 1.95) than male students. This finding is in line with studies done in Malaysian [36], India [38], Majamaah [31], Saudi Arabia, Jazan [32] Assiut [28] Mizan Aman Health Science College [29]. This may be due to the fact that affective nature of females in response to stressors, domestic violence, and hormonal changes during menstruation.

Students having financial distress were 1.64 times (AOR = 1.64), more likely develop mental distress as compared to those who didn’t have financial distress. This result is consistent with studies conducted in Mizan Aman health science college students (29.2%) [29] and Gondar [26] University students. This could be due to the rising cost of stationary materials and photocopy services may create stressful condition in students. Moreover, students with financial difficulty develop anxiety, frustration, and sense of hopelessness and difficulty of sleeping which may further lead students mentally distressed.

Students who had feeling of insecurity were about 2.5 times (AOR = 2.49) more likely develop mental distress than their counter parts. This study is in line with study conducted among Hawassa University medical students [14].

In this study, students who didn’t have interest to their department were 2 times more likely to develop mental distress as compared with those who have interest with their department. This finding is in agreement with study done in Gondar University [26]. This might be due poor achievement in academics since those students who have no interest to their field of study may not be initiated to read more and lost their time.

Students whose grades lower than expected were about five times more likely to develop mental distress than their counter parts. This study result was supported by other study done in Gondar University students [26]. This might be due to the fact that students whose grades lower than expected may experience anxiety, frustration, and sense of hopelessness and difficulty of sleeping which may further lead students mentally distressed.

Limitations of the study

Recall bias may be there since most of the questions assess past history. The study may be prone to reporting bias since the data were collected based on self-reported information. This study investigated mental distress rather than specific mental health disorders. Therefore, mental distress in this study may represent those with mental disorders or those who experience a temporary distress due to situational stresses.

Conclusion

Prevalence of mental distress was high. Sex, financial distress, felling of insecurity, lack of interest to the department and cumulative grade point average less than expected were statistically significant with mental distress.

Since the magnitude of mental distress is high, health professionals working in student’s clinic should be aware that many students complaining of physical symptoms may also be suffering from mental health problems, and thus they better assess for both these issues.

It is also recommended that mental distress needs due attention and remedial action from policy makers, ministry of health, non-governmental organizations, and other concerned bodies to enhance students’ performance on academic and ultimately proper patient care after their graduation. Further research with qualitatively study design should be conducted for further information using this finding as a secondary data.

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23 May 2022

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Abstract:

• Introduction is too long; it should be short. The instrument used to assess mental distress in this study should be

mentioned.

• Key words: There were only three keywords, which may be increased.

Introdcution:

• At the end of the introduction, state the purpose of the study.

Methods:

• Line-144: "Study participants were not excluded from this study." This is not an exclusion criteria.

• Line-146: Earlier, no objectives were mentioned.

• Line 162-163: There is no need to mention the figure title if there is no figure at this point.

• Line 181: In the definition, what type of "specified substance" should be mentioned?

• Line 222: The reference/Id number of the ethical approval should be given.

Results:

• Line 238: There is no need to include 'North West Ethopia' in the Tables title.

• Table 1 shows no consistency in the variables and categories. They need to be rearranged (e.g against the age group

in the variable column, the religion of the students was mentoned in the category column.

• Table-1 is too long

• Line 243-244: ‘Nearly three fourth of the students ……. have interest to their department’ This sentence is

perplexing because of the words ‘with their choice ' and ‘have interest '.

• Line 257-258: There is no need to mention figure title without a figure.

• All the figures are mentioned as Figure No-1.

Discussion:

• Line 303-304: ‘similar study subjects in similar setting, Ethiopia.’ is unclear.

• Line 319-320: ‘health science education environment is more of stressful’ is unclear, need explanation.

• There are some more explanations that are not supported by other studies or the findings of this study.

Conclusion:

• The last paragraph (372–375), not supported by the findings of this study, should be removed from conclusion

References:

• Many of the references are not properly written, and page numbers are missing.

Opinion

• Overall, the manuscript requires improvements in the English language, including grammar.

• The manuscript requires major revisions.

Reviewer #2: 1. What are the exclusion criteria of the study? It has to be written clearly

2. There was merging of variables in table 1 see the rows at Educational status of the mother

3. Spacing problems for instance table 1 and the next paragraph and below table 2

4. Inappropriate or unimportant part in table 3 column 2 part, please check and correct

5. The letters and numbers in figures1 has to be given a key

6. The fonts in the figures must be similar with the main text

Reviewer #3: Authors have work to improve the quality of this study. The discussion part require some improvement. it follows the same fashion just by comparing the findings and then saying lower and higher than this and that. more over some the conclusions and recommendations are not based on the result example; proper time management and the one recommended for the University clinic workers. Overall the current form of manuscript can be suitable for this reputed journal i.e., Plos One with some improvement.

Reviewer #4: The manuscript reported the magnitude of mental distress and associated factors among a school of medicine and college of health sciences students at a university, which is an important topic

The manuscript was clear, generally well-written, structures and organized.

The Introduction provided a comprehensive background. However, grammatical and spelling mistakes presents. I advise to review the whole manuscripts for this particular point.

The methods section was specific. Details that supports the reproducibility of the research is presented very-well. The following was a concern:

-Why only undergraduate students were included? To me, post graduate might exhibit distress as well and might be sometime more than undergraduates as they could have families, work or other commitments. Any explanation?

- I don’t see there is a need for figure 1

The results section is thorough, well-subdivided and appropriately supported by data analyses.

- Please remove Muslim and protestant from age category and mention them as standalone variable- religion.

- I cannot read under “Educational status of the mother” in page 12; I believe there is missing variables which correspond to the mentioned categories, please review.

- Please re-order figures, all are 1? As a reader couldn’t correlate them easily.

- NO need for level of social support; can be written in text only.

- The last figure can be easily demonstrated in a pie chart

- Proper formatting is needed.

The Discussion section is well-sourced and comprehensive. However, future implications and research are missed.

The Conclusion provide a clear summation and identify the next steps for future research. However, it is lengthy little bit. Try to be more concise

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Sk Akhtar Ahmad

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

28 Jun 2022

Author’s Point-by-Point Response to the Reviewer's and Editors Reports

The magnitude of mental distress and associated factors among A school of medicine and college of health sciences students at Debre Markos university, 2021

Corresponding Authors Dejene Tsegaye/ dejenetsegaye@gmail.com

Point by point response to Reviewers and Editors

First and foremost, the authors would like to express their gratitude to the PLOSE ONE Journal editors and reviewers for thoroughly evaluating this work and offering the required corrections. We made changes based on the feedback we received and presented each comment point by point. The authors attempted to address all of the concerns expressed by the editorial board and reviewers. Please note that the response was written in blue font.

Authors' responses to the editors' remarks

Response to the financial issue: This work was not funded in any way by the author(s). We also included it in the main document and in the cover letter.

Response to the Acknowledgement section: Wolkite University was mentioned as a source of financial assistance. However, this did not imply that Wolkite University had supported our research; it was mentioned in error. The necessary changes to the main document have been made, and our cover letter has been attached.

Response to the data availability issue: The data used to summarize this work are in the possession of the relevant author, and anybody can obtain them with a fair request.

Authors' responses to the authors' remarks

REVIEWER #1

ABSTRACT:

Comment: Introduction is too long; it should be short. The instrument used to assess mental distress in this study should be mentioned.

Response: Thank you for your advice. We made the necessary changes.

Comment: Key words: There were only three keywords, which may be increased.

Response: Thank you for your suggestions. We have added one additional keyword that is crucial.

Comment: Introduction: At the end of the introduction, state the purpose of the study.

Response: It is critical to include the study's goal. Thank you for your insightful suggestion. We've added a paragraph that explains it.

METHODS:

Comment: Line-144: "Study participants were not excluded from this study." This is not an exclusion criteria.

Response: We didn't have any criteria in place to reject students from the research because of this. Critically ill students, students on summer break, and those with a history of mental illness were all eliminated from the study as a result of your suggestion.

Comment: Line-146: Earlier, no objectives were mentioned.

Response: We did not include objectives in the manuscript because we followed the journal's guidelines. We've put the objectives in brackets now, as per your advice. Thank you for taking the time to leave such an insightful comment.

Comment: Line 162-163: There is no need to mention the figure title if there is no figure at this point.

Response: Thank you for your input; it was inadvertently mentioned there. We've made a change as a result of your idea.

Comment: Line 181: In the definition, what type of "specified substance" should be mentioned?

Response: We indicated substances that a student may have taken in the previous month under designated substances. Thank you for providing us with such a useful comment.

Comment: Line 222: The reference/Id number of the ethical approval should be given.

Response: Under ethics approval and consent to participants, the ethical approval reference number has been mentioned, thank you. It was HSC/685/16/19.

RESULTS:

Comment: Line 238: There is no need to include 'North West Ethiopia' in the Tables title.

Response: Thank you for your advice. 'North West Ethiopia' has been omitted from all table tittles.

Comment: Table 1 shows no consistency in the variables and categories. They need to be rearranged (e.g against the age group in the variable column, the religion of the students was mentioned in the category column.

Response: Sure, the table needs to be rearranged, and the appropriate adjustments have been made.

Comment:Table-1 is too long

Response: Thank you for your kind feedback. The table was indeed excessively long, and variables that were presented in the description session have been deleted from the table, as per your recommendation.

Comment: Line 243-244: ‘Nearly three fourth of the students ……. have interest to their department’ This sentence is perplexing because of the words ‘with their choice ' and ‘have interest '.

Response: The remark implied that students in various departments were studying their departments despite their lack of enthusiasm. In any case, we made grammatical corrections.

Comment: Line 257-258: There is no need to mention figure title without a figure.

Response: Thank you for your input; it was inadvertently mentioned there. We've made a change as a result of your idea.

Comment: All the figures are mentioned as Figure No-1.

Response: On each figure's reference, the appropriate modification is made.

CONCLUSION:

Comment: The last paragraph (372–375), not supported by the findings of this study, should be removed from conclusion

Response: Based on your insightful comment, the paragraph concerning recommendations (the last paragraph of conclusion) has been delated.

REFERENCES:

Comment: Many of the references are not properly written, and page numbers are missing.

Response: Thank you for taking the time to leave such an insightful comment. Following our attempt to look over the references, we made the necessary revisions.

REVIEWER #2

Comment 1. What are the exclusion criteria of the study? It has to be written clearly

Response: We updated exclusion criteria based on your and another reviewer's comments, which include students on summer break and those with a history of mental illness. These criteria were not included in the exclusion criteria section since they were already factored into the non-participant rate.

Comment 2. There was merging of variables in table 1 see the rows at Educational status of the mother

Response: After going over the original paper, we made the necessary changes. When the manuscript was being produced, the correspondent author made a mistake, sorry.

Comment 3. Spacing problems for instance table 1 and the next paragraph and below table 2

Response: We made equivalent space across the document after all of the comments were fixed.

Comment 4. Inappropriate or unimportant part in table 3 column 2 part, please check and correct

Response: Yes, the variables in Table 3, column 2 and row 2 were inaccurate, and we fixed them. Thank you very much.

Comment 5. The letters and numbers in figures1 has to be given a key

Response: We appreciate your thorough inquiry; we corrected them based on your and other reviewers' comments.

Comment 6. The fonts in the figures must be similar with the main text

Response: It is a valuable comment, and we created it based on it.

REVIEWER #3

Authors have work to improve the quality of this study. The discussion part require some improvement. it follows the same fashion just by comparing the findings and then saying lower and higher than this and that. more over some the conclusions and recommendations are not based on the result example; proper time management and the one recommended for the University clinic workers. Overall the current form of manuscript can be suitable for this reputed journal i.e., Plos One with some improvement.

Response: We appreciate your suggestion. We did a number of things to improve the quality of the study after reevaluating the original document, starting with English language correction. We also attempted to update the discussion section in order to improve the discussion's flow. Inappropriate/unimportant thoughts are omitted from the conclusion and recommendation sections, since we had a similar request from another reviewer. Thank you so much for your insightful comment, which will assist us in improving the overall document quality.

REVIEWER #4

The manuscript reported the magnitude of mental distress and associated factors among a school of medicine and college of health sciences students at a university, which is an important topic

The manuscript was clear, generally well-written, structures and organized.

The Introduction provided a comprehensive background. However, grammatical and spelling mistakes presents. I advise to review the whole manuscripts for this particular point.

The methods section was specific. Details that supports the reproducibility of the research is presented very-well. The following was a concern:

Comment: Why only undergraduate students were included? To me, post graduate might exhibit distress as well and might be sometime more than undergraduates as they could have families, work or other commitments. Any explanation?

Response: We agree with you; actually, post-graduate students may be distressed. However, university for postgraduate students is a second exposure, and they may not have the same mental suffering as undergraduate students in terms of the surroundings, finances, interest in their area, feelings of insecurity, and other factors.

Comment: I don’t see there is a need for figure 1

Response: We removed it, thank you.

The results section is thorough, well-subdivided and appropriately supported by data analyses.

Thank you for your helpful feedback.

Comment: Please remove Muslim and protestant from age category and mention them as standalone variable- religion.

Response: It was a blunder made during the preparation of the manuscript. We received similar feedback from other reviewers as well, and implemented the necessary changes after reevaluating the original document.

Comment: I cannot read under “Educational status of the mother” in page 12; I believe there is missing variables which correspond to the mentioned categories, please review.

Response: Certain factors were merged with the educational status variable in table 1. Now that the changes have been made, it is well written.

Comment: Please re-order figures, all are 1? As a reader couldn’t correlate them easily.

Response: Thank you very much; that was a complete blunder that has now been rectified.

Comment: NO need for level of social support; can be written in text only.

Response: We received a helpful suggestion from a reviewer to shorten the table. Many variables from the tables are now written in text form, as you suggested. Thank you so much for everything.

Comment: The last figure can be easily demonstrated in a pie chart

Response: As per your recommendation, we accomplished it in Pichart.

Comment: Proper formatting is needed.

Response: After a thorough examination, suitable formatting is applied to the entire manuscript.

Comment: The Discussion section is well-sourced and comprehensive. However, future implications and research are missed.

Response: Thank you for your encouraging words. Future implications have been added, which were actually discussed in the recommendation section.

Comment: The Conclusion provide a clear summation and identify the next steps for future research. However, it is lengthy little bit. Try to be more concise

Response: Thank you for your kind words. We tried to condense the concluding section by avoiding irrelevant information.

We appreciate all of the reviewers' and editors' helpful feedback, suggestions, and questions.

Thank you,

With kind regards!

Submitted filename: Authors point by point Response.docx

Click here for additional data file.

28 Aug 2022

1 Sep 2022

Author’s Point-by-Point Response to the Reviewer's and Editors Reports

The magnitude of mental distress and associated factors among A school of medicine and college of health sciences students at Debre Markos university, 2021

Corresponding Authors Dejen Tsegaye/ dejenetsegaye@gmail.com

Point by point response to Reviewers and Editors

First and foremost, the authors would like to express their gratitude to the PLOSE ONE Journal editors and reviewers for thoroughly evaluating this work and offering the required corrections. We made changes based on the feedback we received and presented each comment point by point. The authors attempted to address all of the concerns expressed by the editorial board and reviewers. Please note that the response was written in blue font.

Authors' responses to the editors' remarks

Editor: As you will see in the reviews, you have done a nice job with the revision. Reviewer #3 has raised some specific and important revisions to be made.

Response: Thank you! Reviewer three provided us with some very significant feedback, and we made an effort to make the necessary corrections.

Authors' responses to the authors' remarks

REVIEWER #3

Comment: 1. General:

There are too many editorial problems along the manuscript which include sentence structure, grammatical and spacing errors. There is also inconsistent use of words and phrases.

Response: The authors made an effort to review the paper and make corrections for grammatical, spacing, and other concerns, such as terms or phrases that were used inconsistently in relation to your feedback.

Comment: 2. Abstract

• On the introduction section of the abstract, it didn't show why the study conducted

Response: I appreciate your advice. We have inserted a clause that clarifies the aim of the investigation.

• On page 1 line 36, replace 'conducted' by 'employed'

Response: Thank you for your advice. We made the necessary changes.

• On the Methods part of the abstract include the study period and the total sample size.

Thank you for your advice. We have added the study period and total sample size.

Comment: 3. Introduction

• The introduction section of this manuscript lacks coherence. You started by defining the problem then show the effect of mental health distress. The factors came later after the effect. I suggest this flow; 1st define the problem�  then come across with associated factors�  finally, state the effects of mental health distress.

Response: Thank you for your advice. We made the necessary changes.

• Page 5, line 100; don’t use the short for ‘SMCHS’ at its first mention.

Response: Thank you for your advice. We made the necessary changes.

Comment: 4. Methods

• Page 5, line 107; enter the work “design” between the words ‘study’ and ‘was’.

Response: Thank you for your advice. We made the necessary changes.

• Page 5, line 109; avoid repetition on the study design.

Response: Thank you for your input; we've made a change as a result of your idea.

• Your study area description lacks REFERENCE(S).

Response: Thank you for your suggestion. We have added a reference.

• On the exclusion criteria, is ‘March’ among the summer months in Ethiopian context? Because you stated, ‘students on summer break are excluded’

Response: When viewed in the context of Ethiopia, March is not summer. However, starting March, departments from the school and college are permitted to leave the university for break early if they were able to complete all of their courses. This university's curriculum is year-based rather than semester-based. I appreciate you spending the time to make such a thoughtful response.

• Page 6, lines 131 & 135; replace ‘Gondar university’ by ‘University of Gondar, Ethiopia’

Response: Thank you for your input; we've made a change as a result of your idea.

• On sample size determination, put the formula.

Response: We have added the formula based on your suggestion. Thank you.

• Did you consider design effect in your sample size determination? In this regard, figure 1 is not clear and needs elaboration. Example: how many students are there for each department per each year? There are also letters like; P, M, N, E, ….., which needs clarification.

Response: The study was unable to take design effect into account. The design effect can be utilized to correct the estimated sampling variance, as is well knowledge. The study took into account/involved all departments/sections, hence a design effect is not required. The stratification and proportional distribution of sample size to each department were simply depicted in the picture. The departments were revealed by the personalities that were referenced there. Its legend is supplied below the figure. I appreciate you spending the time to make such a thoughtful response.

Comment: 5. Results

• Page 7, line 158; remove the last sentence.

Response: Thank you for your advice. We made the necessary changes.

• Page 12, lines 231, 235 and 239; figures captions are misplaced. Please revise it for all.

Response: Thank you. We revised and made the necessary change.

Comment: 6. Discussion

• The discussion part still needs revision. The finding is well compared with other’s work. However, the way you used to justify discrepancies of your findings with previous works is poor. Justification based on the assessment tool used, sample size difference may not be sound and convincing.

Response: Thank you for your advice. We tried to make necessary modifications.

Comment: 7. Conclusion and recommendation

• What you have recommended for different stakeholders based on the significant associated factors you had.

Response: Based on the finding, recommendations are given to the concerned body. Thank you!

Comment: 8. Figure Legend

Figure 2 & 3 are missed and Figure 6 & 7 added which are not cited in the text.

Response: For this feedback, we've made an effort to carefully go over the entire document. I appreciate you spending the time to make such a thoughtful response.

Comment: 9. References

• The reference part is not written appropriately. Most of the references lack journal name, volume, number and page number (Ref. 1, 3, 5, 9, 10, 15, 20, 21, 26, 32, 33,….). There are also references without year publication. Sometimes CAPITAL letter is used (ref.10). Not only these, consider the other issues too like; use of punctuations.

Response: For citation, we used the endnote program; manual referencing was not used. Because of this, references are immediately cited from the software without any modification, which accounts for all of the improper referencing methods discussed above. Now, in response to your comment, we have made the necessary changes. I appreciate your thoughts.

Comment: 10. Figures

• Figure 2 & 5 are not visible well, replace with a better visibility.

Response: Thank you. To improve visibility, we created another figure for each. The visibility has improved recently.

We appreciate all of the reviewers' and editors' helpful feedback, suggestions, and questions.

Thank you,

With kind regards!

Submitted filename: Authors point by point Response 2.docx

Click here for additional data file.

12 Sep 2022

The magnitude of mental distress and associated factors among a school of medicine and college of health sciences students at Debre Markos university, 2021

PONE-D-22-05826R2

Dear Dr. Tsegaye,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ali A. Weinstein, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Please see the final reviewer comments below. For the final version of the paper, you may want to revise/recheck these.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Please check the sample size determination farmula. The other thing still on the discussion on page 16, line 292-303, the first three paragraphs are not neccessary. On the references still it needs revision.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Mahmud Ahmednur Mohammed

**********

15 Sep 2022

PONE-D-22-05826R2

The magnitude of mental distress and associated factors among a school of medicine and college of health sciences students at Debre Markos university, 2021

Dear Dr. Tsegaye:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ali A. Weinstein

Academic Editor

PLOS ONE