Anita Shakya^1*, Krishna Sharma^{2, 3}

¹Undergraduate Student, Department of Public Health, Kantipur Academy of Health Sciences, Purbanchal University, Kathmandu, Nepal.

²Training/Field Supervisor for Maternal and Neonatal Health, One Heart Worldwide, Lalitpur, Nepal.

³Bachelor of Public Health, National Academy for Medical Science, Faculty of Medical and Allied Sciences, Purbanchal University, Kathmandu, Nepal.

*Corresponding Author: Anita Shakya, Undergraduate Student, Department of Public Health, Kantipur Academy of Health Sciences, Purbanchal University, Kathmandu, Nepal.

Abstract 
Background
The commonness of psychological illness occurring within the university curriculum, along with the socioeconomic or behavioral status of students, is growing with the development of the deteriorating education system. It is gradually developing into a mental health issue among undergraduate students in Nepal and poses a significant challenge for public health globally. This research study aimed to determine the prevalence and factors associated with depression, anxiety, and stress among undergraduate management students in Kathmandu, Nepal. 

Methods: 
Out of 600 sample sizes, 516 students participated in the descriptive cross-sectional study carried out among undergraduate management students in Kathmandu. Depression, anxiety, and stress were measured using the DASS21 (depression, anxiety, and stress scale 21) tool, designed for self-administered data collection in Nepali and English. The questionnaire comprises four sections: socio-demographic information, depression, anxiety, and stress, to measure the different emotional states of the student. 

Findings: 
The overall prevalence of depression, anxiety, and stress was found to be 57.8 %, 60.9 %, and 43 %, respectively, among undergraduate management students in Kathmandu, and most female students experienced it in contrast to male students. Almost all students (100 %) who participated in the research study have experienced the unnecessary pressure of college studies as the most significant cause of depression, anxiety, and stress. Students, those having less family income (< 20000 NPR per month), those breaking up with loved ones, those having no daily physical exercise, and having pressured college studies were at higher risk of experiencing depression (P=0.004, P=0.007, P=0.023, and P=0.000 respectively). The prevalence rate of extremely severe depression, anxiety, and stress was about 9.1 %, 23.8 %, and 7 %, respectively. 

Conclusion:
The study found that undergraduate management students in Kathmandu had high rates of anxiety, depression, and stress. Special attention and necessary psychological health intervention from their respective colleges/universities and government sectors are highly recommended. 

Keywords: Depression, Anxiety, Stress, Mental Health, Kathmandu 

Introduction  
There is no uncertainty that learning and teaching principles have changed over the years according to psychological development, which may have motivated students in terms of education at their college or university. Teaching methodologies, education systems, and their interests, as well as global necessities, have changed the psychology of students over time and vary from person to person. The student’s negative psychological prospects with the inappropriate education system at college and university according to their interests may lead to mental health issues and threaten the public health sector globally.

An individual's mental health includes cognitive, behavioral, and emotional well-being, as well as their thoughts, feelings, and behaviors, which matter most for mental health. The term "mental health" is sometimes used to refer to the absence of mental disorders [1]. Various conditions can affect mental health and disrupt a person's daily life, including stress, depression, and anxiety [1]. Depression is a common mental disorder characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities, which also disturbs sleep and appetite [2]. Anxiety is a feeling of unease, such as worry or fear, which can be mild or severe [3]. Stress is any change that causes physical, emotional, or psychological strain. Additionally, stress is our body's response to anything that requires attention or action [4]. 

Depression, anxiety, and stress are the most common mental health disorders globally, and more than 264 million people of all ages suffer from depression [7]. It has been projected that in 2020, suicide accounts for one death every 20 seconds, and the large majority of those occur in low and middle-income countries [8]. Depression is the world's leading cause of disability and contributes significantly to the global disease burden. The previous study shows that the higher level of psychiatric morbidity and depression was 29.9 %, anxiety at 41.1 %, and stress at 27 % among undergraduate medical students [9]. Similarly, among Slovak students, the prevalence rate of somatic complaints, anxiety, and depression was 69.5, 34.6, and 47 %, respectively [6]. Depression is also common among Nepalese medical students, especially in their first year with the high pressure of college studies [5]. 

However, the mental health issue is still largely ignored and has not been given priority. To our knowledge, no study reported the prevalence and factors associated with depression, anxiety, and stress among undergraduate management students in the Kathmandu district. Since Kathmandu is Nepal's education hub, students from all over the country prefer to come to Kathmandu for higher education. There is also limited information regarding risk factors associated with the causation of depression, anxiety, and stress in Nepal. This research study aimed to assess the prevalence and risk factors associated with depression, anxiety, and stress among undergraduate management students in the Kathmandu District.

Methods
Study Design:
A descriptive cross-sectional study with a quantitative research methodology was used to determine the prevalence and factors associated with depression, anxiety, and stress among undergraduate management students in Kathmandu. 

Study Area: 
Different management colleges/universities located in the Kathmandu district were taken as a study area for this research study. 

Study Population: 
The study population consisted of undergraduate management students, 18–32 years old, from selected colleges and universities in the Kathmandu district.

Sample Size: 
The total 600 sample sizes was calculated by taking the 50 % prevalence, and the level of significance was set at p < 0.05 with a confidence interval (CI) of 95 %.
Degree of confidence (Z): 95 % (i.e. 1.96) 
Level of significance: 5 % 
The margin of error (d): 4 % (0.04)
Prevalence (p): 50 % = 0.5 
q= 1-p=0.5 

By using formula

Sample size = 600 

However, we were only able to collect 516 samples for this study since the rest of the students refused to participate. 

Sampling Techniques: 
This research study used the students as the study unit and all of Kathmandu's colleges as a sampling frame. Three colleges were picked at random via a lottery method from a simple random sample. The students were chosen using convenience sampling, and the number of students from each college was determined using the proportionate sampling technique.

Tools and Techniques for Data Collection:  
For self-administrative data collection, sets of three scales from the DASS21 (depression, anxiety, and stress scale 21) tool were used to measure the emotional states of depression, anxiety, and stress. The structured data collection tool covered four subtopics: socio-demographic data, depression, anxiety, and stress. The rating scale had four levels: 0 for "not at all," 1 for "some degree or some of the time," 2 for "a considerable degree or a good part of the time," and 3 for "very much or most of the time." 

Data Management, Analysis, and Interpretation Procedures:
EpiData (version 3.1) was used for data entry, and a Statistical Package for the Social Sciences (SPSS) software (version 26) was used for data analysis. Data coding and editing were done manually. Microsoft Office Word (2016), and Mendeley were also used for the documentation and referencing. Descriptive data analysis included frequencies, percentages, and mean, followed by a chi-square test to determine the significance between the dependent and independent variables. The standard α = 0.05 was taken as the cutoff value for the significant result.

Validity and Reliability of Tools:
A sufficient literature review was carried out to ensure the accuracy of the data and the validity of the tools. For the data collection, the DASS21 tool was used as a questionnaire. The research methodology, guidelines, and feedback from the supervisor were strictly followed.

Inclusion Criteria:
Undergraduate students (18-32 years of age group) who are studying management within the Kathmandu district from selected colleges and universities that are capable of giving consent to participate in the study were included as research participants.

Ethical Consideration: 
Formal approval was taken from the Department of Public Health of the Kantipur Academy of Health Sciences (Ethics approval letter Ref. No.: 02/079). And approval was also taken from selected colleges/universities before conducting research among students.
Written consent was taken from each participant before participation in the study. 

Confidentiality:
Each respondent was informed of the purpose of the study before their voluntary participation. The anonymity of personal data ensures the confidentiality of the data. Collected information was utilized only for study purposes.

Timeframe of the Study:
The study was conducted from August 2021 to July 2022.

Operational Definitions:
Depression
Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think, and how you act. It is measured by the depression, anxiety, and stress scale (DASS21). The scale consists of seven questions about depression. The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest or involvement, anhedonia, and inertia. During inferential statistics, we kept no depression as normal and the rest of the others as depression. 

Anxiety
Anxiety is the mind and body's reaction to stressful, dangerous, or unfamiliar situations. It's the sense of uneasiness, distress, or dread you feel before a significant event. It is measured by the depression, anxiety, and stress scale (DASS21). The scale consists of seven questions for anxiety. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. During inferential statistics, we kept no anxiety as normal and the rest of the others as anxiety.  

Stress
Stress is a normal reaction the body has when changes occur. It can respond to these changes physically, mentally, or emotionally. It is measured by the depression, anxiety, and stress scale (DASS21). The scale consists of seven questions for anxiety. The stress scale is sensitive to levels of chronic nonspecific arousal. It assesses difficulty relaxing, nervous arousal, being upset, irritable or over-reactive, and impatient. During inferential statistics, we kept no stress as normal and the rest of the others as stressed.

Table 1: Cut-off scores table for conventional severity label

Results
Socio-demographic and academic characteristics of respondents:
Out of 600 sample sizes, only 516 students participated in the descriptive cross-sectional study carried out among undergraduate management students in Kathmandu. The rest of the students (84) were unable to give consent for the research study. About 53.1 % of the 516 students who participated in the study were female, while 46.9 % were male. The age ranged from 18 to 32, with a mean age of 19.98 (SD= ±1.28). Most respondents were single (98.8 %), and only 1.2 % were married. About 62.8 % were living with family members. Similarly, about 70.7 % of the family was nuclear, and the remaining were joint/extended (29.3 %), with the highest 45.5 % of the income range falling from NPR 25,000–NPR 50,000 per month. Participants were enrolled from two universities (80.2 % from Tribhuvan University and 19.8 % from Pokhara University), studying management courses BBA/BBS (41.5 %), BHM (29.7 %), and BTTM (28.9 %).

Table 2: Socio-demographic and academic characteristics of respondents (n=516)

Personal and behavioral characteristics of respondents:
Among the total participants (n = 516), 17.1 % of the participants had experienced the death of a family member in the last six months. About 64.3 % of participants felt unnecessary pressure from their studies, and among them, 54.7 % always worried about their future. Similarly, COVID-19 was diagnosed as positive in 18.2 % of respondents and 34.5 % of family members diagnosed with COVID-19. About 13.6 % of the participants were smokers, and alcoholism was found to be 45.7 %. Personal and behavioral characteristics of respondents showed that about 14.5% of management students do not have even general physical exercise. Only 21.3 % of the participants always do general physical exercise regularly. (See table 3).

Table 3:  Personal and Behavioral characteristics of respondents (n=516)

Table 4: Prevalence of depression, anxiety, and stress among undergraduate management students (n=516)

Table 5: DAS level among undergraduate management students (n=516)

Association of independent variables with depression, anxiety, and stress:
At the 95 % level of CI, depression, anxiety, and stress correlated with the pressure of college studies (p<0.05). It is also significantly associated with the drinking habits of students (p = 0.03, 0.025, 0.002 < 0.05, respectively). Students who do not get general physical exercise regularly are at a high risk of both depression and anxiety (p = 0.23, 0.08 < 0.05). Similarly, female students (50 %) who have not been married yet (43.5 %) and have broken up with loved ones (52.7 %) are more likely to experience stress. The students who had less family income (< 20000 NPR per month), those who broke up with loved ones, and those who had stressful college studies were also at higher risk of experiencing depression (P = 0.004, P = 0.007, and P = 0.000, respectively). Similarly, depression is also strongly associated (p = 0.00 < 0.05) with the death of family members. Management students studying courses BHM and BTTM are more likely to experience DAS than BBA/BBS students, which is significantly associated with both anxiety and stress (p = 0.001, 0.012 < 0.05, respectively).

Table 6: Association of depression, anxiety, and stress with independent variables (n=516)

In our study, the prevalence of depression (57.8 %), anxiety (60.9 %), and stress (43 %) are higher in Kathmandu, Nepal, than those found in a recent study conducted among Nepalese undergraduate students in Pokhara, which showed the overall prevalence of depression, anxiety, and stress at 38.2 %, 46. 9 %, and 24.1 %, respectively [10]. In comparison to stress and depression, anxiety is correspondingly more common among undergraduate students in Kathmandu. The prevalence rate of extremely severe depression, anxiety, and stress was about 9.1 %, 23.8 %, and 7 %, respectively. It also revealed moderate levels of depression, anxiety, and stress among undergraduate management students at 22.7 %, 18 %, and 15.3 %, respectively, compared with a previous study that also showed a similar prevalence of 25 %, 17 %, and 9 % of moderate levels of depression, anxiety, and stress [13].

In contrast to males, females are more likely to experience depression (62.8 %), anxiety (64.2 %), and stress (50 %) than males (37.2 %, 57 %, and 35.1 %, respectively). Similarly, our study also found that depression and stress are statistically strongly related to gender (p =0.014 < 0.05 and p =0.001 < 0.05, respectively). The pressure to marry at an early age, the pressure to be self-dependent, and less support from family and friends could be the principal cause, as Nepalese society has distinct psychological insecurities toward female students as they mature with college studies, especially if they live outside their home district. Conversely, a survey among undergraduate students in Shaanxi province during the COVID-19 epidemic in China found that male students had higher rates of depression, anxiety, and stress symptoms than female students, as females get more support from family and friends [12].  

The findings further reveal that the prevalence of depression seems to be affected by numerous variables such as family income, courses of study, the death of a family member, break-ups with loved ones, and other personal habits. It also revealed that the possibility of depression increases with age (18–22 years old of 57.2 %, 23–27 of 63.9, and 28–32 of 75 %, respectively). The living status of a student (loneliness) and unfamiliarity with the heavy crowding environment in the city area (most students come from rural villages where there is more competition among individuals) might have affected the prevalence rate. It might be due to the pressure of a better career from family and society with the age maturity of students and an unsecured future by the deteriorating education system in Nepal, as well as financial crisis during student life are the primary causes of depression. Additionally, It might be due to differences in socio-economic background, difficulties in college/university courses, and limited time for self-care among college students. Further in our study, students with a family income of < 20,000 NPR per month have more depressive symptoms than students with a family income of >50000 NPR. On the contrary, in a previous study, financial problems were associated with only anxiety [15].  

Similarly, a study among nursing students at Kathmandu University in 2016 showed academic stress at 18.4 % [14]. This is in contrast to the higher prevalence rate of stress in our study, which was 43 %. Another study done in 2013 correspondingly showed a higher prevalence (100 %) among undergraduate dental students at the Tertiary Health Care Centre in Eastern Nepal [16]. Consequently, most Nepalese students feel under pressure to spend the majority of their working hours on education at their colleges, universities, or even at home due to an inappropriate education system, which adds undue pressure to their academic performance and causes unnecessary stress. Additionally, no statistical association between stress and other factors was found, such as the age of students, family income, type of family, death of a family member, worrying about the future, and the student's diagnosis with COVID-19, a family member diagnosed with COVID-19, physical exercise habits, and smoking habits of students. In particular, female students experienced more stress (50 %) than males (35.1 %), whereas a previous study showed that males were more stressed than females regarding financial concerns [15].

Conclusion and Recommendations
In conclusion, a high prevalence of anxiety, depression, and stress among undergraduate management students has been detected in Kathmandu, and most female students have experienced it in contrast to male students. Approximately one out of 10 students has experienced severe or extremely severe depression, and three out of 10 have experienced severe or extremely severe anxiety, which is significantly related to the unnecessary pressure of college studies. Similarly, stress among undergraduate students was significantly associated with other factors like courses of study, living status, and breakups with loved ones during student life. Therefore, colleges/universities and government sectors need to pay special attention to and provide psychological health interventions to decrease the prevalence of DAS among undergraduate management students. Further studies should emphasize a deeper investigation of the association between a country's educational system and its psychological impact on students.

Limitations
We collected data through self-administered questionnaires, but the subjective experiences of individuals may vary depending on their premorbid personalities, ability to experience anxiety and fear, and ability to tolerate stress. As depression, anxiety, and stress were assessed by self-rating, there was a chance of making a false or over-judgment.

Declarations
The authors have no conflicts of interest to declare. There are no financial interests to disclose, and each co-author has reviewed the manuscript and approved its contents. We certify that the contribution is original and not currently being reviewed by another publication.

Acknowledgment
We highly appreciate the support throughout this research project we have received from Asst. Prof. Mr. Maginsh Dahal, Mr. Pratik Khanal, Mr. Ashok Panday, Ms. Pooja Devkota, Ms. Khusbu Deo, and Mr. Prakash Datt Chataut of the Kantipur Academy of Health Sciences (KAHS), Kathmandu.

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