Prevalence and Factors Associated With Mental Distress Among Undergraduate Students at Kilimanjaro Christian Medical University College

PREVALENCE AND FACTORS ASSOCIATED WITH MENTAL
DISTRESS AMONG UNDERGRADUATE STUDENTS AT

KILIMANJARO CHRISTIAN MEDICAL UNIVERSITY
COLLEGE
By
Eneck Samwel Kibopile TUMA/KCMUCo/2947
Furaha Enos Kasyupa TUMA/KCMUCo/ 2757
Esther Andrew TUMA/KCMUCo/2547
A research proposal submitted in partial fulfilment for the requirements for

the degree of Doctor of Medicine of Tumaini University Makumira
Kilimanjaro Christian Medical University College
Tumaini University Makumira
April 2018 Commented [IM1]: Why page number in the first page?
i
TABLE OF CONTENT Formatted: Heading 1
Formatted: Font color: Auto
TABLE OF CONTENT ............................................................................................................................ i
Formatted: Font: 11 pt
LIST OF TABLES ................................................................................................................................ viii
Formatted: Space After: 0 pt, Line spacing: 1.5 lines
CERTIFICATION ............................................................................................................................... viiv
DECLARATION AND COPYRIGHT ................................................................................................. viiv
ACKNOWLEDGEMENT ................................................................................................................. viiivi
ABBREVIATIONS ............................................................................................................................ ixvii
DEFINITION OF TERM.................................................................................................................... xviii
ABSTRACT........................................................................................................................................ xiix
CHAPTER ONE ..................................................................................................................................... 1
1.0 Introduction ................................................................................................................................... 1
1.1 Background information ................................................................................................................. 1
1.2 Literature review ............................................................................................................................ 3
1.2.1 Literature search strategy ......................................................................................................... 3
1.2.1 Prevalence of mental distress ................................................................................................... 3
1.2.2 Factors associated with mental distress..................................................................................... 4
1.3 Problem statement .......................................................................................................................... 5
1.4 Justification .................................................................................................................................... 6
1.5 Study questions .............................................................................................................................. 6
CHAPTER TWO..................................................................................................................................... 7
2.0 Objectives ...................................................................................................................................... 7
2.1 Broad objective .............................................................................................................................. 7
2.2 Specific objectives ......................................................................................................................... 7
CHAPTER THREE ................................................................................................................................. 8
3.0 Methodology .................................................................................................................................. 8
3.1 Study design .................................................................................................................................. 8
3.2 Study Area ..................................................................................................................................... 8
3.3 Study population ............................................................................................................................ 8
3.4 Eligibility criteria ........................................................................................................................... 8
3.4.1 Inclusion criteria ...................................................................................................................... 8
3.4.2 Exclusion criteria ..................................................................................................................... 9
3.5 Sample size and sampling technique ............................................................................................... 9
3.5.1 Sample size.............................................................................................................................. 9
3.5.2 Sampling technique................................................................................................................ 10
i
3.6 Variables ................................................................................................................................... 10
3.7 Data collection tools, methods and procedures .............................................................................. 10
3.7.1 Data collection tools .............................................................................................................. 10
3.7.2 Data collection methods ......................................................................................................... 11
3.7.3 Data collection procedures ..................................................................................................... 11
3.8 Data management and analysis plan ............................................................................................. 11
3.8.1 Data management plan ........................................................................................................... 11
3.8.2 Data analysis plan .................................................................................................................. 11
3.8.3 Explanation and categorization of variables ........................................................................ 1112
3.9 Ethical consideration .................................................................................................................... 12
3.10 Plan for dissemination ................................................................................................................ 12
3.11 Study limitation .......................................................................................................................... 12
3.12 Project management ............................................................................................................... 1213
WORK PLAN ....................................................................................................................................... 14
BUDGET .......................................................................................................................................... 1615
REFERENCE .................................................................................................................................... 1716
APPENDICES .................................................................................................................................. 3019
Appendix 1: Participant information sheet ...................................................................................... 3019
Appendix 2: Consent form ............................................................................................................. 3221
Appendix 3: Questionnaire ............................................................................................................. 3422
Appendix 4: Dummy Tables ........................................................................................................... 4627
LIST OF TABLES ..................................................................................................................................... ii
CERTIFICATION .................................................................................................................................... iii
DECLARATION AND COPYRIGHT ....................................................................................................... iv
ACKNOWLEDGEMENT .......................................................................................................................... v
ABBREVIATIONS ................................................................................................................................... vi
DEFINITION OF TERM ......................................................................................................................... vii
ABSTRACT........................................................................................................................................... viii
CHAPTER ONE ....................................................................................................................................... 1
1.0Introduction .................................................................................................................................... 1
ii
1.1Background information .................................................................................................................. 1
1.2Literature review ............................................................................................................................. 3
1.2.1Literature search strategy ........................................................................................................ 3
1.2.1Prevalence of mental distress ................................................................................................. 3
1.2.2Factors associated with mental distress ................................................................................. 4
1.3Problem statement ........................................................................................................................... 5

1.4Justification ..................................................................................................................................... 6
1.5Study questions ............................................................................................................................... 6
CHAPTER TWO ...................................................................................................................................... 7
2.0Objectives ....................................................................................................................................... 7
2.1Broad objective ............................................................................................................................... 7
2.2Specific objectives .......................................................................................................................... 7
CHAPTER THREE.................................................................................................................................... 8
3.0 Methodology .................................................................................................................................. 8

3.1 Study design .................................................................................................................................. 8
3.2 Study Area ..................................................................................................................................... 8
3.3 Study population ............................................................................................................................ 8
3.4 Eligibility criteria ........................................................................................................................... 8
3.4.1 Inclusion criteria ..................................................................................................................... 8
3.4.2 Exclusion criteria .................................................................................................................... 9
3.5 Sample size and sampling technique ............................................................................................... 9
3.5.1 Sample size............................................................................................................................. 9
3.5.2 Sampling technique ............................................................................................................ 10
3.6 Variables ................................................................................................................................. 10
3.7 Data collection tools, methods and procedures .............................................................................. 10
3.7.1 Data collection tools ............................................................................................................ 10
3.7.2 Data collection methods ..................................................................................................... 11
3.7.3 Data collection procedures ................................................................................................. 11
iii
3.8 Data management and analysis plan ............................................................................................. 11
3.8.1 Data management plan ....................................................................................................... 11
3.8.2 Data analysis plan ................................................................................................................ 11
3.8.3 Explanation and categorization of variables ...................................................................... 12
3.9 Ethical consideration .................................................................................................................... 12

3.10 Plan for dissemination ................................................................................................................ 12
3.11 Study limitation .......................................................................................................................... 12
3.12 Project management ................................................................................................................... 12
WORK PLAN ........................................................................................................................................ 14
BUDGET ............................................................................................................................................... 15
REFERENCE .......................................................................................................................................... 16
DUMMY TABLES .................................................................................................................................. 19
APPENDICES ........................................................................................................................................ 24
iv
LIST OF TABLES
Table 1 : Socio-demographic characteristics and other factors associated with mental distress...27
Table 2 : Symptoms of mental distress, SRQ- 20 for the past 30 days..................................... 4829 Formatted: Line spacing: 1.5 lines
Field Code Changed
Table 3 : Substance use ............................................................................................................. 4829
Formatted: Font: (Default) Times New Roman, 12 pt
Table 4 : Social support ............................................................................................................ 4930 Formatted: Font: (Default) Times New Roman, 12 pt
Table 5 : Academic problems ................................................................................................... 4930

Table 1 : Socio-demographic characteristics ...................................................................................... 19
Table 2 : Factors associated with mental distress ............................................................................... 20
Table 3 : Symptoms of mental distress, SRQ- 20 for the past 30 days .................................................. 21
Table 4 : Social support .................................................................................................................... 23
Table 5 : Academic problems .......................................................................................................25
v
CERTIFICATION
The undersigned certifies that this is a work of the candidates carried out during their
undergraduate training under our direct supervision. The undersigned certifies that he has read
and hereby recommends for consideration by Tumaini University Makumira the study entitled: Formatted: Not Highlight
Prevalence and factors associated with mental distress among undergraduate students.
This proposal is submitted in partial fulfilment of the requirement for degree of Doctor of Formatted: Not Highlight
Medicine of Tumaini University Makumira.
………………………………. ……………………………………
Innocent B. Mboya Date
(SUPERVISOR)
vi
DECLARATION AND COPYRIGHT
We Eneck Samwel Kibopile, Furaha Enos Kasyupa and Esther Andrew declare that this proposal
is our own original work and that it has not been presented or submitted to any other university
for a similar or any other degree award, and is not previously or currently under copyright.
Names Signature Date
Esther Andrew ………… …………
Eneck Samwel Kibopile …………. …………
Furaha Enos Kasyupa …………. …………
This proposal is copyright material protected under the Berne convention, the copyright act 1966
and other international and national enactments, in that behalf or intellectual property. It may not
be reproduced by any means, in full or in part, except for short extract in fair dealing,
forresearchfor research or private study, critical scholarly review or discourse with an
acknowledgement, without the written permission of the director of undergraduate studies on
behalf of both author and Tumaini University Makumira.
vii
ACKNOWLEDGEMENT
First we would like to thank our supervisor Mr. Innocent Mboya for his unlimited support,
advices, valuable comments and encouragement during the preparation of this work. Also we
thank the Community Health Department for their guidance and material support to this
proposal.
viii
ABBREVIATIONS
DALYs Disability Adjusted Life Year
KCMUCo Kilimanjaro Christian Medical University College
UK United Kingdom
USA United State of America
WHO World Health Organization
DALYs Disability Adjusted Life Year
KCMUCo Kilimanjaro Christian Medical University College
UK United Kingdom
USA United State of America
WHO World Health Organization
ix
DEFINITION OF TERM
Mental health: Is a state of wellbeing in which every individual realizes his or her own potential, Formatted: Font: (Default) Times New Roman, 12 pt, Not
Bold
can cope with the normal stresses of life, can work productively and fruitfully and is able to Formatted: Space After: 10 pt
make a contribution to her or his community (WHO, 2014). Formatted: Font: (Default) Times New Roman, 12 pt
Mental distress: Is a state of emotional suffering characterized by symptoms of depression Formatted: Font: (Default) Times New Roman, 12 pt, Not
Bold
(example lost interest, sadness and hopelessness), anxiety (example restlessness and feeling
tense) and somatic symptoms (example insomnia, headache and lack of energy) (Drapeau et al,
2012; Dachew et al, 2015). Formatted: Font: (Default) Times New Roman, 12 pt
x
ABSTRACT
Background: Mental distress is an important public health problem which includes anxiety, Formatted: Font: (Default) Times New Roman, 12 pt
Formatted: Normal, Space After: 0 pt
depression and somatic symptom. Undergraduate students are reported to have significantly
higher level of mental distress than their community counterparts. Undergraduate students with
mental distress have a significantly impaired cognitive functioning, learning ability and academic
performance. However burden of mental distress among university students in Tanzania is not
known. This study is aimed at determining prevalence and factors associated with mental distress
among undergraduate students in northern Tanzania.
Objective: To determine prevalence and factors associated with mental distress among Formatted: Normal, Space Before: 0 pt, After: 0 pt
undergraduate students at KCMUCo.
Methodology: This will be an analytical cross-sectional studytostudy to be conducted at Formatted: Space After: 10 pt, Tab stops: Not at 2.13" +
3.51"
KCMUCo from April to June. Simple random sampling technique will be used to enrol a Formatted: Font: (Default) Times New Roman, 12 pt
minimum of 410students. A self-administered interview based questionnaire will be used for

data collection. Data entry, cleaning and analysis will be performedusingperformed using SPSS Formatted: Font: (Default) Times New Roman, 12 pt
Version 21.Descriptive statistics will be used to summarize data. Categorical variables will be Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri)
summarised using frequency and percentages, mean (standard deviation) or median (inter-quartile Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri)
range) will be used to summarise numerical variables. Odds ratio (OR)will be used to determine factors
associated with mental distress among undergraduate students. A p-value of<0.05 will be considered Formatted: Font: (Default) Times New Roman, 12 pt, Font
color: Auto
statistically significant. Data will be presented using tables and figures.
Intended use of the results: This study will provide evidence on the burden of mental distress Formatted: Normal, Space Before: 0 pt, After: 0 pt
among university students in Tanzania hence becoming a basis for informed interventions. It Formatted: Font: (Default) Times New Roman, 12 pt, Not
Bold
xi
may also contribute in raising awareness about the burden of this problem among students in
universities and colleges in Tanzania. This may encourage relevant interventions and informed
policy decisions towards addressing this problem. Formatted: Font: (Default) Times New Roman, 12 pt
xii
CHAPTER ONE Commented [IM2]: Your work still contains track changes
1.0 Introduction
1.1 Background information

Mental distress is an important public health problem which includes anxiety, depression and Formatted: Font: (Default) Times New Roman, 12 pt
somatic symptoms for example sleeping problems, fatigue, headache and back ache (Dachew et
al, 2015). It has been reported that mental distress is a leading cause of disability worldwide
accounting for one third of disabilities (WHO, 2008). Undergraduate students have significantly
higher level of mental distress than their community counterparts (Helen, 2010).
The estimated prevalence of mental distress among undergraduate students is 30% in UK Formatted: Normal, Space Before: 0 pt, After: 0 pt
(Sender et al, 2004) and 19.2% in Australia (Farrer et al, 2016). In USA and Canada, prevalence
was 53% and 30% respectively (Thomas et al, 1994; Edward et al, 2010). The burden of mental
distress is observed to be higher among medical students in Asia compared to other regions.
Prevalence is reported to range between 41.9% in Malaysia (Sherina et al, 2004) and 71.9% in
Saud Arabia (Sani et al, 2012). The lowest prevalence of mental distress among university
students in African countries was 19.8% in Somalia (Hersi et al, 2017) with the highest being
49.1% in Ethiopia (Tesfaye 2009). The estimated prevalence ranged between 21.6% and 49.1%
in Ethiopia (Yadeta et al, 2013; Tesfaye, 2009).
Factors that have been associated with mental distress among university students include sex (i.e.
female students are reported to have significantly high levels of mental distress as compared to
male peers(Bayati et al, 2009), financial problems, family history of mental illness and lack of
break or vocation (Dachew et al, 2015; Sani et al 2012). Other factors includes; high parental
expectations (Sreeramareddy et al. 2007), exam criteria dissatisfaction, overburden of test
schedule (Alvi et al, 2010) as well as year of study (Hamza, 2008). It is important to understand
factors associated with mental distress among university students for targeted interventions.
Mental distress may lead to further development of severe psychiatric illness episodes and
sometimes can influence decision making (Bayati et al, 2009). Undergraduate students with
mental distress have significant impaired cognitive functioning, learning ability and academic
performance (Khan et al,2006). Also, they have higher anxiety and lower self-efficacy, have
hightendency of drug abuse which is associated with unsafe sexual activities (Tran et al, 2017)
1
among other risk behaviours. Furthermore, students with poor mental health negatively influence
many other people on campuses, including roommates, classmates, faculty members and stuffs to
engage in risk behaviours such as drug abuse and unsafe sexual practices (Hersi et al, 2017).
WHO recommended establishment of national policies, programs and legislation among other
strategies to promote mental health (Kaaya, 2014).Tanzania has a policy on mental health which
is aimed at providing equitable, affordable and acceptable mental health services with
community participation in planning and implementation (Kaaya, 2014). However, mental health
is not a priority for health interventions in the country evidenced by less than 2.4% of the
National budget allocated to mental health services (WHO, 2011).This has impacted research in
this field and specifically on mental distress among different population subgroups.
The burden of mental distress among undergraduate students in Tanzania is not known.
University students have been reported to experience episodes of suicide attempts, poor
academic performance, postponement of studies, drop out or discontinuation from studies which
is a loss not only to the individual student and his/her family, but also to the nation at large
(Onditi et al, 2014; Ndosi and Waziri, 1997).This study is aimed at determining prevalence and
factors associated with mental distress among undergraduate students in northern Tanzania.
2
1.2 Literature review
1.2.1 Literature search strategy

Literature search was done from electronic data base of PubMed, Google scholar and Hinari. Formatted: Font: (Default) Times New Roman, 12 pt
Key words used included; mental distress, prevalence of mental distress, factors associated with
mental distress, mental health, mental distress in Africa, and mental distress among
undergraduate students.
1.2.1 Prevalence of mental distress

somatic symptoms (Dachew et al, 2015). It is reported to be a leading cause of disability

worldwide accounting for one third of disabilities (WHO, 2008).Globally, information on mental
distress among undergraduate students are scarce. However, it has been reported that
undergraduate students have significantly higher levels of mental distress than their community
counterparts (Helen, 2010).
The estimated prevalence of mental distress among undergraduate students in UK was 30%
(Sender et al, 2004), 12.6% in France (Ferrar et al, 2013)while in North America prevalence was
53% in USA and 30% in Canada(Thomas et al, 1994; Edward et al, 2010). These findings
suggest that, prevalence of mental distress in Europe is relatively lower compared to that
reported in USA. This could be attributed to different sample sizes applied in these studies
whereby 4,184 and 7,800 university students in France and Canada were enrolled respectively
compared to 69 in USA (Tran et al, 2013; Thomas et al, 1994; Edward et al, 2010).
On the other hand, the burden of mental distress is also high among medical students in Asia
compared to other regions. Prevalence is reported to be 41.9% in Malaysia (Sherina et al, 2004)
and 71.9% in Saud Arabia (Sani et al, 2012) which translates to 4 of 10 students in Malaysia and
7 in 10 students in Saud Arabia suffering from mental distress. High prevalence reported in these
studies could be because they were conducted specifically among medical students. Formatted: Font: (Default) Times New Roman, 12 pt, Not
Bold
The estimated prevalence of mental distress among University students in Sub Sahara African Formatted: Font: (Default) Times New Roman, 12 pt
countries ranged from19.8%in Somaliato49.1%in Ethiopia (Hersi et al, 2017;

Tesfaye,2009).Prevalence of 40.9% was also reported in Northwest in Ethiopia (Dachew et al,
2015). In Nigeria the estimated prevalence of mental distress was reported to be 21.3%.
3
The burden of mental distress among undergraduate students in Tanzania is not known.
University students may be experiencing different consequences such as poor academic
performance (that may lead to discontinuation), attempted suicide, and postponement of studies
and / or drop out. For instance, higher suicide cases have been reported in the past whereby, in
two-year period, 300 suicides cases were admitted at Muhimbili National hospital in which most
of them were undergraduate students and university leavers who are unemployed(Ndosi and
Waziri, 1997).Understanding the burden of mental distress may contribute to efforts in
intervening the problem.
1.2.2 Factors associated with mental distress

The most common factors reported to be associated with higher odds of mental distress across Formatted: Font: (Default) Times New Roman, 12 pt
regions include; being a female, having financial problems, history of mental illness in the
family, lack of vacation and tight academic schedule (Dachew et al, 2015; Hersi et al, 2017; Sani
et al, 2012; Muhammad et al, 2006; Bayati at al, 2009; Tran et al, 2013).
In USA, family history of mental disorder and absence of strong social support and coping
strategies to the learning process (Wilson et al, 2014) increased the odds of having mental Formatted: Font: (Default) Times New Roman, 12 pt
distress while factors reported in Canada were year of study (high in initial and last years of
study) and being a female (Edward et al, 2010). Other factors associated with mental distress in
Europe include; study pressure, financial difficulties in terms of school fees and accommodation,
having learning disabilities such as poor long or short memory, lack of abstract reasoning, lack
of organization and time planning, and dissatisfaction with living condition both in and off
compass (Tran et al, 2013; Gorter et al, 2008).
Family history of mental illness was strongly associated with mental distress in Iran and Saud Formatted: Space Before: 0 pt
Arabia (Sani et al, 2012; Bayati et al, 2009). Year of study was also associated with mental
distress in Pakistan whereby first year medical students were more likely to be stressful compare
to other years (Khan et al, 2006),maybe be due to high academic pressure. These findings are
contrary to those from Saudi Arabia whereby the level of mental distress increased with
increased year of study (Sani et al, 2012).Female university students were less likely to have
mental distress in Pakistan(Khan et al,2006) probably because they utilized more effective
coping mechanisms to deal with mental stress by sharing their problems easily to their friends
compare to men (Khan et al, 2006). The likelihood of having mental distress increased with lack
4
of entertainment in the campus, individual history of psychiatric disorder, lack of satisfaction
with university facilities, substance abuse, high parental expectation and poor home environment
(Hamza et al, 2008; Sani et al, 2012; Bayati et al, 2009; Tesfaye, 2009).
In Sub Saharan African countries various factors have been associated with mental distress. Like
in other studies female gender, lack of interest in the field of study, lack of vacation break, lack
of social support, the use of khat and conflict with friends were associated with mental distress in
Ethiopia and Somalia (Dachew et al, 2015; Hersi et al,2017). Also, there was a significant
association between mental distress and poor funding for school fees and accommodation, male
gender, parental influence on choice of faculty, student’s low level of adherence to their faith and
alcohol abuse among University students in Nigeria (Robchaud et al, 2017).
University students in Tanzania may not be immune to mental distress. However, factors
associated with mental distress in Tanzania are not documented. This study is aimed at
determining the burden of this problem and the associated factors. This may also contribute to
designing of relevant interventions to prevent and/ or address related consequences hence
improve school performance among university students. Formatted: Font: (Default) Times New Roman, 12 pt, Not
Bold
1.3 Problem statement

somatic symptoms for example sleeping problems, fatigue, headache and back ache (Dachew et
al 2015). It has been reported that mental distress is a leading cause of disability worldwide
accounting for one third of disabilities (WHO, 2008). Undergraduate students have significantly
higher level of mental distress than their community counterparts (Helen, 2010).
Undergraduate students with mental distress have a significantly impaired cognitive functioning,
learning ability and academic performance (Hersi et al, 2009). Mental distress among university
students has been associated with sex, financial problems, family history of mental illness, lack
of break or vocation, high parental expectation, overburden of test schedule, exam criteria
dissatisfaction and year of study (Bayati et al, 2009; Dachew et al, 2015; Sani et al, 2012;
Sreeramareddy et al 2017; Tabassum et al, 2009; Hamza, 2008).
The burden of mental distress among undergraduate students in Tanzania is not known. Formatted: Normal, Space Before: 0 pt, After: 0 pt
University students have been reported to experience episodes of suicide attempts, poor
5
academic performance, postponement of studies, drop out or discontinuation from studies which
is a loss not only to the individual student and his/her family, but also to the nation at large
(Onditi et al, 2014; Ndosi and Waziri, 1997).This means that, university students could be
suffering from different mental health problems including mental distress. This study is aimed at
determining prevalence and factors associated with mental distress among undergraduate
students in order to provide baseline data for further research and for informed interventions.
1.4 Justification
This study will provide evidence on the burden of mental distress among university students in Formatted: Font: (Default) Times New Roman, 12 pt
Tanzania hence becoming a basis for informed interventions. It may also contribute in raising
awareness about the burden of this problem among students in universities and colleges in
Tanzania. This may encourage relevant interventions and informed policy decisions towards
addressing this problem. Furthermore, findings from this study may also contribute to improved
case management especially among university students reporting various signs of mental health
issues. Findings from this study may also provide baseline information for further studies.
1.5 Study questions

What is the prevalence and factors associated with mental distress among undergraduate students Formatted: Font: (Default) Times New Roman, 12 pt
at KCMUCo?
6
CHAPTER TWO
2.0 Objectives
2.1 Broad objective

This study is aimed at determining prevalence and factors associated with mental distress among
undergraduate students at Kilimanjaro KCMUCo.
2.2 Specific objectives

1. To determine prevalence of mental distress among undergraduate students at
KCMUCo.
2. To determine factors associated with mental distress among undergraduate students at
KCMUCo.
7
CHAPTER THREE
3.0 Methodology
3.1 Study design

This will be an analytical cross-sectional study to be conducted at KCMUCo from April, 2018to Formatted: Font: (Default) Times New Roman, 12 pt
Formatted: Pattern: Clear (Background 1)
June,2018. This study design was selected because it is not expensive, it is fairly quick to
perform and both outcome and exposures of interest can be studied at one point in time.
3.2 Study Area

The study will be conducted at Kilimanjaro Christian Medical University Collage Formatted: Font: (Default) Times New Roman, 12 pt
(KCMUCo)which is located at Moshi Municipality, six kilometres from Moshi urban. Moshi
Municipality is one of 7 Districts of Kilimanjaro region 184,292 according to the 2012 census.
The Municipality covers about 59 square kilometres and is the smallest municipality in Tanzania
by area. There are 4 universities in Moshi municipality which are KCMUCo, Mwenge Catholic
University (MWECAU), Moshi Cooperative University (MOCU), and Stefano Moshi Memorial
University College. KCMUCo is located at the foothill of the snow-capped; Mount Kilimanjaro
in Moshi Municipality, Northern Tanzania. KCMUCo has a population of about 1100 students
from all regions of Tanzania as well as from other countries. KCMUCo is the only university in
the region offering medical education and other basic science programs, KCMUCo offers
Diploma and Bachelor in Health laboratories, Bachelor in Nursing, Diploma in Occupation
Therapy, Diploma and Bachelor in Physiotherapy, Diploma and bachelor in Prosthetics and
Orthotics , Doctor of Medicine, Bachelor in Optometry and Diploma in HIV and AIDS care,
3.3 Study population

Undergraduate students at KCMUComeeting the inclusion criteria will be involved in this study Formatted: Font: (Default) Times New Roman, 12 pt
3.4 Eligibility criteria
3.4.1 Inclusion criteria

This study will include all undergraduate students who will be available during data collection Formatted: Font: (Default) Times New Roman, 12 pt
and provide their informed consent.
8
3.4.2 Exclusion criteria
Those with serious medical conditions such as those admitted for mental illness, as well as those
students who visiting KCMUCo for different exchange programs will not be included in this
study.
3.5 Sample size and sampling technique
3.5.1 Sample size

The minimum sample size has been obtained by Kish Leslie formula:
Sample size (N) = Z1-/22 x p (1-p)

2
Where;
Z1-/2=Standard normal value corresponding to 95% confidence interval
p=Expected prevalence of internet addiction based on previous studies
ε=Acceptable tolerable error/ precision
Taking Z=1.96 standardized normal value for 95% confidence interval.
p=Prevalence of mental distress among undergraduate students of university of Gondar

University that was 40.9% (Dachew et al, 2015)
e=Maximum error allowed, 5% (0.05)
Therefore;
N=1.962(0.409) (1-0.409)
(0.05)2
N=371, adding 10% of non-response (37 participants)
Therefore, the minimum sample size in this study will be 410 participants.
Formatted: English (United Kingdom)
9
3.5.2 Sampling technique
Simple random sampling technique will be used to obtain study participants. The list of undergraduate Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri)
students will be requested at the admissions office in order to determine the number expected from Formatted: Normal
each class. The number of students in a class will be divided by total number off undergraduate students
to a KCMUCo then multiplying with sample size to know how many students will be needed from a
particular class. To sample researchers will count the number of available students in class. Then
consecutive numbers will be assigned to all students in the list from which the candidates will be Formatted: Font: (Default) Times New Roman
Formatted: Default Paragraph Font, Font: (Intl) +Body
selected. A list of random numbers will be used to select 410 students from a list of 1100 students and (Calibri)
this will be obtained using a random number table. Commented [IM3]: This is still not formatted. See that there
are some of the words which have been cut at the end of each line
of this paragraph
3.6 Variables Formatted: Default Paragraph Font, Font: (Default) Times
New Roman, 12 pt
The dependent variable will be mental distress. It will be measured by self reporting questionnaire (SRQ-
Formatted: Default Paragraph Font, Font: Not Bold, (Intl)
20) which contains 20 symptoms of mental distress; They will be asked if they had those symptoms +Body (Calibri)
within one month. In this study, student who will be found to have 8 or more symptoms of the 20 items (Calibri)
of self reporting questionnaires (SRQ-20) in the last 4 weeks will considered as having mental distress. Formatted: Normal
The cut off points will be used based on the reports from the validation study of SRQ-20 that gave Formatted: Font: (Default) Times New Roman
highest sensitivity and specificity which correspond to a cut off point of 8. (Calibri)
Commented [IM4]: As above
Independent variables will be age in years, sex (male, female), marital status (single, cohabiting, Formatted: Font: (Default) Times New Roman
married, divorced), year of study will take year one up to year five. Financial problems, family history of Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri)
mental illness, lack of break or vocation, high parental expectation, exam criteria dissatisfaction, Formatted: Default Paragraph Font, Font: (Default) Times
New Roman, 12 pt
overburden of test schedule, substance abuse, use of tobacco products, alcohol use, increased class
work load all of these will be measured as yes or no. +Body (Calibri)
(Calibri)
3.7 Data collection tools, methods and procedures Formatted: Default Paragraph Font, Font: Not Bold, (Intl)
+Body (Calibri)
3.7.1 Data collection tools

Data will be collected using a questionnaire with structured questions. The questionnaire is divided in to Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri), English (United Kingdom)
five parts, first part contains questions on socio-demographic characteristics of students, The second Formatted: Space After: 10 pt, Adjust space between Latin
and Asian text, Adjust space between Asian text and numbers
part will contain a self-reporting questionnaire (SRQ-20which is a20-item standardized tool originally
developed by World Health Organization (WHO) to assess mental distress (Dachew et al, 2015), the third
part will be substance use, fourth part is academic problems and the last part will be social support. The
questionnaire is designed in English language which is a standard language of instruction in Universities
and Colleges in Tanzania. +Body (Calibri), English (United Kingdom)
10
3.7.2 Data collection methods
Interview method using a self-administered questionnaire will be used for data collection. Interviews Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri)
will be conducted in respective classes. Formatted: Normal
3.7.3 Data collection procedures +Body (Calibri)
Researchers will visit students during their lecture hours then introduce themselves, clearly explaining Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri)
study purpose and who should take part. Before selecting participants for inclusion, researchers will Formatted: Normal
address all questions or concerns that may be raised. Once they are satisfied with the explanations, we
will select participants for inclusion and administer informed concert. All concerting participants will be
handled over questionnaire (which is in English language) and asked to respond in about 15- 25 minutes. Formatted: Font: (Default) Times New Roman
Researchers will be available to ensure that participants respond to questionnaires themselves (given (Calibri)
that they will be in the class with fellow students) and also clarifying any concern that will be raised. Formatted: Font: (Default) Times New Roman
Finally the researchers will correct all the completed questionnaires and thank respondents for their (Calibri)
time and the class for their preparation. Commented [IM5]: Words are cut at the end of the line!
Formatted: Default Paragraph Font, Font: (Default) Times
New Roman, 12 pt
3.8 Data management and analysis plan
+Body (Calibri)
3.8.1 Data management plan
For quality assurance, researchers will be reviewing all completed questionnaires immediately when Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri)
they are collected. This will allow correcting all errors while participant has not left. Every day after data Formatted: Normal
collection, researchers will be meeting again to review the data. All completed questionnaires will be
stored at Institute of Public Health at KCMUCo. Formatted: Default Paragraph Font, Font: Not Bold, (Intl)
+Body (Calibri)
3.8.2 Data analysis plan

Data will be entered, cleaned and analyze using Statistical Package for Social Science (SPSS) version 21. Formatted: Default Paragraph Font, Font: (Intl) +Body
(Calibri)
Descriptive statistics will be used to summarize data whereby categorical variables will be summarised Formatted: Space After: 10 pt, Tab stops: Not at 2.13" +
3.51"
using frequency and percentages. Mean (standard deviation) or median (inter-quartile range) will be
used to summarise numerical variables. Odds ratio (OR) and the corresponding 95% confidence interval (Calibri)
will be used to determine factors associated with mental distress among undergraduate students. A p- (Calibri)
value of<0.05 will be considered statistically significant. Data will be presented using tables and Formatted: Font: (Default) Times New Roman, 12 pt, Font
color: Auto
figures.
3.8.3 Explanation and categorization of variables
11
All variables will be measured directly. Mental distress will be measured by using twenty Formatted: Font: (Default) Times New Roman, 12 pt
symptoms in which each of the symptom will be categorised as 0= no and 1= yes , participants
who will score eight or more symptoms will be categorized as having mental distress. Age will
be divided into three categories from <18, 18-25. >25. Sex will be categorized into 1=male and
2=female. Faculty choice, 1=preferred and 2=not preferred. Year of study will be categorised as
1=first year, 2=second yeah, 3=third year, 4= forth year and 5=fifth year. Sexual relationship, Commented [IM6]: What did I say about sexual relationship
before?
1=having a boyfriend or girlfriend, 2= no. Conflicts with your friends in the hostels or classroom Formatted: Font: (Default) Times New Roman, 12 pt
1=always, 2= often, 3=sometimes, 4=never. Having a pocket money 1=yes or 2=no, if yes, Formatted: Default Paragraph Font, Font: (Default) Times
New Roman, 12 pt
monthly amount of pocket money in Tanzanian shillings. Family history of mental illness, 1=yes Formatted: Font: (Default) Times New Roman, 12 pt
or 2=no. Substance abuse 1=yes or 2=no, if yes for how long. Commented [IM7]: This has not addressed my previous
comments
3.9 Ethical consideration New Roman, 12 pt
The ethical approval will be obtained from Kilimanjaro Christian Medical College Research Ethics and Formatted: Font: (Default) Times New Roman, 12 pt
Review Committee (CRERC) prior to commencement of the study. Informed consent will be sought from (Calibri)
study participants. For confidentiality of participant information, unique identification numbers will be Formatted: Normal
Formatted: Font: (Default) Times New Roman
used.
(Calibri)
3.10 Plan for dissemination Formatted: Font: (Default) Times New Roman
Results obtained from this study will be shared to the Institute of Public Health of KCMUCo, the (Calibri)
KCMUCo online repository and KCMC physical library as well as publication in a peer reviewed journal. Formatted: Default Paragraph Font, Font: Not Bold, (Intl)
+Body (Calibri)
3.11 Study limitation (Calibri)
Formatted: Normal
Some participants may under report or over-report information relating to their risk behaviors
such as smoking, substance abuse and sexual experiences. Also some participants may suppress +Body (Calibri)
information on their past psychiatric history. To avoid this bias, participants will beassured of
Formatted: Normal
anonymity and confidentiality of their information and by emphasizing that self-identifying
information will not be used. Commented [IM8]: Text is cut at the end of the line
New Roman, 12 pt
3.12 Project management
All stages of proposal development are expected to take 5 months. Data collection for this study Formatted: Font: (Default) Times New Roman, 12 pt
Formatted: Normal
is expected to take 3 months. A team of 3 researchers will be responsible for data collection.
Details timeline for these activities are shown in section 4.1 while the budget for this activity is
shown in section 4.2 below. Formatted: Font: 12 pt
12
13
WORK PLAN Commented [IM9]: Is this how it should be arranged? What
does the guidelines say?
Nov Dec Jan Feb March Apr May June July
2017 2017 2018 2018 2018 2018 2018 2018 2018
Submission of Formatted: Left
research topic

title and
supervisor to
the
department
research
objective
submission of Formatted: Left
concept notes
Proposal Formatted: Left

development
Proposal Formatted: Left
submission
Data Formatted: Left
collection
Data entry Formatted: Left
Data analysis Formatted: Left
Complete Formatted: Left

result section
Report writing Formatted: Left

report
Formatted: Normal
Formatted: Font: (Default) +Body (Calibri), 11 pt, Not Bold
14
Formatted: Font:
Commented [IM10]: You have re-arranged this table while I

formatted it for you!
Formatted: Default Paragraph Font
Formatted: Heading 1, Left, Line spacing: single
Field Code Changed
Formatted: Font: Not Bold
Formatted: Font: Not Bold, English (United Kingdom)
Formatted: Heading 1
15
BUDGET
Formatted: Normal
This project will require a total of 128,300/=Tshs. The main source of these funds will be Formatted: Font: (Default) Times New Roman, 12 pt
research funding from Higher Education Students’ Loan Board (HESLB).
Unit
S/No. Item Total cost (Tshs) Formatted: Right
cost(Tshs) Formatted Table
-Rim
paper 12,000
1 Rim paper, pens, correction fluid. -Pen 1,000 15,000/= Formatted: Right
-Correction
fluid 2,000
-Printing
7000/=
2 Printing and binding 12,000/= Formatted: Right
-Binding
5000/=
3 Photocopying of data questionnaires 50,000/= 50,000/= Formatted: Right
GRAND TOTAL 77,000/= Formatted: Right
Formatted: English (United States)
Formatted: Font:
16
REFERENCE
Alvi T, Assad F, Ramzan M, Khan F (2010). Depression , Anxiety and Their Associated Factors
Among Medical Students. Journal of College of Physicians and Surgeons
Pakistan, 20(2)122–126.
Bayati A, Muhammad BA, Muhammad SN (2009). Depression Prevalence and Related factors in
Iranian Students.Pakistan Journal of Biological Sciences, 12(20) 1
Dachew BA, BisetegnTA,Gebremariam RB(2015). Prevalence of Mental Distress and

Associated Factors among Undergraduate Students of University of Gondar ,
Northwest Ethiopia : A Cross-Sectional Institutional Based Study. PLOS one,
10(3)1–10.
Farrer LM, Gulliver A, Bennett K, Fassnacht DB, Griffiths M (2016). Demographic and
psychosocial predictors of major depression and generalised anxiety disorder in
Australian university students. BMC Psychiatry, 16(241)1–9. Available at:
http://dx.doi.org/10.1186/s12888-016-0961-z.
Gorter R, Freeman R, Hammen S, Murtomaa H, Blink horn A,Humphris G (2008).

Psychological stress and health in undergraduate dental students: fifth year
outcomes compared with first year baseline results from five European dental
schools. European journal of dental education, 12(2)1-7
Hersi L, Tesfay K, Gesesew H, Krahl W, Ereg D, Tesfaye M (2017). Mental distress and
associated factors among undergraduate students at the University of Hargeisa ,
Somaliland : a cross ‑ sectional study. International Journal of Mental Health
Systems, 11(39) 1–8.
James BO, Thomas IF, Omoaregba JO, Okogenin EO, Okonoda KM, Ibrahim AW, Salihu AS,
Oshodi YO, OrovwighoAO,Odinka PC, Eze GO, Onyebueke GC, Aweh BE
17
(2017). Psychosocial correlates of perceived stress among undergraduate medical
students in Nigeria. International journal of Medical Education 7(26)382–388.
Kaaya S (2014). Mental health service systems in Tanzania.http://www.ntnu.no/documen Formatted: Font: (Default) Times New Roman, 12 pt
t/1323615/1221071181/KAAYA. Web accessed 08.04.2018
Khan MS, Mahmood S, Badshah A, Ali SU, Jamal Y (2006).Original Article Prevalence of
Depression , Anxiety and their associated factors among medical students in
Karachi , Pakistan. Jinnah Postgraduate Medical Centre , 56(12) 583–586.
Mosley TH, Perrin SG, Neral SN, Dubbert PM, Grothues CA, Pinto BM (1994). Stress, coping
and wellbeing among third year medical students.,69(9)765-767
Ndosi NK, Waziri MC(1997). The nature of Para suicidein Dar esSalaam, Tanzania. Social
science med, 44(1)55-61
Onditi HZ, Moses I, Masath FB (2014). Psychological Stressors and Help Seeking Behaviour
among Undergraduate Students Teachers in Tanzania. International Journal of
Leaning and Development, 4(1) 1-17
Onditi HZ, Moses I, Masath FB (2014). sychological Stressors and Help Seeking Behaviour
Sani M, Mahfouz MS, Bani I, Alsomily AH, Alagi D, Alsomily NY, Madkhaly FM, Mad,
Mashiakhali R, Hakami AAM, Hakami A, Shaqraa S, Al Ebrahim, Ageel B, Asiri
S (2012).Prevalence of stress among medical students in Jizan University. Gulf
Medical Journal, 1(1) 19–25.
Sherina MS, Rampal L, Kaneson N (2004). Psychological Stress Among Undergraduate Medical
Students. Med J Malaysia, 59(2)207–211.
Sreeramareddy CT, Shankar PR, Binu VS, Mukhopadhyay C, Ray B, Menezes

RG(2007).Psychological morbidity, sources of stress and coping strategies among
undergraduate medical students of Nepal. BMC Medical Education, 8(7)1–8.
18
Tesfaye A(2009). Prevalence and correlates of mental distress among regular undergraduate
students of Hawassa university : a cross sectional survey. East Africa J public
health , 6(1) 85-94
Tran A, Tran L, Geghre N, Darmon D, Rampal M, Brandone D, Gozzo J, Haas H, Rebouillat K,

Caci H, Avillach P (2017). Health assessment of French university students and
risk factors associated with mental health disorders. PLOS one, 12(11)1–18.

WHO (2014). Mental health: a state of wellbeing. http://www.int/features/factfiles/mental_healt Field Code Changed
h/en/&rct=j&sa=U&ved=0ahUKEwjx8. Wed accessed 08.04.2018
Wilson KT, Bohnert AE, Ambrose A, Davis DY, Jones DM, Magee MJ (2014). Social,
behavioral , and sleep characteristics associated with depression symptoms among
undergraduate students at a women ’ s college : a cross-sectional depression
survey. BMC Women`s Health, 14(8)1-9
Alvi T, Assad F, Ramzan M, Khan F (2010). Depression , Anxiety and Their Associated Factors
Among Medical Students. Journal of College of Physicians and Surgeons
Pakistan, 20(2)122–126.
Dachew BA, BisetegnTA,Gebremariam RB(2015). Prevalence of Mental Distress and

Associated Factors among Undergraduate Students of University of Gondar ,
Northwest Ethiopia : A Cross-Sectional Institutional Based Study. PLOS one,
10(3)1–10.
19
Farrer LM, Gulliver A, Bennett K, Fassnacht DB, Griffiths M (2016). Demographic and
psychosocial predictors of major depression and generalised anxiety disorder in
Australian university students. BMC Psychiatry, 16(241)1–9. Available at:
http://dx.doi.org/10.1186/s12888-016-0961-z.
Gorter R, Freeman R, Hammen S, Murtomaa H, Blink horn A,Humphris G (2008).

Psychological stress and health in undergraduate dental students: fifth year
outcomes compared with first year baseline results from five European dental
schools. European journal of dental education, 12(2)1-7
Hersi L, Tesfay K, Gesesew H, Krahl W, Ereg D, Tesfaye M (2017). Mental distress and
associated factors among undergraduate students at the University of Hargeisa ,
Somaliland : a cross ‑ sectional study. International Journal of Mental Health
Systems, 11(39) 1–8.
James BO, Thomas IF, Omoaregba JO, Okogenin EO, Okonoda KM, Ibrahim AW, Salihu AS,
Oshodi YO, OrovwighoAO,Odinka PC, Eze GO, Onyebueke GC, Aweh BE
(2017). Psychosocial correlates of perceived stress among undergraduate medical
students in Nigeria. International journal of Medical Education 7(26)382–388.
Kaaya S (2014). Mental health service systems in Tanzania.http://www.ntnu.no/documen Formatted: Font: (Default) Times New Roman, 12 pt
t/1323615/1221071181/KAAYA. Web accessed 08.04.2018
Khan MS, Mahmood S, Badshah A, Ali SU, Jamal Y (2006).Original Article Prevalence of
Depression , Anxiety and their associated factors among medical students in
Karachi , Pakistan. Jinnah Postgraduate Medical Centre , 56(12) 583–586.
Mosley TH, Perrin SG, Neral SN, Dubbert PM, Grothues CA, Pinto BM (1994). Stress, coping
and wellbeing among third year medical students.,69(9)765-767
Ndosi NK, Waziri MC(1997). The nature of Para suicidein Dar esSalaam, Tanzania. Social
science med, 44(1)55-61
20
Onditi HZ, Moses I, Masath FB (2014). Psychological Stressors and Help Seeking Behaviour
Onditi HZ, Moses I, Masath FB (2014). sychological Stressors and Help Seeking Behaviour
Sani M, Mahfouz MS, Bani I, Alsomily AH, Alagi D, Alsomily NY, Madkhaly FM, Mad,
Mashiakhali R, Hakami AAM, Hakami A, Shaqraa S, Al Ebrahim, Ageel B, Asiri
S (2012).Prevalence of stress among medical students in Jizan University. Gulf
Medical Journal, 1(1) 19–25.
Sherina MS, Rampal L, Kaneson N (2004). Psychological Stress Among Undergraduate Medical
Students. Med J Malaysia, 59(2)207–211.
Sreeramareddy CT, Shankar PR, Binu VS, Mukhopadhyay C, Ray B, Menezes

RG(2007).Psychological morbidity, sources of stress and coping strategies among
undergraduate medical students of Nepal. BMC Medical Education, 8(7)1–8.
Tesfaye A(2009). Prevalence and correlates of mental distress among regular undergraduate
students of Hawassa university : a cross sectional survey. East Africa J public
health , 6(1) 85-94


WHO (2014). Mental health: a state of wellbeing.

http://www.int/features/factfiles/mental_health/en/&rct=j&sa=U&ved=0ahUKEw Formatted: Font: (Default) Times New Roman, 12 pt
jx8. Wed accessed 08.04.2018
21
Wilson KT, Bohnert AE, Ambrose A, Davis DY, Jones DM, Magee MJ (2014). Social,
behavioral , and sleep characteristics associated with depression symptoms among
undergraduate students at a women ’ s college : a cross-sectional depression
survey. BMC Women`s Health, 14(8)1-9
Formatted: English (United States)
Formatted: Font:
22
DUMMY TABLES
Table : socio-demographic characteristics and other factors associated with mental distress Field Code Changed
Variable Frequency Percent Formatted: Font: (Default) Times New Roman, 11 pt

Age(years) Formatted: Space After: 0 pt, Line spacing: single
<18 Formatted: Font: (Default) Times New Roman, 11 pt
18-25
>25
Sex Formatted: Font: 11 pt, Font color: Text 1
Male Formatted: Font: 11 pt

Female Formatted: Font: 11 pt, Font color: Text 1
Marital status Formatted: Font: 11 pt
Married
Formatted: Space After: 0 pt, Line spacing: single
Cohabiting
Separated
Divorced Formatted: Font: (Default) Times New Roman, 11 pt
Widow Formatted: Font: (Default) Times New Roman, 11 pt
Single Formatted: Font: (Default) Times New Roman, 11 pt
Occupation(participants)
In service
Fresh from school
Religion Formatted: Font: (Default) Times New Roman, 11 pt
Christian Formatted: Font: (Default) Times New Roman, 11 pt
Muslim Formatted: Font: (Default) Times New Roman, 11 pt
Others Formatted: Font: (Default) Times New Roman, 11 pt
Faculty of
choice
Preferred Formatted: Font: (Default) Times New Roman, 11 pt
Not Formatted: Space After: 0 pt, Line spacing: single
preferred Formatted: Font: (Default) Times New Roman, 11 pt
Year of Formatted: Font: (Default) Times New Roman, 11 pt
enrolment Formatted: Font: (Default) Times New Roman, 11 pt
First year
Second
year Formatted: Font: 11 pt
Third year Formatted: Font: 11 pt
Fourth
year
Conflict with Formatted: Font: 11 pt
your friends
Always
Often
Sometimes
Never
Pocket money Formatted: Font: 11 pt
Yes
No
Substance Formatted: Font: 11 pt
abuse
23
Yes
No
Substance Formatted: Font: 11 pt
type
Tobacco
product
Marijuana
Others
Alcohol use Formatted: Font: 11 pt
Always
Often
Sometimes
Never
History of Formatted: Font: 11 pt
mental illness
in the family
Yes Formatted: Font: 11 pt
No Formatted: Font: 11 pt
24
25
Table 2: Symptoms of mental distress, SRQ- 20 for the past 30 days Formatted: Font: Not Bold
Formatted: Caption, Left, Line spacing: single
Variable Frequency percent
Often have headache
No
Yes Formatted: Space After: 0 pt, Line spacing: single
Poor appetite Formatted Table

No Formatted: Font: Not Bold
Yes Formatted: Space After: 0 pt, Line spacing: single
Lack of sleep Formatted: Font: Not Bold
No Formatted: Space After: 0 pt, Line spacing: single
Yes Formatted: Font: Not Bold
Formatted: Left, Space After: 0 pt, Line spacing: single
Easily frightened
No
Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Uncontrollable hand shaking
No Formatted: Left, Space After: 0 pt, Line spacing: single
Yes Formatted: Font: Not Bold

Feeling nervous Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Poor digestion Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Trouble on thinking Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Feeling unhappy Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Crying more than usual Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Difficult to enjoy daily Formatted: Left, Space After: 0 pt, Line spacing: single
activities Formatted: Font: Not Bold
No
Yes
Daily work suffering Formatted: Left, Space After: 0 pt, Line spacing: single
Unable
No to play a useful part Formatted: Font: Not Bold
in
Yeslife Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
26
Lost of interest in things Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Feeling of worthlessness Formatted: Font: Not Bold
Yes
Thought of ending life Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Feeling tired all the time Formatted: Font: Not Bold
Yes
Uncomfortable feeling in the Formatted: Left, Space After: 0 pt, Line spacing: single
stomach Formatted: Font: Not Bold
No
Yes
Difficult to make decisions Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Easily tired Formatted: Left, Space After: 0 pt, Line spacing: single
Yes
Formatted: Caption
27
TABLE 3: Substance use
Variables Frequency Percent Formatted Table
Ever use marijuana
Formatted: Indent: Left: 0"
Marijuana use in the last one
month
Alcohol drinking in your life time
Alcohol use in the past last one
month
Ever use tobacco products such
cigarette, shisha or others
Tobacco products use in the last
one month
Ever use other substances such as
khat, heroine, cocaine or others.
khat, heroine, cocaine or others in
the last one month
28
Table : Social support Field Code Changed
Variables Frequency Percent Formatted Table

Having a special person who is
around when in need
Formatted: Font: Bold, Font color: Text 1
Having a special person with whom Formatted: Indent: Left: 0"
you can share you joys and sorrows
Formatted: Font: (Default) +Body (Calibri), 11 pt, Bold,
Your family really try to help you Font color: Text 1
Emotional help and support from Formatted: Font: Bold, Font color: Text 1
your family
Having a special person who is the Formatted: Font: Bold, Font color: Text 1
real source of comfort Formatted: Indent: Left: 0"
Your friends really try to help you
Counts on your friends when things
go wrong Formatted: Indent: Left: 0"
Can talk about your problems with Formatted: Indent: Left: 0"
your family
Having friends with whom you can Formatted: Font: (Default) Times New Roman, 10 pt
share your joys and sorrows Formatted: Normal, Indent: Left: 0"
Having a special person in your life
who cares about your feelings
You family is willing to help you in Formatted: Indent: Left: 0"
making decision Formatted: Font: (Default) Times New Roman, 10 pt
Formatted: Normal, Indent: Left: 0"
Can talk about your problems with
your friends
Formatted: Caption
29
TABLE 5:Academic problems
Variable Frequency Percent
Increased class work load
Decreased grade than anticipated Formatted Table
Missed too many classes
Serious arguments with
instructors
Lack of vacation or break
APPENDICES
Appendix 1: Participant information sheet Formatted: Heading 2, Line spacing: single
Title of the study: Prevalence and factors associated with mental distress among undergraduate
students at KCMUCo.
Objective of the study: to assess prevalence and factors associated with mental distress among
undergraduate students at KCMUCo.
Research team:
Eneck Samwel Kibopile, Esther Andrew and Furaha Enos Kasyupa: MD4 students at KCMUCo.
Introduction
Dear participants my name is __________ ,I am working as a researcher in this study together
with___________and ___________. The study is proposed to assess the prevalence and factors
associated with mental distress among undergraduate students at KCMUCo. The results of this
study may help to understand the burden of mental health problems in students and to guide
interventions that decrease risk as well as improve student’s psychological wellbeing.
Information about the study
Your part in the study
Your role in this study is as a study participant. The choice is made randomly by computer
generated random number. It is entirely your choice whether to participate in this study or not.
Therefore, you can decide freely based on the information that we gave you. Moreover, we
would like to inform you that involved and uninvolved student will be treated equally. When you
agree to participate in this study, you will be asked on some socio-demographic related
questions, mental distress related, behavioral factors, social support and academic related
questions. It will take about 30 minutes to answer the questions.
30
Possible risks and benefits
There is no direct benefit that you will get from this study right now. Similarly, there is no
incentive for those who participated in the study. However, the results of this study will benefit
you and other students in the future by identifying factors associated with mental distress in
students. Moreover, policy makers and other concerned bodies will take the recommendations to
develop policy for prevention, early diagnosis and treatment of common mental illness in
students. With regard to risks, there is no risk which is attached to this study and only grouped
data will be reported.
Confidentiality
We strongly assure that your confidentiality will be protected. Therefore, there is no need of
writing your name or ID number on the format. Moreover, we will never tell anyone else any
piece of information about your response. Although members of the research team may look at
the filled questionnaire, you will be identified only by code number. All study documents will be
kept in a locked cabinet by members of the research team until the study is being completed and
will be completely destroyed at the end of the study.
Voluntariness of the study
The study is in voluntarily basis as described above. As a result, there is no penalty for someone
who decided not to be included in the study. Furthermore, it is your right to withdraw from study
participation at any time, for any reason.
Right as a participant
It is your full right to ask any member of the research team or any relevant body for questions or
clarification about the study at any time. Therefore, you will be provided with the contact
information of members of the research team and relevant others on a separate sheet of paper. Your
honest participation will have significant contribution to generate valid information that can be used
for intervention designs. If there is anything that require clarification please don’t hesitate to ask
members of the research team for clarification.
Thank you!
31
Appendix 2: Consent form Formatted: Heading 2, Line spacing: single
Hello! We are Eneck Samwel Kibopile, Esther Andrew and Furaha Enos Kasyupa, MD 4
students.
We are conducting a research for the partial fulfilment of first degree on “Prevalence and factors
associated with mental distress among undergraduate students at KCMUCo”. We have received
permission from Institute of Public health at KCMUCo to conduct this study.
The objective of this study is to assess prevalence and factors associated with mental distress
among undergraduate students at KCMUCo. You are selected to participate in the study. The
choice is made randomly by computer generated random number. The information you give us is
confidential and will be used only for study purpose .A code number will identify every
participant and no names will be used. If a report of the result is published, only summarized
information of the total group will appear. Participation in the study is voluntary; you have the
right to participate, or not to participate or refuse at any time. Similarly, there is no incentive for
those who participated in the study. However, the results of this study will benefit you and other
students in the future by identifying factors associated with mental distress in students. If there
are things that require clarification please don’t hesitate to ask the facilitators for clarification.
Do you wish to participate in the study?
1) Yes, I want to participate
2) No, I don’t want to participate
Having been well explained and informed of the intentions and benefits of the study, I
voluntarily consent to participate in the study,
___________________ ________________
32
Sign Date
33
Appendix 3: Questionnaire Formatted: Heading 2, Line spacing: single
Part I. Socio-economic and demographic characteristics of the respondents

This part of the questionnaire assess about your socio economic and demographic information’s,
after reading the following the questions please give appropriate answer concerning your socio-
economic and demographic information.
No Questions Response/Options Remark

1. Age in years _____________
2. Sex 1. Male
2. Female
3. Residence 1. Urban
2. Rural
4. Faculty choice 1. Preferred
2. Not preferred
5. Year of study 1. 1st year
2. 2nd year
3. 3rd year
4. 4th year
5. 5th year
6. Females: Do you have boyfriend 1. Yes
2. No
7. Males: Do you have girlfriend 1. Yes
2. No
8. Marital Status 1. Not married
2. Married
3. Cohabiting
4. Divorced
9. How often do you take part in 1. Always
religious practices 2. Often
3. Some times
4. Never
10. How often do you face conflict with 1. Always
your friends in the dormitories/class 2. Often
rooms 3. Some times
4. Never
11. Do you have pocket money? 1. Yes If No, go
2. No to Q13
12. If yes for question no 11, what is your
monthly amount of pocket money in __________
Tanzanian shillings?
13. In your family, is there a history of 1. Yes
mental illness? 2. No
34
Part II. Mental distress Self-Reporting Questionnaire
The following questions are related to certain pains and problems that may have bothered you in
the last 30 days. Please tick the ‘Yes’ box if you have had this symptom in the last 30 days. On
the other hand, if you have not experienced this symptom in the last 30 days please tick the ‘No’
box. 0= No, 1= Yes.
Please tick the ‘yes box if you have had experienced these symptom in the last 30 days
and tick the ‘no box if you had not.
1. Do you often have headaches? No Yes
2. Is your appetite poor? No Yes
3. Do you sleep badly? No Yes
4. Are you easily frightened? No Yes
5. Do your hands shake? No Yes
6. Do you feel nervous? No Yes
7. Is your digestion poor? No Yes
8. Do you have trouble thinking clearly? No Yes
9. Do you feel unhappy? No Yes
10. Do you cry more than usual? No Yes
11. Do you find it difficult to enjoy your daily activities? No Yes
12. Do you find it difficult to make decisions? No Yes
13. Is your daily work suffering? No Yes
14. Are you unable to play a useful part in life? No Yes
15. Have you lost interest in things? No Yes
16. Do you feel that you are a worthless person? No Yes
17. Has the thought of ending your life been on your mind? No Yes
18. Do you feel tired all the time? No Yes
19. Do you have uncomfortable feelings in the stomach? No Yes
20. Are you easily tired? No Yes
35
PART III. Substance use
The following questions focuses on Khat chewing practices, Alcohol drinking, Cigarette
smoking other substances like Heroin use and sedatives use. So you are kindly requested to give
a genuine answer about your personal behavior on the use of these substances.
Please tick the ‘yes box if you have had use and ‘no box if you don’t use the mentioned substance
in your life time or in the last 1 month as directed. 0= No, 1= Yes
1. Have you ever used khat in your life? No Yes
2. Have you used Khat in the last 1 month? No Yes
3. Have you ever used alcohol drinks (like beer or any other No Yes
alcohol drinks) in your life time
4. Have you used any kind of alcohol drinks in the last one No Yes
month?
5. Have you ever used Tobacco products such as cigarette No Yes
smoking, shisha any other tobacco products in your life time?
6. Have you used any kind of tobacco product in the last one No Yes
month?
7. Have you ever used other substances such as khat, marijuana, No Yes
heroin, cocaine, cannabis or others?
8. Have you used any other substances such as khat, marijuana, No Yes
heroin, cocaine, cannabis or others in the last one month?
9. Have you ever injected drugs? No Yes

10. If Yes in Q9 above, In the past one month, have you injected No Yes
drugs
36
Part IV. Academic problems
This part assess academic problems that students face/experience in the course of their studies.
The answer is provided by “Yes” or “No”.
Please tick the ‘lease box if you have experienced and ‘ox inbox if you don’t in the last
academic year.
1. Increase class work load No Yes
2. Decrease grade than anticipated No Yes
3. Missed too many class No Yes
4. Serious arguments with instructors No Yes
5. Lack of vacations /break No Yes
37
Part V: Social Support
This part assess about social support that you have got from your family, friends and significant
others. Each item is scored 1= strongly agree, 2= Agree, 3=Neutral, 4= Disagree, 5= Strongly
disagree. Circle the appropriate response.
Strongly agree neutral disagree Strongly
agree disagree
1. There is a special person who is around 1 2 3 4 5
when I am in need
2. There is a special person with whom I can 1 2 3 4 5
share my joys and sorrows
3. My family really tries to help me 1 2 3 4 5
4. I get emotional help and support I need 1 2 3 4 5
from my family
5. I have a special person who is a real source 1 2 3 4 5
of comfort to me
6. My friends really try to help me 1 2 3 4 5
7. I can count on my friends when things go 1 2 3 4 5
wrong
8. I can talk about my problems with my family 1 2 3 4 5
9. I have friends with whom I can share my 1 2 3 4 5
joys and sorrows
10. There is a special person in my life who 1 2 3 4 5
cares about my feelings
11. My family is willing to help me make 1 2 3 4 5
decisions
12. I can talk about my problems with my 1 2 3 4 5
friends
Thank you very much for your participation!
38
DUMMY TABLES
Table 1 : socio-demographic characteristics and other factors associated with mental distress Field Code Changed
Variable Frequency Percent Formatted: Font: (Default) Times New Roman, 11 pt

Age(years) Formatted: Space After: 0 pt, Line spacing: single
<18 Formatted: Font: (Default) Times New Roman, 11 pt
18-25
>25
Sex Formatted: Font: 11 pt, Font color: Text 1
Male Formatted: Font: 11 pt

Female Formatted: Font: 11 pt, Font color: Text 1
Marital status Formatted: Font: 11 pt
Married
Cohabiting
Separated
Divorced Formatted: Font: (Default) Times New Roman, 11 pt
Widow Formatted: Font: (Default) Times New Roman, 11 pt
Single Formatted: Font: (Default) Times New Roman, 11 pt
In service
Fresh from school
Religion Formatted: Font: (Default) Times New Roman, 11 pt
Christian Formatted: Font: (Default) Times New Roman, 11 pt
Muslim Formatted: Font: (Default) Times New Roman, 11 pt
Others Formatted: Font: (Default) Times New Roman, 11 pt
Faculty of choice
Preferred
Not preferred Formatted: Font: (Default) Times New Roman, 11 pt
Year of enrolment Formatted: Space After: 0 pt, Line spacing: single
First year Formatted: Font: (Default) Times New Roman, 11 pt
Second year Formatted: Font: (Default) Times New Roman, 11 pt
Third year
Fourth year
Conflict with your friends Formatted: Font: (Default) Times New Roman, 11 pt
Always Formatted: Font: 11 pt
Often Formatted: Font: 11 pt
Sometimes Formatted: Font: 11 pt
Never
Pocket money Formatted: Font: 11 pt
Yes
No
Substance abuse Formatted: Font: 11 pt
Yes
No
Substance type Formatted: Font: 11 pt
Tobacco product
39
Marijuana
Others
Alcohol use Formatted: Font: 11 pt
Always
Often
Sometimes
Never
History of mental illness in the Formatted: Font: 11 pt
family
Yes Formatted: Font: 11 pt
No Formatted: Font: 11 pt
40
41
Table 3 : Symptoms of mental distress, SRQ- 20 for the past 30 days Field Code Changed

Often have headache
Poor appetite
Lack of sleep
Easily frightened
Feeling
No nervous
Yes
Poor digestion
Trouble on thinking
Crying more than usual

Difficult to enjoy daily activities
Daily work suffering
Unable to play a useful part in life
Lost of interest in things

Feeling of worthlessness
Thought of ending life

Feeling tired all the time
Uncomfortable feeling in the
stomach
Difficult to make decisions
Easily tired
TABLE 4: Substance use
42
Variables Frequency Percent
Ever use marijuana

month

month
one month
the last one month
43
Table 5 : Social support
around when in need
Formatted: Font: (Default) Times New Roman, 10 pt, Bold,
Having a special person with Font color: Text 1
whom you can share you joys Formatted: Normal, Indent: Left: 0"
and sorrow
Your family really try to help you
Emotional help and support from

your family
Having a special person who is the

real source of comfort

go wrong
Can talk about your problems

with your family
Having friends with whom you can
share your joys and sorrows
Having a special person in your

life who cares about your feelings
You family is willing to help you
in making decision
your friends
44
TABLE 5:Academic problems

Decreased grade than anticipated

instructors
45
Appendix 4: Dummy Tables Formatted: Heading 2
Table 2 : Socio-demographic characteristics and other factors associated with mental Field Code Changed
distress
Age(years)
<18 Formatted: Font color: Text 1
18-25 Formatted: Font color: Text 1
>25
Sex
Male
Female
Marital status
Married
Cohabiting
Separated
Divorced
Widow
Single
In service
Fresh from school
Religion
Christian
Muslim
Others
Faculty of
choice
Preferred
Not
preferred
Year of
enrolment
First year
Second
year
Third year
Fourth
year
Conflict with
your friends
Always
Often
Sometimes
Never
Pocket money
Yes
No
46
Substance
abuse
Yes
No
Substance
type
Tobacco
product
Marijuana
Others
Alcohol use
Always
Often
Sometimes
Never
History of
mental illness
in the family
Yes
No
47
Table 3 : Symptoms of mental distress, SRQ- 20 for the past 30 days Field Code Changed

Often have headache
Poor appetite
Lack of sleep
Easily frightened
Feeling nervous
Poor digestion
Trouble on thinking
Feeling unhappy
Crying more than usual
Difficult to enjoy daily
activities
Daily work suffering
Unable to play a useful part
in life
Lost of interest in things
Feeling of worthlessness
Thought of ending life
Feeling tired all the time
Uncomfortable feeling in the
stomach
Difficult to make decisions
Easily tired
Table 4 : Substance use Field Code Changed

Ever use marijuana
month
month
one month
the last one month
48
Table 5 : Social support Field Code Changed

around when in need
Having a special person with whom
you can share you joys and sorrows
Your family really try to help you
Emotional help and support from
your family
Having a special person who is the
real source of comfort
go wrong
your family
Having friends with whom you can
share your joys and sorrows
Having a special person in your life
who cares about your feelings
You family is willing to help you in
making decision
your friends
Table 6 : Academic problems Field Code Changed

Decreased grade than anticipated
instructors
49
50
51

Prevalence and Factors Associated With Mental Distress Among Undergraduate Students at Kilimanjaro Christian Medical University College

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Prevalence and Factors Associated With Mental Distress Among Undergraduate Students at Kilimanjaro Christian Medical University College

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PREVALENCE AND FACTORS ASSOCIATED WITH MENTAL

DISTRESS AMONG UNDERGRADUATE STUDENTS AT

Eneck Samwel Kibopile TUMA/KCMUCo/2947

Furaha Enos Kasyupa TUMA/KCMUCo/ 2757

Esther Andrew TUMA/KCMUCo/2547

A research proposal submitted in partial fulfilment for the requirements for

Kilimanjaro Christian Medical University College

Tumaini University Makumira

LIST OF TABLES ..................................................................................................................................... ii

CERTIFICATION .................................................................................................................................... iii

DECLARATION AND COPYRIGHT ....................................................................................................... iv

DEFINITION OF TERM ......................................................................................................................... vii

CHAPTER ONE ....................................................................................................................................... 1

1.2.1Literature search strategy ........................................................................................................ 3

1.2.1Prevalence of mental distress ................................................................................................. 3

1.2.2Factors associated with mental distress ................................................................................. 4

1.3Problem statement ........................................................................................................................... 5

CHAPTER TWO ...................................................................................................................................... 7

3.0 Methodology .................................................................................................................................. 8

3.4.1 Inclusion criteria ..................................................................................................................... 8

3.4.2 Exclusion criteria .................................................................................................................... 9

3.5 Sample size and sampling technique ............................................................................................... 9

3.5.1 Sample size............................................................................................................................. 9

3.5.2 Sampling technique ............................................................................................................ 10

3.6 Variables ................................................................................................................................. 10

3.7 Data collection tools, methods and procedures .............................................................................. 10

3.7.1 Data collection tools ............................................................................................................ 10

3.7.2 Data collection methods ..................................................................................................... 11

3.7.3 Data collection procedures ................................................................................................. 11

3.8.1 Data management plan ....................................................................................................... 11

3.8.2 Data analysis plan ................................................................................................................ 11

3.8.3 Explanation and categorization of variables ...................................................................... 12

3.9 Ethical consideration .................................................................................................................... 12

WORK PLAN ........................................................................................................................................ 14

DUMMY TABLES .................................................................................................................................. 19

Table 5 : Academic problems ................................................................................................... 4930

Medicine of Tumaini University Makumira.

Innocent B. Mboya Date

Names Signature Date

Esther Andrew ………… …………

Eneck Samwel Kibopile …………. …………

Furaha Enos Kasyupa …………. …………

KCMUCo Kilimanjaro Christian Medical University College

USA United State of America

WHO World Health Organization

DALYs Disability Adjusted Life Year

KCMUCo Kilimanjaro Christian Medical University College

USA United State of America

WHO World Health Organization

undergraduate students at KCMUCo.

minimum of 410students. A self-administered interview based questionnaire will be used for

1.1 Background information

1.2.1 Literature search strategy

1.2.1 Prevalence of mental distress

somatic symptoms (Dachew et al, 2015). It is reported to be a leading cause of disability

countries ranged from19.8%in Somaliato49.1%in Ethiopia (Hersi et al, 2017;

1.2.2 Factors associated with mental distress

1.3 Problem statement

1.5 Study questions

2.1 Broad objective

2.2 Specific objectives

3.1 Study design

3.2 Study Area

Somaliland : a cross ‑ sectional study. International Journal of Mental Health

Somaliland : a cross ‑ sectional study. International Journal of Mental Health