INTRODUCTION……………………………………………… 1-14 1.1 Background and significant of research problem
Gaps of knowledge
Mental well-being is significantly influenced by various factors, including personal experiences, workplace environments, and social and economic conditions, collectively known as the social determinants of mental health These determinants play a crucial role in shaping individuals' lives and have a profound impact on both mental and physical health Research indicates that different communities and populations experience these social determinants in diverse ways, leading to varying mental health outcomes.
(63, 64, 66, 67, 71) Therefore, this requires researcher to expand this body of knowledge to deeply understand about the context, the special target population (medical students) and potential solutions at school setting
Preventing mental disorders is significantly easier than addressing them after they occur Evidence indicates that promoting good mental well-being can effectively prevent these disorders, with intervention activities focusing on stress management and enhancing coping skills Unfortunately, in Vietnam, there has been a lack of initiatives aimed at promoting mental well-being, particularly in schools This study will implement strategies to strengthen the coping abilities of medical students, aiming to enhance their overall mental well-being.
This exploratory study addresses the limited research on mental health among medical students in Vietnam by developing a wellness program aimed at increasing awareness of mental health issues and enhancing personal stress management skills By adopting an ecological approach, the program seeks to consider broader environmental influences on mental well-being The effectiveness and feasibility of the proposed supportive activities will be assessed by comparing the mental well-being indices of medical students in the intervention group with those not participating, before and after the intervention period.
Research questions
Research question 1: How individual, interpersonal, and institutional level characteristics potentially influence to Vietnamese medical student’s mental well- being?
Research question 2: How does mental well-being program promote better mental well-being of medical students in Vietnamese medical school context?
Research objectives
Research objective 1: To explore the context and multi-level factors that related to mental health and mental well-being of Vietnamese medical students
Research objective 2: To identify potential solutions that can be implemented in a medical school to promote student’s mental well-being
Research objective 3: To develop and evaluate the effect of the mental well-being intervention program in promoting mental well-being of medical students.
Research hypotheses
Research hypothesis 1: Students will have better mental well-being, emotional well-being, psychological well-being and social well-being after participating on the Well-being intervention program
Research hypothesis 2: Medical school environment will be improved after implementing the Well-being intervention program.
Scope of research
This research focus on promoting mental well-being of medical students at
Ho Chi Minh University of Medicine and Pharmacy is implementing multilevel interventions aimed at enhancing the mental well-being of first-year medical students This research focuses on raising awareness among university staff regarding the importance of student mental health, while also addressing intrapersonal factors affecting students Additionally, it seeks to transform the faculty environment to better support and promote the mental well-being of medical students.
Variables of the study
In this study, variables such as gender, religion, ethnicity, hometown, parental marriage status, parent’s education, parent’s job, and family economic status will be collected
The mental well-being program is a comprehensive initiative that engages medical students, university administrators, faculty, and support staff in creating and executing strategies aimed at enhancing the mental health of medical students.
This study focuses on the impact of an intervention program on students' mental well-being and school policy changes Key outcomes include stress coping skills, perceived social support, and satisfaction with the school environment.
Operational definition
1.8.1 The mental well-being intervention program
The mental well-being intervention program is a comprehensive initiative that engages medical students, university administrators, faculty, and support staff in creating and executing strategies to enhance the mental health of medical students This program encompasses activities at intrapersonal, interpersonal, and institutional levels, with a primary emphasis on intrapersonal development Spanning one academic semester (approximately five months), the program includes skill training courses, physical activities, peer group sessions, a review of school policies, and counseling services.
This research highlights the well-being of medical students, emphasizing their ability to recognize their strengths and manage the typical stresses encountered during their studies It underscores that the mental health of medical students encompasses both negative and positive aspects, reflecting the complex nature of their experiences in medical education.
(which called mental disorders or mental health problems) and positive (which called mental well-being) aspects
Mental well-being refers to a student's ability to experience positive emotions and effectively manage everyday stressors It encompasses three key domains: emotional well-being, psychological well-being, and social well-being This research will utilize the WHO-5 Well-being Scale to assess mental well-being, with higher scores indicating better mental health status.
Emotional well-being is essential for students, as it fosters a positive sense of self that propels their lives forward This research will assess emotional well-being using the Mental Health Continuum-Short Form (MHC-SF).
Psychological well-being refers to how optimistic student evaluates and perceives their live In this research psychological well-being will be measured by MHC-SF
Social well-being refers to student’s sense of involvement with other people and with their community In this research it will be measured by MHC-SF
1.8.4 Awareness about mental well-being
Awareness of mental well-being among medical students and school members is crucial, as it reflects their understanding and attention to mental health issues Recognizing the importance of mental well-being can significantly impact their academic performance and overall quality of life.
Stress coping skills are essential strategies that help students identify the sources of stress in their daily lives and effectively manage the challenges and frustrations they face during their studies These skills encompass various approaches, including problem-solving, cognitive restructuring, seeking social support, expressing emotions, problem avoidance, wishful thinking, self-criticism, and social withdrawal These strategies can be evaluated using the Coping Strategies Inventory Scale (CSI).
Perceived social support involves how students recognize and interpret the comfort, care, and assistance they receive from family, friends, and school staff This support can be categorized into three types: instrumental support, which provides tangible help; informational support, which offers guidance and advice; and emotional support, which delivers empathy and understanding.
This research examines the school environment within medical schools, focusing on the physical and academic aspects, as well as the overall atmosphere It will evaluate student perceptions regarding changes in the physical environment, support activities, and interactions among school members.
School policy refers to current school statement which uses to regulate student, teacher and supporting staffs in behaving and offering service for students
Relationship between school members refers to the four kinds of relationship, such as student- student relationship, teacher-student relationship, staff- student relationship, and administrator-student relationship
Student-student relationship or peer relationship refers to the feeling of connectedness which student believes that their peer concern about their learning and about them as individual
Teacher-student relationship refers to the feeling of connectedness which student believes that their teacher concern about their learning and about them as individual
Staff-student relationship refers to the feeling of connectedness which student believes that medical school staff concern about their learning and about them as individual
Administrator-student relationship refers to the feeling of connectedness which student believes that medical school administrator concern about their learning and about them as individual
Ethnicity refers to student’s cultural background In this research, it includes four options, such as Kinh, Hoa, Kmer and others Student who chooses
“others” is requested to write down the ethnicity’s name
Religion encompasses the belief in and worship of a superhuman controlling power, particularly a personal God This research explores six religious options: no religion, Buddhism, Christianity, Protestantism, Cao Dai, and Islam.
The current place of living for a student is the registered address where they reside during their studies, which can be located in Ho Chi Minh City or other provinces.
In Vietnam, the score at entrance is calculated as the average score from three subjects taken during the national entrance examination Certain students may receive additional points due to their minority status or urban temporary residence However, this research focuses solely on the standard entrance scores, excluding any extra points awarded.
Parental marriage status refers to the parent’s state of being and remaining a married couple
Family relationship refers to feeling of student about the closed relationship between student and their own parent and/or other family members
Multi-level factors in this research refer to determinants of mental well- being which were classified at intrapersonal (student level), interpersonal (friend level) and institutional levels (school level)
This research explores potential solutions proposed by medical students and school personnel to enhance the mental health and well-being of medical students Suggested strategies include skill training, improvements to the academic environment, and upgrades to school facilities and infrastructure.
LITERATURE REVIEW……………………………………… 15-75 2.1 Overview about medical school context and student’s mental health
The concepts of mental health, mental well-being and mental health promotion
2.2.1 Concepts of mental health and mental well-being
Since its definition in 1948, the World Health Organization (WHO) has emphasized the positive dimensions of health, stating that "health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Mental health, as defined by WHO, is a state of well-being where individuals recognize their abilities, cope with normal life stresses, work productively, and contribute to their communities This highlights the importance of mental well-being in overall health, as numerous studies indicate a strong association between mental well-being and improved health outcomes Mental well-being encompasses more than just the presence or absence of mental illness; it is described by Sarah Stewart-Brown as "feeling good and functioning well." It is also characterized as a dynamic state that enables individuals to develop their potential, engage creatively, build positive relationships, and contribute to their community Good mental well-being is crucial as it influences various aspects of life and even physical health However, the impact of mental well-being on specific populations is still under-researched.
A literature review indicates that the healthcare and public health sectors currently prioritize screening, diagnosis, and treatment of mental illnesses over mental well-being There is a lack of research focused on safeguarding the mental health of individuals without diagnosed mental disorders Prolonged periods of low mental well-being significantly increase the risk of developing mental disorders Thus, enhancing mental well-being may contribute to a reduction in the incidence of mental health issues.
Researchers suggested that there are three domains should be considered when mention about people’s mental well-being (105, 108-112) These are:
1 Emotional well-being (such as perceived life satisfaction, happiness, cheerfulness, peacefulness)
2 Psychological well-being (such as self-acceptance, personal growth including openness to new experiences, optimism, hopefulness, purpose in life, control of one’s environment, spirituality, self-direction, and positive relationships)
3 Social well-being (such as social acceptance, beliefs in the potential of people and society as a whole, personal self-worth and usefulness to society, sense of community)
2.2.2 Mental health promotion - the positive approach of mental health
Historically, mental health professionals focused primarily on mental disorders, often neglecting positive emotions and personal strengths like emotional well-being and optimism However, the field of positive psychology gained traction in 1999 when Harvard psychiatrist George Valliant introduced a seminar on the subject at Harvard University This shift has led experts in mental health to concentrate on the beneficial traits of the mind, rather than solely its issues The asset-based paradigms of positive psychology provide innovative strategies for enhancing psychological resilience and promoting mental health, fostering greater collaboration between positive psychology and public health.
The Copenhagen document by WHO emphasizes the importance of involving the entire population in health promotion, rather than solely targeting at-risk individuals To effectively support mental health, there is an urgent need for intervention programs that promote positive mental health, rather than just focusing on those with mental illnesses WHO defines mental health promotion as creating environments that support mental well-being and encourage healthy lifestyles This approach prioritizes positive mental health and well-being, aiming to enhance individual competencies by improving coping skills and psychological strengths, while also strengthening community resources to prevent mental disorders and improve overall quality of life Key differences between positive and traditional approaches to mental health are outlined in Table 3.
Table 3 Key differences between positive approach and traditional approach of mental health
Issues Positive approach of mental health Traditional approach
Perspective Positive aspect of mental health as the presence of well-being across the lifespan
(1) Positive experiences/positive emotions focus on happy feeling in the present and having hope for the future
(2) Positive individual traits focus on one's strengths and virtues
(3) Positive relationships focus on interaction between people
(4) Positive institutions based on strengths to better a community of people
(1) Reducing health inequalities and achieving other social goals have focused on the deficits and problems of individuals and communities
(2) Risk factors or risk behaviors that relevant to mental disorders or mental illnesses
Goal To discover and promote the protective factors those allow individuals and communities to adapt with daily stressors and thrive
To assessing and curing psychopathology and mental illnesses
To understand the risk factors that may lead to mental disorders
General population People at risk
Individual, interpersonal and institutional levels
Table 3 Key differences between positive approach and traditional approach of mental health
Issues Positive approach of mental health Traditional approach
Mental disorders or mental illness
2.2.3 School as the setting for promoting mental well-being of medical students
Medical school education is one of the most demanding and stressful training processes, requiring students to dedicate significant time to their studies, even on weekends As a result, medical schools have become focal points for public health research and health promotion interventions A review by Eva Jané-Llopis et al in 2005 highlighted the importance of school settings in promoting mental health and preventing disorders among adolescents and youth across various income levels This review indicated that school-based interventions not only enhance mental well-being, social skills, and competence but also reduce depression, anxiety, and health-risk behaviors Furthermore, a systematic review by Calear et al in 2010, which analyzed 42 school-based studies using randomized controlled trial methodology, confirmed that implementing mental health prevention and early intervention programs in schools yields positive effects on students' mental health.
Recent years have seen a growing interest in mental health research and well-being among both researchers and public policymakers Many countries are recognizing the need to focus on preventing common mental disorders, such as anxiety and depression, by addressing the social determinants of health and enhancing existing services Additionally, promoting mental health in school settings is crucial for helping medical students manage stress during their studies and fostering their overall mental well-being.
2.3 Social determinants of mental health
Mental well-being and common mental disorders are influenced by various social, economic, and physical environments throughout different life stages Preventive actions that enhance mental health are crucial for improving overall health and addressing health inequities Understanding the protective and risk factors for mental health is essential for determining effective interventions These factors operate at multiple levels, including intrapersonal, interpersonal, organizational, and community/public policy Research indicates that medical education and social support significantly affect the mental well-being of medical students.
In 2013, researchers at Cardiff University's School of Medicine, led by Cohen, investigated factors affecting medical student well-being from a risk perspective using a mixed-methods approach Their qualitative analysis, based on 12 focus groups across four English medical schools, identified five key areas impacting student well-being: financial concerns, non-academic demands, academic pressures, work-life balance, and health The focus groups also proposed solutions for better student support Feedback from participating medical schools contributed to recommendations, highlighting the study's strength in providing insights for future research However, a significant limitation was the validity of the quantitative questionnaire used to measure well-being, which relied on two non-validated items related to feeling valued and respected, overlooking the multifaceted nature of mental well-being.
Figure 10 Quotes from Focus group discussion (83)
Box 3 Some quotes from focus discussion
Figure 8 illustrates the key determinants influencing the mental well-being of medical students, based on research findings from around the globe These factors are categorized according to the ecological model and will be explored in detail in the following sections.
“The terms are longer than other courses; however the student loan amount is exactly the same Medical students have an extra 13 weeks of term compared to other courses”
“The highly competitive environment is worrying and reiterated constantly”
“It’s difficult to predict working hours so I’m unable to organize anything”
“Too many exams to revise for in too little time”
“Too much is expected from you”
Time constraints can make it feel like there aren't enough hours in the day For instance, a one-hour lecture often requires an additional four hours of work to complete the necessary reading and organize notes effectively.
“Not knowing what to expect is really stressful and causes a lot of anxiety”
Long hours during placement can lead to significant exhaustion, leaving you too tired to engage in activities or go out after returning home.
Figure 8 Social determinants in each level of ecological model that impact on medical student’s mental well-being
Research indicates a complex relationship between gender and student mental health, with some studies showing a correlation while others do not A 2008 study by Blanch D.C and colleagues revealed that female medical students were perceived as less confident than their male counterparts during clinical examinations Additionally, a 2012 study involving 220 Iranian medical students found that gender and training level significantly impacted mental well-being, with male students reporting better mental health than females These results align with findings from a similar study conducted in eight medical schools in Vietnam.
A recent study published in March 2015 analyzed baseline data from a large national longitudinal cohort of American medical students, revealing that psychosocial resources significantly influence their mental well-being, alongside race and gender The research explored the interaction effects of race and gender on key psychosocial factors, including active coping, social support, mastery, cognitive ability, and self-esteem The authors emphasized the need for medical schools to actively identify the causes, consequences, and solutions to these mental health challenges.
A 2010 study involving 125 Hungarian medical students utilized backward stepwise regression to develop models for estimating mental well-being based on various determinants The research found that mental well-being, characterized by a sense of coherence, positively correlated with perceived health, social support, and female gender, while negatively correlating with psychological distress Additionally, the study revealed that psychological distress and the use of sedatives without a prescription were inversely related to mental well-being The findings emphasized that social support and female gender contribute positively to students' mental health, while sense of coherence serves as a significant predictor of psychological distress The results highlight the importance of addressing mental well-being and psychological distress among future medical doctors during their training.
A 2009 study in China found that female students experienced greater happiness from family love, group activities, and academic performance compared to male students Overall, students reported that academic success was their primary source of happiness Additionally, research by Goebert et al in the same year involving over 2,000 medical students and residents revealed that female participants exhibited significantly lower levels of mental well-being than their male counterparts.
Existing mental health promotion programs and research design that
This article summarizes various mental health interventions designed to enhance the well-being of young adults and students in the United States, England, and Canada Schools have implemented wellness programs that can be categorized as reactive, such as student counseling services, or proactive, which focus on stress management techniques, peer and faculty support, and self-care empowerment to prevent mental disorders Many of these programs employ multilevel interventions and have been evaluated for their positive impacts on student mental health.
2.4.1 Dynamic model of risk D.E.T.T.O.L model in Cardiff University, England – developed by Cohen, D and Sayeed Khan in 2013
In a 2013 program in the United Kingdom, researchers implemented an intervention for medical students based on the validated D.E.T.T.O.L model, developed by professors at Cardiff University This model, which stands for demand, environment, timing, travel, organizational, and layout, highlights how perceptions of risk are influenced by individual traits like personality and health background, as well as organizational factors that support student well-being The model distinguishes between individual and organizational effects, suggesting that students' daily strategies, such as their revision techniques and work-life balance, can moderate sources of risk Additionally, skill development was identified as an effective strategy for enhancing both physical and mental health.
This model illustrates the impact of various risk factors on student mental well-being and highlights how these risks can be mitigated through both organizational and individual strategies To enhance support effectiveness in medical schools, strategies should prioritize organizational support, skill development, and maintaining a balanced study-life dynamic.
Figure 9 Dynamic model of risks (D.E.T.T.O.L model) – conducted by Cohen D et al in Cardiff university, England
2.4.2 The Population Health Promotion Model – developed by Public Health Agency Canada, 2001 (161)
This model was developed to elucidate the connection between population health and health promotion, as illustrated in Figure 10 It is applicable to both physical and mental health promotion, grounded in three fundamental questions.
The full cube model for health promotion addresses three critical questions: "What actions should we take?", "How should we implement these actions?", and "Who should we collaborate with?" This model encompasses 12 key determinants of health, positioned at the front of the cube, alongside five strategic approaches to health promotion outlined on the side, and various levels of intervention represented at the top.
The recommended population health promotion model offers a comprehensive set of action strategies aimed at enhancing various health aspects, including mental health While it is applicable to a wide range of health issues, its relevance to the unique challenges faced by medical students necessitates careful consideration Given the specific characteristics of medical schools and their students, tailoring this model to address mental health within this context is essential for effective implementation.
Figure 10 The population health promotion, Canada, 2001
(Source: Public Health Agency Canada, 2001)
2.4.3 The National Association of Student Personnel Administrators Ecological model (NASPA model) – conducted by the Wellness and Health Promotion Knowledge Community, Washington D.C in 2007 (162)
The NASPA ecological model illustrates the dynamic relationship between students, who seek developmental opportunities, and the environmental settings that offer these opportunities Each aspect of the model highlights a key developmental area—such as mental, physical, or social growth—provided by various environments, aimed at enhancing student experiences both individually and in groups.
Personal health practice Supportive environments
(Source: The Wellness and Health Promotion Knowledge Community, Washington D.C., 2007)
Data for this linkage can be gathered from various sources, including questionnaires, student feedback, case studies, observations, systematic needs analyses, and research publications This data will then be shared with the environmental settings from which it was obtained, offering insights into the development needs of students and their perceptions and satisfaction with the provided development structures The interventions within this NASPA ecological model address both population-level and individual-level health determinants, emphasizing community-based issues rather than solely individual concerns.
Public policy plays a crucial role in fostering a healthy campus environment by allocating resources to build and sustain a coalition that connects individuals with the broader social context Key policies include restrictions on tobacco use and alcohol sales, alongside behavioral incentives that encourage positive actions while discouraging negative ones Moreover, policies addressing violence, social injustice, environmental sustainability, foreign affairs, economic stability, and global warming are also essential components of this comprehensive approach.
At the community level, key factors include the location within the community, the built environment, and the presence of neighborhood associations and community leaders Essential elements also encompass on/off-campus housing options, local businesses such as bars, fast food restaurants, and farmers markets, as well as considerations for commuting, parking, and transportation Additionally, walkability and access to parks play a significant role in shaping the community experience.
Institutional factors significantly influence the campus experience, encompassing elements such as campus climate, which reflects levels of tolerance and intolerance Other critical aspects include class schedules, financial policies, and overall competitiveness Additionally, factors like lighting, cleanliness of environments, proximity to classes and buildings, noise levels, availability of study and common lounge spaces, air quality, and safety all contribute to the overall institutional atmosphere.
⎯ At level of Interpersonal factors: it includes friends, supervisors, resident advisors, customs, traditions, economic forces, diversity, recreation, sports, clubs,
Intrapersonal factors encompass a range of personal attributes, including gender, religious and racial/ethnic identities, sexual orientation, and economic status Additionally, they involve financial resources, individual values, goals, expectations, age, genetics, and resilience Essential skills such as coping mechanisms, time management, health literacy, and the ability to access healthcare services also play a significant role Furthermore, the stigma surrounding counseling services can impact these intrapersonal dynamics.
The NASPA ecological model emphasizes the importance of the school environment, intrapersonal factors, and community and public policy over individual-level influences in promoting student mental health Widely adopted by North American colleges and universities, this systemic model aims to enhance mental health support for students However, it is important to note that, like previous models, it is not specifically tailored for medical schools and their students.
2.4.4 UK Healthy Universities model – developed by group of researchers from The UK National Healthy Universities Network from 2009 to
The UK Healthy University model integrates an ecological health framework, a systems perspective, and a holistic approach, building on principles established by the Ottawa Charter for Health.
Health is shaped by individuals in their daily environments—where they learn, work, play, and love This approach emphasizes health interventions aimed at students while also prioritizing the well-being of staff members.
Overview about instruments that were used to measure people’s
Various scales have been developed to assess individuals' mental well-being Table 6 summarizes the most commonly used scales from previous research, highlighting their significance in measuring mental health effectively.
The Warwick-Edinburgh Mental Wellbeing Scale has been widely utilized but is not recommended for screening purposes Consequently, this research opted to employ the World Health Organization Well-Being Index (WHO-5) to assess students' mental well-being The WHO-5 scale has been translated into over 30 languages and validated in numerous countries, including Vietnam.
Table 6 Summarizing scales that were used to measure mental well-being
Scales Items What it measure
(Note: this scale does not require permission to use)
Score ≤13 or if respondents have answered
0 to 1 to any of the five items, it is recommended to administer the Major Depression (ICD-10)
Positive feelings, happy emotions, energy
Adults Widely used to measure mental wellbeing particularly in large surveys Brief instructions are given for scoring, interpretation and monitoring change
The WHO-5 is free of charge and does not require permission to use
Adults Used in health research to measure
Table 6 Summarizing scales that were used to measure mental well-being
Scales Items What it measure
Usage from 0 to 12 for items scored dichotomously or 0-36 for items scored continuously
Higher scores on the assessment indicate poorer health, encompassing four subscales: somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression This scale not only highlights the prevalence and determinants of probable mental illness but is also utilized for evaluation in intervention studies.
Positive emotions and psychological functioning including: happiness, relaxed, confidence, agency, autonomy, energy, optimism and positive relationships
Widely used especially in the
UK as an outcome of services and impact of policies Included in large publicly available government surveys and cohort studies Validated in both clinical and nonclinical populations
Table 6 Summarizing scales that were used to measure mental well-being
Scales Items What it measure
Instructions for scoring and administering on the website
Strongly correlated with depression scales and cut points available to indicate possible clinical problems However not recommended for screening
Online form for self- completion and scoring
Score range from 1 to 6 each question
Equal number of positive and
Measures happiness positive feelings, enjoyment and creativity
Based on personality theory relating to motivation
Adults Advice given to the individual on how to improve wellbeing and reduce negativity from website Publication gives access to the questionnaire (in the appendix, Hills and Argyle
Table 6 Summarizing scales that were used to measure mental well-being
Scales Items What it measure
Usage negative items and success and the factors that contributes to it
Psychologica l, social and emotional wellbeing
12 to 84 Can be used as a continuous measure in the general population
Used mainly in the US and Canada
The scale has been used mainly in large population surveys to investigate the nature of mental well-being
Score range from 0 to 10 (for each
Four questions which are analyzed separately
Adults General population in National Surveys Data available at small area level in
Table 6 Summarizing scales that were used to measure mental well-being
Scales Items What it measure
Three positive items and one negative covering satisfaction with life, purpose in life, happiness and anxiety
2.6 Theory applied in this research Scope of research
Mental health promotion aims to enhance overall wellbeing by engaging in activities that foster positive emotions, improve health, and optimize functional abilities According to Karen Glanz and Goodson, no single theory dominates health promotion and education, necessitating an ecological approach that incorporates various theories This research will focus on Lazarus and Folkman’s Theory of Stress, Appraisal, and Coping, as well as concepts of social networks and support, alongside modern organizational development theory.
2.6.1 Theory of stress, appraisal and coping – Lazarus and Folkman
The theory emphasizes three key concepts: stress, cognitive appraisal, and coping According to Lazarus, stress is defined as the relationship between an individual and their environment, which is perceived as taxing or exceeding their resources, ultimately threatening their well-being Since stress is an unavoidable aspect of daily life, individuals must engage in coping processes to manage it effectively.
Lazarus highlighted that cognitive appraisal involves evaluating threats and assessing the resources needed to manage stressors effectively A student's mental well-being can be influenced by meaning-based coping processes, which not only foster positive emotions but also influence subsequent appraisals and coping strategies.
Figure 17 Theoretical framework of stress, appraisal and coping
2.6.1 Social network and social supports
Social networks encompass the web of relationships that influence students, significantly affecting their mental well-being Social support, a crucial aspect of these relationships, can be categorized into four types: emotional support, instrumental support, information support, and appraisal support.
To effectively translate theory into practice and enhance the positive impact of social networks on students' mental well-being in school settings, research must identify key features of social support This includes determining who should provide support, the types of support needed, the target recipients, and the timing for delivering this support Strategies for designing social support interventions may involve fostering positive emotions among students, enhancing student support activities, and activating counseling services.
Developing peer support groups is essential for enhancing mental well-being among students By strengthening personal coping skills through informational support, we can foster meaningful connections between students and school members Additionally, implementing social support interventions can create a network that promotes overall mental health and well-being for students.
2.6.2 The modern organizational development theory
This article explores the significance of organizational climate and organizational capacity in the development of effective interventions within schools A positive school climate is crucial for the successful implementation of new initiatives, as it directly impacts students' mental well-being Therefore, when designing mental health promotion interventions, researchers must also take into account the concept of organizational capacity to ensure their effectiveness.
In summary, this study aims to implement three key theories: the stress, appraisal, and coping theory; the social network and social support theory; and the modern organizational development theory Additionally, an ecological model will serve as the foundational framework for designing effective behavior change interventions.
• Awareness on mental well- being
• Satisfaction on school climate change
The mental well-being intervention program
(1) Distribute leaflet at Orientation days
*Life skills: Time management and study skills, Communication and problem-solving skill
*Mental health coping skill: Stress coping skill, Maintaining positive emotion and living with mental well-being
(1) Encouraging student-to-student orientation via club’s activities
(2) Partnered new student with a “family” of more senior students who can offer advice and support
(1) Cooperating to student support office to organize student experience session in Friendship camping
(2) Running counseling service and developing phone application
(3) Cooperating to student support office to organize sport competition
(4) Reviewing school policies and student support services
Research conceptual framework
• Awareness on mental well- being
• Satisfaction on school climate change
The mental well-being intervention program
(1) Distribute leaflet at Orientation days
*Life skills: Time management and study skills, Communication and problem-solving skill
*Mental health coping skill: Stress coping skill, Maintaining positive emotion and living with mental well-being
(1) Encouraging student-to-student orientation via club’s activities
(2) Partnered new student with a “family” of more senior students who can offer advice and support
(1) Cooperating to student support office to organize student experience session in Friendship camping
(2) Running counseling service and developing phone application
(3) Cooperating to student support office to organize sport competition
(4) Reviewing school policies and student support services
Research design
This sequential exploratory mixed-methods research aimed to gain a comprehensive understanding of medical student mental well-being in Vietnam, an area that has been underexplored The initial qualitative phase involved gathering insights from medical students, their family members, friends, faculty, and other stakeholders at the Faculty of Medicine, Ho Chi Minh City University of Medicine and Pharmacy These insights informed the development of targeted intervention activities to enhance students' mental well-being, which were then assessed in the second phase using a quasi-experimental design.
The study assessed the mental well-being index of medical students at HCMC UMP and a comparison group, measuring changes before and after a targeted intervention It aimed to test the hypothesis that the intervention would enhance mental well-being among students in the intervention group compared to both their own baseline and the comparison group Additionally, the study evaluated changes in emotional well-being, psychological well-being, stress coping skills, perceived school environment, and social support as outcomes of the intervention program Furthermore, it analyzed changes in school policies regarding student mental well-being to gauge the overall success of the intervention.
Figure 19 The sequence of Exploratory sequential mixed method design that applied in this research
Research method for phase 1
This sequential exploratory mixed-method research aimed to gain an in-depth understanding of medical student mental well-being in Vietnam, where limited studies have been conducted on this topic The initial qualitative phase involved gathering insights from medical students, their families, friends, faculty members, and other stakeholders at the Faculty of Medicine, Ho Chi Minh City University of Medicine and Pharmacy These insights informed the development of intervention activities designed to enhance student mental well-being, which were implemented in the second phase using a quasi-experimental design.
The study examined the mental well-being index of medical students at HCMC UMP, comparing changes before and after an intervention to determine its effectiveness It aimed to assess whether the intervention improved mental well-being among students in the intervention group compared to a control group Additionally, the research analyzed changes in emotional well-being, psychological well-being, stress coping skills, perceived school environment, and social support as outcomes of the intervention program Furthermore, the evaluation included changes in school policies regarding student mental well-being to measure the overall success of the intervention.
Figure 19 The sequence of Exploratory sequential mixed method design that applied in this research
Phase 1 of this research was conducted at Faculty of Medicine, HCMC UMP and Tay Nguyen UMP (TN UMP) where having the highest and lowest rate of mental disorders among medical students (180) In phase 2, medical students from HCMC UMP and Can Tho University of Medicine and Pharmacy (CT UMP) were recruited in the comparison group (see figure 20) CT UMP is one medical school from southern that has similar characteristics about the culture and not much different in ethnicity and economic characteristic Therefore, CT UMP was chosen as the comparison site The detail of CT UMP will be presented on next coming part 3.2.2
3.2.1 The Ho Chi Minh University of Medicine and Pharmacy
The Ho Chi Minh University of Medicine and Pharmacy (HCMC UMP) is one of Vietnam's top-ranked universities, originally established in 1947 as a medical school under the University of Saigon In 1961, the institution was restructured under the authority of the Republic of Vietnam's government, leading to its current status.
In 1976, following the Vietnam War, the Saigon College of Medicine, Saigon College of Pharmacy, and Saigon College of Dentistry were merged to form HCMC UMP The university has since expanded, establishing the Faculty of Fundamental Science, Faculty of Traditional Medicine, Faculty of Nursing, Faculty of Medical Technique, Faculty of Public Health, and a University Hospital between 1994 and 2000 By 2005, HCMC UMP was recognized as one of the two strategic teaching institutions in the country, offering a comprehensive range of training for health professionals at both undergraduate and graduate levels The university employs statistical methods such as Chi-square tests, paired-sample t-tests, and independent t-tests in its research and educational practices.
Figure 20 Map of research settings
The Faculty of Medicine at HCMC UMP is recognized as the largest medical school in Vietnam, renowned for its educational excellence developed over decades to meet international standards Comprising five functional offices and 38 departments, the faculty trains both general practitioners and specialists, serving healthcare needs across southern Vietnam, from district health units to major hospitals in urban areas.
3.2.2 The Can Tho University of Medicine and Pharmacy (181)
The Can Tho University of Medicine and Pharmacy (CTUMP), established in 1978, operates under the direct oversight of the Ministry of Health and the Ministry of Education and Training, with administrative support from the Can Tho City People's Committee Originally part of Can Tho University, CTUMP began with basic science courses taught by Can Tho University lecturers due to a shortage of faculty From 1979 to 1984, medical subjects were primarily delivered by visiting lecturers from Ho Chi Minh University of Medicine and Pharmacy In 2002, after two decades of development, CTUMP became an independent institution, featuring six faculties and 12 offices and centers dedicated to medical education and research.
The University has emerged as a key resource for supplying healthcare providers in the Mekong Delta region, establishing itself as a leader in higher medical education Alongside its growth, the CTUMP Hospital was founded in late 2011, playing a crucial role in the regional health system It has quickly gained recognition as one of the most prestigious referral hospitals in both the city and the surrounding area.
The Faculty of Medicine at Can Tho University of Medicine and Pharmacy (CTUMP) was established in July 1979 to address the growing need for medical education in the Mekong Delta Committed to advancing medical sciences and enhancing the healthcare system in the region, the Faculty of Medicine has played a pioneering role in medical education, fostering optimism for healthcare improvements in the Mekong area.
3.3 Research method of Phase 1 – Qualitative research
3.3.1 The characteristics of this qualitative research
The interpretivism or qualitative approach is a valuable research paradigm for gaining insights into mental well-being, particularly among medical students in Vietnamese medical schools This phase of qualitative research aims to explore the complexities and in-depth aspects of students' mental health, seeking to understand the factors that contribute to their well-being and how medical institutions can support them By examining the underlying assumptions of interpretivism, the study investigates how various multilevel social determinants, identified through a literature review, impact student mental well-being in Vietnam, highlighting potential differences from Western and other Asian contexts.
This exploratory research investigates Vietnamese medical students' perceptions of mental well-being and the effects of both positive and negative influences on their mental health throughout their training It also examines the impact of social determinants identified in the literature on the mental well-being of these students Additionally, the study discusses and highlights potential solutions proposed by faculty members to enhance the mental well-being of medical students.
In qualitative research, the researcher plays a crucial role in data collection, making it essential to address potential biases stemming from personal experiences and interests related to the research topic Training in qualitative research during a master's program, along with additional courses at HCMC UMP and Mahidol University, enhanced the researcher's skills After completing the master's degree in 2009, the researcher took on the role of Vice Head of the Department of Undergraduate Education at the Faculty of Public Health – HCMC UMP, where involvement in student affairs and curriculum development provided valuable insights into the administrative context and collaboration with the Faculty of Medicine This experience heightened the researcher's awareness of the challenges faced while working with informants, although it also introduced potential biases based on previous interactions with students Nonetheless, collaboration with a skilled research team and guidance from experienced supervisors is believed to effectively mitigate these biases, ensuring a more objective interpretation of the collected data.
3.3.4 Key informants (KI), sample size and sampling method
This research involved 24 in-depth interviews with key informants, including medical students, faculty administrators, staff, and teachers, to explore the multi-level factors affecting the mental health and well-being of Vietnamese medical students The study aimed to identify potential solutions to enhance mental well-being within medical schools in Vietnam Additionally, observations and document reviews were conducted to gain insights into the school environment, existing policies, and student activities.
Table 7 Key informants – Number and sampling method
Students whom were identified by faculty staff that “very active school activities and GPA at first semester ≥8.0” OR “very active school activities and have GPA at first semester