Study design

An institution-based quantitative cross-sectional study was undertaken among 321 undergraduate students studying medicine, public health, medical laboratory sciences, nursing and midwifery science at both public and private universities in Mogadishu, Somalia.

Study setting and context

The study was conducted in four different public and private universities in Mogadishu, Banadir region, Somalia. The programs included are the health science courses including Doctor of Medicine MBBS which is a seven-year program including the mandatory foundation year, while the Nursing and Midwifery, Public Health, and Laboratory Sciences programs are often complete in 5 academic years including the foundation year.

Medical and health education in Somalia has faced significant challenges due to decades of conflict, instability, and limited resources [32, 38]. However, in recent years, the country has made significant strides in rebuilding its health sector through educational institutions like SIMAD University, Banadir University, Jamhuriyya University, and Mogadishu University among many other which offer health sciences training programs. Although, the curriculum often lacks standardization, and there are shortages of qualified faculty and modern training facilities. Notwithstanding, partnerships with international organizations, members of the diaspora community, and other local initiatives are helping to address these gaps.

The present study was conducted in the period between January 2024 and June 2024 to assess the prevalence of depressive symptoms among these undergraduate health science students.

Study population and selection criteria

A multistage stratified sampling technique was used to target a total of 326 health science students from four departments in each of the four selected universities in the study area. Each respondent was selected by simple random sampling technique using the class register as a frame. In the event a student refused to participate, the next student was contacted. Undergraduate students pursuing a Bachelor of Medicine and Bachelor of Surgery, Public Health, Laboratory Science, as well as Nursing and Midwifery Sciences constituted the study population. The 7-year MBBS curriculum consists of 1 year of mandatory foundation studies recommended by the Somali National Government, followed by 2 years of preclinical training in basic biomedical sciences and 3 years of clinical rotations. On the other hand, the Public Health, Laboratory Science, and Nursing and Midwifery Sciences program is completed in 5 years comprising of 1 foundation year, 2 years of preclinical and 2 years of clinical training.

Sample size estimation

The sample size was calculated using the Cochrane single population proportion formula; Cochran formula: n = (Z^2 * p * (1-p)) / e^2. The parameters considered were n = sample size, Z = Z-score (1.96 for a 95% confidence level), p = proportion of depression among undergraduate students as previously reported (28.2%) [5], d = desired precision or margin of error (5%). In addition, a 5% non-response rate was added to get a total sample size of 326.

Samples were allocated to each of the four universities proportionately based on the total number of students in the university register as well as across each department. Accordingly, 40, 68, 118, and 100 students were allocated to SIMAD university, Jamhuriya university, Banadir university, and Mogadishu university respectively.

Data-collection tools and procedure

A self-administered, well-structured questionnaire was developed based on an extensive review of the literature to collect data from participants. Data were collected using a web-based questionnaire designed with Google Forms, ensuring accessibility and convenience (Supplementary 1).

Class representatives, serving as class leaders, facilitated dissemination of the survey link through class WhatsApp groups and assisted in identifying selected participants using class registers under the guidance of the research team. Their role was limited to logistical support and closely monitored to reduce bias.

The questionnaire comprised three sections. The first section collected sociodemographic characteristics, the second included ten “Yes” or “No” questions assessing potential risk factors associated with depression, and the third featured nine 4-point Likert scale items from the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9, adapted from validated tools in previous studies [6, 35]. The PHQ-9 is a widely recognized instrument for screening, diagnosing, and assessing the severity of depression [17]. To further ascertain the reliability and internal consistency of the questionnaire, Cronbach’s alpha Coefficient was calculated and found to have a good overall score of 0.86. Each item in the PHQ-9 is scored from 0 to 3, corresponding to “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively. The total score ranges from 0 to 27, with higher scores indicating greater severity of depressive symptoms.

Measurement of depression

A diagnosis of depressive status of a participant was made based on the following PHQ9 grading; 0–4, 5–9, 10–14, 15–19 and 20–27, which correspond to no depression, mild depression, moderate depression, and severe depression, respectively [22].

Data quality management

Validity and completeness of data was assured via regular supervision to ascertain consistency on daily basis. In the event an incomplete questionnaire was detected, the data collection supervisor removed the entry as it was difficult to trace the specific participant.

Data management and analysis

The web-based data submissions from Google forms were downloaded in Microsoft Excel format before cleaning and allocation of codes (Supplementary 2). The formal analysis was performed using SPSS Statistical Software v27 (IBM SPSS). Descriptive analyses were in the form of frequencies and percentages was used for each of the categorical variables, while the age of the respondents was expressed as mean ± SD. To understand the associations between depression and the potential risks factors and participants demographics, Chi-square (χ2) tests and logistic regressions were performed. A P-value of < 0.05 was considered statistically significant.

All variables from socio-demographic characteristics of participants and the potential risk factors in the bivariate analysis were fitted into the binary logistic regression model to identify independent predictors of depression among the students.