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Validation of depression, anxiety and stress scales (DASS-21): Immediate

psychological responses of students in the e-learning environment

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Validation of depression, anxiety and stress scales (DASS-21):

Immediate psychological responses of students in the e-learning
environment
Hoang Thi Quynh Lan1, Nguyen Tien Long1 & Nguyen Van Hanh1
1
School of Engineering Pedagogy, Hanoi University of Science and Technology
Correspondence: Nguyen Van Hanh, School of Engineering Pedagogy, Hanoi University of Science and Technology,
No. 1 Dai Co Viet Street, Hai Ba Trung District, Hanoi, Vietnam.

Received: June 27 2020 Accepted: July 16, 2020 Online Published: July 17, 2020
doi:10.5430/ijhe.v9n5p125 URL: https://doi.org/10.5430/ijhe.v9n5p125

Abstract
The COVID-19 epidemic has caused higher education institutions in Vietnam to immediately transfer from
traditional classrooms to e-learning environments. This interacts with high expectations and habits of learning and
training can adversely affect the mental health of students. The purpose of this study is to validate the DASS-21 scale
for use in the mental health screening in Vietnamese students when they suffer an immediate psychological reaction
in the e-learning environment. Strict statistical analyzes (including Cronbach's alpha, Exploratory Factor Analysis,
Confirmatory Factor Analysis, Average Variance Extracted, Average Shared Variance) have led to a well-fitting
model of DASS-18 with a three-factor structure to measure the mental health of Vietnamese students in an e-learning
environment. Results DASS-18 reported the rates of depression, anxiety, and stress in levels of moderate severity or
above in Vietnamese students at 50%, 19.7%, and 37.3%, respectively. However, a rate of anxiety up to 43.1% by
using DASS-21 indicating that many students may be misdiagnosed for the level of anxiety. Finally, linear regression
analyses are used to examine the influence of socio-demographic factors on the immediate psychological responses
of students to an e-learning environment in the context of the COVID-19 epidemic.
Keywords: depression, anxiety, stress, DASS-21, DASS-18, COVID-19, E-learning environment, Vietnamese
students, psychological responses
1. Introduction
The 2019 coronavirus disease (COVID-19) is a public health emergency of international concern (Wang et al., 2020).
The COVID-19 epidemic has greatly affected every aspect of social life and business production. In Vietnam, in an
unprecedented move to prevent the spread of the virus, the government closed all schools in the country from
February 3, 2020 to May 3, 2020. With the policy of the Ministry of Education and Training is "pausing to school,
but not stopping learning", e-learning, television-based learning becomes the optimal solution when COVID-19
epidemic can be prolonged and complicated. At the primary and secondary education level, television-based learning
has been used to maintain students' knowledge, while waiting to return to school. At the higher education level,
e-learning is applied to the maximum extent possible in the formal university courses. On March 23, 2020, the
Ministry of Education and Training recognized all results of online teaching and learning by higher education
institutions, while previously only allowed 30% of the training program. However, the instant transition of higher
education from traditional classrooms to e-learning, they interact with high expectations and habits of learning and
training that can adversely affect the mental health of students (Kulsoom & Afsar, 2015). Besides, the academic
context in the COVID-19 epidemic could further exacerbate the mental health of students.
Previous studies have shown that the high expectation of academic achievement has created a stressful environment,
which if left untreated, they can be hazardous to their mental health (Shamsuddin et al., 2013). Bayram and Bilgel
(2008) reported high rates of depression, anxiety, and stress in levels of moderate severity or above in Turkish
university students at 27%, 47%, and 27%, respectively. Junior students have a higher response to stress than seniors,
due to their difficulty adapting to a new environment (Aysan, Thompson & Hamarat, 2001). Many studies reported
female students have higher levels of depression, anxiety, and stress (Dyrbye, Thomas & Shanafelt, 2006).
University students who originate from rural areas were reported to higher levels of depression, anxiety, and stress
scales compared to students with an urban background (Bayram & Bilgel, 2008). This can be explained by financial
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struggles that can further exacerbate depression, anxiety and stress (Andrews & Wilding, 2004). Therefore, these
factors are used by us to explain the depression, anxiety and stress of Vietnamese university students in an e-learning
environment. Currently, to the knowledge of researchers, there is no information on mental health of Vietnamese
university students when they suffer an immediate psychological reaction in the e-learning environment with the
context of COVID-19.
One of the commonly used scales for the detection of mental health problems is the Depression, Anxiety, and Stress
Scale - DASS (P. Lovibond & S. Lovibond, 1995). The reliability and validity of DASS and its short-form—the
DASS-21 have been widely recognized to assess depression, anxiety, and stress among adults (Le et al., 2017).
Because DASS and DASS-21 are developed in Australia and applied to different socio-cultural contexts and types of
populations, they need to be carefully considered (Le et al., 2017). Much evidences have been found showing that
DASS-21 may not be valid when applied in several different contexts (González-Rivera, Pagán-Torres &
Pérez-Torres, 2020). Currently, to the knowledge of researchers, no research paper has examined the reliability,
validity, and factorial structure of DASS-21 for university students in an e-learning environment. In the Vietnamese
context, DASS-21 has been confirmed to be reliable and suitable for use to assess symptoms of common mental
health problems, especially depression and anxiety among Vietnamese adolescents, but its ability in detecting stress
may be limited (Le et al., 2017). However, university students do not appear in previous research samples in Vietnam
(Le et al., 2017; T.D. Tran, T. Tran & Fisher, 2013). This increased doubts about the validity of the DASS-21 among
university students, at least in Vietnam.
The main purpose of this study is to validate the DASS-21 scale for use in the mental health screening in Vietnamese
students when they suffer an immediate psychological reaction in the e-learning environment of the COVID-19
outbreak. Specifically, this study had three main objectives:
- To assess whether the original DASS-21 is a good model for measuring the mental health of Vietnamese students in
an e-learning environment.
- To investigate the mental health of Vietnamese students in the first two weeks, they are immediately transferred
from the traditional classroom to the e-learning environment of the COVID-19 outbreak.
- To determine how socio-demographic factors affect the mental health of Vietnamese students in the e-learning
environment.
2. Materials and Methods
2.1 Materials Information
This research was conducted at Hanoi University of Science and Technology (HUST), Vietnam. HUST is one of the
most prestigious universities in Vietnam, top 1.000 rankings of Times Higher Education 2019. In 2010, HUST
became a member of the ACU (ASEAN Cyber University) project to transform from traditional learning to
e-learning. In 2012, HUST started implementing the first e-learning courses through the link "http://lms.hust.edu.vn".
By the first half of 2019, only 25 e-learning courses are developed, and many of them are elective. Although
e-learning exists for a relatively long time, but it still seems to be in its infancy. However, when the government
closed all schools due to the COVID-19 epidemic, e-learning actually played a prominent role at HUST. All
traditional classroom-based activities at HUST are instantly transformed into an e-learning environment based on the
"Microsoft Teams" platform. Although HUST has strived to support its faculty and students by providing
instructional documents, online videos, and online training courses on e-learning lectures. In the initial stage, both
faculty and students feel pressured to teach and learn in an e-learning environment. Four weeks later, a midterm
exam in the traditional classroom was also transformed into an e-learning environment. This further exacerbates the
level of depression, anxiety, and stress among students.
2.2 Design
This was a study of instrument design. For 2 weeks from March 6 to March 20, 2020, we conducted an online survey
using convenience sampling techniques. The data collection was conducted using online questionnaires through the
Microsoft Forms platform. A total of 15 online classes (about 2000 students) was selected to collect survey
information.
2.3 Measurement
Participants’ socio-demographic characteristics, including gender, residential area, grade point average (GPA), and
residence status were assessed using study-specific questions. A yes / no question was used to test students'
attendance to learning in an e-learning environment. If the students' response is "Yes", they will continue to answer
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with DASS-21. While other students will not answer anything more. In other words, this helps us eliminate online
truancy students in the collected data.
The DASS-21 is the shortened version of the DASS developed by P. Lovibond and S. Lovibond (1995) which was
used. The three-dimensional self-reporting scales assess the presence and intensity of affective states of depression,
anxiety, and stress in the last week on a 4-point Likert response scale. Each subscale has seven items and its total
score ranges from 0 to 21 points. A higher score indicates higher symptomatology of depression, anxiety, and stress.
We used the Vietnamese version of DASS-21 which was validated by Tran et al. (2013). Three subscales of
DASS-21 are named DASS-21-Depression (DASS-21-D), DASS-21-Anxiety (DASS-21-A), and Stress
(DASS-21-S).
2.4 Data Analysis
The task of data analysis was performed in SPSS. In the first step, Cronbach alpha statistics were conducted to assess
reliability in terms of internal consistency. A cut-off point of 0.7 of Cronbach's alpha value actually reflects internal
consistency (Cortina, 1993). The Exploratory Factor Analysis (EFA) was conducted for the 21 items of the DASS-21
to analyze the factorial structure. We used the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy and
Bartlett's test of sphericity. A cut-off point of 0.45 of KMO values was used to select items for a factor (Cohen, 2013).
Then, Cronbach alpha statistics were conducted to assess reliability in terms of internal consistency in each factorial
structure.
When EFA and Cronbach alpha statistics were statistically significant, the Confirmatory Factor Analysis (CFA) in
AMOS version 20 software was conducted to examine the fit of the DASS-21. In the Chi-Square test (χ2), the model
fit is acceptable if p> 0.05. However, a p-value is usually less than 0.05 due to the χ2 value being sensitive to sample
size. This would lead to a model fit being rejected if p < 0.05 (Anderson & Gerbing, 1988). Thus, model fit was
assessed using a guideline for determining model fit is developed by Hooper, Coughlan and Mullen (2008), including:
a ratio of χ2/df as high as 5.0; RMSEA value ranging from 0.05 to 0.07; a higher cut-off of 0.9 for GFI, NFI and
AGFI; SRMR values as high as 0.08; a higher cut-off of 0.95 for CFI and TLI. The convergent and discriminatory
validity of DASS-21 were examined through the Average Variance Extracted (AVE). The AVE must be equal to or
greater than 0.50 for determining the convergent validity. In order to determine the discriminatory validity of each
dimension, the Maximum Shared Variance (MSV) and the Average Shared Variance (ASV) must be less than the
value obtained from the AVE of each factor. In addition, the correlation between the instrument factors was
calculated using Pearson's coefficient (r). Values less than 0.35 were considered to be low correlations, values
between 0.36 and 0.67 were considered moderate correlations, values between 0.68 and 0.89 were considered high
correlations and values from 0.90 onwards were considered to be very high correlations (Taylor, 1990).
Finally, linear regression analyses were used to examine the influence of socio-demographic factors on the
immediate psychological responses of students to an e-learning environment in the context of the COVID-19
epidemic.
3. Results
3.1 Exploratory Factor Analysis
After two weeks of online surveys, we received 304 questionnaires with complete data, and there were no questions
left blank. The Cronbach alpha test results in a DASS-21 value of 0.909, a DASS-21-D value of 0.882, a DASS-21-A
value of 0.807, a DASS-21-S value of 0.842. Cronbach alpha values were greater than 0.7 in all cases indicating that
all collected data achieved internal consistency within a large group and subgroups.
An EFA was conducted to examine the factor loading of DASS-21 with a sample size of 304 university students in
Northern Vietnam (Table 1). They achieved a KMO value of 0.913 (greater than 0.45), a p-value of 0.00 (less than
0.05) so the rotated factor loading matrix was statistically significant. The results of Total Variance Explained result
an Eigenvalues values in the "Total" column of 1.062 (greater than 1) and a Cumulative value of 59.16% (greater
than 50% of total variance). In other words, 21 original items explained to 59.16% of the total variance of the new
factors. The result of the rotated factor loading matrix indicates that the 21 original items loaded for the four new
factors. In all cases, factor loading values were greater than 0.5 and no items loaded more than two new factors. The
original items loaded correctly to DASS-21-D and DASS-21-S by P. Lovibond and S. Lovibond (1995). However,
the items on the DASS-21-A scale loaded for two new factors, which are formed from a group of physical items (A2,
A4, A7) and a group of mental items (A9, A15, A19, A20). The results of Cronbach alpha for four new factors show
that items A2, A4 and A7 of the DASS-21-A scale were deleted, because their alpha value is less than 0.7. The result
of Cronbach's alpha for the remaining 18 items results in an alpha value of 0.908 (greater than 0.7) showing that
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deleted items do not really contribute to the reliability of the DASS scale.
Table 1. The EFA for the DASS-21
Factor loadinga
Code Items DASS-18-A( DASS-18-A
DASS-18-D DASS-18-S
Mental) (Physical)
D3 I couldn’t seem to experience any positive feeling at.779
all
D5 I found it difficult to work up the initiative to do.776
things
D10 I felt that I had nothing to look forward to .748
D13 I felt down-hearted and blue .747
D16 I was unable to become enthusiastic about anything .728
D17 I felt I wasn’t worth much as a person .653
D21 I felt that life was meaningless .633
S1 I found it hard to wind down .757
S6 I tended to over-react to situations .726
S8 I felt that I was using a lot of nervous energy .659
S11 I found myself getting agitated .651
S12 I found it difficult to relax .621
S14 I was intolerant of anything that kept me from .614
getting on with what I was doing
S18 I felt that I was rather touchy .601
A9 I was worried about situations in which I might .739
panic and make a fool of myself
A15 I felt I was close to panic .714
A19 I was aware of the action of my heart in the absence .620
of physical exertion
A20 I felt scared without any good reason .618
A2 I was aware of dryness of my mouth .775
A4 I experienced breathing difficulty .688
A7 I experienced trembling .527
KMO 0.913
Cronbach Alpha 0.882 0.842 0.819 0.575
Total 1.062
Cumulative % 59.16
a
Extraction Method: Principal Component Analysis.
3.2 Confirmatory Factor Analysis
In AMOS, the Confirmatory Factor Analysis (CFA) was conducted to examine the fit of a new DASS-18 model. But
a good model fit of DASS-18 was achieved when covariance links were added between error variances of D10 and
D17, D10 and D21, D17 and D21, S6 and S18, and S8 and S12 (Figure 1). The DASS-18 model was a good fit to the
data: χ2 = 227.693, df = 127, χ2/df = 1.793, RMSEA = 0.051, GFI = 0.958, SRMR = 0.27, NFI = 0.911, CFI = 0.958,
TLI = 0.950 and AGFI = 0.90.
In all cases, the Pearson's correlation coefficients between DASS-18-D, DASS-18-A, and DASS-18-S was a
moderate level (lower than 0.68) indicating that the scales of stress, depression, and anxiety were moderately
discriminatory. AVE calculations show that the depression, and anxiety scales achieved convergence effect (with the

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AVE of anxiety is 0.550; the AVE of depression was 0.504, greater than 0.5). But the AVE of the stress scale was
0.424 (less than 0.5), showing that its ability to detect stress is limited in Vietnamese university students.

Figure 1. CFA for DASS-18.

Table 2. Immediate psychological responses of students in the e-learning environment
DASS-18 If using DASS-21
Levels D (%) A (%) S (%) A (%)
Normal 31.3 64.8 39.1 32.2
Mild 18.8 15.5 23.7 24.7
Moderate 36.5 6.6 20.1 16.8
Severe 11.2 4.9 15.5 10.5
Extremely severe 2.3 8.2 1.6 15.8
Total 100 100 100 100
Table 2 describes the depression, anxiety, and stress status of Vietnamese university students in the early stages of
learning in an e-learning environment taking place in the context of COVID-19. More specifically, 13.5% of students
have depression from severe or above; 13.1% of students have anxiety from severe or above, and 17.1% of students
have stress from severe or above. If using the anxiety scale of DASS-21, 26.3% of students could have anxiety from
severe or above. In other words, some students may not have anxiety, they may be diagnosed with anxiety if we use
DASS-21. High rates of depression, anxiety, and stress in levels of moderate severity or above at students were 50%,
19.7%, and 37.3%, respectively.

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3.3 Socio-demographic Factors and Psychological Impact

The relationship between socio-demographic factors and psychological impact was shown in Table 3.
Table 3. Socio-demographic factors and psychological impact
Depression Anxiety Stress

Factor N (%) Adjusted Beta (95%)

R-Squared
2 R-Squared R2 AR2 B R2 AR2 B
(R ) 2 (B)
(AR )
Gender
Male 217 (71.4) .005 .002 .072 (-.370.027 .023 .163* .005 .002 .072
Female 87 (28.6) to 1.650) (.268 (-.354 to
to 1.606)
1.431)
Residential area
Rural 212 (69.7) .007 .004 -.084 (-1.729.004 .000 -.061 .007 .003 -.082
Urban 92 (30.3) to .256) (-.893 (-1.663
to .265 to .263)
)
Current residence
status
Motel room alone 20 (6.6) .003 .000 -.054 (-.703.007 .003 -.082 .016 .013 -.126*
Motel room with42 (13.8) to .249) (-.477 (-.974 to
others to .076 -.056)
)
Dormitory 11 (3.6)
Family house 231 (76.0)
GPA
Poor 47 (15.5) .000 -.003 -.022 (-.552.000 -.003 .012 .000 -.003 .021
Fair 91 (29.9) to .370) (-.240 (-.364
to .297 to .530)
Good 125 (41.1) )
Very good 32 (10.5)
Excellent 9 (3.0)
Note: * p < 0.05
Of the total respondents, 71.4% of the students were male, 28.6% were female, and they were mostly from rural
areas (69.7%). During the implementation of the social distancing to prevent COVID-19, the majority of students
stayed in their family home to study online (76%). The student's GPA was mostly distributed at the "Good" level.
Female gender was significantly associated with higher scores in the DASS-18 anxiety (B = 0.163, 95% Confidence
Interval from 0.268 to 1.431). Similarly, living with relatives and friends (dormitory, family house) was significantly
associated with lower DASS-18 stress subscale scores (B = -0.126, 95% Confidence Interval from -0.974 to -0.056).
Other sociodemographic factors were not associated with DASS-18 subscale scores.
4. Discussion
Some previous studies show that the linguistic and cultural factors of each country have a significant effect on the
validity of the DASS 21 scale as they are translated and applied (González-Rivera et al., 2020). This led us to doubt
about the validity of the DASS-21 scale when Vietnamese students faced e-learning culture in the context of the
COVID-19 epidemic. The findings show that the DASS 21 scale is ineffective in measuring the mental health of
Vietnamese students in the e-learning environment. Strict statistics have led to a well-fitting model of DASS-18 with
a three-factor structure to measure the mental health of Vietnamese students. This resulted in the removal of 3 items
(A2, A4, A7) from the anxiety scale of the original DASS-21 by P. Lovibond and S. Lovibond (1995). This result is
different from the studies of Le et al. (2017) and Tran et al. (2013) when they confirmed that the DASS-21 scale is
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valid for adolescents, and pregnant or postpartum women in Vietnam. From there, we question why the DASS-21
scale is not valid for Vietnamese students, at least in an E-learning environment? Similar to the findings of this study,
several previous studies also showed many other versions of the original DASS-21 scale, such as DASS-20,
DASS-18, DASS-17, DASS-12, DASS-9 (Table 4). Most of these versions result in a three-factor structure, but there
is no similarity between items removed from the original DASS-21.
Table 4. Shortened versions of DASS-21
DASS Author Structure of Participants Item removeda
versions scales
DASS 20 Azma, Rusli, Quek and Three-factor Nurses in Malaysia D3
Noah (2014)
DASS 18 Oei, Sawang, Goh and Three-factor Malaysian, Indonesian, S8, S11, S12
Mukhtar (2013) Singaporean, Sri Lankan,
Taiwanese and Thai
Ahmad, Roslan, and Three-factor Malaysian students A7, A15, S8
Shamsuddin Othman
(2018)
Shea, Tennant, and Three-factor Employees of schools, A2, S11, D5
Pallant (2009) hospitals, small businesses
in Melbourne, Australia.
DASS 17 Ali and Green (2019) One-factor Inpatient Egyptian drug A2, S6, S14, S18
users
DASS 12 Osman et al. (2014) Three-factor Teenagers in Malaysia D5, D13, D16, S8,
S11, S12, A9, A15,
A20
DASS 9 & Yusoff, Rahim, Baba, Three-factor Medical students in D3, D13, D17, D21,
DASS 12 Ismail and Pa (2013) Malaysia S1, S8, S18, S12; A2,
A4, A19, A20
a
Order of items on DASS-21 scale by P. Lovibond & S. Lovibond (1995)
Data from a cross-sectional survey presented a picture of anxiety, depression, and stress among students who were
immediately confronted with an e-learning environment in the context of the COVID epidemic. The findings showed
that the anxiety factor has the lowest rate (19.7%) among students in an e-learning environment, which is in contrast
to the highest rate (47%) of anxiety among general university students reported by Bayram and Bilgel (2008).
Similarly, the anxiety factor among students in an e-learning environment was also strongly contrasted with a very
high anxiety rate (up to 54.5%) of prospective medical students by Yusoff et al. (2013), and up to 55% of medical
students by Teh, Ngo, Binti Zulkifli, Vellasamy and Suresh (2015). The highest rate of depression (up to 50%)
among students in e-learning environments exceeds the average rate of 30.6% (Ibrahim, Kelly, Adams & Glazebrook,
2013). All of these rates are calculated from moderate severity or above. In general, the immediate psychological
responses of students to an e-learning environment in the context of the COVID-19 epidemic indicate that a rate of
anxiety among students was low, however, the rate of depression and stress is very high. The findings of this study
also showed that there was a significant difference in the rate of anxiety among students through the use of the
DASS-18 and DASS-21 scales. We were surprised that an anxiety rate among students was significantly increased
from 19.7% of using DASS-18 to 43.1% of using DASS-21. In other words, many students may be misdiagnosed for
the level of anxiety when using DASS-21. This implies that the validity of the DASS-21 scale needs to be clearly
verified before they can be applied in each specific context.
The analysis of the relationship between socio-demographic factors and psychological impact shows that female
students are significantly associated with a higher level of anxiety. This result only partially supports the results of
Dyrbye et al. (2006) when they suggested that female students have a higher level of all three DASS subscale.
Residential factors are shown to be unrelated to DASS-18 scores of students with an e-learning environment in the
context of the COVID-19 epidemic. They differ from those reported by Bayram and Bilgel (2008) when they assert
that students from rural areas are associated with higher levels of depression, anxiety, and stress. Besides, living with
relatives and friends is associated with a lower level of stress for students with an e-learning environment, which
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have not been found in previous studies. GPA is also reported to be unrelated to the mental health of students in an
e-learning environment.
In general, this study contributes to the existing DASS literature a new DASS-18 model with three-factor structures
for measuring the mental health of Vietnamese students in an e-learning environment. The findings also show that
there are serious shortcomings if using the DASS-21 scale to test students' anxiety for an e-learning environment in
the context of the COVID-19 epidemic.
Acknowledgements
This research is funded by Hanoi University of Science and Technology (HUST) under grant number T2018-TT-002.
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