Assessing Mental Health Among Thai University Students: A Cross-Sectional Study

Even before the COVID-19 pandemic, experts warned of the increasing rate of mental well-being issues among university students. The pandemic impacted the university-age populations, which studies have found to be particularly at risk for COVID-related stress, anxiety, and depression. There is cause for concern, particularly in countries such as Thailand that have relatively underdeveloped mental health systems and greater stigmatization of psychopathology. As a step toward addressing this concern, this study assessed student well-being at a Thai university (N = 367) using three online survey instruments: the EPOCH Measure of Adolescent Well-being, the Subjective Happiness Scale (SHS), and the Satisfaction with Life Scale (SWLS). Participants’ scores on all three scales were relatively low compared to the results of previous studies conducted in Thailand and internationally. Based on these results, the authors call for further investigation and interventions to address the growing need for the cultivation of well-being among university students in Thailand.


Introduction
In recent years, the mental health of students in higher education has been a cause of increasing concern (Brown, 2021). Recently, more attention is being given to identifying the mental health challenges students face (Kendler et al., 2015;Mojtabai et al., 2015). Much such research has been conducted in Western contexts; this study seeks to contribute to the ongoing investigation of university students' mental health by conducting a crosssectional investigation of the mental health of students at a Thai university. The study uses three well-established instruments for assessing well-being and mental health: the EPOCH Measure of Adolescent Well-being, Subjective Happiness Scale (SHS), Satisfaction with Life Scale (SWLS). Earlier studies (e.g., Phulkerd et al., 2021) have applied these scales in the Thai context; however, these studies often targeted populations other than university students and most were conducted pre-pandemic. The objective of the study is to better understand the current state of Thai university students' mental health. Based on this understanding, appropriate interventions could designed and deployed.
It is well established that the typical ages during which one normally progresses through higher education (18-23) coincide with the average age of onset for a number of psychopathologies such as mood disorders, anxiety disorders, and substance abuse (Pedrelli et al., 2015). The epidemiological evidence within this target population, which indicates a higher prevalence of these psychopathologies, typically refers to the impact of significant life transitions and stressful events, which are associated with negative effects on academic performance (Bruffaerts et al., 2018). In order to understand the significance of assessing the consequences of the COVID-19 pandemic on youth mental health, the unique developmental changes that take place during adolescence should be taken into consideration (Magson et al., 2021). The term ''storm and stress'' is often used to describe adolescence, partly because of the intensified emotional responses to stressors caused by physical and chemical changes that are happening during this period (Bailen et al., 2019;Casey et al., 2010). Further, the onset of many emotional disorders or symptoms such as anxiety, depression, irritability, or anger tends to occur during adolescence and may result in sudden fluctuations in mood and emotional outbursts (World Health Organization, 2020). Altogether, the developmental changes of adolescents, early onset of certain mental disorders, and the additional stress and changes due to COVID-19 indicate that adolescents may be at a greater risk of mental illness (Magson et al., 2021).
This period, emerging adulthood, is an important time for students to gain increased autonomy from parents (Sussman & Arnett, 2014) and to explore the educational, occupational, and social opportunities available on campus. Unfortunately, given the 2020 global pandemic and its' impact on global higher education, students today have been studying online for over a year and do not have access to the college experience.
Previous investigations on psychological well-being have reported that gender was an important aspect of analysis. The study of the impact of gender has resulted in differing outcomes. For example, Gustems-Carnicer et al. (2019) found that male students reported lower well-being whereas Lucktong et al. (2018) claimed that male respondents had higher life satisfaction than females. This becomes even more problematic when Pumpuang et al. (2020) concluded that there were no gender specific differences in psychological well-being in Thailand. While it is well established that women are more likely to experience greater prevalence of stress, anxiety and mood disorders (Rainville & Hodes, 2019), the analysis of gender and well-being among Thai respondents is intended to gain a better understanding of the role, if any, gender has on well-being measurements within the Thai context.
With the implicit understanding that this pandemic is a significant and stressful event, the authors of this study aim to present data from three well-being surveys from university students in Thailand. We further aim to determine the level of well-being in relation to other national results of adolescent well-being. This study recognizes the fundamentally problematic nature of defining wellbeing (Diener, 1998). It has long been recognized that well-being should be conceptualized as a state of living which is greater than merely the absence of illness or the presence of symptoms which are often used in the diagnosis of psychopathology (Keyes, 2005). The inclusion of three quantitative well-being measures was intended to highlight the focus of well-being on functioning well and feeling good (Huppert & Johnson, 2010).
Therefore, from this perspective, the assessment of well-being in Thailand during the pandemic will allow for a potentially more nuanced understanding of the role and necessity of positive psychology, and positive psychology based interventions within the Thai context. Positive psychology, which aims to help individuals and communities to thrive (Seligman, 1998;Seligman & Csikszentmihalyi, 2000), may provide both a useful means of understanding the current state of well-being in Thailand and, based on this understanding, to effecting positive change in this time of crisis.

Overall State of Mental Health in Thailand
Mental distress has long been acknowledged as a universal health concern, yet the challenge remains prominent in some countries. Thailand, though advancing greatly in the latter half of the 20th century, still struggles to accurately assess and treat many mental health issues even as the prevalence of psychological distress grows. According to Surawith Konsomboon, the Deputy Health Minister of Thailand, around 20% or 13 million Thai nationals suffer from mental distress, but only 3 million seek professional help within a healthcare setting (Fernquest, 2012). In 2020, a mental health hotline in Thailand reported that among adolescent callers aged 9 to 11, stress or anxiety made up 37.3% of the calls, followed by problems with romantic relationship and depression or mixed anxiety depression at 31.9% and 13.4%, respectively (Department of Mental Health, 2021). In addition, suicidal ideation or suicide attempts accounted for only 0.99% of the callers of all ages in 2020 (Department of Mental Health, 2021). However, the rate of suicide in the same year was 7.37 per 100,000 compared to 5.77 in 2006 (Department of Mental Health, n.d.).
Globally, students often encounter various academic, financial, and social stressors that might adversely affect their mental health (Dusselier et al., 2005). Saipanish (2003) investigated the prevalence of stress among medical students in Thailand and reported that over half of the students reported mild stress. The students referred to exams as the main source of stress, followed by falling behind with the program reading schedule (Saipanish, 2003). Another study (Ratanasiripong & Rodriguez, 2011) examined depression among 320 Thai undergraduates and found that only 23% of the students were within the normal range. Further studies indicate approximately 47% of Thai nursing students were depressed (Ratanasiripong & Wang, 2011), which was slightly less than a previous study that reported 50% depression prevalence among Thai nurses (Ross et al., 2005). Cross-cultural research examining happiness among college students from 24 countries reported that students from Southeast Asia (including Thailand) had lower levels of happiness when compared to students from South America, sub-Saharan Africa, and the Caribbean (Peltzer et al., 2017). This result was consistent with a study conducted by Calderon et al. (2021) which assessed the happiness, psychological well-being, perceived stress, and health behaviors of Thai undergraduates by distributing a health and well-being survey to 478 students. Results indicate that Thai undergraduates had lower levels of happiness and a higher degree of perceived stress than the U.S. and the U.K. samples. In addition, the percentage of Thai undergraduates who reported that they had poor sleep patterns was 67%, while 40% of the students reported experiencing depressive symptoms (Calderon et al., 2021).
The increasing prevalence of mental health issues in Thailand becomes more problematic when one considers the lack of psychological practitioners, the stigmatization of psychological issues, and the impact of COVID-19. An assessment of the mental healthcare system in Thailand in 2017 noted the rate of psychiatrists and child psychiatrists was only 1.25 for every 100,000 people, and merely 0.75 of psychologists for the same amount of population (World Health Organization, n.d.). Wang, Tee, et al. (2021) reported that COVID-19 has had a more severe psychological impact on Thais than on citizens of six other middle-income countries in Asia. Even with the increasing trend of mental distress, the number of mental health professionals remains deficient in Thailand.

Measures
This study utilized three measures to investigate the wellbeing among undergraduate students in Thailand: the EPOCH Measure of Adolescent Well-being, the Subjective Happiness Scale (SHS), and the Satisfaction with Life Scale (SWLS). The use of the EPOCH as a tool to measure well-being among adolescents was based on the internal consistency coefficients of the measure across 10 samples ranging between 0.85 and 0.95, and the test-retest reliability proved stable in short term, with lower stability over longer periods (r = .71 for a 3-week interval and r = .39 for a 3-year interval). There was also supported data of convergent and discriminant validity (Kern et al., 2016). These instruments were chosen as the reliability and validity of the EPOCH (Kern et al., 2016), SHS (Lyubomirsky & Lepper, 1999), and SWLS (Diener, 1985) are well-established and widely implemented instruments for the assessment of wellbeing (Frazier et al., 2003). The study received approval from the university ethics committee before the start of data collection. The EPOCH Measure of Adolescent Well-being comprises five subscales: engagement, perseverance, optimism, connectedness, and happiness. Each subscale is measured by four Likert items, which are scored on a range of 1 to 5, and the subscale score is obtained by averaging the results of the four associated Likert items. The EPOCH scale was selected for this study because the ages of the majority of participants were in the range of 18 to 19. Furthermore, the language of the EPOCH scale would generally be easily comprehensible to students at the international college, which requires an IELTS score of 6.0 or equivalent for entry. The Subjective Happiness Scale (SHS) is a measure of global subjective happiness. It comprises four Likert items on a seven-point scale; the fourth item is reverse coded. An individual's score on the SHS is calculated by averaging their scores on the four items. The SHS has demonstrated admirable psychometric properties that were validated by multiple studies. Lyubomirsky and Lepper (1999) enlisted almost 3,000 respondents from 14 distinct samples varying in age, cultural, and occupational groups and reported that the SHS presented good to excellent internal consistency with a Cronbach's alpha, ranging from .79 to .94 (Lyubomirsky & Lepper, 1999). Test-retest and self-peer correlations also indicate good to excellent reliability, and the convergent and discriminant validity further indicates the use of SHS to accurately measure happiness based on a subjectivist approach (Lyubomirsky & Lepper, 1999). The Satisfaction with Life Scale (SWLS) measures global life satisfaction. It comprises five Likert items, each of which is scored on a seven-point scale. The results of the five items are averaged to yield a respondent's SWLS score. The utilization of the SWLS was based on the convergent validity with other scales and on its reliability and sensitivity. In the original research, Diener (1985) showed a coefficient alpha of .87. A meta-analysis of 62 studies that examined the reliability of the scale revealed a mean Cronbach's alpha of .78 with a 95% confidence interval ranging from 0.766 to 0.807 (Vassar, 2007). Combined, these three measures include a total of 29 items and are effective in providing an overall perspective on the participants' well-being. The questionnaires were administered during the April to July 2021 academic term.

Participants
Questionnaires were administered to first-and secondyear undergraduate students in the second and third weeks of the academic term via Google Forms. The questionnaires were distributed in general education courses to reach students from a wide range of programs. The researchers contacted the teachers of these courses, and the teachers posted the questionnaires to the learning management system of their respective courses. To complete the survey, participants were required to be logged into their university-provided Google for Education account, and only one response was allowed per account. The questionnaires, which had been approved by the university ethics committee, included an explanation indicating that they were voluntary. A total of 367 students completed the survey, of whom 149 selected ''male,'' 205 selected ''female,'' and 13 selected ''prefer not to say.''

Results
All analyses were performed in R (CAIE, 2019). First, descriptive statistics were calculated for each scale, and in the case of EPOCH for each subscale. These statistics were calculated for all respondents and for subsamples classified by the students' indicated gender. The descriptive statistics for the EPOCH measure and subscales are reported in Table 1 below.
The descriptive statistics of the responses to the SHS are reported in Table 2. The SHS provides one global measure of subjective happiness, so no subscales are indicated. The scoring of the fourth item was reversed before calculating the mean scores indicated in the table.
The global SWLS scores are shown in Table 3. These were calculated by averaging participants' responses to the five items that compose the scale.
Further inferential statistical methods were then used to compare the male and female subsamples. As the number of respondents who indicated ''Prefer not to say'' was small (n = 13), this subgroup was excluded from the comparisons. Note. The EPOCH subscales scores of the entire sample (N = 367), ''male'' (n = 149), ''female'' (n = 205), and ''prefer not to say'' (n = 13) subgroups are shown in Figure 1. Male and female students' responses on each subscale of EPOCH, on the SHS, and the SWLS were compared to determine whether there were any statistically significant differences between the groups. Participants' responses in each of the EPOCH subscales were examined to determine their normality. Visual inspection of Q-Q plots indicated that the data were not normally distributed; therefore, nonparametric methods were used to compare the groups. Table 4 shows the results of a Mann-Whitney U test comparing the median responses of male and female students. In the case of connectedness, the Mann-Whitney U test indicated that the median score for female students (Mdn = 4.25) was higher than the median score for male students (Mdn = 4.00), U = 12,854, p = .011. There was no statistically significant difference between the median scores of male and female students in engagement, perseverance, optimism, or happiness.
The SHS global scores of male and female students were then compared. Visual inspection of Q-Q plots showed that the data were normally distributed. An F-test did not indicate unequal variances, so a t-test was performed. There was no significant effect of gender, t(352) = .49, p = .625 on the means of male (M = 457) and female (M = 4.51) students.
The global SWLS scores of male and female students were similarly compared. Visual inspection of Q-Q plots indicated a normal distribution of the data, and an F-test failed to show differences in variance between these groups. A t-test showed no significant effect of gender between the male (M = 21.85) and female (M = 22.26) students, t(329.72) = 2.73, p = .465.

Discussion
The increasing popularity and subsequent growth in well-being literature as applied to university students highlight the importance of assessing well-being in this population. The COVID-19 pandemic continues to spread throughout Thailand, and based on the results of Pramukti et al. (2020), Wang, Tee, et al. (2021), and the data presented in this study, the reasonable  determination is that the SHS, SWLS, and EPOCH scores among Thai university students are comparably low. The mean score on the SHS in Thailand was 4.50. This is a slight reduction from the Calderon et al. (2021) study, which reported that Thai females had slightly higher SHS (M = 4.72) than Thai males (M = 4.51). The Calderon et al. (2021) data was collected in 2016, prior to the COVID-19 epidemic, which may explain this reduction.
The results from the EPOCH survey suggest that Thai students have a high degree of connectedness and a rather low level of engagement. This was unexpected given the harsh measures to combat the COVID-19 pandemic such as online education, mandatory social distancing, and almost a full year of lockdown in the capital. The relatively high degree of connectedness may help to mitigate the negative impact of the pandemic on wellbeing, as positive peer relationships can be a major source of social and psychological support, whereas negative peer relationships can lead to conflict, stress, and rejection, which may increase depressive symptoms and anxiety (La Greca & Harrison, 2005;Somerville, 2013).
Concerning gender and well-being, the present study indicated no statistically significant results between males and females. This contrasts with the previous studies in Romania (Preoteasa et al., 2016), China (Wang, Yan et al., 2019), and Belgium (De Coninck et al., 2019), which reported that female students had lower well-being than male students. Our results are in agreement with a study in the Republic of Georgia (Turashvili & Japaridze, 2012) and another in Columbia (Useche & Serge, 2016), which reported no significant differences among male and female well-being as measured by the SWLS.
The Satisfaction with Life Scale (SWLS) is a commonly-chosen metric of life satisfaction and is perhaps the most commonly used scale of well-being among cross-cultural or internationally comparative samples (Jang et al., 2017). A previous study of older Thais (Phulkerd et al., 2021) reported an average SWLS of 25 with men and women scoring equally, yet the same study indicated that the participants with a bachelor's degree or higher had a SWLS of 28, which is significantly higher than the 22.01 reported in this study. The authors posit that the variance in SWLS results is due to the timing of data collection. The Phulkerd et al. (2021) study collected data in Thailand prior to the COVID-19 outbreak, whereas the current study collected data during the outbreak. The results in Thailand are slightly lower than those reported among students in Jordan (Alorani & Alradaydeh, 2018) and in South Korea (M = 21.9) (Yun et al., 2019), and slightly higher than the results from a large study involving 4,795 respondents in China (M = 20.32) (Bai et al., 2011). A potentially problematic interpretation of items 4 and 5 on the SWLS is often discussed within the Asian context. Item 4 states ''So far I have gotten the important things I want in life'' whereas item 5 states ''If I could live my life over, I would change almost nothing.'' In studies with Asian populations, items 4 and 5 often receive lower responses than items 1 to 3. McDonald's (1999) study suggested items 1 to 3 on the SWLS were correlated with the present, whereas items 4 and 5 correlated with the past. Similar results from Wu and Yao (2006) also found a strong correlation between ''present'' and ''past'' items within the instrument.
Respondents in the ''prefer not to say'' category did report significantly lower levels of well-being on the SHS and the SWLS. Previous studies (Anderssen et al., 2020; of life satisfaction among transgender and gender incongruent participants report lower levels of life satisfaction. The Anderssen et al. (2020) study indicated 70% of binary transgender and 64% of non-binary transgender respondents had an SWLS of below 19, whereas only 35% the cisgender respondents had similar scores. Possible reasons for this include the discrimination, prejudice, stigmatization, and resulting negative psychological outcomes which are common for these groups (Testa et al., 2015). While this study provided the option ''prefer not to say,'' there is a body of research which suggests that the experiences of each subgroup outside of the binary cisgender representation differ (Johnson, 2016). Subjective well-being and life satisfaction measures within the non-binary sample are an important aspect of future research with large sample sizes as the experiences of this group will not necessarily overlap with the ''male'' or ''female'' identity and these individuals may identify with both or neither . The experience of various groups during crises may differ; considering the impact of such events on their experience may be a source of useful insight. While ''prefer not to say'' is not necessarily equivalent to gender diverse, participants' selection of this gender option is a likely indicator of gender diversity and a cause for further investigation in a later study.

Future Directions
Based on these preliminary findings, the authors have concluded that the inclusion of positive psychologybased interventions in the Thai educational curriculum should be considered. The development of a positive curriculum within the Thai context may be as successful, as the ''positive university'' has gained momentum, with universities in the United States, Mexico, Portugal, China, and others embracing the application of positive psychology principles to enhance the well-being of their students, faculty, staff, and the organization as a whole (Harzer, 2020;Oades et al., 2011;Seligman & Adler, 2018). The EPOCH, SWLS, and SHS were created to measure well-being within the Western context. The validation of local language psychometrics that take into account the unique sociocultural variances is essential to gain a more nuanced understanding of this phenomenon. Previous studies have suggested that the conceptualization of well-being in the West is different to that in the East (Suh & Choi, 2018). The development of a Persian EPOCH (Taheri et al., 2022) among female Iranian students reported consistency, validity, and suitability as a measure of well-being within that context. Given the limited number of studies among adolescent populations in collectivist cultures such as Portugal (Silva, Taveira et al., 2015), Turkey (Durak et al., 2010), and Serbia (Jovanovic´, 2016), and the impact of the COVID-19 pandemic, the authors of this study argue that the translation, validation, and investigation of various psychometrics of well-being is fundamental to the development of understanding well-being in Thailand specifically and throughout Asia in general.

Limitations
The study reported in this article is a preliminary investigation of well-being among Thai university students. The participants in this study were drawn from a single university, which limits the generalizability of the results. The use of questionnaires to collect data also presents limitations, as respondents may not be completely forthright in their responses. Gaining a thorough understanding of this complex issue will require investigation using a variety of research methods. The collection of longitudinal data would provide further insight, as would the use of qualitative or mixed methods.

Conclusion
In summary, the measurement of well-being in Thailand, particularly among adolescents and young adults during the post-pandemic period, is a fundamental aspect of understanding the psychological impact of the COVID-19 pandemic. The Thai government's responseimplementing emergency decrees, stay-at-home orders, mandatory quarantine systems for the infected, physical and social distancing, and the closing of public and private institutions including schools-seems to have had an impact on the public's mental health. Regular assessments of well-being over a prolonged period will help to identify and track transitions in adolescent mental health. The identification of low EPOCH, SWLS, or SHS scores can help academics and psychologists develop specific interventions aimed at increasing wellbeing and improving the overall quality of life.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research has been generously provided by Mahidol University International College. The research was funded by a grant to the Positive Psychology Research Cluster.

Ethical Approval
All procedures performed in this study were in accordance with the ethical standards of Mahidol University with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The institutional IRB protocol number is MU-CIRB2021/108.0203.

Informed Consent
Informed consent was obtained from all participants in the study.