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The relationships between the use of

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self-regulated learning strategies and
depression among medical students: An
accelerated prospective cohort study
ab cd
Hung Van Nguyen , Wongsa Laohasiriwong , Jiamjit
c c ef
Saengsuwan , Bandit Thinkhamrop & Pamela Wright
a
Public Health Program, Graduate School, Khon Kaen University,
Khon Kaen, Thailand
b
Faculty of Public Health, Hue University of Medicine and
Pharmacy, Hue city, Vietnam
c
Faculty of Public Health, Khon Kaen University, Khon Kaen,
Thailand
d
Board Committee of Research and Training Centre for Enhancing
Quality of Life of Working Age People (REQW), Khon Kaen
Univeristy, Khon Kaen, Thailand
e
The Netherlands Project Among Eight Medical Universities,
Hanoi, Vietnam
f
The Medical Committee Netherlands-Vietnam, Hanoi, Vietnam
Published online: 14 Mar 2014.

To cite this article: Hung Van Nguyen, Wongsa Laohasiriwong, Jiamjit Saengsuwan, Bandit
Thinkhamrop & Pamela Wright (2015) The relationships between the use of self-regulated learning
strategies and depression among medical students: An accelerated prospective cohort study,
Psychology, Health & Medicine, 20:1, 59-70, DOI: 10.1080/13548506.2014.894640

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 Psychology, Health & Medicine, 2015
Vol. 20, No. 1, 59–70, http://dx.doi.org/10.1080/13548506.2014.894640

The relationships between the use of self-regulated learning strategies

and depression among medical students: An accelerated prospective
cohort study
Hung Van Nguyena,b, Wongsa Laohasiriwongc,d*, Jiamjit Saengsuwanc,
Bandit Thinkhamropc and Pamela Wrighte,f
Downloaded by [Gebze Yuksek Teknoloji Enstitïsu ] at 19:59 25 December 2014

a
Public Health Program, Graduate School, Khon Kaen University, Khon Kaen, Thailand;
b
Faculty of Public Health, Hue University of Medicine and Pharmacy, Hue city, Vietnam;
c
Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; dBoard Committee of
Research and Training Centre for Enhancing Quality of Life of Working Age People (REQW),
Khon Kaen Univeristy, Khon Kaen, Thailand; eThe Netherlands Project Among Eight Medical
Universities, Hanoi, Vietnam; fThe Medical Committee Netherlands-Vietnam, Hanoi, Vietnam
(Received 13 May 2013; accepted 10 February 2014)

We conducted this study to determine the relationships between the use of

self-regulated learning strategies (SRL) and depression scores among medical
students. An accelerated prospective cohort study among 623 students at a public
medical university in Vietnam was carried out during the academic year 2012–2013.
The Depression, Anxiety and Stress Scales (21 items) was used to measure depression
scores as the primary research outcome, and to measure anxiety and stress scores as
the confounding variables. Fourteen SRL subscales including intrinsic/extrinsic goal
orientation, task value, self-efficacy for learning, control of learning beliefs, rehearsal,
elaboration, organization, critical thinking, meta-cognitive strategies, time and study
environment, effort regulation, peer learning, and help seeking were measured using
the Motivated Strategies for Learning Questionnaire. Data were collected at two
points in time (once each semester). There were 744 responses at the first time
(95.88%) and 623 at time two (drop-out rate of 16.26%). The generalized estimating
equation was applied to identify any relationships between the use of each SRL sub-
scale and depression scores at time 2, adjusting for the effects of depression at time 1,
anxiety, stress, within cluster correlation, and potential demographic covariates.
Separate multivariate GEE analysis indicated that all SRL subscales were significantly
negatively associated with depression scores, except for extrinsic goal orientation and
peer learning. Whereas full multivariate GEE analysis revealed that self-efficacyT1,
help-seekingT1, time and study environmentT2 were found to be significantly
negatively associated with depressionT2, adjusting for the effects of depressionT1,
anxiety, stress, and demographic covariates. The results should be used to provide
appropriate support for medical students to reduce depression.
Keywords: depression; self-regulated learning; medical students; Vietnam

Introduction
Purpose and hypothesis
Medical education has consistently been found to be a stressful environment that
exposes students to higher risk of depression than in other education (Dyrbye, Thomas,

*Corresponding author. Email: hcmp@huemed-univ.edu.vn

© 2014 Taylor & Francis

 60 H.V. Nguyen et al.

& Shanafelt, 2006; Goebert et al., 2009). Depression can impair students’ academic
achievement, clinical performance, mental and physical well-being (Al-Qaisy, 2011;
Yasin & Dzulkifli, 2011).
The use of self-regulated learning strategies (SRL) has been assumed to reduce this
condition (Akin, 2008; Artino, Hemmer, & Durning, 2011; Doron, Stephan, Maiano, &
Le Scanff, 2011; Pekrun, Goetz, Titz, & Perry, 2002; Shikai, Shono, & Kitamura,
2009). However, research on this issue has been very limited. According to Pintrich,
SRL is “an active, constructive process whereby learners set goals for their learning and
then attempt to monitor, regulate, and control their cognition, motivation, and behaviors,
guided and constrained by their goals and the contextual features of environment”
(Pintrich, 2010, pp. 453). The use of this strategy has been consistently found to affect
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positively students’ academic achievements and negatively their anxiety (Hosain,

Eghbal, & Fatemeh, 2012; Kosnin, 2007). However, studies on its effect on depression
are very limited and mainly focused either on the effect of a singular aspect of SRL or
on the general symptomatic manifestations of depression (Akin, 2008; Artino et al.,
2011; Pekrun et al., 2002). There may be no comprehensive study yet, considering all
SRL aspects in relation to depression among medical students.
In Vietnam, medical education has undergone changes toward a more student-cen-
tered approach (Fan et al., 2012). However, students’ passivity in learning and a high
prevalence of depression remain as emerging problems (Do & Tasanapradit, 2008).
Furthermore, the lack of evidences about these problems has created difficulties for pol-
icy-makers. This study, therefore, aims to investigate the relationships between the use
of SRL strategies and depression scores among medical students. The findings can be
helpful for learners, teachers, and school authorities to create policies and programs that
can improve students’ learning and their mental well-being.

Theoretical background
Although the mechanism underlying the relationship between SRL and depression is not
well documented, recent studies have suggested that using this strategy can influence
students’ depression by strengthening coping mechanisms (Doron et al., 2011; Shikai
et al., 2009). When reviewing the SRL model of Pintrich (2004) and the Coping model
of Carver, Scheier, and Weintraub (1989), we recognized an interactive sharing between
these models (appraisal, planning, reinterpretation, and evaluation). Thus, from a learn-
ing perspective, SRL could be seen as an active coping strategy in response to academic
stressors that could enable students to reduce their vulnerability to depression and to
improve their academic achievement (Doron et al., 2011; Newman, 2002; Shikai et al.,
2009). According to Pintrich (2004), SRL learners often execute a learning task through
four typical phases: forethought (appraisal and planning), monitoring and control (rein-
terpretation), and reflection (evaluation). Through these phases, they appraise the task
demands, intrinsic and extrinsic characteristics that form the basics for planning to deal
with that task. When facing challenging tasks, SRL learners tend to treat them as oppor-
tunities for improvement even if that task is uninteresting and difficult for them (Elliot,
Thrash, & Murayama, 2011; Newman, 2002). Towards the end of the learning cycle,
SRL learners often evaluate whether their learning strategies, learning motivation, and
contextual characteristics are suitable to the task demands and the goal attainment. In
case they fail to attain the learning goal, SRL learners tend to attribute this failure to
inappropriate strategies and/or insufficient motivation rather than to their inability to
learn (Ertmer & Newby, 1996; Tavakolizadeh & Qavam, 2011). Then they make
 Psychology, Health & Medicine 61

necessary changes and/or adjustments, plan additional time and effort, and seek
necessary help to optimize their learning. These systematic activities make them aware
of the nature of the task (task value and difficulty) and its demands in accordance with
intrinsic characteristics (goal orientation, self-efficacy, and effort regulation) and
extrinsic features (time and study environment, help-seeking, and peer learning). That
helps them to commit optimal effort, motivation, and strategies to deal with academic
stressors, resulting in less vulnerability to depression (Doron et al., 2011; Elliot et al.,
2011; Madjar et al., 2012; Rijavec & Brdar, 2002; Shikai et al., 2009; Tavakolizadeh &
Qavam, 2011). Based on this evidence, we hypothesized that using SRL strategies could
help students to cope better with academic stressors which would help to reduce
depressive moods among medical students.
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Methods
Design and ethical approval
To answer the research question and to improve the weaknesses of previous study
designs, a prospective cohort design with repeated measurement was applied. The cur-
rent training curriculum for the general practitioners at Hue University of Medicine and
Pharmacy (HUMP) is a six-year program. Obviously, each academic year is a distinctive
educational context in terms of curriculum, subjects to be learned, and instructors. It is
also highly likely that students’ use of SRL strategies and their experience of depressive
symptoms can vary depending on the educational period and context (Pintrich, 2004).
To tackle this complexity, conventionally, a five-year longitudinal study with repeated
measurement should be applied since students attend the medical college until year five.
However, this design would be very expensive in terms of time and effort. An acceler-
ated prospective cohort design can be a good solution. In this design, a pooled cohort
consisting of five sub-cohorts representing students from five academic years was fol-
lowed up during one academic year. The measures of exposures and outcomes of inter-
est were repeated at two times during the academic year 2012–2013. This method
allowed us to shorten the time of follow-up to one year while the magnitude of effect
can be generalized to the target population attending all five years, using the data from
one year of follow-up.
The proposal and tools of the study were approved by the Ethics Committee for
Human Research of Khon Kaen University, Thailand. Before data collection, the
Explanation and Informed Consent forms were sent to participants. Those who agreed
to join the study completed and signed the Informed Consent Form and returned it to
the research team. The names of participants were coded as numbers to protect students’
anonymity.

Participants
Stratified random sampling resulted in 776 undergraduate medical students in the first to
the fifth years at HUMP who were invited to join the study. The sixth-year students
were not invited to join because they were about to graduate at the time the study was
carried out. To recruit the required study sample, we first stratified students by years
then by classes they were belonging to. A simple random sampling procedure was then
applied to each class to recruit the required sample size.
 62 H.V. Nguyen et al.

There were 744 responses at the first time (95.88%) and 623 at time two (drop-out
rate of 16.26%). There was no difference in depression and SRL scores between the
group who stayed in the study and those who later dropped out.

Instruments
The Depression Anxiety and Stress Scales 21 items (DASS-21) (Livibond & Livibond,
1995)
The DASS-21 was used to measure depression scores as the primary research outcome
and to measure anxiety and stress scores as confounding variables. It was translated into
Vietnamese by two psychiatrists and two teachers of English at HUMP using forward
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and backward procedure to check accuracy. The Depression subscale assesses dysphoria,
hopelessness, devaluation life, self-deprecation, lack of interest/involvement, anhedonia,
and inertia. The Anxiety subscale assesses autonomic arousal, skeletal muscle effects,
situational anxiety, and subjective experience of anxious affect. The Stress subscale
assesses difficulty relaxing, nervous arousal, being easily upset/agitated, irritable/over-
reactive, and impatient (Psychology Foundation of Australia, 2012). Each subscale com-
prises seven items and each item is scored from 0 to 3 on a Likert scale ranging from
“does not apply to me” (0) to “applies to me very much or most of the time” (3). The
sum of scores for each subscale provides total score. Therefore, the minimum score was
0 and the maximum score was 21. The Cronbach’s alpha of the depression, anxiety, and
stress was .81, .75, and .78, respectively, indicating that it was internally consistent
(Crawford & Henry, 2003; Tran, Tran & Fisher, 2013).

The Motivated Strategies for Learning Questionnaire (Pintrich, Smith, Garcia, &
McKeachie, 1991)
The Motivated Strategies for Learning Questionnaire (MSLQ) is a self-reporting instru-
ment used with permission from its developers to assess students’ motivational orienta-
tions and their use of different learning strategies. There are essentially two sections to
the MSLQ. The motivational section consists of 26 items that assess students’ goal ori-
entation (intrinsic/extrinsic goal orientation), value beliefs for the course (task value),
and their beliefs about their skills to succeed in the course (control of learning beliefs
and self-efficacy) (Pintrich et al., 1991). The learning strategy section includes 19 items
regarding students’ use of different cognitive strategies (rehearsal, elaboration, critical
thinking, and organization), 12 items concerning meta-cognitive strategy, and 19 items
referring to management of different learning resources (time and study environment,
help seeking, peer learning, and effort regulation).
Participants were asked to score each item from 1 to 7 on a Likert scale ranging
from “not at all true of me” (1) to “very true of me” (7). The Cronbach’s alphas of most
SRL subscales approached or exceeded .70, indicating that each subscale was internally
consistent. There were two subscales which had low Cronbach’s alphas: effort regulation
(α = .56) and help-seeking (α = .51), which is consistent with those of the original ver-
sion used by the developers (Pintrich et al., 1991). The total score for each subscale
was computed by taking the average of the scores on the items that make up that sub-
scale. Thus, the minimum score of each subscale was 1 and the maximum score was 7.
In addition, a questionnaire developed by the researchers was used to record demo-
graphic data including age, sex, ethnicity, permanent residence, years of study, GPA,
 Psychology, Health & Medicine 63

parents and parental marital status, financial difficulty, part-time job, family history of
depression, and loss of relatives within one year.

Measurement
The students’ class schedule prevented randomized administration of instruments with
regard to time of day. Therefore, a battery consisting of DASS-21, MSLQ, and demo-
graphic questionnaires was administered to participants in classrooms after lecture ses-
sions; it took them 30 min to complete. There were two time points of data collection
during the academic year 2012–2013. The first was in June 2012 (first semester) and
the second was in January 2013 (second semester). All data were collected outside of
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the exam period to avoid its effect on depression.

Statistical analysis
We analyzed the data using STATA version 10.0 (StataCorp, 2007). Mean and standard
deviation (SD) were used to summarize continuous data, frequency and percentage (%)
for categorical data. Generalized estimating equation (GEE) was used to identify any
relationships between SRL subscales and depression scores adjusting for the effects of
other covariates. The following quantities were used to build the GEE model. Type of

Table 1. Demographic characteristics of the study sample (n = 623).

Time 1 Time 2
Characteristics Response n % n %
Age (mean, SD) Years 623 20.29 ± 1.5 623 20.29 ± 1.5
Year of study Year 1 141 22.6 141 22.6
Year 2 145 23.3 145 23.3
Year 3 116 18.6 116 18.6
Year 4 120 19.3 120 19.3
Year 5 101 16.2 101 16.2
Sex Male 342 54.9 342 54.9
Female 281 45.1 281 45.1
Ethnic groups Minority 04 .6 04 .6
Majority 619 99.4 619 99.4
Residence Urban area 183 29.4 183 29.4
Rural area 392 62.9 392 62.9
Remote area 48 7.7 48 7.7
Financial difficulty Yes 61 9.8 52 8.3
No 562 90.2 571 91.7
Part-time working Yes 72 11.6 69 11.1
No 551 88.4 554 88.9
Family history of depression Yes 14 2.2 14 2.2
No 609 97.8 609 97.8
Loss of relative within 1 year Yes 102 83.6 83 13.3
No 521 16.4 540 86.7
Orphaned Yes 37 5.9 37 5.9
No 586 94.1 586 94.1
Parental divorced Yes 19 3.1 19 3.1
No 604 96.9 604 96.9
Note: SD = Standard deviation.
 64 H.V. Nguyen et al.

model: Population Average, cluster identifier variable: students’ class, Link function:
Identity, Correlation structure: Exchangeable (Hardin & Hilbe, 2003). Prior to multivari-
ate analysis, we performed univariate analysis to explore the effects of each SRL sub-
scale on depression. From this analysis, the variables with a p-value less than .20 were
selected for the multivariate model.
SRL subscales were found to be highly intercorrelated (r ranges up to .76), indicat-
ing that there might be multicollinearity if we included all at once into the same multi-
variate model (full model). Therefore, we fitted the model for each SRL subscale
separately to predict depressionT2, adjusting for the effects of depressionT1, anxiety,
stress, and other covariates (separate model).
The QIC test (quasilikelihood under the independent model criterion) and standard
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errors of the estimators were used to fit the GEE model. The best fitted model was the
one which had smallest QIC value and standard errors of estimators (Cui, 2007; Hardin
& Hilbe, 2003).
Results were reported showing mean difference, 95% confident interval (95% CI),
and the level of statistical significance was set at .05.

Results
Descriptive statistics
Among the 623 participants followed up to the end of the study, slightly more than half
were male (54.9%); their ages ranged from 18 to 27 years (mean 20.92, SD = 1.5). Of
these, 619 (99.4%) reported belonging to the Kinh ethnic group (the majority in the
population) and 4 (.6%) belonged to minority groups (Table 1). The descriptive statistics
of depression, SRL subscales, and other covariates are presented in Tables 1 and 2.

Table 2. Descriptive statistics of DASS and SRL subscales (n = 623).

Time 1 Time 2 Alpha (Pintrich
Subscales Total items (mean ± SD) (mean ± SD) Alpha et al., 1991)
DASS-21 subscales
Depression 7 4.28 ± 3.01 4.43 ± 3.28 .81 –
Anxiety 7 5.62 ± 3.17 5.31 ± 3.52 .75 –
Stress 7 7.03 ± 3.06 7.05 ± 3.48 .78 –
SRL subscales
Intrinsic goal orientation 4 4.82 ± .99 4.84 ± 1.03 .68 .74
Extrinsic goal orientation 4 4.29 ± 1.10 4.30 ± 1.09 .68 .62
Task value 6 4.88 ± .92 4.99 ± .94 .78 .90
Control of learning beliefs 4 5.71 ± .83 5.58 ± 1.06 .64 .68
Self-efficacy for learning 8 4.32 ± .96 4.47 ± .92 .87 .93
Rehearsal 4 4.54 ± .97 4.61 ± .92 .64 .69
Elaboration 6 4.70 ± .91 4.78 ± .97 .81 .76
Organization 4 4.68 ± 1.04 4.79 ± 1.07 .72 .64
Critical thinking 5 4.30 ± .98 4.44 ± .96 .76 .80
Meta-cognitive 12 4.62 ± .77 4.67 ± .82 .81 .79
Time and study environment 8 4.43 ± .84 4.48 ± .85 .69 .76
Effort regulation 4 4.11 ± 1.08 4.17 ± 1.02 .56 .69
Peer learning 3 3.52 ± 1.13 3.89 ± 1.10 .74 .76
Help seeking 4 4.18 ± .96 4.09 ± .92 .51 .52
Notes: DASS-21: Depression Anxiety and Stress Scales 21 items; SRL: self-regulated learning; SD: standard
deviation.
 Psychology, Health & Medicine 65

The relationships between SRL subscales and depression scores

Results from separate multivariate models indicated that all the SRL subscales (except
extrinsic goal orientation and peer learning) were found to have significant negative
associations with depression scores, controlling for the effects of depressionT1,
anxiety, stress, and other demographic covariates (Table 3). Whereas, the full multivar-
iate model indicated that self-efficacyT1, help-seekingT1, time and study environ-
mentT2, and peer learningT2 were found to be significant predictors of depressionT2
(Tables 4 and 5).

Discussion
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Our purpose was to investigate the relationships between the use of SRL strategies and
depression scores among medical students. The findings strongly supported our hypothe-
sis that increased use of SRL strategies could help to reduce depressive scores among
medical students. The magnitudes of the observed effects were considered to be large
and clinically significant. For instance, those who reported a medium score (4) for
learning motivation, learning strategies, and management of learning resources at time
two also tended to report lower scores for depression (−4.386, 95% CI: −7.596 to
−2.076; −7.864, 95% CI: −11.408 to −4.32; −4.628, 95% CI: −6.876 to −2.38,
respectively).
Our findings were consistent with those of previous studies (Akin, 2008; Bandura,
2001; Ghaderi & Salehi, 2011; Scott & Dearing, 2012; Sideridis, 2005). However, those
studies mainly focused on the effects of self-efficacy and goal orientation on depression,

Table 3. Summary of the separate multivariate models for estimating the effect of each SRL
subscale on depressionT2, controlling for the effects of depressionT1, anxiety, stress, and other
demographic covariates (n = 623).
DepressionT2
Time 1 Time 2
Model SRL subscales Mean dif. 95% CI Mean dif. 95% CI
Learning motivation
1 Intrinsic goal orientation −.173 −.395; .048 −.274*** −.438; −.110
2 Extrinsic goal orientation .057 −.142; .254 −.099 −.253; .053
3 Task values −.291* −.541; −.042 −.344*** −.527; −.161
4 Control of learning beliefs .015 −.247; .277 −.198* −.356; −.040
5 Self-efficacy −.407*** −.640; −.174 −.393*** −.578; −.208
Cognitive and meta-cognitive strategies
6 Rehearsal −.427*** −.652; −.203 −.390*** −.559; −.221
7 Elaboration −.444*** −.687; −.200 −.413*** −.587; −.239
8 Organization −.247* −.461; −.032 −.411*** −.567; −.255
9 Critical thinking −.218 −.447; .010 −.264** −.441; −.087
10 Meta-cognitive −.540*** −.824; −.257 −.488*** −.698; −.278
Resources management
11 Time and study environment −.558*** −.831; −.285 −.579*** −.785; −.373
12 Effort regulation −.365*** −.576; −.154 −.309*** −.481; −.137
13 Peer learning −.175 −.371; .021 −.113 −.268; .042
14 Help seeking −.361** −.586; −.136 −.269** −.453; −.085
Notes: Mean dif.: mean difference; SRL: self-regulated learning; 95% CI: 95% confident interval.
*
p < .05; **p < .01; ***p < .001.
 66 H.V. Nguyen et al.

Table 4. Full multivariate model for estimating depressionT2 from SRL subscales, depression,
anxiety, stress, and other demographic variables measured at time 1 (n = 623).
DepressionT2
Variables Mean difference 95% CI
Exposures (SRL subscales)
Motivation
Intrinsic goal orientationT1 .059 −.227 .345
Extrinsic goal orientationT1 .173 −.039 .386
Task valuesT1 .045 −.264 .354
Self-efficacyT1 −.342* −.657 −.027
Cognitive and meta-cognitive strategies
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RehearsalT1 −.269 −.568 .028

ElaborationT1 −.225 −.646 .196
OrganizationT1 .222 −.080 .525
Critical thinkingT1 .213 −.133 .557
Meta-cognitionT1 −.158 −.627 .311
Resources management
Time and study environmentT1 −.174 −.563 .214
Effort regulationT1 −.107 −.369 .156
Peer learningT1 .102 −.135 .339
Help seekingT1 −.277* −.531 −.024
Confounding variables (significant predictors)
DepressionT1 .526*** .431 .621
AnxietyT1 .072 −.019 .164
StressT1 .114* .014 .213
Notes: GEE: Generalized estimating equation; SRL: self-regulated learning; T1: measurement at time 1;
T2: measurement at time 2; 95% CI: 95% confident interval.
*
p < .05; ***p < .001.

while the effects of other SRL subscales such as cognitive, meta-cognitive, and resources
management were not studied (Pekrun et al., 2002). As hypothesized, these strategies
were found to be significantly negatively associated with depression, suggesting that
those who better regulate their learning process tend to score lower for depression.
Medical education is recognized as having an extremely heavy academic burden in terms
of workload, too much content, and lack of leisure time. This burden has been found to
produce negative emotions among students (Dyrbye et al., 2006; Goebert et al., 2009).
Our findings provided important evidences that can improve the learning environment in
medical schools. Promoting the use of SRL strategies could not only help to improve stu-
dents’ academic achievements (Hosain et al., 2012; Kosnin, 2007; Pintrich, 2010) and
clinical performance (Kuiper, Pesut, & Kautz, 2009) but could also help reduce the occur-
rence of depressive moods among medical students (Artino et al., 2011).
Regarding the magnitude of the effects, the separate multivariate model indicated
that all SRL subscales (except extrinsic goal orientation and peer learning) were found
to be significantly negatively associated with depressionT2 when adjusted for depres-
sionT1, anxiety, stress, and other demographic covariates. However, the full multivariate
model revealed that only self-efficacy for learning, time and study environment, and
help seeking were significant negative predictors of depression, while peer learning was
found to be significantly positively associated with depression. Theoretically, this find-
ing seemed to be inconsistent. According to Zidek, Wong, Le, and Burnett (1996); high
multicollinearity among explanatory variables can cause underestimation problem in
causal models. Our data indicated that SRL subscales were highly intercorrelated
 Psychology, Health & Medicine 67

Table 5. Full multivariate model for estimating depressionT2 from SRL subscales, depressionT1,
anxiety, stress, and other demographic variables measured at time 2 (n = 623).
DepressionT2
Variables Mean difference 95% CI
Exposures (SRL subscales)
Motivation
Intrinsic goal orientationT2 −.050 −.291 .190
Task valuesT2 .066 −.217 .349
Control of learning beliefsT2 −.008 −.206 .190
Self-efficacyT2 −.211 −.457 .035
Cognitive and meta-cognitive strategies
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RehearsalT2 −.059 −.309 .190

ElaborationT2 −.115 −.449 .218
OrganizationT2 −.193 −.450 .064
Critical thinkingT2 .126 −.149 .401
Meta-cognitionT2 .034 −.366 .434
Resources management
Time and study environmentT2 −.333* −.616 −.049
Effort regulationT2 −.079 −.285 .125
Peer learningT2 .199* .008 .392
Help seekingT2 −.139 −.354 .075
Confounding variables (significant predictors)
DepressionT1 .323*** .260 .386
AnxietyT2 .174*** .110 .237
StressT2 .376*** .310 .442
Notes: GEE: Generalized estimating equation; SRL: self-regulated learning; T1: measurement at time 1;
T2: measurement at time 2; 95% CI: 95% confident interval.
*
p < .05; ***p < .001.

(r ranges up to .76), therefore, multicollinearity might have caused an underestimation

problem. To eliminate the multicollinearity statistically, we included parts of each SRL
subscale in the multivariate model to estimate its effect on depressionT2, controlling for
the effects of depressionT1, anxiety, stress, and other demographic covariates. The
results indicated that all SRL subscales had significant negative associations with
depression, except for extrinsic goal orientation and peer learning. In addition, the stan-
dard errors of the estimators in the separate models were found to be smaller than those
in the full model. This suggested that the separate multivariate models might be better
fitted with the data than the full model. We suggest that a future study should seek alter-
native instruments for measuring SRL which consist of fewer subscales and display
higher reliability.
Although significant relationships between the use of SRL and depression were
found, however, several limitations should be also noted to provide direction for future
research. First, the fact that all of our participating medical students were following a
traditional curriculum means that these findings cannot be generalized to other student
populations nor to medical students following other types of curriculum that are more
student-centered, such as problem-based learning. It has been suggested in the literature
that students following a problem-based learning curriculum may apply SRL strategies
more appropriately than those in a traditional curriculum (Lycke et al., 2006; Sungur &
Tekkaya, 2006). Therefore, the magnitude of effects of SRL strategies on depression
scores could be optimized. We suggest that a future study should involve students from
a more student-centered curriculum to confirm these effects. Second, although the
 68 H.V. Nguyen et al.

findings have suggested a direction of the relationships between SRL and depression,
however, previous researchers have claimed that the relationship might be reciprocal.
Our study design might not be sufficient to address fully this causality, because it could
not determine which preceded the other. We suggest that a future experimental study
would be necessary to confirm the causal direction. Thirdly, the MSLQ strategies con-
sisting of many subscales were found to be highly intercorrelated. This might cause a
multicollinearity problem for the predictive models. In addition, some subscales of
MSLQ such as peer learning and help seeking had extremely low reliability. These
problems can lead to underestimation of the magnitude of effects. We suggest that future
studies should seek alternative instruments which consist of fewer subscales and display
higher internal consistency.
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Conclusion
The findings strongly supported our hypothesis that using SRL strategies could help to
prevent depressive moods among medical students. Promoting use of SRL strategies
could not only help to optimize the students’ academic achievement and clinical
performance, but could also help to improve their mental well-being. Therefore, the
innovation of teaching and learning in medical schools should take SRL into account as
an effective strategy (Artino et al., 2011).

Acknowledgments
The authors wish to thank The Royal Netherlands Embassy in Hanoi and the Management Board
of Vietnam – The Netherlands Project among Eight Medical Universities in Vietnam for their
financial support for this study.

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