INTRODUCTION
Adverse childhood experiences (ACEs) encompass a wide range of traumatic events occurring before the age of 18, including physical, sexual, and emotional abuse; neglect; and exposure to household dysfunction such as domestic violence, parental separation, mental health issues, or substance eISSN 1976-3026 OPEN ACCESS misuse [1,2]. The risk of suffering ACEs can be influenced by various individual, family, and community circumstances, such as living in unstable housing, having parents who have encountered ACEs, and growing up in areas with high levels of social and environmental dysfunction [3]. ACEs are common in the general population, and global epidemiological investigations highlight the pervasive nature of ACEs. For example, the US Centers for Disease Control and Prevention estimates that 61% of adults have encountered at least one ACE, with 16% reporting four or more ACEs [4].
The negative consequences of ACEs for both physical and mental health are far-reaching. Research has shown that ACEs are linked to a range of health conditions, including asthma, arthritis, chronic obstructive pulmonary disease, heart disease, health risk behaviors, and mental health disorders [5,6]. Among these, depression stands out as one of the most common chronic conditions for those with a history of ACEs. In North America, for instance, ACEs are attributed to approximately 40% of depression cases, the highest proportion among all health conditions [7]. Furthermore, ACEs are associated with at least five of the top ten leading causes of death, underscoring their significance as a public health concern. However, ACEs are preventable, and it is estimated that addressing or mitigating their psychological impact could prevent approximately 44% of mental health disorders in adults [4]. Preventing ACEs is therefore crucial to addressing multiple public health and social challenges, as well as improving the well-being of children, families, and communities.
Young adulthood is a pivotal stage in human development, during which many mental health disorders first emerge, with 75% of all mental illnesses either appearing or fully developing before the age of 25 [8,9]. Among this group, first-year university students are increasingly recognized as particularly vulnerable to the enduring effects of ACEs [10]. Indeed, the transition to university life, which involves navigating new academic, social, and personal challenges, can amplify pre-existing psychological vulnerabilities. To date, several studies have documented the prevalence of childhood adversities in university student populations. For example, a study of 2,637 college students in the USA found that 16.3% reported experiencing multiple ACEs [11]. Among these, emotional abuse—either alone or combined with other forms of abuse and neglect— was particularly linked to mental health negative outcomes such as anxiety and depression. Similarly, a web-based survey of 1,260 first-year students from two universities in South Africa revealed that 48% had encountered one or more forms of ACEs, with emotional abuse (26.7%) and physical abuse (20.8%) being the most common. Both types of abuse were strongly predictive of current depression, anxiety, and substance use [12]. Furthermore, these findings are consistent with broader research that shows university students report significantly higher levels of depression, anxiety, and stress compared to the general population, underscoring the unique psychological challenges faced during this pivotal life stage [13].
Despite growing recognition of the impact of childhood adversities, research on the extent and specific effects of ACEs among university students remains limited, particularly in low- and middle-income countries such as Vietnam, where unique cultural and socio-economic contexts may shape the experiences and impacts of ACEs in ways that remain insufficiently explored. For example, a 2015 study conducted among 2,099 medical students across eight universities identified significant associations between ACEs and mental health outcomes [14]; however, its findings are limited by only focusing on medical students, a subgroup that may not reflect those of the broader student population. More recently, a 2023 study examined the association between ACEs and substance use among young adults, but its narrow focus on substance use precluded a broader understanding of mental health and life satisfaction outcomes [15]. Building on these prior studies, the present research seeks to bridge the gaps by focusing specifically on first-year university students across diverse fields of study and examining the associations of ACEs with both mental health and subjective well-being. By focusing on this vulnerable group, the study seeks to be among the first to provide insights that may inform policies and interventions designed to promote mental health and resilience in academic settings in Vietnam.
METHODS
Study design and sampling method
A cross-sectional study was conducted from August 2021 to August 2022 among first-year college students at six out of 10 universities of Vietnam National University, Hanoi (VNUHanoi), Vietnam. Particularly, VNU-Hanoi is a public research university system in Vietnam, comprising 12 member universities and faculties, including 1) VNU University of Economics and Business (VNU-UEB); 2) VNU University of Languages and International Studies (VNU-ULIS); 3) VNU University of Social Sciences and Humanities (VNU-USSH); 4) VNU University of Science (VNU-HUS); 5) VNU University of Medicine and Pharmacy (VNU-UMP); 6) VNU International School (VNU-IS); 7) University of Engineering and Technology (VNU-UET); 8) University of Education (VNUUEd); 9) Vietnam Japan University (VNU-VJU); 10) University of Law (VNU-UL); 11) Hanoi School of Business and Management (VNU-HSB); and 12) School of Interdisciplinary Sciences and Arts (VNU-SIS). Participants were eligible to participate in the study if they were (a) aged 18 years and above, (b) were first-year college students at a university or faculty of the VNU-Hanoi, (c) had the capacity to answer the Vietnamese questionnaire, and (d) were able to provide informed consent.
This research utilized a multi-stage sampling technique to ensure a representative distribution of participants. First, we employed a computerized system to randomly select six out of the 12 universities and faculties from VNU-Hanoi. Subsequently, we used a convenience sampling technique to recruit participants from each selected university or faculty. Particularly, well-trained investigators visited the classrooms of first-year students at the selected universities or faculties to invite them to participate in the study. Students who were absent during the classroom visits were not invited to participate in the study.
The formula for estimating a population proportion was used for calculating the sample size for the current study. Particularly, the expected proportion of students who experienced depression was 0.49 (according to a previous finding in Vietnam [16]), the confidence level was 0.95, and the relative precision was 0.05. Thus, after calculating, the necessary sample size for this study was 1,600 respondents. Furthermore, to mitigate participant withdrawal from the study, 10% of the sample size was added, leading to a final sample size of 1,760 participants. At the end of data collection, a total of 1,700 students agreed and were eligible to participate in this study, of which only 1,391 completed the questionnaire and were included in the analysis (with a completion rate of 81.8%).
Procedure and instruments
In this study, the research instrument was developed according to a standard procedure. Firstly, the research team conducted a systematic review to assess the situation and important facets associated with ACEs and mental health that have been mentioned in previous studies as well as identify the gaps of issues that needed further studies. Subsequently, an initial research instrument was developed that covered all aspects of interest. During this process, we invited experts who were psychiatrists, policymakers, and public health professionals to jointly discuss the content, structure, and logical order of the questionnaire. Then, this questionnaire was piloted on a group of 50 first-year college students to ensure the meaning, paraphrasing, language, and texts. Finally, a structured questionnaire with four main components was utilized to collect the information from the participants, including 1) socio-demographic characteristics, 2) health behaviors, 3) ACEs, and 4) depression and satisfaction with life. During the data collection process, a face-to-face interview within 15-20 minutes was conducted by investigators who were well-trained to use questionnaires once the participants agreed to be involved in the study. Furthermore, the interview was carried out in a closed room to ensure privacy and minimize outside influences. Participants were thoroughly informed about the study’s purpose, potential benefits and risks, and their rights, including assurances regarding the protection of their privacy and confidentiality. Furthermore, participants were also informed that they could decline to answer any question they found uncomfortable. All collected data were securely stored in a protected system and were used exclusively for research purposes.
Measurement
Primary outcomes
The Patient Health Questionnaire-9 (PHQ-9) was utilized to assess depression levels among participants, encompassing nine dimensions. For each question, participants’ responses were recorded on a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). The total score of nine dimensions was summed to assess the depression severity, ranging from 0 to 27, with a higher score indicating a higher level of depression. Furthermore, a PHQ-9 cut-off point greater than 5 was applied to categorize people into depression groups [17]. In Vietnam, PHQ-9 has been widely applied and validated in several previous studies [18-20]. The Cronbach’s alpha of PHQ-9 was acceptable at 0.80.
Satisfaction with Life Scale (SWLS) was developed to assess satisfaction overall with life. This scale consists of five items and utilizes a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree) to record responses for each item. To evaluate the level of life satisfaction, the total score of the five items is summed, with a possible range of 5-35 points and a higher score indicating a higher level of life satisfaction [21]. Up until now, SWLS has also been widely used and validated in previous studies in the Vietnamese population [22,23]. In the current study, the Cronbach’s alpha of SWLS was good at 0.81.
Covariates
Socio-demographic characteristics and health behaviors: Information about university/faculty; sex (male/female), academic performance (excellent/good/average-weak), family affluence (high/medium/low), time spent on using social media networks per day (below 2 hours/2-4 hours/4-6 hours/above 6 hours), tobacco use (yes/no), and alcohol consumption (yes/no) were collected.
Adverse Childhood Experiences Abuse Short Form (ACEASF) is a short version of the Childhood Experiences International Questionnaire with eight dimensions to assess three aspects, including physical (2 items), emotional (2 items), and sexual (4 items) child abuse victimization. Particularly, emotional abuse explored whether a participant experienced events such as being shouted at or threatened. Physical abuse was identified whether a participant encountered spanking, hitting, slapping, kicking, or hitting with an object. Sexual abuse asked participants whether they experienced unwanted fondling, having to touch someone sexually against one’s will, or unwanted sexual [24]. For each item of ACE-ASF, participants indicated whether they had experienced the event by responding “yes” or “no.” A score of one point was assigned for each “yes” response. Furthermore, to date, the ACE-ASF has been validated and shown a high level of reliability and validity [24]. In this study, the Cronbach’s alpha of the ACE-ASF was good at 0.84.
Data analysis
Data processing was performed using Stata 16.0 (Stata Corp.). For the data cleaning strategy, the respondents with more than 10% of missing data were excluded from the analysis (according to the suggestion of Bennett [25]) to mitigate the potential bias. Continuous variables were presented as means and standard deviations, while categorical variables were represented as frequencies with percentages. The chi-square, Kruskal- Wallis, and Mann-Whitney U tests were used to assess the differences in socioeconomic characteristics, health status, and ACEs between those who had depressive symptoms and those who did not. We employed multivariate linear regression models to identify factors associated with the PHQ-9 score and life satisfaction among participants. Moreover, the forward stepwise selection strategy was utilized to construct a reduced model by including only variables with p-values below 0.2. A p-value of less than 0.05 was considered statistically significant. This threshold (0.2) was chosen to reduce the risk of prematurely excluding potentially predictive variables that may not show a strong univariate association but could be significant in the multivariate context [26].
Ethics approval statement
The study procedures were carried out in accordance with the Declaration of Helsinki. The Ethics Council in Biomedical Research of Hanoi National University Hospital approved the study protocol (Code: 01/2024/BB-HDD). Participants were asked to give written informed consent and were thoroughly informed about the study’s purpose, potential benefits and risks, and their rights, including assurances regarding the protection of their privacy and confidentiality. All methods were performed in accordance with the relevant guidelines and regulations.
RESULTS
Table 1 describes the socio-demographic characteristics and health behaviors of first-year college students. Particularly, there were 54.4% of participants reported experiencing depressive symptoms. Most of the participants were females (78.8%), achieved good to excellent academic performance (95%), and had family affluence at the medium level (71.2%). Regarding tobacco and alcohol consumption, while only 3.2% of the participants reported using tobacco, there were 64.3% of the first-year college students reported alcohol consumption behavior during the last month. Furthermore, there was a statistical difference (p<0.001) in the average time spent using social media networks between participants who experienced depression and those who did not, with 5.7±4.7 hours and 3.6±3.8 hours, respectively. People having depressive symptoms reported a significantly lower score of satisfaction with life compared to those who did not have any symptoms, with 20.4±6.9, and 23.2±4.3 points, respectively. This difference was statistically significant with p<0.001.
The characteristics of the ACEs of the participants are presented in Table 2. Out of eight types of ACEs, spanking, slapping, kicking, punching, or beating was the most common experience with 35.6%, followed by experiencing yelling, screaming, or humiliating with 32.1%, and experiencing threatening, abandoning, or throwing out of the house with 24.9%. Compared to ACEs related to emotional abuse and physical abuse, the frequencies the participants experienced related to sexual abuse were lower. Specifically, 16.0% of the participants reported that they had been touched or fondled when they did not want to, and 11.3% of participants experienced someone making them touch their body in a sexual way. Regarding the number of ACEs, 50% of the participants reported that they experienced at least one ACE, and there were 34.8% experienced multiple ACEs (from two or more ACEs). Furthermore, there were significant differences in the frequency of experiences for all eight ACEs between people who had depressive symptoms and those who did not, with p<0.001. Particularly, people in the depression group had higher experienced frequencies in eight ACEs than others.
Table 3 presents the factors associated with the level of depression and satisfaction with life among the participants. Regarding family affluence, participants who lived in a family with a medium condition had a lower level of depression compared to those with a high condition (Coef.=-0.46, 95% confidence interval [CI]=-0.88 to -0.04). In terms of health behaviors, a higher amount of time spent using social media networks was associated with a higher score of PHQ-9 and a lower score of satisfaction with life. Furthermore, people who smoked (Coef.=1.09, 95% CI=0.19 to 1.99), and alcohol consumption (Coef.=-0.51, 95% CI=-0.92 to -0.10) were associated with higher levels of depression and lower life satisfaction, respectively. Participants who experienced emotional or physical abuse were more likely to suffer from depression and lower levels of life satisfaction compared to those who did not. Particularly, people who experienced one or two/above emotional abuse events were likely to increase their score of PHQ-9 (one event: Coef.=0.84, 95% CI=0.29 to 1.39; two or above events: Coef.=2.81, 95% CI=2.34 to 3.28) and decrease their score of SWLS (one event: Coef.=-6.55, 95% CI=-7.23 to -5.87; two or above events: Coef.=-9.72, 95% CI=-10.30 to -9.13). Similarly to emotional abuse experiences, people who experienced one or two/above physical abuse events were likely to increase their score of PHQ-9 (one event: Coef.=1.30, 95% CI=0.95 to 1.64; two or above events: Coef.=6.07, 95% CI=5.42 to 6.72) and decrease their score of SWLS (two or above events: Coef.=-1.01, 95% CI=-1.81 to -0.22).
DISCUSSION
This study is one of the efforts to evaluate the prevalence of ACEs and their impacts on mental health status and life satisfaction among Vietnamese young adults. There are several key findings arising from the current study. Firstly, the findings of this study provide critical insights into the mental health status of the participants, with a prevalence of depression at 54.4%. Additionally, half of the participants reported experiencing at least one ACE, and among the three types of ACEs evaluated, physical abuse and emotional abuse were notably more common than sexual abuse. Besides, 22.9% had encountered four or more ACEs. Moreover, participants with ACEs were found to have poorer mental health and lower life satisfaction, underscoring the profound and lasting impact of early life adversity on overall well-being.
Based on the survey conducted in this study, the prevalence of depression among college students was 54.4%. This finding aligns with similar studies, such as a prevalence of 49.8% in the study by Luo et al. [27], or 53% in U.S. college students [28], or 53.6% of Saudi Arabian students in the Middle East [29]. Although the current depressive tendencies observed were predominantly mild, the proportion of affected students is still concerning because these figures are significantly higher than the global prevalence of depression (approximately 5% in adults, per WHO estimates [30]) and findings from other regions, such as 2.1% in 27 European countries [31] and 29.4% in six ASEAN countries (Cambodia, Laos, Malaysia, Myanmar, Thailand, and Vietnam) [32]. This discrepancy can be attributed to variations in depression assessment tools and contextual factors. Nota-bly, this study focused on first-year college students, a group particularly vulnerable to negative emotions due to the transitional challenges of university life, such as academic pressures, interpersonal issues, and career uncertainties. If not intervened, college students’ depressive inclinations might turn into depression, which has a significant negative impact on academic performance, interpersonal relationships, and individual physical and mental health, and even brings a huge economic burden to society. Thus, early intervention and identification of influencing factors are critical to mitigating the impact of depressive tendencies among college students.
The current findings revealed that 50% of the sample had experienced at least one ACE, and among them, 22.9% reported four or more ACEs, confirming that university students commonly face childhood adversities, which is consistent with previous literature. For example, a meta-analysis found that the proportion of participants having at least one ACE falls within the range of 46.4% to 79.5% [33]. Furthermore, a previous investigation in Vietnam has indicated that 48.9% of Vietnamese adolescents experience at least one ACE [16], consistent with the current finding. The multinational survey found variation in the prevalence of suffering four or more ACEs between the countries [34]. However, previous studies reported that the prevalence of participants encountering at least four ACEs ranges between 13% and 17%, significantly lower than our current finding [4,35]. These differences can be explained by the fact that cultural norms may influence how individuals perceive ACEs, leading to differences in reporting. Additionally, differences in study design, measurement tools, and definitions of abuse contribute to variations, highlighting the complexity of measuring ACEs.
This study also demonstrated a strong association between ACEs and mental well-being outcomes in a large sample of university students, including high levels of depression and poor life satisfaction. Particularly, individuals with single or multiple ACEs are more likely they were to report low satisfaction with life scores and higher levels of depression, which aligns with a substantial body of literature. For example, Elmore and Crouch [36] reported that adults with four or more ACEs were 2.2 times more likely to experience depression compared to those with less than four ACEs. This study’s findings corroborate these trends and further highlight the longterm psychological burden carried by individuals exposed to multiple adversities. A variety of mechanisms explained the association between ACEs and long-term poor mental wellbeing. In which, maltreatment and other stressors during children’s growing up might affect brain development, leading to negative effects on their emotional functioning in the long term [37]. Particularly, children who encounter ACEs can develop attachment difficulties, including poor emotional regulation, lack of trust, and fear of getting close to other people [38]. They can also create negative self-images, lack self-esteem, and suffer feelings of incompetence, all of which can be retained into adulthood [39,40].
The findings of this study underscore significant public health and social policy implications, emphasizing the urgent need for a multi-faceted approach to address the high prevalence of ACEs and their long-term effects. Preventive strategies should prioritize raising awareness about ACEs, promoting positive parenting practices through community-based programs, and implementing early screening for ACEs and mental health conditions in primary care and educational settings. Policies and programs that address environmental and societal factors contributing to childhood adversity should be integrated with the goals of the UN 2030 Agenda for Sustainable Development. These goals emphasize the importance of early childhood development, gender equality, and reducing violence and inequality as essential elements for lifelong health and societal progress [41]. Additionally, resilience-building initiatives are vital for empowering children to overcome adversity and reduce the intergenerational transmission of ACEs. Universal programs in schools to enhance coping and problem-solving skills, as well as tailored interventions for vulnerable populations in social care or youth justice, are key strategies. Although the complete eradication of ACEs remains an aspirational goal, integrating prevention, intervention, and resilience-focused measures across sectors can significantly reduce their prevalence and impact, contributing to healthier individuals and societies.
There are several strengths of this study. This study contributes to identifying the prevalence of ACEs and their impacts on mental health status and life satisfaction among young adults in Vietnam. Furthermore, this study addresses shortcomings in the literature by utilizing validated international measures such as PHQ-9, SWLS, and ACE-ASF, thereby enhancing the comparability of our results to other studies. Despite these strengths, several limitations remain. Firstly, most of the information we obtained was based on self-report, and hence, there might be recall biases. Furthermore, this was only a cross-sectional study, which might hinder our ability to draw causal relationships. Secondly, alongside ACEs, positive childhood experiences (PCEs) have recently gained increasing attention due to their contribution to individual development [42]. Hence, the current study suggests that further study should examine both ACEs and PCEs to provide more comprehensive evidence on the impact of childhood experiences on adult development. Finally, although the sample size was sizeable, however, this study recruited participants from only six universities and faculties in Vietnam and applied the convenience sampling method, mitigating the representativeness of the overall sample and external validity to some extent. Therefore, future research should incorporate longitudinal study designs and be conducted among a large number of first-year college students to explore the long-term effects of childhood experiences on mental well-being and ensure the representativeness of the study.
Conclusion
The present study shows a relatively high prevalence of depression and ACEs among first-year college students. This study also highlighted that ACEs were strongly associated with mental health, and life satisfaction in young adulthood. The results thus suggest that fostering protective factors in childhood may be beneficial for their development by mitigating multifaceted risks in young adulthood.
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