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Barriers to accessing support for mental health issues at university

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Student mental health is an issue of great concern for universities, with rising numbers of mental health problems being reported and students reporting issues with accessing support. The current study, using a participatory research framework, investigated the possible barriers preventing students from accessing support, in terms of help-seeking intentions and actual help-seeking behaviour. Three hundred and seventy-six current UK students completed a questionnaire which measured help-seeking and possible barriers including perceived public stigma, self-stigma, educational impact, disclosure, coping behaviours and current mental health symptoms. Findings indicated that self-stigma, in particular, was a barrier to accessing support. Disclosure, educational impact, previous diagnosis, suspected diagnosis and mental health symptoms also interacted with help-seeking. These findings have implications for universities in tackling the barriers preventing students accessing support for their mental health.
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Barriers to accessing support for mental health issues at university
Eilidh Cage1, Melissa Stock1, Alex Sharpington1, Emma Pitman1 and Rachel Batchelor1
1Royal Holloway, University of London, Surrey, UK
Corresponding author: Dr Eilidh Cage, eilidh.cage@rhul.ac.uk; Twitter: @DrEilidh
Manuscript accepted for publication in Studies in Higher Education, 31/10/18
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Abstract
Student mental health is an issue of great concern for universities, with rising numbers
of mental health problems being reported and students reporting issues with accessing
support. The current study, using a participatory research framework, investigated the
possible barriers preventing students from accessing support, in terms of help-seeking
intentions and actual help-seeking behaviour. Three hundred and seventy-six current
UK students completed a questionnaire which measured help-seeking and possible
barriers including perceived public stigma, self-stigma, educational impact,
disclosure, coping and current mental health symptoms. Findings indicated that self-
stigma in particular was a barrier to accessing support. Disclosure, educational
impact, previous diagnosis, suspected diagnosis and mental health symptoms also
interacted with help-seeking. These findings have implications for universities in
tackling the barriers preventing students accessing support for their mental health.
Key words: student mental health; student support; barriers; student wellbeing; self-
stigma
Words: 6993
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Mental health issues in university students is an issue of utmost importance: in the academic
year 2016/17, there were 53,045 students with a recorded mental health condition in the UK
(Higher Education Statistics Authority 2018). Two percent of first-year students in the UK
disclosed a mental health condition in 2015/16, five times that reported in 2006/7 (Thorley
2017). Many students likely experience mental health difficulties, but these go unreported or
the students do not utilise support services (Eisenberg, Golberstein and Gollust 2007).
University students appear to be at a higher risk of developing mental health problems (Eskin
et al. 2016), report that they frequently miss academic commitments due to their mental
health (Eisenberg et al. 2007) and those with mental health difficulties are more likely to drop
out of university (Thorley 2017). Therefore, it is vital student mental health is understood to
ensure students access the necessary support for their needs while at university.
However, students may not access support for their mental health: Rosenthal and
Wilson (2008) found that over three quarters of students with significant mental distress did
not receive counselling. There may be several barriers preventing students from accessing
support, including a lack of available counsellor appointments (Mowbray et al. 2006).
Universities with on-campus General Practitioners (GPs) in the U.S. have been criticised for
providing minimally adequate treatment for depression (Eisenberg and Chung 2012). A lack
of knowledge about available treatments may also play a role, with a third of students not
knowing where to access support (NUS-USI 2017). Finally, students may not access support
because they do not believe they need treatment, even if they have an elevated risk for suicide
(Czyz et al. 2013).
Stigma how society reacts towards people with mental health difficulties could
also be a barrier to accessing support (Bathje and Pryor 2011). People with mental health
conditions are at risk of discrimination, with the label “mentally-ill” associated with negative
connotations (Corrigan 2004). In interviews with UK students, Quinn et al. (2009) noted
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reluctance to seek support was linked to perceptions of stigma. The experience of stigma
likely exacerbates mental health problems and may prevent people from seeking help
(Vidourek et al. 2014). Students may also experience self-stigma - an individual’s own
internalised attitudes, often adopting the stigmatising public discourse towards their own
mental health (Corrigan, Watson and Barr 2006) and self-stigmatising the act of help-seeking
(Tucker et al. 2013). Self-stigma and public stigma independently contribute to mental health
help-seeking (Bathje and Pryor 2011). In one systematic review, both types of stigma were
the biggest barrier to help-seeking for young people (Gulliver, Griffiths and Christensen
2010).
A systematic review conducted by Clement et al. (2015) found stigma was only the
fourth most important barrier to help-seeking in the general population. Instead, concerns
around disclosing mental health issues was the top barrier. Individuals may differ in their
willingness to disclose mental health difficulties due to concerns over shame and
embarrassment (Kahn and Hessling 2001). Gulliver et al. (2010) found that concerns around
confidentiality after disclosure represented a major source of concern for many young people.
An individual may fear that a breach of confidentiality following disclosure may lead to
stigma from peers or family (Gulliver et al. 2010). Consequently, this fear may prevent an
individual from disclosing their mental health issues to a professional.
The ability to cope with psychological distress must also be considered it may be
that individuals who are good at coping are less likely to seek help. The act of coping
efforts to reduce or prevent stress, harm or threat (Carver and Connor-Smith 2010) is often
vital in determining an individuals’ psychological adjustment and well-being (Monzani et al.
2015). Actively attempting to improve circumstances and solve problems is advantageous
(Carver and Connor-Smith 2010), linking to higher rates of attained goals and positive affect
(Mackay et al. 2011), as well as higher academic performance (Struthers, Perry and Menec
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2000). Thus, those with a higher ability to cope may not seek help, due to lower perceived
need.
Individual differences in help-seeking intentions should also be considered as a
barrier to accessing support. With help-seeking intentions, people may report that they plan to
seek help if they experience psychological distress (Wilson et al. 2005). The theory of
planned behaviour suggests that intention is the strongest predictor of actual behaviour
(Abraham, Sheeran and Henderson 2011). The theory argues that intention is predicted by a
person's attitude towards the specific behaviour, their subjective norm of significant others
(Montano and Kasprzyk 2015) and perceived control in the ability to carry out the behaviour
(Abraham et al. 2011). However, intentions do not necessarily translate into actual behaviour
(de Bruijn, Out and Rhodes 2014), particularly in the domain of mental health (Li 2016).
Rickwood et al. (2005) conducted a systematic review of adolescents help-seeking intentions
for mental health problems and found mixed evidence on the relationship between intentions
and behaviour. The relationship between intention and actual help-seeking has been
suggested to be dependent upon specific mental health problems and barriers people face
(Rickwood et al. 2005).
As shown by the number of students with mental illness, and the noted challenges in
receiving adequate support, there is an issue with students accessing and receiving treatment
from mental health issues while at university. Highlighting the barriers that students face may
be the first step to implementing strategies to overcome these barriers. The current study
therefore aimed to examine the possible barriers preventing UK students from accessing
support for mental health issues. Based on the discussed literature, the following variables
were examined as barriers to both intentions to seek help and actual help-seeking behaviour:
perceived public stigma, self-stigma, educational impact, disclosure, coping and current
mental health functioning in terms of depression, anxiety and stress. We hypothesised that
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there would be significant barriers to students’ accessing support for their mental health
needs.
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Methods
Participants
Three hundred and seventy-six current students took part with a mean age of 20.73 (SD =
3.34). Most participants were female (83.5%, n = 314; male 15.7%, n = 59; other/prefer not
to say .8%, n = 3). Eighty-two percent were born in the United Kingdom. Most were White
British (76.9%) or from another White Caucasian background (12%); 5.6% were Asian/Asian
British, 3.7% were multi-ethnic and .5% were Black/Black British. Most were heterosexual
(76.8%) with 12.6% reporting that they were bisexual and 7.7% homosexual. Participants
were recruited via word of mouth, social media and the UK student mental health charity
Student Minds’ website.
Information regarding university and student status is displayed in Table 1. This
information shows that most participants were undergraduate, full-time Home students,
recruited from the South East of England.
[Insert Table 1 here]
Ethical approval was obtained via [blinded for peer review] and all participants gave
full informed consent before participating.
Materials
Participants completed an online survey, with the following measures presented using the
‘Qualtrics’ survey software.
Help-seeking.
Help-seeking intentions for mental health problems was measured using the General Help
Seeking Questionnaire (Wilson et al. 2005). Participants rated their likelihood of seeking help
for personal or emotional problems, from four informal sources (parents, other family
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member, friends and intimate partner) and three formal sources (GP, mental health
professional and helpline), on a 7-point Likert scale (extremely unlikely (1) to extremely
likely (7)). Higher scores represented higher intentions to seek help. Participants also rated
the item ‘I would not seek help from anyone’. Responses were categorised into three
subscales (informal or formal source, or no-one). Internal consistency was acceptable for
intentions from informal sources (ω =.62) and from formal sources (ω =.69).
Actual help-seeking behaviour was measured by asking participants “which of the
following services have you accessed with regards to your mental health since you have been
at university?” Participants could select from nine sources, such as a mental health advisor,
counsellor or GP. Participants could also indicate if they had not accessed any support.
Responses were coded into either ‘accessed support of any form’ or ‘none’.
Perceived Public Stigma.
Perceived stigma for receiving psychological help was measured using the Adapted Stigma
Scale (Golberstein, Eisenburg and Gollust 2008). Participants rated agreement with five
statements, such as ‘It is a sign of personal weakness or inadequacy to receive treatment for
mental health problems’. Each item was scored on a 5-point scale (strongly disagree (1) to
strongly agree (5)). Scores were summed to derive a total ranging from 5 to 25, with higher
scores representing higher stigma. Internal consistency was good (ω =.77).
Self-Stigma.
Self-stigma was measured using the Self-Stigma of Seeking Help Scale (Vogel, Wade and
Haake 2006). Participants rated agreement with ten statements on a 5-point scale (strongly
disagree (1) to strongly agree (5)), such asIf I went to a therapist, I would be less satisfied
with myself’. Scores were summed to obtain a total ranging between 10 and 50, with higher
scores indicating a greater self-stigma. Internal consistency was very good (ω =.87).
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Educational impact.
Impact on academic functioning was measured with two questions rated on a 5-point scale
(‘never’ (1) to ‘a great deal’ (5)) from Einsberg et al. (2007): ‘How often have you missed
classes/other academic obligations in the past four weeks due to mental health difficulties?’
and ‘How often has your academic performance been affected in the past four weeks due to
mental health difficulties? Scores ranged from 2 to 10 with higher scores indicating greater
difficulties with academic functioning. Internal consistency was very good (α =.83).
Coping behaviours.
Coping behaviours for mental health issues were measured using the Brief Cope Scale
(Carver 1997). Participants were asked to consider ‘the ways they had been coping with
mental health problems in their life’. They rated how often they had been engaging in 21
positive coping behaviours, such as ‘I've been getting comfort and understanding from
someone’, on a 4-point scale (‘I haven’t been doing this at all’ (1) to ‘I’ve been doing this a
lot’ (4)). Scores ranged between 21 to 84 with higher scores indicating greater use of positive
coping behaviours when dealing with mental health issues. Internal consistency was very
good (ω =.88).
Disclosure.
Disclosure was measured using the Distress Disclosure Index (Kahn and Hessling 2001).
Participants rated agreement with 12 statements such as ‘When I feel upset, I usually confide
in my friends’ on a 5-point scale (strongly disagree (1) to strongly agree (5)). Scores were
summed to obtain a total ranging from 12 to 60, with higher scores indicating more
disclosure. Internal consistency was excellent (ω =.94).
Current mental health symptoms.
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Depression, anxiety and stress were measured using the short-form version of the DASS
(DASS-21; Henry and Crawford 2005). Participants rated 21 statements on a 4-point scale
(did not apply to me at all’ (0) to applied to me very much or most of the time’ (3)). There
were three subscales with seven items each, corresponding to depression, anxiety and stress.
Scores were summed for each subscale and multiplied by two to derive three totals ranging
from 0 to 42. Higher scores represented higher symptoms of depression, anxiety and stress
respectively. Internal consistency was excellent for the depression subscale (ω =.92), very
good for the anxiety subscale (ω =.88) and stress scale (ω =.87).
Participants were asked to self-report previously diagnosed mental health conditions.
Details were recorded on specific diagnoses and age of diagnosis. Participants were also
asked whether they believed that they had an undiagnosed mental health condition, indicated
which condition they suspected, and whether they were seeking diagnosis.
Procedure
The current study used a participatory approach (Cornwall and Jewkes 1995), putting
students at the centre of this research. Four students were the experts on student mental health
and worked with an academic as researchers to develop the aims of the project. First, the
group discussed the problem that needed addressed. Based on lived and peer experience, the
group identified that accessing mental health services and the need for support should be the
research focus, given the high prevalence of mental health problems for students.
Specifically, the aim was to investigate the barriers that may prevent students from accessing
support.
Second, the group investigated the pre-existing literature to establish current
knowledge regarding the aim, and to identify how the current study could add to the
literature. The group also researched potential barriers to accessing support. Next, the group
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decided how to address the aim. Quantitative questionnaire methods were deemed
appropriate and could be used to reach a large sample of students.
In the survey, participants first completed demographic information (including about
their studies) and information about their mental health conditions, if applicable. Participants
were then asked whether they had received support for their mental health during their time at
university. Participants then completed measures on educational impact, self-stigma,
perceived stigma, current mental health, coping behaviour, disclosure and help-seeking
intentions. The survey took approximately 30 minutes and was part of a larger study with
some data not reported here. Upon completion, participants were debriefed, signposted to
useful resources and had the option to enter a prize draw. Data was collected between
December 2017 and February 2018.
Design
A cross-sectional survey was used to examine the barriers to students accessing support for
mental health. Hierarchical linear regression was used to test whether the proposed variables -
stigma, self-stigma, educational impact, coping behaviour, disclosure and depressive, anxiety
and stress symptoms - could predict help-seeking. Binary logistic regression was used to test
whether these variables could predict whether participants had sought help for mental health
issues while at university.
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Results
Mental health conditions.
In the sample, 40.2% (n = 151) self-reported a diagnosed mental health condition. Specific
conditions reported are detailed in Table 2. For undiagnosed conditions, 29 participants
(7.7%) reported that they suspected a mental health condition and were currently seeking
diagnosis. Further, 137 participants (36.4%) reported that they suspected a mental health
condition but were not seeking diagnosis. 55.9% (n = 210) did not suspect an undiagnosed
mental health condition. The most commonly suspected conditions were anxiety and mood
disorders (Table 2). Overall, 55.9% (n = 210) had accessed support for their mental health
since they had been at university.
[Insert Table 2 here]
Barriers to mental health support.
Intentions to seek help.
First, three separate hierarchical linear regressions were used, with help-seeking intention
scores (formal, informal or no-one) as the outcome variables. In the first step for all
regressions, age, gender, previous diagnosis (yes/no) and suspected diagnosis (yes/no) were
entered. In the second step, educational impact, perceived stigma, self-stigma, disclosure,
coping, depression, anxiety and stress scores were entered.
For help seeking intentions from formal sources, the first step explained 8.3% of the
variance in intentions, and the model was significantly better at predicting the outcome than
the mean alone (F(4, 341) = 7.65, p<.001). The final model explained 16.0% of the variance
(a significant increase, p<.001) and the model was significant (F(12, 341) = 5.24, p<.001).
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In the final model (Table 3), gender was a significant predictor of intentions, with
male participants (M = 34.03, SD = 6.73) more likely to intend to seek help than female
participants (M = 31.26, SD = 6.45). Those with a diagnosed mental health condition (M =
10.38, SD = 4.05) were more likely to intend to formally seek help than those who did not (M
= 8.55, SD = 4.15). Self-stigma significantly predicted help-seeking intentions, such that with
increasing self-stigma, help-seeking intentions decreased. With increasing educational impact
and perceived public stigma, help-seeking intentions from formal sources significantly
increased.
[Insert Table 3 here]
For help seeking intentions from informal sources, the first step explained 14.4% of
the variance in help-seeking intentions, with the model significantly better at predicting the
outcome than the mean alone (F(4, 337) = 14.00, p<.001). The final model explained 41.2%
of the variance (significant increase, p<.001) and was significant (F(12, 337) = 19.00,
p<.001).
In the final model (Table 3), age was a significant predictor of intentions to seek help
from informal sources, such that with age participants were less likely to seek help from
informal sources. Those who suspected an undiagnosed mental health condition (M = 15.75,
SD = 4.87) were less likely to intend to seek help from informal sources than those who did
not (M = 18.82, SD = 4.85). Disclosure significantly predicted help-seeking intentions, such
that with increasing disclosure, help-seeking intentions increased. With increasing stress,
help-seeking intentions from informal sources increased, but with increasing depression
symptoms, intentions significantly decreased.
For help seeking intentions from no-one, the first step explained 4.3% of the variance
in non-help-seeking intentions, and the model was significantly better at predicting the
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outcome than the mean alone (F(4, 338) = 3.79, p =.005). The final model explained 45.4%
of the variance (significant increase, p<.001) and was significant (F(12, 338) = 22.57,
p<.001).
Self-stigma was a significant predictor of intentions to not seek help in the final model
(Table 3): with increasing self-stigma, the likelihood of not seeking help increased. With
increasing depression symptoms, intentions to not seek help significantly increased. With
increasing disclosure, intentions to not seek help decreased.
Actual help-seeking behaviour. The variables which could predict actual help-seeking
behaviour were examined. Descriptive statistics for each variable according to whether the
participants had accessed support, are shown in Table 4.
[Insert Table 4 here]
Binary logistic regression was used to test whether the variables could predict whether
or not participants had accessed support for their mental health while at university. The
predictors entered were age, gender, previous diagnosis, suspected undiagnosed condition,
educational impact, perceived public stigma, self-stigma, help-seeking intentions (formal,
informal and no-one), disclosure, coping, depression, anxiety and stress. Results are shown in
Table 5.
[Insert Table 5 here]
Those with a previous diagnosis were 4.24 times more likely to access support since
they had been at university, and those who suspected an undiagnosed mental health condition
were 2.41 times more likely than those who did not. With increasing educational impact,
help-seeking intentions from formal sources and stress symptoms, the odds of accessing
support increased. With increasing self-stigma, the odds of accessing support decreased.
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Discussion
This study examined potential barriers preventing students from accessing mental health
support. The examined barriers included perceived public stigma, self-stigma, educational
impact, disclosure, coping and current mental health symptoms. In the study, four in ten
participants reported a diagnosed mental health condition, with anxiety and mood disorders
commonly reported. Further, a third of participants suspected a mental health condition, but
were not seeking a diagnosis, and only 8% were seeking a diagnosis. Over half of the sample
(55%) had accessed support for their mental health since being at university. In analyses
examining the barriers to accessing support, both in terms of intentions to seek help and
actual help-seeking behaviour, self-stigma associated with seeking help was a significant
barrier.
Self-stigma was a significant predictor of a lack of help-seeking intentions and actual
help-seeking behaviour, suggesting that self-stigma attached to help-seeking affects both
intentions and behaviour. This finding supports previous qualitative research (Quinn et al.
2009) and research with non-student populations (Bathje and Pryor 2011; Gulliver et al.
2010). Corrigan (2004) suggests that self-stigmatising mental health issues affects self-
esteem, linking to feeling ashamed and demoralised. Tucker et al. (2013) noted that self-
stigma around seeking help (rather than self-stigma of having a mental illness) relates to self-
blame and explains more variance in help-seeking intentions such that the act of help-
seeking is the barrier, rather than being labelled ‘mentally ill’. The current study measured
only self-stigma of seeking help, therefore future studies would benefit from also measuring
the self-stigma of mental illness. Nonetheless, the current findings indicate that the self-
stigma of seeking help acts as a barrier to accessing support.
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Notably, self-stigma did not predict help seeking intentions from informal sources.
This finding may relate to informal sources offering help only in the form of social support.
Indeed, with greater disclosure, participants were more likely to seek help from informal
sources, but disclosure did not predict help-seeking from formal sources. This supports prior
research that family and friends are more often recipients of disclosure than professionals for
those with suicidal ideation (Husky et al. 2016) and severe mental illnesses, with higher
levels of disclosure associated with higher perceived social support (Pahwa et al. 2017).
Disclosure to family and friends is thought to be beneficial due to the empathy received upon
disclosure (Bril-Barniv et al. 2017).
Notably, only intentions to seek help from formal sources predicted actual help-
seeking behaviour. Together, these findings suggest that disclosing mental health issues to
informal sources does not necessarily relate to actual help-seeking. Nonetheless, social
support is still important in mental health recovery (Hendryx, Green and Perrin 2009). For
young people, Gulliver et al. (2010) found a preference to seek help from family and friends
rather than professionals. Gulliver et al. (2012) also found that people are more likely to seek
help from informal sources who provide social support rather than professionals.
Nevertheless, help-seeking from professional services is a fundamental pathway towards
support for mental health issues.
While self-stigma and public stigma are separate but interrelated concepts (Corrigan
2004), perceived public stigma only positively predicted help-seeking intentions from formal
sources. Perceived public stigma did not predict intentions in other analyses, nor did it predict
actual help-seeking behaviour. Previous studies have found the perceived public stigma does
not predict help-seeking in students (Eisenberg et al. 2009). Further, Vogel et al. (2006)
found that self-stigma fully mediates the relationship between public stigma and help-seeking
intentions for students. Together, these findings suggest that self-stigma although
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influenced by perceived public stigma is a significant barrier to support for students, and
more research is needed to understand the relationship between stigma and mental health in
students.
Educational impact was also a significant predictor of actual help-seeking behaviour
and help-seeking intentions from formal sources. As mental health issues begin to affect
academic performance, it makes sense that students would be more inclined to seek help.
This finding also demonstrates the impact mental health conditions could have on academic
functioning such as reducing concentration and motivation and increasing fatigue and social
withdrawal (Kitzrow 2003). Positively, with increasing educational impact participants were
more likely to seek help suggesting that they feel able to seek help when their studies are
affected. However, this finding may also indicate that more needs to be done to prevent
mental health problems affecting academic studies in the first place. Interventions focusing
on improving students’ resilience to academic-related stress may be beneficial (Hartley
2011).
In terms of mental health symptoms, increasing depressive symptoms predicted
decreased help-seeking from informal sources and increased likelihood of seeking help from
no-one. With depression, symptoms such as feeling guilty may relate to decreased motivation
to seek help (D’Avanzo et al., 2012). Barney et al. (2009) found that participants were
reluctant to talk to informal sources about depression due to concerns over appearing ‘weak’
or being ‘viewed less as a person. For actual help-seeking, increasing stress symptoms
predicted greater likelihood of accessing support. As stress levels rise, seeking support to
manage stress may be less stigmatised than depression, however greater understanding of
stress at university is needed (Robotham and Julian 2006).
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In this study, regardless of whether they were accessing support or not, participants
reported high rates of depression, anxiety and stress in comparison to general population
means (Henry and Crawford 2005). Many were therefore experiencing elevated levels of
mental health symptoms, yet may not perceive that they need help or believe that their
experience is “normal” (Brown 2018). These findings may reflect normalisation of the
narrative around elevated mental health issues in students. In general, mental health
conditions are more prevalent and have their onset in adolescence or young adulthood (Patel
et al. 2007). However, circumstances at universities in the UK, such as academic pressures
and financial issues, may exacerbate mental health issues (Brown 2016). An Australian study
comparing students to age-matched non-students, found that mental health conditions were
more prevalent in students (Stallman 2011). In UK universities, 21% of students rated
themselves as having low anxiety, compared to 43% of age-matched non-students (Brown
2016). These findings suggest there are specific stressors within universities that aggravate
mental health issues.
Finally, previous diagnosis predicted help-seeking intentions from formal sources and
actual help-seeking behaviour. In Hartrey, Denieffe and Wells’ (2017) systematic review,
students with good previous experience of mental health services were more likely to seek
help than those who were not familiar with these services. In the current study those who
suspected a mental health condition were less likely to intend to seek help from informal
sources, but they were more likely to have sought actual help. One explanation is that these
individuals felt that formal support would be more beneficial to them than informal support.
Limitations and future research
One significant limitation of the current study is its generalisability. Most participants
attended universities in South East England, reflecting the location of the study authors. Most
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were also White British. Mental health statistics in England vary by ethnicity: Black, Asian
and mixed-race individuals report more mental health concerns than White people (Baker
2018). Another limitation is that most participants were female. Women are more likely to
take part in survey research (Sax, Gilmartin and Bryant 2003) and the topic may have been of
greater interest to females, who are more likely to experience internalising problems
(Kuehner 2003). Despite the limited generalisability, the current study still has value in
understanding the barriers some students face.
The study also assumes no change in mental health issues or help-seeking behaviours
during the academic year. Knoesen and Naude (2012) found that first-year students initially
‘languished’ and struggled academically, however over the academic year developed skills
that allowed them to ‘flourish’. Brown (2018) suggests that longitudinal research would
indicate such fluctuations and provide better understanding of mental health problems at
university. Thus, future longitudinal research would be highly beneficial.
Future research should also examine ways of reducing the self-stigma. Those with
mental health conditions who self-stigmatise commonly state that treatment provides little
personal empowerment, linking to reduced motivation to seek treatment (Corrigan 2004).
Therefore, interventions that target self-stigma and increase personal empowerment may
increase help-seeking behaviour. Lucksted et al. (2011) piloted an intervention to reduce self-
stigma in those with mental illnesses and found a significant decrease in self-stigma and
increase in personal empowerment after the intervention. Future research should endeavour to
test further interventions in this area.
Conclusion
Overall, the current study identified possible barriers preventing students from accessing
support, both in terms of help-seeking intentions and actual help-seeking behaviour. Self-
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stigma was a significant barrier of help-seeking behaviour, and disclosure, educational
impact, previous diagnosis, suspected diagnosis and current mental health symptomology
also interacted with help-seeking. This study makes an important contribution in deepening
our understanding of the barriers faced by UK students in relation to mental health. More
work needs to be done, however, on taking down these barriers, and promoting better student
wellbeing.
Acknowledgements
Thank you to all of the participants in this study and peers and colleagues for their support in
recruitment.
Declaration of interest
This work received no grant funding support. The authors have no conflicts of interest to
declare.
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30
Table 1. Demographic information on university and student status variables.
Percentage
Region of university
South East England
East and West Midlands
Wales
South West England
London
Yorkshire and the Humber
North West and North East England
Scotland
East of England
65.3
7.2
6.8
6.1
5.1
3.2
4.3
1.2
0.8
Student status
Home
EU
International
86.2
9
4.8
Study status
Full-time
Part-time
Other
97.9
1.9
.3
Level of study
Undergraduate
Postgraduate taught (e.g. Masters)
Postgraduate research (e.g. PhD)
Other
89.1
6.6
3.7
.5
Current year of study
Year one
Year two
Year three
Year four
Other
26.6
28.5
39.6
5.1
.3
31
Table 2. Diagnosis details, including mean age of diagnosis, and suspected diagnoses. Note:
participants could report more than one condition.
N diagnosed
(%)
Mean (SD) age of
diagnosis
N suspected
diagnosis (%)
114 (30.3%)
17.19 (4.65)
96 (25.5%)
84 (22.3%)
16.96 (4.26)
64 (17%)
30 (8%)
16.20 (3.01)
18 (4.8%)
22 (5.9%)
17.77 (8.94)
16 (4.3%)
14 (3.7%)
20.58 (7.83)
14 (3.7%)
14 (3.7%)
18.38 (3.15)
12 (3.2%)
8 (2.1%)
22.50 (13.43)
7 (1.9%)
6 (1.6%)
22.17 (11.44)
1 (.3%)
4 (1.6%)
17.75 (9.03)
7 (1.9%)
3 (.8%)
17.00 (1.00)
7 (1.9%)
2 (.5%)
15.50 (3.54)
1 (.3%)
32
Table 3. Hierarchical linear regression predicting help-seeking intentions from formal sources, informal sources and ‘no-one’.
Help-seeking intentions:
Formal sources
Help-seeking intentions:
Informal sources
Help-seeking intentions:
No-one
B
SE B
β
B
SE B
β
B
SE B
β
Step One
Age
-.002
.065
-.002
-.17
.076
-.12*
.009
.031
.017
Gender
2.18
.60
.19***
-.21
.70
-.016
.42
.29
.081
Previous diagnosis
-2.17
.47
-.25***
2.12
.55
.21***
-.29
.22
-.072
Undiagnosed condition
-.12
.45
-.015
-3.33
.52
-.33***
.77
.21
.19***
Step Two
Age
-.026
.064
-.021
-.16
.065
-.11*
.006
.024
.010
Gender
2.25
.61
.20***
.31
.62
.023
.20
.23
.038
Previous diagnosis
-1.34
.54
-.16*
.76
.54
.074
.042
.20
.011
Undiagnosed condition
-.21
.48
-.025
-1.85
.49
-.18***
.16
.18
.040
Educational impact
.30
.12
.18*
-.19
.12
-.091
-.028
.045
-.036
Perceived public stigma
.13
.062
.12*
-.026
.062
-.020
-.006
.023
-.011
Self-stigma
-.13
.035
-.22***
-.027
.035
-.039
.040
.013
.15**
Disclosure
.041
.023
.11
.17
.023
.37***
-.097
.008
-.54***
Coping
-.026
.023
-.067
.036
.023
.076
-.001
.009
-.006
Depression
-.031
.031
-.083
-.11
.031
-.25***
.039
.012
.23***
Anxiety
.035
.032
.087
-.038
.032
-.079
-.005
.012
-.025
Stress
.003
.040
.008
.089
.040
.17*
-.017
.015
-.086
Note: ***p<.001 **p=.002 *p<.05
33
Table 4. Descriptive statistics for the barriers for individuals who had or had not accessed
support for their mental health since being at university.
Have you accessed support for your
mental health since you have been at
university?
Total Mean
(SD)
Yes (n = 210)
Mean (SD)
No (n = 163)
Mean (SD)
9.29 (4.21)
10.30 (4.14)
7.89 (3.86)
17.45 (5.09)
16.91 (5.00)
18.10 (5.14)
3.64 (1.97)
3.47 (1.89)
3.88 (2.06)
34.23 (10.86)
34.07 (10.85)
34.18 (10.73)
27.07 (7.15)
26.30 (6.80)
28.15 (7.47)
14.64 (3.97)
15.09 (3.71)
14.09 (4.24)
45.51 (10.68)
47.33 (9.36)
43.30 (11.81)
5.24 (2.48)
6.13 (2.42)
4.12 (2.07)
17.59 (11.51)
20.32 (11.46)
14.33 (10.67)
15.04 (10.50)
18.15 (10.40)
11.14 (9.25)
20.49 (10.04)
23.54 (9.32)
16.80 (9.59)
Note. Non-clinical population means (SD) for DASS-21 from Henry and Crawford (2005):
depression 5.66 (7.74), anxiety 3.76 (5.90) and stress 9.46 (8.40)
34
Table 5. Binary logistic regression examining predictors of accessing support while at
university.
95% CI for Odds Ratio
B(SE)
Lower
Odds
Ratio
Upper
Age
.025(.058)
.92
1.03
1.15
Gender
.42 (.41)
.68
1.52
3.36
Previous diagnosis
1.49 (.35)***
2.23
4.21
8.75
Undiagnosed condition suspected
.90 (.36)*
1.21
2.45
4.95
Educational impact
.28 (.085)***
1.12
1.32
1.56
Perceived public stigma
-.008 (.043)
.93
1.01
1.10
Self-stigma
-.054 (.025)*
.90
.95
.99
Help-seeking intentions: Formal
.12 (.039)**
1.04
1.13
1.21
Help-seeking intentions: Informal
-.047 (.039)
.88
.95
1.03
Help-seeking intentions: No-one
-.18 (.10)
.68
.84
1.03
Disclosure
-.006 (.019)
.96
.99
1.03
Coping
.009 (.015)
.98
1.01
1.04
Depression
-.023 (.022)
.94
.98
1.02
Anxiety
.023 (.022)
.98
1.02
1.07
Stress
.065 (.028)*
1.01
1.07
1.13
Note R2= .38(Cox and Snell), .51 (Nagelkerke). Model χ2(15) = 158.97, p<.001. ***p<.001
**p =.002 *p<.05.
... Benefits and evidence of impact of the MHA role Many of the items identified in the literature search and review refer to the MHA role in relation to a university's range of support for a student with a mental health condition, for example, as a group specifically employed to work with students with mental health needs (Universities UK and MWBHE, 2021) or an increase in the number of students receiving support from MHAs (Robinson, 2022). They are also mentioned briefly as part of the university ecosystem of support for student mental health but not in any particular depth, see for example, Knott and Taylor, 2014;Byrom, 2019;Batchelor et al., 2020;Cage et al., 2020;Broglia et al., 2021;Pollard et al., 2021;Byrom et al., 2022;Edwards-Bailey et al., 2023;Lisiecka et al., 2023;Zile, 2023 andOsborn et al., 2024. The earliest reference found in this review relating to the impact of MHA support (Thomas et al., 2002) notes that whilst there were no formal monitoring procedures in place since the post was relatively new, feedback from university wardens and GPs suggested that the "scheme is valuable" and that the service provides an "e ective and rapid response" (41). ...
Technical Report
Full-text available
This new report details the findings of a small-scale research study on the role and impact of Mental Health Advisers (MHAs) in UK Higher Education (HE) which consisted of a review of the literature, focus groups with MHAs and a survey of students who had received support from a MHA whilst at university. Written by UMHAN's Policy and Engagement Officer, Dr. Rachel Spacey in September 2024.
... In addition, only one third of higher education students were found to have accessed services during their study, with around one fifth of students using outpatient services, as revealed in the first systematic review and meta-analysis of students" use of mental health services (Osborn et al., 2022). A number of common barriers to accessing formal support have been reported in previous studies, such as stigmatising experiences, self-stigma, poor mental health literacy, difficulties and concerns surrounding disclosure, complex and severe mental health issues, complexity and limited availability to approach support services, and a lack of trust in mental health professionals (Broglia et al., 2021;Cage et al., 2020). ...
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Full-text available
Background The benefits of positive psychology interventions (PPIs) have become increasingly popular. While there is an emerging evidence base on the effectiveness of applying positive psychology in curriculum as preventive, early mental health intervention for higher education students, little is known about the content and pedagogy in these promising courses. Objective This article describes (a) the rationale for and development of a positive psychology course embedded into the curriculum that aims to foster posttraumatic growth, psychological flexibility, and socio-emotional competencies for higher education students; and (b) a mixed-method non-randomised pre-post study to evaluate the effectiveness of the positive psychology course in achieving positive participant outcomes. Methods Higher education students from different disciplines will be enrolled to a general education course, “Positive Psychology and Personal Growth”, where they will learn progressive topics and complete summative assessments related to key areas in positive psychology. In addition to lectures, participants will engage in constructivist-based experiential activities that are guided by research on PPIs, life-design interventions and constructivist learning principles. The primary outcome is posttraumatic growth, and the secondary outcomes are psychological flexibility, and socio-emotional competencies. Expected results We hypothesised that after the curriculum-embedded PPI, participants will have significantly higher levels of posttraumatic growth, psychological flexibility, and socio-emotional competencies. Results derived from the questionnaire survey will be supported by corroborating evidence identified from qualitative analysis of participants' summative assessments and follow-up semi-structured interviews on their perceptions of the present course. Discussion The current study will fill in a gap in existing intervention research and practise in curriculum-embedded PPIs and promote research transparency and pedagogical advancement. The intervention provides guidance and recommendations for educators to consider embedding positive psychology into the formal curriculum as cost-effective, low-intensity, structured, and sustainable educational interventions for higher education students.
... Considering college students' heightened stress levels, it is not surprising that this is a time in life when mental disorders are commonly diagnosed or existing symptoms are exacerbated (Pedrelli et al., 2015). Given the relationship between stress and mental health, as well as the prevalence of mental illness, research has focused on identifying protective factors, such as resilience (Kokou-Kpolou et al., 2021), especially because many college students choose not to seek treatment (Acharya et al., 2018;Cage et al., 2020;Ebert et al., 2019). In accordance with Lazarus and Folkman's (1984) perspective on the importance of coping resources, we consider the protective role social support and emotional expression may serve. ...
... Students' health outcomes and academic attainment directly and indirectly refect their physical, social, and mental health during their time at university [28]. Currently, universities are actively seeking efective strategies to improve the positive health and wellbeing of their student body [29,30]. However, this pursuit is complicated by the increasing diversity among students, especially with the rising numbers of international students, posing challenges in providing adequate support [31,32]. ...
Article
Full-text available
Aim. To explore how Black African international students adjust to their new university environment and gain insight into how they feel supported to engage in physical activity (PA). Background. People from ethnic minority backgrounds have poor physical activity levels compared with white populations in the UK. The Black population is known to have the lowest PA levels among the ethnic minority groups in the UK. This trend is suggested to be the case among university students, but no research has examined this. Ethnic minority students, including international students, encounter adaptation difficulties such as cultural barriers and social isolation which affect their university experiences and health behaviours such as physical activity. Methodology. This was a qualitative method, with in-depth semistructured interviews conducted with five African students (two males and three females) aged between 21 and 40 years from a university in the West Midlands. The transcribed interviews were analysed using Braun and Clarke’s thematic analysis. Results/Findings. Culture and lifestyle of physical activity; knowledge, experience, and self-motivation; the effect of various social groups, activities, and services at the university; and weather variations and physical settings were the identified themes. The key finding of the study is that respondents engaged in PA to a greater extent at the British university than they did in their home countries. This was due to a combination of factors, including low-cost gym memberships and events and a general lack of racial or gender-based discrimination. Conclusions/Recommendations. Participants expressed satisfaction with the cultural and social support systems at their university, such as sports clubs and societies, and mental health support services that encouraged them to learn about and engage more in physical activity. Although some barriers, such as weather variations, were mentioned, various indoor options coupled with cheaper gymnasiums motivated students to remain or become active. Understanding the experiences of minority student groups in physical activity could help in reviewing current provisions and extending them to a wider population.
... Although the willingness of seeking help is also an issue prevalent among students. In a study conducted by Cage et al. (2018) three hundred and seventy-six present UK students participated in a survey aimed at gauging their tendencies to seek help and identifying potential obstacles, such as perceived public stigma, self-stigma, the impact on academics, openness about their mental health, coping mechanisms, and current mental health indicators. The results of the study revealed that self-stigma notably hindered the utilization of support services. ...
Thesis
This bachelor's thesis examines the development and impact of an online exhibition fo- cusing on the mental health challenges experienced by university students. Through in- terviews and portraits of six students, the exhibition aims to raise awareness, empathy, and understanding of mental health issues among viewers. A study was conducted to assess the exhibition's effectiveness, involving a survey of 224 participants using the Mental Illness Attitude Items scale by Kobau et al. (2009). The findings reveal a positive shift in attitudes towards mental illness and recovery post-exhibition. This research con- tributes to existing literature by emphasizing the importance of diverse narratives in re- shaping attitudes towards mental health and promoting societal dialogue. The insights gained, hold promise for further examination and research towards combating stigma in the context of mental health issues.
... Australia is not alone in this regard: a study conducted across eight countries with over 13,000 students (Auerbach et al., 2018) found that the majority of university students reported poor mental health with high levels of stress, anxiety and depression. Indeed, student mental health has received significant scholarly attention in recent years (Cage et al., 2020;Cao et al., 2021;Carter et al., 2017;Cvetkovski, Jorm, & Mackinnon, 2019;Laidlaw, McLellan, & Ozakinci, 2016;Wyatt, Oswalt, & Ochoa, 2017) as university students report higher rates of mental health challenges than their non-university peers (Farrer et al., 2016;Stallman, 2010). ...
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This article explores the interplay between perceived employability (PE), mental health, and equity group membership amongst students at a large public urban university in Australia. The article reports from a study conducted between 2017 and 2022, during which students self-assessed their PE. Differences in PE by equity group membership were assessed using responses to structured fields in the questionnaire (n=24,329). Custom measures were constructed using student responses to open-ended fields to proxy student wellbeing based on sentiment analysis and mention of mental health or synonymous terms (n=12,819). Analyses included two-way tests of differences between groups and multivariate analyses considering the effect of equity group membership and mental health concerns on employability beliefs. Results indicate that students with a disability, with English as a second language, or with wellbeing concerns report lower perceived employability. Of all the PE dimensions, academic self-efficacy is most consistently affected by equity group membership and wellbeing concerns. Further, wellbeing concerns are more prevalent for students with disabilities. The findings strengthen support for policy and institutional initiatives focusing on student wellbeing in general but also specifically for equity groups that are already associated with poorer employability beliefs. In particular, students with disabilities appear to have poorer self-esteem and academic self-efficacy and are more likely to have mental health concerns.
... Australia is not alone in this regard: a study conducted across eight countries with over 13,000 students (Auerbach et al., 2018) found that the majority of university students reported poor mental health with high levels of stress, anxiety and depression. Indeed, student mental health has received significant scholarly attention in recent years (Cage et al., 2020;Cao et al., 2021;Carter et al., 2017;Cvetkovski et al., 2019;Laidlaw et al., 2016;Wyatt et al., 2017) as university students report higher rates of mental health challenges than their non-university peers (Farrer et al., 2016;Stallman, 2010). ...
Article
Full-text available
This article explores the interplay between perceived employability (PE), mental health, and equity group membership amongst students at a large public urban university in Australia. The article reports from a study conducted between 2017 and 2022, during which students self-assessed their PE. Differences in PE by equity group membership were assessed using responses to structured fields in the questionnaire (n = 24,329). Custom measures were constructed using student responses to open-ended fields to proxy student wellbeing based on sentiment analysis and mention of mental health or synonymous terms (n = 12,819). Analyses included two-way tests of differences between groups and multivariate analyses considering the effect of equity group membership and mental health concerns on employability beliefs. Results indicate that students with a disability, with English as a second language, or with wellbeing concerns report lower perceived employability. Of all the PE dimensions, academic self-efficacy is most consistently affected by equity group membership and wellbeing concerns. Further, wellbeing concerns are more prevalent for students with disabilities. The findings strengthen support for policy and institutional initiatives focusing on student wellbeing in general but also specifically for equity groups that are already associated with poorer employability beliefs. In particular, students with disabilities appear to have poorer self-esteem and academic self-efficacy and are more likely to have mental health concerns.
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University students are particularly prone to mental health issues such as anxiety and depression, in part due to their transition to emerging adulthood and higher education. Recent studies have established that a considerable number of students go through mild-to-severe episodes of depression, anxiety, and stress during their university years. Despite the exponential increase in interest in this problem, an integrated overview is still lacking. The initial sections of the present review aim to: (i) give an updated view of the state of the art regarding university students' mental health; (ii) present the prevalence and associated consequences of mental health issues, (iii) identify the risk and protectives factors; and (iv) summarize the types of interventions available. The concluding section focuses on making recommendations for the future and proposes new research directions based on the identified literature gaps, namely courses of action, help-seeking behaviours and mental health literacy, and positive mental health.
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