Exploring Mental Health Challenges Among University Students

Introduction and background

Mental health crisis is a major public health issue faced by the society as a whole and includes mental disorders such as somatic symptoms insomnia, depression, stress, psychosis and anxiety (Dachew et al 2015, Tarik et al, 2017). According to Tarik et al (2017), reports of mental health problems are generally more rampant among university students compared to the general population. Similarly studies by Stallman (2010) and Sharp & Theiler (2018) reported significantly higher cases of mental health problems in Australian University students compared to the general population. Furthermore, reports by Student Minds (2021) indicate that at least 1 in 3 university students in the UK have experienced a mental health issue for which they needed professional help. Further UK university student mental health data indicate that 33% of them always or often feel lonely while 8% of the always or often feel worried or anxious (Student Minds 2021). A study by Czyz et al (2013), found that more than 50% of the students who had considered suicide attempt had not received professional mental health assistance within the past one year of the study. This academic study presented an opportunity to evaluate some of the factors that could contribute to mental health crisis among university students and suggest evidence-based recommendations on how to create mental health awareness and improve help-seeking among the students.

Evans et al (2018) defined mental health crisis as any situation in which an individual’s behaviours, actions and feelings put them at risk of being unable to care for themselves and healthily function in the community. Situations such as trauma, violence, environmental stress, stress at university and conflicts with loved ones are known to be significant causes of student mental health crisis (Husky et al 2020).

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Individuals that have been diagnosed with a mental illness are at a greater risk of going into mental crisis (Islam et al, 2020). However, according to Tang et al (2018), mental health crisis often occurs before the individual is diagnosed with mental illness.

Existing research evidence has linked mental crisis among university students to various factors including gender (whereby female students report a higher prevalence of mental health problems than male), family history of mental illness, loneliness, examinations, limited support from their social circles, lack of extracurricular activities in school and tight academic schedules (Dachew et al 2015; Soh et al 2013; Sreeramareddy et al 2007; Sani et al 2012). In such situations, university students experience exacerbation, first onset, or persistence of mental health problems despite receiving medical attention (Gristsenko et al 2020).

University students face many challenges in meeting their mental health needs; many of them do not even consider their mental health needs as a priority. Some of the needs that they might face include lack of access to trained medical personnel, lack of specific diagnosis and treatment and stigmatisation associated with mental health problem (Ambikile & Iseselo, 2017). As a result of these challenges, the students may experience more intensified mental health problems compared to the general population.

The Literature review method

This study applied integrative literature review methodology to achieve its objectives. According to Aveyard (2014), integrative literature review entails the assessment, evaluation and appraisal of literature on a discussion topic, with an aim of developing new perspectives of addressing the underlying research problem. This was a systematic process that entailed a comprehensive search and analysis of literature material to provide the most reliable answers to the research question. Similarly, as Paul & Criado (2020) commented, the systematic search and selection of literature enhanced the duplication and transparency of the study results, improving the study’s reliability.

Development of the research question

The study relied on the PEO (population, exposure, outcome) framework to develop the research question. According to Xiao & Watson (2019), PEO is a research tool in healthcare that facilitates the identification of key concepts that will help to develop the key words for conducting the search.

Search Strategy

The study relied on CINAHL, Medline and PsychInfo as the most reliable and appropriate databases for conducting the literature search. As per PubMed Central (2021) the PubMed database contains at least 32 million journal articles, some of which are biomedical literature materials. On the other hand, Medline provides an extensive variety of medical and nursing literature material, including systematic literature reviews and qualitative studies on mental health (Dogson, 2021). PsychInfo provided extensive articles on psychology. Finally, CINAHL is a widely recognised online database with a wide range of selected peer-reviewed journal articles covering both nursing and mental health research (Aveyard et al 2016). By using the three online databases, the current study had the advantage of accessing a pool of resources from which primary research journal articles could be identified and retrieved to answer the underlying research question.

Search results

After conducting a comprehensive search on Psych Info, Medline and CINAHL, a total of 289 relevant journal articles were identified and were considered eligible to be subjected to further screening using the inclusion/exclusion criteria. More journal articles were eliminated for not being full text, not having abstract or references and reducing the number of years to range from 2015-2021. A further reduction of some of the journals were excluded for not being peer-reviewed while others were excluded for not being a qualitative study which reduced to 10 journals. The remaining 10 journals were subjected to further screening, by reading the abstract and the full journal article to find out if they answer the research question. Ultimately, 5 studies fully satisfied the inclusion/exclusion criteria. No other journal articles were retrieved from sources other than the three online databases.

Keywords

The search process relied on key words to facilitate a faster search. The search terms included: anxiety, depression, distress, students, studies, pressure, and university. These keywords were selected to facilitate a comprehensive search of literature materials from the three databases. A manual search was also conducted to ensure that no eligible article was left out in the search. As illustrated below, synonyms were also used to broaden the search process.

Boolean operators

The search terms were organized using Boolean operators (AND/OR), to help in combining the words and develop precision in the literature search. Moreover, the Boolean operators were useful in developing the search process’ sensitivity and specificity, so that the relevant articles could easily be retrieved. For example, the OR was used to broaden the search process by combining unrelated words, while AND was used to narrow the search by combining related words.

Inclusion and Exclusion criteria

Xiao & Watson (2019) argued that inclusion/exclusion criteria determine the relevance and scope of the literature materials searched and retrieved for further review. The relevant journal articles were written in English language to enable an accurate understanding and interpretation of data. Furthermore, the literature had to be after the year 2015 ensure that the most current evidence is reviewed. Moreover, the journal article had to be in full text to facilitate a comprehensive review of literature. The following table illustrates the inclusion/exclusion criteria:

There are several theoretical reasons why qualitative studies were of interest to the current study. Fundamentally, qualitative studies were deemed to be the best fit for answering the underlying research question. This is because they could provide the best approach for exploring and describing the cause of mental health crisis based on the student’s experiences (Aveyard, 2014).

Furthermore, qualitative studies examine, assess and evaluate university students' experiences of mental health crisis. Focus groups and interview methods are employed to allow the participants to be open and provide an in-depth account of their experiences of the phenomenon under investigation (Holloway and Galvin, 2016). However, a significant lamination of qualitative studies is the difficulty encountered in assessing its methodological rigor and therefore the validity of findings can be difficult to establish (Anderson, 2010). Furthermore, according to Holloway and Galvin (2016), qualitative studies have an inherent risk of bias as the researcher can subjectively interpret the data to mean differently from what the participants meant.

This justified the use of a Critical Appraisal Skills Program, CASP (2014) to critically evaluate the methodological rigor and credibility of the studies to ensure that all the selected studies had credible, valid and reliable findings that could be used to answer the research question. A total of two themes were extracted from the journal articles namely: Loneliness and poor help seeking both of which will be further evaluated in the results section to support the research question.

Data extraction

Independent data extraction is conducted from each journal article, a process that involved the collection of specific information about each journal article including the authors’ name, the location of investigation, the age-range of subjects, sample size, methods and main findings of the study. Appendix 2 illustrates the data extraction table.

Results

This section illustrates the results of the review. The review identified two themes that answered the research question, with all the selected articles being critically appraised and discussed under one theme (loneliness and isolation). The section compared, contrasted and analysed the research findings of each article while evaluating, comparing the methodological results of each journal article through the Critical Appraisal Skills Program (CASP). The following table illustrates the key themes and major concepts that emerged under them.

Theme 1: Isolation and loneliness

The theme of isolation and loneliness emerged in two out of the five reviewed studies. In the study by Vasileiou et al (2019), the researchers intended to explore how university students cope with loneliness as a psychological state that predicts mental health outcomes. As such, they sought how young adults deploy various coping skills to deal with loneliness by conducting a qualitative cross-sectional study. They interviewed 15 university students who went through semi-structured interviews in which the results revealed that the students used a variety of coping strategies including social isolation, support-seeking and self-reliance. According to Vasileiou et al (2019), for the students living on campus or off campus, the significant change in their living environment was a reduced personal interaction with their roommates, as well as staying in self-isolation led to social isolation and loneliness. In turn, the loneliness contributes to poor decision-making, depressive thoughts, and to some extent, drug abuse. These findings corroborated with the findings of Walker & Raval (2017) that loneliness, and social isolation, led to uncertainty, insecurity, overthinking and consequently, depressive thoughts. Through a thematic analysis of interview data, Walker and Raval (2017) found that the participants felt lonely and isolated in their rural homes and therefore had to device various coping strategies. Meanwhile, Walker and Raval (2017) also noted that the participants could feel part of their communities by knowing each other and being known as well as by receiving support or supporting others. After conducting an in-depth interview with the participants, it emerged that loneliness and isolation was a major contributing factor to social anxiety, especially after experiencing relationship break-ups, feeling the urge to hide their vulnerable self from others and when deciding to face their social fears (Walker & Raval, 2017). Across these three studies, it emerged that the pandemic contributed to increased levels of social isolation as students’ overall interaction with friends and family significantly reduced, lack of face-to-face meetings and in-person interaction, and a disruption on social or outdoor activities.

Theme 2: Financial Challenges

Studies have shown financial challenges as one of the risk factors for university student’s mental health crisis. According to Charles et al (2021), the increasing university tuition fee as well as the fear of increased student finance loan and debt post-graduation can cause stress, anxiety, depression and psychosis. As governments try to adjust their financial expenditures, there has been a significant shift in funding towards university education, with most governments reducing their funding towards post-secondary education (Macaskill, 2018). This reduction in government funding reduces the total revenue from universities and ultimately leads to an increase in tuition fee that the students must bear.

Research indicates that the increasing financial burden has detrimental effects on student mental health, especially for the students who incur huge amounts of debts while in the university.

The differences of tuition costs have enabled researchers such as Hjeltnes et al (2015) and Merani et al (2010) to identify the impact of financial burden on the students mental and academic well-being. Merani et al (2010) conducted a survey on Canadian students enrolled in the University of Toronto and University of Montreal’s medical program, where the tuition fees had comparatively risen by $1,257. The study involved over 7,795 students and found that the university of Montreal students were significantly more stressed than the University of Ontario students. Unsurprisingly, these findings suggest that there is a positive correlation between the amount university students pay at school and the financial stress they report. Hjeltnes et al (2015) found that those who experience large financial burden while at the university tend to be less motivated and perform less that their peers who do not experience financial challenges and may be at a higher risk of mental health problems.

Theming and Critical analysis

From a critical point of view, there are several methodological issues with the convenient purposive sampling method used by Walker & Raval (2017), Vasileiou et al (2019), Hjeltnes et al (2015) and Charles et al (2021). As per Aveyard & Sharp (2013), the natural tendency of convenient sampling to treat the findings as representative may not give an accurate representation of the situation at hand. Similarly, according to Bazeley (2009), results from convenient sampling are usually hard to replicate, and any attempt to do so will lead to dramatic differences in findings, leading to low validity and reliability of the findings.

When conducting qualitative research, ethical approval is required (Caldwell et al, 2011), and the authors must seek informed consent and approval from local ethics committee. Macaskill (2018) sought informed consent from the participant but did not mention any information about gaining an ethical approval from the local ethics committee. On the other hand, Hjeltnes et al (2015) and Charles et al (2021) received ethics approval from the local ethics committee and received consent from participant through voluntary participation. That aside, Walker & Raval (2017), Vasileiou et al (2019), Hjeltnes et al (2015) and Charles et al (2021) used general methodological approaches that were consistent with their research aim. However, it is important to note that the five qualitative studies did not mention or discuss the details of their philosophical stance, which was a significant limitation because qualitative studies often strongly rely on philosophical research background to justify their data collection and analysis approaches.

However, despite failure to define their philosophical backgrounds, Walker & Raval (2017), Vasileiou et al (2019), Hjeltnes et al (2015) and Charles et al (2021) have appropriately discussed and justified their research designs and other data collection processes. Similarly, the general concepts explored in the introduction and background relate to themes discussed in the main body and conclusion of the studies, indicating an appropriate means of identifying topics for analysis. Walker & Raval (2017) and Vasileiou et al (2019), gathered data through semi-structured interviews, which were not substantially justified in both studies. However, this was a suitable method of data collection because semi-structured interviews allow researchers to obtain detailed narratives form each participant. More impressively, both Vasileiou et al (2019) and Hjeltnes et al (2015) gave details of the semi-structured interview processes in the main body of the journal, which is an essential indicator of research transparency (Daly et al, 2007). The use of semi-structured interviews and recording the transcripts makes the data collection process auditable, contributing to the validity of the study (Denzin & Lincoln,2011).

RECOMMENDATION AND CONCLUSION

The Five Year Forward View for Mental Health aims to improve mental health outcomes by 2020/21, through the promotion of positive mental health, creating mentally healthy communities and strengthening the workforce. Alongside this, NHS England’s report Future in Mind states that in order to improve mental wellbeing, professionals need to be equipped to promote positive mental health and educate individuals and their families about the possibilities and importance of appropriate and timely intervention (Future in Mind, 2015)

According to Nursing and Midwifery Council (2018), all nurses have the responsibility to promote good health by supporting patients and preventing problems that might lead to mental illness (NMC 2018). This study has established that university students experience mental health crisis differently. In general, loneliness and isolation have emerged as some of the factors contributing to mental health crisis among university students and contributes to failure to access or seek mental health interventions.

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One of the most affective approaches to reducing mental health distress among university students is mental health promotion (Cone & Unni, 2020). Ideally, mental health promotion presents as the best approach to creating a change because loneliness and isolation, (as evidenced by the five journals) reveal the importance of university well-being team, nurses and GP in addressing the issue through a mental health promotion approach. Mental health promotion entails enhancing an individual’s optimal functioning through positive emotion. As per Kobau et al (2020) and Power (2010), health is not only indicated by the absence of illness but rather, it also entails harnessing the society’s and individual’s resources to improve their lives. Ultimately, through mental health promotion, the individual is capable of other aspects of well-being such as good self-esteem and social inclusion (Power, 2010).

Mental health nurses have the responsibility to promote good health by supporting patients and preventing problems that might lead to mental illness as they work in a variety of settings and offer a variety of support to people with mental illness (Thorpe, 2015). They are best placed to promote better mental health among university students.

Effect

Therefore, training courses, led by mental health nurses, can be used to inform the rest of the multidisciplinary team including university well-being on various mental health promotion skill such as building healthy relationships (National Institute for Health and Care Excellence, NICE, 2021). Having effective mental health promotion skills will ultimately increase healthy relationship practices and increased access to mental healthcare, which will help reduce mental health distress among the students.

Change

This mental health promotion can be implemented through the Lewin Change Model. Kurt Lewin proposed that change can be implemented in three steps namely: unfreezing, changing and refreezing (Burnes, 2020). The first step (unfreezing) will involve the multidisciplinary team being informed of the reasons behind the planned mental health promotion change.

For instance most of the healthcare professionals might not be confident to speak or in front of multitude of students to educate them about the importance of mental wellbeing. Mohindra et al (2020) found that effective health promotions can be implemented using marketing and communication tools and skills. This will be effective in implementing the new interventions because it will help in developing positive attitudes and behaviours towards the proposed change.

In the changing phase, the multidisciplinary team will be educated on the research supporting the use of various health promotion techniques such as working with the students from pre-entry through to enrolment and induction (especially the freshers’ welcome week) to educate the students about mental health, as well as including mental health education as part of the main agenda in strategic student welfare meetings. Similarly, this stage would involve educating the team on how they can take advantage of mental wellbeing events held throughout the year to promote mental health and signpost the students on how they can access mental health help. As per Jennings & Bamkole (2019), this is essential because all practice interventions must be based on evidence. Moreover, Aung et al (2020) stipulate that in order to facilitate effective change among healthcare professionals, the professionals must not only understand the scientific reasons behind the change but also how to implement the changes.

Meanwhile, after implementing the change, the team will be asked to offer their feedback regarding its effectiveness. This step is also referred to as the refreezing stage. According to Kichbusch (2019), it is important to gather feedback on implemented change because it helps to determine whether it was effective enough to achieve the desired outcomes, which are always specific, measurable, relevant and timely.

The Lewin’s force model acknowledges that in any planned change, there are barriers and drivers that must be addressed to ensure effective change implementation (Cislaghi & Heise, 2019). as such, one of the most eminent barriers to this proposed change is the negative attitudes of the multidisciplinary team members towards change, a phenomenon that has been found to be common especially when the change contradicts what they have been accustomed to (Laverack, 2017). However, this barrier can be overcome through an effective education on evidence-based guidelines to mental health promotion.

The cost of an elaborate health promotion plan may also cause lack of motivation among the team to implement it (Jennings & Bamkole, 2019). In this context, some of the resources that are likely to be inadequate include staff for personal tutors, unsupportive parents, or even lack of computer experience to support mental health promotion and training. However, the benefits of these resources would greatly outweigh their costs to both the university and to the individual student.

The other potential barrier to an effective health promotion plan implementation is the lack of free time of overstretched support staff (Laverack, 2017). However, according to NMC (2015), continuous training is part of the nurse’s professional development requirements; and is also one of the prerequisites for revalidation. The proposed training can be considered as part of this continuing professional development.

Existing research evidence has linked mental health problems among university students to various factors including gender, lack of interests in their fields of studies, lack of religious support, drug abuse, a family history of mental illness, loneliness, examinations, limited support from their social circles, lack of extracurricular activities and tight academic schedules. In such situations, university students experience exacerbation, first onset, or persistence of mental health problems while receiving inadequate or no medical attention.

This study has found that loneliness and isolation, financial challenges, educational obligations and poor access to support emerged across the reviewed studies as some of the factors contributing to mental health crisis among university students. based on these findings, universities should adopt a mental health promotion program to facilitate effective deliver of student mental health support, which facilitates easy and flexible access to mental health interventions, while eliminating barriers to help seeking such as stigma. Moreover, failure to recognize and address university students’ mental health challenges, could have long-term consequences on student’s mental health, and consequently education. Despite these findings and conclusions through, there are several limitations to the current study that are worth noting. For instance, being a literature review research, the study must have researched from selection bias and a deficiency in comprehensiveness. However, this problem was much solved with the use of multiple databases to facilitate a widespread search of literature. Secondly, because the study selection was based on predetermined criteria, the exclusion might have resulted in misleading or incomprehensive conclusions.

Conclusion

Considering the magnitude of a mental health promotion program within the university, it is important to have an elaborate implementation plan to achieve success. Through the Lewin’s change management theory, the relevant university departments such as mental health wellbeing team can use mental health promotion program for university student support to promote the students’ mental health well-being by encouraging and promoting seeking help and ease of access to professional mental programs. The Lewin’s change model helps to receive support from all the relevant stakeholders, while building their ownership and autonomy of the change implementation project, ultimately leading to success.

Mental health promotion is one of the most effective approaches to reducing mental health distress among university students. It presents as the best approach to creating change because financial challenges, loneliness and isolation are the major causes of mental crisis for university students, as evidenced by the seven journals. It thus provides an alternative for the students unwilling to seek professional mental health counselling due to self-stigma.

Appendix 2: Data Extraction Table:
Data Extraction Table Data Extraction Table Data Extraction Table Data Extraction Table
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