Mental distress, perceived need, and barriers to receive professional mental health care among university students in Ethiopia

Mental distress is among the most common type of experience that accompanies mental health problem characterized by a mixture of different complaints such as feeling sad, worried, tense or angry [1]. Common mental disorders are a collective noun for anxiety, depression, and somatoform disorders that can adversely affect individuals across the world [2, 3]. According to the World Health Organization [4] 2015 report, over 300 million (4.4%) and 264 million (3.6%) of the total word population are estimated to suffer from anxiety and depression, respectively [5]. In particular, the contribution of these disorders to the global mental health burden from low- and middle-income countries (LMICs) is high [6]. However, the accessibility of mental health service is still very low, which accounts for the 76–85% treatment gap [7]. This gap has been linked to the lack of skilled human resources, lack of mental health policies, lack of access to mental health services, poverty, the preference for informal treatments, a lack of mental health literacy, the fear of stigma, and a low commitment from funders to access the services [8‐12]. As a result, the majority of people living with anxiety and depression in LMICs do not receive professional mental health care [13].

As in any other LMICs, the prevalence and burden of anxiety and depression in Ethiopia is high. For example, a systematic review and meta-analysis study reported that the pooled prevalence of these disorders is 22% [14], which is associated with risk factors such as food insecurity [15], poverty, violence, migration, and substance use [16]. The burden of depression alone contributes to about 6.5% of the burden of diseases [16], however, as noted above few people are able to receive formal mental health services. Evidence showed that the pooled prevalence of help-seeking behaviors of people with depression is 38% [17]. In Ethiopia, most people with mental illness first contact non-professional care providers such as religious leaders and herbalists [18]. But, if the patient remains affected, he/she will go to western trained psychiatric care providers [18]. The psychiatric services are mainly concentrated in the capital city of Ethiopia, Addis Ababa [19].

To scale-up the limited mental health services across the country, the government of Ethiopia has planned to expand 100% of mental health care by 2020 [20]. The National Mental Health Strategy was developed in 2012 by the Federal Ministry of Health aimed to decentralize and integrate mental health services at the primary health care level [19]. At the university level, mental health services have been established to support students with mental health problems, although the quality of the service provided is under question. Currently, Ethiopia has 45 public universities, where 392,788 (255,657 male and 137,131female) undergraduate students enrolled in 2017. These students are adolescents, economically dependent on their family and full-time learner, they came from rural-urban backgrounds with diversified cultures, languages, and ethnicity.

The prevalence of mental distress is high among university students [21]. A cross-cultural web-based survey of 17,348 university students from 23 high-middle-and low-income countries reported that the average depression prevalence is 20% [22]. Another study also reported that the prevalence of depression and anxiety is 68.5 and 54.4%, respectively [23]. Similarly, the prevalence of these disorders ranges from 21.6–49% among Ethiopian university students [24, 25]. This high prevalence is associated with several factors including: (i) vulnerability of adolescence age for early onset of mental distress [26]; (ii) new identity formation [27]; (iii) challenges of being away from home for the first time [28]; and (iv) academic pressure, substance use [29], and financial difficulties [30]. Moreover, family histories of mental illness, conflicts with friends, not attending religious services, and being freshman are risk factors for mental distress among university students in Ethiopia [31, 32]. On the other hand, having high social support and enough pocket money are protective factors from mental distress [32].

Mental distress has a negative impact on university students’ academic performance [29]. Evidence shows that mentally distressed students scored poor examination result compared with non-distressed students [33]. Although mental distress has such impact, the treatment gap remains large ranging from 37 to 84% [34]. This treatment gap is also high among Ethiopian university students, where majority of the students receive treatment from informal sources such as family, friends, relatives, and religious leaders [35]. There are several barriers that hinder students with mental distress from receiving mental health services. Among these: (i) receiving help from friends or family; (ii) preferring to manage mental illness by self; (iii) normalizing mental illness; (iv) thinking that mental illness would get better by itself [36]; (v) lack of perceived need; (vi) being unaware of the existence of professional mental health services; (vii) fear of stigma, concerns about privacy; (viii) skepticism about treatment effectiveness; (iv) socio-economic problem [34]; and (x) denying mental illness [37].

There are associations between demographic variables and perceived need for mental health care. Female students have more positive attitudes to the utilization of mental health services compared with male students; the possible explanations could be that women experience more mental distress and they give more value for support received from professionals [38]. Conversely, male students are more likely to seek mental health care compared with female students; this might be caused by the interaction effect of other demographic variables in the analysis model [39]. Despite this, there is a finding reporting gender is not a predictor for seeking mental health care; possibly this is caused by insignificance gender difference in mean scores of depression and self-esteem [40]. Likewise, there is no gender difference in reporting barriers to receive mental health care [41]. Older students are more likely to have positive attitudes toward seeking mental health care than younger students; possibly caused by the past mental health care received [42]. Adolescents have a more positive attitude to seek mental health care than adults, because adolescents had more confidence in and better experience of using modern mental health care [39]. There are also insignificant difference in reporting barriers to access mental health care based on age [41].

Class years, family history of mental illness, and substance use are also reported as predictors to receive mental health care. For instance, first and fourth-years students are less likely to use mental health services compared with second and third-years students [43], although there is no change based on rural-urban backgrounds [44]. However, students who had personal contact with someone with a history of mental illness were significantly associated with decreased help-seeking intention; this could be possibly due to the negative experiences students had with a person who they know to have a mental illness [45]. Moreover, students with mental distress use substances to manage feeling of discomfort, which might hinder their interest or preparedness in seeking mental health care [46]. Mental distress, predictors, and barriers to receiving mental health care among university students occur globally, however, there might be higher prevalence, more complex stressors, lower help-seeking behaviors, and a higher treatment gap in LMICs compared with developed countries [47]. For example, even if the prevalence of mental distress is high among university students in LMICs, the majority of them do not receive professional mental health care [48, 49].

Most studies conducted in Ethiopian universities are primarily focused on assessing the prevalence of mental distress rather than looking at the possible barriers to receiving professional help. Besides of this, there is a literature gap with regard to identifying the perceived need for mental health service and demographic factors associated with barriers to receive mental health care among university students in Ethiopia. Therefore, this current study is aimed to assess the prevalence of mental distress, perceived need, and identify common barriers to receive professional mental health care among undergraduate students in Wolaita Sodo University (WSU). Our study also investigated the demographic predictors of the barriers to mental health care. The current study findings will fill the literature gap on professional help-seeking intention, predictors, and barriers to receive mental health service among undergraduate students in LMICs. Besides this, our findings inform to adapt and study feasibility of psychological intervention for students with mental distress within Ethiopian universities with potential implication for other LMICs universities.

In this study, there is high prevalence of mental distress and perceived need for professional mental health care services among university students. The top five frequently reported barriers to receive professional mental health service were: thinking the problem would get better by itself, being unsure where to go to get professional care, wanting to solve the problem by oneself, denying a mental health problem, and preferring to get alternative forms of care. Having a rural background, being a second and fourth-year student, and a family history of mental illness were significantly associated with barriers to receive professional mental health service.

The prevalence of mental distress which is reported in the present study is higher than what has been reported in the meta-analysis of the general population studies in Ethiopia [14]. Perhaps our finding is not surprising, because university students are more likely than the general population to be exposed to mental stress [21]. The possible difference between individual studies reviewed in the meta-analysis [14] and the present study could be partly attributed to the discrepancy in data collection instrument with cut-off points used, age group, and setting. The data collection tools used in the most individual article within the meta-analysis study were ICD-10, PHQ-9, EPDS, K10, HADS etc. with different cut-off points, but in our study we have used SRQ-20 that might be one cause for the discrepancy. The other was a difference in age group and setting, where young person experience higher mental distress compared with adults in the general population.

The current prevalence of mental distress is higher than that reported in previous studies conducted among university students [24, 64]. One possible reason for the discrepancy is the difference in the cut-off values used to define mental illness [24, 64]. The other explanation for the difference is other studies did not use locally validated instrument [64]. On the other hand, the present finding is lower than what was reported in previous studies in Ethiopian universities [35, 65]. The first possible justification for the difference might be data collection tool being used to screen mental distress [35, 65]. The second possible reason for the difference could be the timing of the data collection, where our data collected prior to the approaching final examinations. The present finding is comparable with a study report conducted in Jima University [66]. This might be resulted from similarity of the data collection tool and the cut-off points used to define mental distress.

The high prevalence of perceived need for professional mental health services in the current study suggests that most students with mental distress in Wolaita Sodo University remain untreated. This may not be surprising, because most universities in LMICs are ill-equipped to provide services for students’ mental health issues [47]. Previous study also reported only a few university students receive mental health services for their mental health problems as a result of lack of appropriate services [67]. Our finding is higher than previously reported in the general population of Ethiopia. For instance, a meta-analysis study reported that the pooled prevalence of the help-seeking intention of people with depression in Ethiopia is 42% [17], which is much lower than the current finding. The possible explanations for the difference could be a difference in mental health literacy, study population and the data collection instruments being used. Moreover, our study supports the previous web-based survey reporting that 37 to 84% of university students screened positive to mental distress did not receive any professional mental health service [34]. The similarity of the result may be due to using similar data collection tool and similar age group of participants.

Among the top five reported barriers to receive professional mental health service by the students who recognized a need for care, the first was thinking mental distress would get better by itself. This indicates that students perceive mental distress would get better without receiving any treatment, which may be associated with considering mental health problems as less serious so they are reluctant to use available mental health services [68] and it may also be associated with having poor mental health literacy [69]. The current finding supports a prior study reporting that the majority of college students believed that time by itself would solve their mental health problem [59].

Lack of information where to go to get professional care was reported as the second barrier to receiving mental health service in the University. However, WSU has two counseling offices and a teaching referral hospital that aim to provide mental health services for students with mental health problems. This information gap is probably caused by a lack of awareness creation of these services by the mental health service providers. Our finding is supported by prior studies, where the majority of university students had no information about the availability of mental health service in their university [70, 71].

Wanting to solve mental health problems by oneself is reported as the third common barrier to receive mental health service in the present study. This suggests that most students may not want to share their mental health problems with professionals preferring to handle the problem by themselves. This is possibly due to perceiving their problem as not serious or transitory, being skeptical about the effectiveness of professional mental health service, fear of stigma, and privacy issue [34]. As a result, they might prefer to manage their mental health problem alone perhaps utilizing both positive and negative strategies such as problem-solving [72], substance uses, and isolation [73] as examples. The present finding supports past studies reporting a major barrier to receiving formal mental health service among university students with mild to moderate depression and anxiety is preferring to self-medicate [74, 75].

The fourth barrier identified in the present study is denying mental health problems. Students may not want to recognize their mental health problems due to lack of knowledge about mental illness [69] or they may deny their mental health problem as a coping strategy by rejecting reality and not taking appropriate action to treat their problem [73]. Our finding support a prior study finding reporting that the majority of university students deny mental health problems which hindered them from receiving mental health care [37]. Furthermore, the present study interestingly showed that a family history of mental illness significantly associated with a student denying mental distress. This could be due to students had negative experiences by being with individual with mental illness previously so that they could deny their illness as a coping mechanism [45].

The fifth commonly reported barrier for using mental health service is preferring to get mental health service from informal sources. This suggests that majority of the students receive mental health help from friends, family, relatives, religious leaders, and traditional healers [35], which is also common practice in the general population of Ethiopia [76]. The present finding is also supported by previous studies, where informal sources of mental health care reported by college students was cited as a reason for not receiving mental health services at their university [69, 77].

Interestingly, the current study found that fourth-year students with mental distress are more likely than fifth-year students to report attitudinal, instrumental, and stigma related treatment barriers. Since, the majority of the fourth- and fifth-years students in the present study were from the engineering department, the possible difference could be resulted from as the level of study year/age increases, students become more stable and have better mental health literacy [78, 79]. In this sense, fourth-year students might encounter more barriers to receiving mental health care compared to fifth-year students. However, our finding contradicts a study finding first-year students are more likely than their third-year and senior students to perceive a greater number of barriers to receiving mental health care [37]. The result difference with the present study possibly due to the difference in the data collection tool, study setting, and sample size in each level of the study year. Caution in the present study, the number of the fourth-year students was small.

Our study also found that students from rural backgrounds are more likely than students from urban backgrounds to face instrumental related barriers to access professional mental health care. This might be because of young person from rural areas may not have a knowledge of mental illnesses so that they may not have sufficient information about the availability of free mental health services in the university and they may not be psychologically open toward professional mental health services [80]. Our finding compare positively with a study conducted in Australia reporting that adolescents from rural areas have more instrumental related challenges for receiving formal mental health care than adolescents from urban areas [81]. Our study also shows that second-year students reported more instrumental-related barriers compared with fifth-year students. This was probably due to the interaction effects of other controlled variables in the adjusted model. This may need further study in the future.

The present study implies that mental distress is prevalent among undergraduate students. Likewise, the need for mental health services is increasing, even though the students are not be able to receive the service provided in the university. This was because of attitudinal, instrumental and stigma-related barriers. Particularly, fourth-year students and students from rural background were more likely to report these barriers compared with fifth-year and students from urban backgrounds, respectively. This indicates to a need for designing practical mental health interventions to treat students’ mental distress, to alleviate their psychological suffering and minimize the effect on their academic work, general and social functioning [29]. Therefore, the present findings provide useful information and directions for university mental health service providers to create awareness about mental health problems and their service, the benefits of receiving mental health care, and when and where to seek mental health services by distributing flyers, preparing training, and mental health day. All these together enhance to develop active university-based mental health intervention to reduce the prevalence of mental distress and to satisfy the need for receiving mental health service by minimizing the reported major barriers.

Any research has its own limitations; similarly, the present study is not limitation free. First, data were collected using self-reported questionnaires so that recalling bias may occur for mental distress symptoms that happened in the past 1 month and rating the degree of barriers to mental health care may also difficult to remember. Second, the barriers to the provision of mental health care measuring instrument was not locally adapted, although it was properly translated and piloted for the present research. Third, a screening tool was used to identify participants positive for mental distress; it would have been better to use a diagnosis tool. Fourth, data collectors were classroom representatives, so that they were in a position to know the participants’ response to each item while checking missing on the questionnaires. Fifth, since the participants were recruited from a single public university, it is difficult to generalize the result to all public universities and private colleges that are found in Ethiopia. Finally, students who received treatment from the informal sources should have to complete BACE-III to understand whether they were aware of their needs for professional care or not, but we did not do that.

Further, future research is needed to study barriers to receiving professional mental health care among students with mental distress who do not wish to receive mental health care from professionals as a result of receiving treatment from informal sources. Additionally, the present study has also investigated some demographic predictors of barriers to receive mental health care, but further study is necessary to examine the associations of other variables such as mental health literacy and academic results with barriers to receive mental health services. Despite the limitations mentioned above, the present study has some strengths. First, a large number of students participated in the prevalence study. Second, the study used a locally adapted instrument, SRQ-20. Third, the research contains findings of the prevalence of mental distress, perceived needs, predictors, and barriers to receive professional mental health services together; all this information taken together can serve as input for future feasibility studies of mental health interventions for mental distress among university students.

There is high prevalence of mental distress and perceived need for professional mental health service among undergraduate students at Wolaita Sodo University that identify the need for professional mental health interventions. Mental health providers in the university should make their services accessible to the students and promote the service for better utilization. Besides the interventions, developing preventive mental health education strategies is essential to address the prevalence of mental distress with the creation of conducive environments that promote and sustain positive mental health for every student. Moreover, preparing for the celebration of mental health day in the university can play a role in changing the attitude of students toward mental health care and improving mental health literacy, because out of the five major barriers, four of them were attitudinal related. In this celebration day, creating awareness about the treatment of mental distress like any other physical illness can be emphasized, as well as the benefits of receiving mental health care from professionals, recognizing mental distress in the early stages, and educating students to seek mental health care from professionals in parallel with receiving treatment from alternative sources. Therefore, this paper is a call for action from university administrations, university mental health care providers, and the Ministry of Science and Higher Education for helping undergraduate students with mental distress and to work to minimizing mental health distress on campus.