Socio-demographic and substance-related factors associated with mental distress among Wollo university students: institution-based cross-sectional study

Mental distress can be defined as a state of mind with vague manifestations of anxiety, depression as well as ranges of somatic symptoms like headache, backache, and disturbance of vegetative functions such as disturbed sleep [1, 2]. The contribution of mental disorders like mental distress to the burden of diseases and disability is alarmingly increasing globally. The latest reports from World Health Organization (WHO) showed that nearly 33.3% of the disability-adjusted life years in the world is due to psychiatric disorders of different type and of all population in the world, one in four individual is affected by a mental disorder [3]. Though little attention is given, African countries also take the highest share of mental distress and the contribution of mental distress to the burden of disease and disability in Africa has been documented to be 5% and 19%, respectively [4].

University students are at a higher risk of mental distress when compared to the general population [5] or their community counterparts [6‐8] and the prevalence of mental distress in students varies widely in different countries and study periods. The Worldwide prevalence of mental distress among medical students was documented to be in a range of 25–90% [9, 10]. A study at Fayoum University showed that 62.4%, 64.3%, and 60.8% of students were found to have mental distress, anxiety, and depression, respectively [11]. Many other studies also revealed that mental distress was 39.7% (20.7% mild, 7.8% moderate, and 11.2% severe distress) in Canada [12], 50% in Singapore [13], 70% in Pakistan [14], 19.2% and 16.5% in Australia [8, 15], 41% in Malaysia [16], 52% in India [17] and 26.9% in Nigeria [18], 19.8% in Somaliland, 40.9%, 30% and 39.6% in Ethiopia [19‐21].

Many factors were identified so far that contribute to a higher prevalence of mental distress in university students [22‐26]. A study in France justified that female gender, alcohol abuse, smoking cigarette, and cyber addiction were contributing risks for mental distress [27]. Other studies also showed that a family history of mental illness was an associated factor for mental distress in students in Iraq [10], Pakistan [14], and Ethiopia [19, 28]. Besides, substance-related variables in France [27], Nepal [29] and Somaliland [30], Female gender in United States [26], Iran [10], Sweden [31], Australia [8] and Somaliland [30], poor worship practice in Ethiopia [19, 28] were some of the factors identified to account for mental distress in university students.

Mental distress affects many aspects of a student's life such as problems of interpersonal relationship, cognitive, physical, and emotional dysfunction, and inability to attain and sustain pleasure in life in many ways as well as increased test anxiety and poor-self-efficacy. This, in turn, will have a detrimental impact on the ability of students to study and finally will end in poor academic achievement; lowers student grades [8, 31, 32]. Above all, mental distress in students if not addressed timely will progress to more severe psychiatric disorders. Despite this, there is a poor help-seeking intention for mental distress among university students [33‐35].

However, little has been done in this area among university students in Ethiopia; even those studies done focused particularly on medical students [20, 36] and it might not be representative of other university students. Moreover, some of the studies are done in the long past and might not be consistent with the changing situation of university students at present. The aim of this study was therefore to assess the prevalence and factors associated with mental distress among students in Wollo University.

To investigators' knowledge, this study is the first to assess the magnitude and associated factors of mental distress among university students in Ethiopia using the Kessler-10 item mental distress assessment scale. This might make it an important overview of magnitude as well as factors associated with mental distress in students in Ethiopia.

Out of 585 university students, 106 (19.3%); 95% CI (16.10, 22.80) had mental distress in this survey. At most 22.8% (upper bound of the 95% CI) of the university students included in this survey had suffered from mental distress within the 4 weeks before data collection. Considering severity, 65 (11.9%), 28 (5.1%), and 13 (2.4%) of study subjects were with mild, moderate, and severe mental distress, respectively.

A lower magnitude of mental distress was obtained in the current study as compared to a study conducted at Canadian university among medical students and residents, in which the prevalence of mental distress was found to be 39.7% (20.7% mild, 7.8% moderate, and 11.2% severe distress [12]. It is also lower than results of earlier studies which found that mental distress among university students was 50% in Singapore [13], 70% in Pakistan [14], 61.3% in Iraq [10] and 41% in Malaysia [16], 52% in India [17] and 26.9% in Nigeria [18] and 40.9%, 30%, and 39.6% in Ethiopia [19‐21].

On the contrary, this study was higher than a study finding from Michigan; the USA in which only 15.6% of students have emotional distress [43] and 10.8% in Kenya [44]. The difference in prevalence between the current study and the above-mentioned studies might be due to differences in socio-economic, environmental, and behavioral risk factors. Besides, cultural factors in which mental illness is stigmatized by society in low-income countries like Ethiopia may hinder the help-seeking intention and practice of students, thus increasing the prevalence of mental distress. Also, most of the previous studies were conducted among medical students and it might be the stress full nature of medical study due to the high workload which increased the prevalence. Moreover, most of the previous studies used SRQ-20 and the current study used the Kessler-10 distress scale to screen mental distress and sample size variation might account for the difference in prevalence.

However, a result of this survey is consistent with studies in Australian universities (19.2%) [8] and 16.5% [15], 19.8% in Somaliland [30] and 21.6% in Ethiopia [28]. In the current study feeling that “everything was an effort”, feel restless/ fidgety and feel depressed was the mental distress symptoms complained most of the time by students within the past 4 weeks of study. This was more or less consistent with an Australian study at which the symptoms contributing most to mental distress were found to be feeling tired, ‘everything being an effort and being nervous [15].

In the current study, never attending a place of worship was a risk factor for mental distress. No matter how University students follow any type of religion, those students who never attend worship programs were 4.2 times more risky to developmental distress than students who attend worship programs daily. Supportive evidence for this was also found in studies from Adama [28] and Gondar [19]. The possible reason for this would be religion practice builds the highest strength in life and those with good religious practice will have good coping mechanisms from stressful events and factors [45, 46].

A family history of mental illness was also a determinant variable showing a positive association with mental distress in this study. Students who have a family member with mental illness were almost 2 times more likely to have mental distress as compared to those who have no family history of mental illness. These premises are supported by similar findings from studies conducted in Iraq [10], Pakistan [14], Adama [28], and Gondar [19]. Genetic predisposition, and the socio-economic as well as psychological burden caused by the mental illness of family members and care for it, might contribute to such a higher magnitude of mental distress [19].

In this study, current cigarette smoking, current alcohol use as well as current cannabis use were found to have a significant association with mental distress. University students included in current study and who were smoking cigarette, drinking alcohol and using cannabis within the past 4 weeks of study was 3.2, 2.5, and 3.4 times more likely to have a problem of mental distress as compared to those students who did not smoke cigarette, did not drink alcohol and did not use cannabis in the specified time period above respectively. Supportive findings for these were from a study in France [27], Nepal [29], Somaliland [30], and Gondar [19]. This might be due to multi-dimensional effects of substance use like a disturbance in the sleep–wake cycle, dependent producing effects of substances thus causing withdrawal, disturbing interpersonal relationships, increased class absence, and finally leading to poor academic achievement and development of mental distress [47].

Even though, female sex was not found to have a significant association with mental distress in current study, previous studies in the United States [26], Iran [10], Sweden [31], Australia [8], Somaliland [30], and Gondar [19] showed an association between sex (being female) and mental distress in university students. The reason for this could be because, biologically females are predisposed to affective disorders, hormonal factors, and violence from environmental factors [48].

One in five undergraduate regular students in Wollo University has been affected by mental distress as per the result of this study and never attending a place of worship, family history of mental illness, current cigarette smoking, current alcohol use as well as current cannabis use were its risk factors. Therefore, all stakeholders should emphasize this problem and strive to overcome it, since otherwise mental distress affects cognitive, emotional as well as interpersonal functioning and academic performance. Besides clubs regarding behavioral and substance-related issues should be established in the university and have to play an active role in bringing behavioral change to substance use.