Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
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Matloob Ahmed Khan
Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
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Girmay Medhin
Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
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Dawit Wondimagegn
Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
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Mesfin Araya
Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
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Author information Article notes Copyright and License information Disclaimer
Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
Assegid Negash, Email: moc.liamg@ndigessa.
Received 2019 Jul 12; Accepted 2020 Apr 14.
Copyright © The Author[s] 2020
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author[s] and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit //creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver [//creativecommons.org/publicdomain/zero/1.0/] applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Associated Data
Supplementary MaterialsAdditional file 1. Instruments used for data collection.
12888_2020_2602_MOESM1_ESM.docx [32K]
GUID: FEB845B7-2EC4-4F98-8532-2369DE19AE8F
Additional file 2. The association between demographic variables and common barriers to receive professional mental health care.
12888_2020_2602_MOESM2_ESM.docx [32K]
GUID: A6A3BA63-C3DC-4B2F-9632-EF1591BCFE13
Data Availability StatementThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Abstract
Background
There is limited evidence on the extent of the perceived need and barriers to professional mental health service delivery to university students with mental distress in low- and middle-income countries [LMICs]. This study was designed to assess the prevalence of mental distress, perceived need for professional mental health care and barriers to the delivery of services to affected undergraduate university students in Ethiopia.
Methods
A multi-stage sampling technique was used to recruit 1135 undergraduate university students. Symptoms of mental distress were evaluated using the Self-Reported Questionnaire [SRQ-20] and a score of above seven was used to identify positive cases. The perceived need for professional mental health care was assessed using a single ‘yes or no’ response item and barriers to mental health care were assessed using Barriers to Access to Care Evaluation [BACE-30] tool. Percentage, frequency, mean, and standard deviation were employed to summarize demographic characteristics of the participants and to identify common barriers to mental health care service. Moreover, the association of demographic variables with total mean scores of BACE-III sub-scales was modeled using multiple linear regression.
Results
The prevalence of mental distress symptoms was 34.6% and the perceived need for professional mental health care was 70.5% of those with mental distress. The top five barriers to receiving professional mental health service were [a] thinking the problem would get better with no intervention, [b] being unsure where to go to get professional help, [c] wanting to solve the problem without intervention, [d] denying a mental health problem existed, and [e] preferring to get alternative forms of mental care. Coming from 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.
Conclusion
The high prevalence of mental distress, the paucity of mental health care, and the report of barriers to access what professional mental health care there is among Ethiopian undergraduate students is a call to address the disparity.
Keywords: Mental distress, Perceived need, Barrier, Professional mental health care, Ethiopia, Undergraduate students
Background
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.
Methods
Study setting
The current study is conducted at WSU, a public university located in the Sodo town of Wolaita Sodo Zone, Southern Nations, Nationalities, and Peoples’ Regional State [SNNPR] of Ethiopia. Sodo town is located 320 km south of Addis Ababa. WSU was established in 2007 as a result of the rapid expansion of higher education in Ethiopia. The university began with an intake of 801 students [609 males and 192 females] in four faculties and sixteen departments. Currently, the university runs undergraduate and graduate programs in six colleges and five schools. During the study period, a total of 12,028 [7321males and 4707 females] undergraduate students were registered. These students qualify to join the university by taking the Grade 12 national entrance examination prepared by Ministry of Education. WSU has two counseling offices and two health centers. There are three psychologists in the counseling offices that provide counseling services for students with mental health problems. The two health care centers are the Ottona hospital and the students’ clinic, both of which provide health care services. Ottona hospital is a referral hospital that provides health care services for the community and for the students with severe mental health problem by providing medication.
Study design, objectives and study period
An institution-based cross-sectional survey was conducted among WSU undergraduate students from December 2017 to January 2018. The objective was to estimate the prevalence of mental health problems, perceived need, and to identify barriers and demographic predictors to receive professional mental health care.
Sample size
A sample size of 1135 was estimated with an assumed prevalence rate of mental distress 40.9% [32], precision of ±3, 95% confidence interval, and 10% non-response considered. For the other two objectives [perceived need and barriers to receive mental health care] separate sample sizes were not estimated. All the participants who were screened positive for mental distress [> 7] were used as the denominator to estimate the proportion of students having a perceived need for professional mental health care. Those participants who had mental distress symptoms and who did not receive mental health services from professionals in the past 3 months were eligible to be part of the study.
Sampling and procedures
A stratified multi-stage sampling technique was used to recruit study participants. A list of students’ names from all first to fifth years was obtained from the registrar office of WSU. The first participant’s name was selected randomly; the remaining participants were selected using systematic random sampling. To accomplish, the first step was stratifying undergraduate students by their schools/colleges [six colleges and five schools]. For the second step, the total sample size was allocated into the 11 strata using probability proportional to the number of the students as a measure of size. The third step was selecting participants from each school and college based on the proportion of the size of each department. The fourth step was selecting participants from first to fifth-years based on the proportion to each year. Then, the final step was randomly selecting the first participant and systematically selecting the rest participants from each level and section of the study year.
Measurements
The survey questionnaire consisted of four parts: Demographic Characteristic Questionnaire: used to document variables including participants’ sex, age, religion, ethnicity, marital status, current place of living, area where they grew up, level of the study years, family history of mental illness, and substance use.
Self-Reported Questionnaire [SRQ-20]: It is a screening tool for mental distress developed by WHO [50]. SRQ-20 is a self-report instrument with 20 binary responses [yes/no] questions. It has the potential of detecting cases and non-cases with sensitivity ranging from 63 to 90 and specificity ranging from 44 to 95 [51]. WHO recommends SRQ-20 as a reliable and valid instrument to detect general Common Mental Disorders [51]. It was developed specifically for use in LMICs [50]. SRQ-20 has been previously translated into Amharic language in Ethiopia, locally validated [52, 53], and used in different community [54–56] and institution-based surveys [24, 25, 32, 57] with cut-off points ≥ 4 [57], ≥ 7 [25], ≥ 8 [32] and ≥ 11 [24]. SRQ-20 has good psychometric properties [i.e. sensitivity 86% and specificity 84%] for detecting individuals with mental distress in the Ethiopian population with an optimal cut-off point at ≥8 [58]. To identify cases in the current study, a cut-off point of > 7 was used based on a previous validation study of SRQ-20 in Ethiopia that resulted in good sensitivity and specificity using a cut-off point of 8 [58]. The pilot data collected from 38 undergraduate students in a similar population but in a different setting to the current study showed that the internal consistency of SRQ-20 was 0.77.
The Perceived Need for Professional Mental Health Care Questionnaire: Used to assess the perceived need for professional mental health services in the past 3 months. It has been used in the previous studies [59, 60]. The question is phrased as follows: ‘Was there a time when you thought you should see a doctor, counselor or other health professionals for your mental distress, but you did not go in the past three months?’ with the response options of Yes/No. “Yes” response implies the perceived need for mental health care but not received in the past 3 months, whereas “No” response implies no need for mental health care for mental distress. Therefore, the perceived need for professional mental health care in this study implies the number of students who reported “Yes” option.
Barriers to Access to Care Evaluation [BACE-III]: BACE was originally developed to identify barriers to receive professional mental health service for people with mental health problems [61]. It has 30 items to be completed by the participant [self-complete measure]. This instrument has good psychometric properties [i.e. validity, reliability, and acceptability] [61]. BACE-III has three dimensions of potential barriers of stigma [12 items], attitudinal [10 items] and instrumental [8 items] related. This instrument asks about a range of issues that have ever stopped, delayed or discouraged an individual from receiving professional care for a mental health problem in the past 3 months. The response scale ranges from 0 [not at all] to 3 [a lot]; the higher score indicating a greater barrier. Five of the thirty items contain a fifth option: “Not applicable”. Findings for each barrier are presented in three ways: mean score for the item, barrier to any degree [the percentage of answering 1, 2 or 3] or major barrier [the percentage of answering 3] based on BACE-III manual for researchers.
For the current study, BACE-III was translated into the Amharic language by two Amharic language experts whose first language is Amharic and their second language is English. One expert who knows the subject matter translated the instrument based on the BACE-III translation guide. The masked back-translation was made by two English language experts and one mental health expert. The research team compared the back-translated instrument with the original version of BACE-III and agreed upon the consistency of the translation. The translated BACE-III was piloted on 40 undergraduate students in a similar population but in a different area of the current study setting. Its internal consistency was 0.85.
After the pilot study, the authors examined the applicability of each question in the university set-up and noticed that item number 27 and 28 need some modifications. Discussion was made with a mental health expert who has experience of adapting mental health instruments. Then, question number 27 which says ‘difficulty taking time off work’ was modified as ‘difficulty taking time off education’ and question number 28 which says ‘concern about what people at work might think, say or do’, was modified as ‘concern about what students might think, say or do’. The final version of the instrument was administered to students who scored > 7 on the SRQ-20 and who had a need [those who answered “Yes”] to receive professional mental care in the past 3 months of the study period. The internal consistency of the overall BACE-III scale after the revision was 0.85, whereas for stigma sub-scale = 0.83; attitudinal sub-scale = 0.67 and instrumental sub-scale = 0.60. Those participants who answered “No” for the perceived need for mental health care measuring questionnaire were asked ‘In the past three months, did you receive help from a psychologist, doctors, friends, family, religious leaders or traditional healers?’ by skipping the BACE-III questionnaire. See supplementary file 1.
Training of data collectors and data collection procedures
Classroom representatives served as data collectors. A half day training was given by the principal investigator to data collectors about the aim of the research, the contents of data collection tools, how to approach participants, ethical issues, and responsibility of controlling missing data. The classroom representatives both males and females were contacted by the researcher through the help of their department heads, because they had cell phone numbers of each classroom representative. Then, with the assistance of the classroom representatives, the student participants came to the selected lecture halls and classrooms and the data collectors explained the aim of the study. Finally, after verbal agreement was received, the data collectors started to collect the data by explaining the instructions of all questionnaires with the close supervision of the principal investigator. To protect the confidentiality of the participants, personal identifiers were not included in the questionnaires; instead, a code was applied.
The data collection was carried out before the students’ final examination to control for an inflation of the prevalence of mental distress. Those who scored > 7 on SRQ-20 were asked to answer the questions about the perceived need for professional mental health care and then answer questions in the BACE-III questionnaire. Participants who answered “No” the question about the perceived need for professional mental health care skipped the BACE-III and answered why they did not need mental health treatment in the past 3 months. Finally, after the participants completed the self-administered questionnaires, the data collectors immediately checked the existence of incomplete and missed information before the participants left the room.
Data analysis
Data cleaning and cross-checking were done before analysis using Statistical Packages for the Social Sciences [SPSS version 20]. Descriptive statistical measures [i.e. percentage, frequency, mean, and standard deviation] were employed to summarize demographic characteristics of the participants and to identify barriers to mental health care services. Pearson chi-square test was used to examine the association between demographic variables with mental health care seeking intention and with the five most commonly reported barriers to receive mental health services. Furthermore, multiple linear regression was also used to model the association between demographic variables with a mean score of BACE-III sub-scales. Univariate regression analysis was used to identify potential candidate variables for multivariable linear regression with a p-value of 7 on SRQ-20. The majority [60.5%] were male. The age of the participants ranged from 17 to 38 years with a mean age of 21.53 years [SD = 2.42]. The participants were from diverse ethnic groups, the majority were from Amhara [34.6%] and Wolaita [20.9%] ethnic groups. Regarding marital status, 82.8% were single and 95.3% were living in the campus. Over half [54.7%] were from urban backgrounds. First-year, second-year, and third-year undergraduate students took 27.7, 26.6, and 25.9% of the sample, respectively [Table [Table11].
Table 1
Demographic characteristics of the study sample
VariablesTotal Sample [n] % N [980]Screened positive for mental distress [n] % N [339]Participants with mental distress who have not received formal Mental Care % N [239]Sex Male593 [60.5]176 [51.9]127 [53.1] Female387 [39.5]163 [48.1]112 [46.9]Age Mean21.5321.2121.22 SD2.421.951.82 Minimum171818 Maximum383028Religion Christian Orthodox543 [55.4]241 [71.1]164 [68.6] Christian Protestant330 [33.7]50 [17.7]46 [19.2] Islam80 [8.2]30 [8.8]22 [9.2] Christian Catholic8 [0.8]2 [0.6]2 [0.8] No religion8 [0.8]4 [1.2]3 [1.3] Others11 [1.1]2 [0.6]2 [0.8]Ethnicity Amhara339 [34.6]164 [48.4]110 [46.0] Oromo155 [15.8]58 [17.1]41 [17.2] Wolaita205 [20.9]44 [13]35 [14.6] Gurage80 [8.2]24 [7.1]15 [6.3] Tigre24 [2.4]11 [3.2]8 [3.3] Sidama58 [5.9]9 [2.7]7 [2.9] Hadiya32 [3.3]8 [2.4]6 [2.5] Gamogofa30 [3.1]8 [2.4]6 [2.5] Others57 [5.7]13 [3.9]11 [4.6]Marital status Single811 [82.8]268 [79.1]194 [81.2] In a relation114 [11.6]50 [14.7]31 [13.0] Married but not living together35 [3.6]11 [3.2]9 [3.8] Divorced14 [1.4]7 [2.1]3 [1.3] Married and living together6 [0.6]3 [0.9]2 [0.2]Residence In Campus934 [95.3]320 [94.4]223 [93.3] Off Campus20 [2]8 [2.4]7 [2.9] Both26 [2.7]11 [3.2]9 [3.8]Area of growing Urban536 [54.7]176 [51.9]127 [53.1] Rural444 [45.3]163 [48.1]112 [46.9]Level of study year First-year271 [27.7]117 [34.5]81 [33.9] Second-year261 [26.6]85 [25.1]58 [24.3] Third-year254 [25.9]84 [24.867 [28.0] Fourth-year96 [9.8]28 [8.3]18 [7.5] Fifth-year98 [10.0]25 [7.4]15 [6.3]Family history of mental illness Yes67 [6.8]34 [10.0]22 [9.2] No913 [93.2]305 [90.0]217 [90.8]Substance use Yes58 [5.9]39 [11.5]31 [13.0] No922 [94.1]300 [88.5]208 [87]
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Mental distress
The prevalence of mental distress was 34.6%, indicated by 339 participants with SRQ-20 scored higher than 7. It was slightly higher [51.9%] among male students. The item-based response of the study participants to the SRQ-20 is summarized in Fig. 1. The top three frequently reported symptoms were: loss of interest in things [37.60%], being tired [36.90], and thought of ending one’s life [36.80%]. The least reported symptom was handshaking/hand trembling [19.7%].
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Fig. 1
Prevalence of mental distress and its distribution of specific symptom
Perceived need for professional mental health care
Of 339 participants with elevated symptoms of mental distress, 70.5% [n = 239] reported a perceived need for professional mental health care in the past 3 months. The remaining 29.5% did not report a need for professional mental health treatment, because they have received the service from informal sources [25.5% from religious leaders, friends, family, and traditional healers] and formal sources [4% from doctors and psychologists]. There was no significant gender difference in seeking mental health service, χ2 [1] = 0.48, p = 0.49. Likewise, there were no significant differences among the remaining demographic variables in those seeking mental health services [Table [Table22].
Table 2
The association between demographic variables and perceived need for professional mental health care
VariablesNeed for professional mental health careχ 2P-valueYes [n]No [n]Sex Female112510.480.49 Male12749Religion Orthodox164773.020.39 Protestant4614 Muslim228 Others71Ethnicity Amhara111533.770.88 Oromo4117 Wolaita359 Gurage159 Hadiya62 Tigre83 Sidama72 Gamogofa62 Others103Marital status Single193756.830.15 In a relationship3119 Married but no living together21 Divorced101 Married and living together34Residence In campus223971.890.39 Off campus71 Both92Area of growing Rural112510.480.49 Urban12749Level of study year First-year81365.610.23 Second-year5827 Third-year6717 Fourth-year1810 Fifth-year1510Family history of mental illness No217880.610.44 Yes2212Substance use No208921.710.19 Yes318
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Barriers to receive professional mental health care for mental distress
Of the 339 participants who screened positive for mental distress, 239 [127 male and 112 female] had not received mental health services in the past 3 months, because of the barriers to receive the treatment, although they desired mental health care as indicated in Table 3. This table shows mean scores of an individual item, standard deviation, percentage to any degree, and major barriers to receive mental health care. There were top five barriers to receiving mental health care the reported percentage was greater than 60% to any degree [sum of responses of a little, quite a lot, and a lot].
Table 3
Barriers to receiving professional mental health care among students with mental distress who have not received mental care in the past three months [n = 239]
Barriers to Mental Health CareMental Distress who did not receive professional mental health treatment [N = 239]Total [N]Item Mean and [SD]Barrier to any degree % [n]Major barrier % [n]Stigma-related barriers Concern about what my family might think, say, do or feel48.1 [115]18.4 [44]2390.98 [1.18] Concern that I might be seen as weak for having a mental health problem38.9 [93]14.2 [34]2390.76 [1.10] Feeling embarrassed or ashamed29.8 [71]10.9 [26]2390.58 [1.01] Concern that I might be seen as ‘crazy’31.9 [76]10.5 [25]2390.61 [1.02] Not wanting a mental health problem to be on my medical records26.0 [62]8.4 [20]2390.50 [0.95] Concern that people might not take me seriously if they found out I was having professional care28.0 [67]7.1 [17]2390.51 [0.93] Concern that people I know might find out28.4 [68]6.7 [16]2390.47 [0.87] Concern about what my friends might think, say or do33.5 [80]6.7 [16]2390.56 [0.92] Concern about what students might think, say or do31.4 [75]6.3 [15]2390.53 [0.90]Attitudinal-related barriersThinking I did not have a problem67.4 [161]38.1 [91]2391.59 [1.29]Thinking the problem would get better by itself74.4 [178]36.8 [88]2391.65 [1.22]Preferring to get alternative forms of care66.5 [159]34.3 [82]2391.51 [1.27]Wanting to solve the problem on my own71.1 [170]28.0 [67]2391.50 [1.18] Preferring to get help from family or friends58.6 [140]22.2 [53]2391.20 [1.20] Dislike of talking about my feelings, emotions or thoughts38.0 [91]9.6 [23]2390.69 [1.02] Concerns about the treatments available [e.g. medication side effects]36.8 [88]9.6 [23]2390.65 [1.01] Thinking that professional care probably would not help30.9 [74]7.5 [18]2390.54 [0.93] Fear of being put in hospital against my will21.4 [51]7.1 [17]2390.41 [0.89] Having had previous bad experiences with professional care for mental health16.7 [40]4.6 [11]2390.30 [0.76]Instrumental-related barriers Not being able to afford the financial costs involved56.0 [134]25.5 [61]2391.23 [1.25] Having no one who could help me get professional care59.8 [143]24.7 [59]2391.26 [1.22]Being unsure where to go to get professional care71.6 [171]21.0 [51]2391.36 [1.11] Difficulty taking time off education55.2 [132]17.6 [42]2391.10 [1.16] Problems with transport or travelling to appointments44.4 [106]17.6 [42]2390.92 [1.18] Being too unwell to ask for help51.9 [124]14.6 [35]2390.96 [1.11] Professionals from my own ethnic or cultural group not being available26.4 [63]6.7 [16]2390.47 [0.89]
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Note: Question number 5, 14, 24, and 29 in the BACE-III were not included in this table, because more than 97% of the participants responded “Not applicable” option for each item. Barriers reported percentage greater than 60% to any degree were indicated in bold color
The first barrier to seeking mental health care was ‘thinking the problem would get better by itself’ reported by 74.4% to any degree and 37% thought that it would act as a major barrier to receive mental health services. The second was ‘being unsure where to go to get professional care’ which accounted for 71.6% to any degree and 21% reported as a major barrier. The third was ‘wanting to solve the problem on their own’, whereby 71% of the participants reported this as a barrier to any degree and 28% thought that it would act as a major barrier to receiving mental health care. The fourth was ‘denying a mental health problem’, where 67.4% of the participants reported this as a barrier to any degree and 38% reported it as a major barrier. The fifth was ‘preferring to get alternative forms of care’ reported as any degree of the barrier by 67%, while 34% of the participants reported it as a major barrier to receiving mental health service. Of all the demographic variables, only a family history of mental illness had a significant association, X2 [3] = 14.48 = p = 0.01 with ‘denying mental health problem’ of the top five barriers. See supplementary file 2.
Of the top five barriers, the top four were attitudinal related barriers to receiving professional mental health services. The fifth, ‘being unsure of where to get professional care’ was an instrumental-related sub-scale of BACE-III. As a result of, the mean score of attitudinal related barriers sub-scale of BACE-III [M = 1.26, SD = 0.68] was the highest when compared with instrumental related barriers sub-scale [M = 0.78, SD = 0.43] and stigma related barriers sub-scale [M = 0.61, SD = 0.65] of BACE-III.
Predictors of attitudinal related barriers to receive professional mental health care
In univariate regression analysis [Table 4], fourth-year students perceived significantly more attitudinal related barriers [β = 0.27; 95%CI = 0.24, 1.16; p = 0.003] than the fifth-year students. Multivariable analysis also showed that only fourth-year students perceived significantly more attitudinal related barriers [β = 0.27; 95% CI = 0.21, 1.14; p = 0.01] than the fifth-year students.
Table 4
Predictors of attitudinal related barriers to receiving professional mental health care in univariate and multivariable linear regression [n = 239]
VariablesAttitudinal related barriersUnivariateMultivariableBeta95% CIP-valueBeta95% CIP-valueAge.09−.02, .08.18.01−.05, .06.91Level of study years First year.01−.36, .38.9701−.41, .42.97 Second year.03−.33, .43.80.03−.35, .46.81 Third Year.11−.20, .54.37.12−.21, .57.37 Fourth Year.27.24, 1.16.003.26.21, 1.14.004 Fifth Year [Ref.]–.80, 1.48