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MENTAL HEALTH LITERACY, MENTAL HEALTH STATUS AND PSYCHOLOGICAL WELLBEING AMONG UNIVERSITY STUDENTS: A CROSS-CULTURAL STUDY IN PAKISTAN
ZOONISH AZIZ
PhD Scholar, Department of Behavioural Sciences, Fatima Jinnah Women University
DR. SAJIDA NAZ
Associate Professor, Department of Behavioral Sciences, Fatima Jinnah Women University
ABSTRACT
Despite of the fact that Mental Health and wellbeing is declared as one of the priority areas globally by the UN, mental health is not as much prioritized in the developing countries such as Pakistan. With respect to the student's community, there is an evidence of elevated risk of mental disorders due to the pressure the face in the real world. The primary objective of this study was to examine extent of Mental Health Literacy (in terms of maintenance of positive mental health, attitude to mental illness stigma, recognition of mental illness, help seeking attitude and help seeking efficacy), mental health status (i.e., Depression and Anxiety) and Psychological Wellbeing among University Students. A survey research design was used to gather from Students across all of public universities of Pakistan. A total of 1628 (1163 males and 465 females) students completed the survey. The questionnaire included Hospital anxiety and depression scale, Mental health literacy scale and Warwick Eddinburgh Mental well being scale. The results revealed an elevated level of stress, anxiety, and depression among participants, which was negatively related with their mental health and wellbeing. In conclusion, this study highlights the need to prioritize mental health and wellbeing among university students in Pakistan and other countries.
Keywords: Mental Health Literacy, Mental Health Status, Psychological Wellbeing
INTRODUCTION AND LITERATURE REVIEW
For many young people, starting university is a time of change. During this time, students must take on new responsibilities and encounter new individuals, juggling the academic demands of an unstructured learning environment. As an added disadvantage, many students must leave their families and friends behind for the first time (Cleary et al., 2011). University students may experience a decline in their emotional and psychological health because of these obstacles. There is evidence that university students' mental health suffers after they enroll and improves as they progress through their degrees (Mey and Yin, 2015; Macaskill, 2013). It never fully recovers to its level before university (Bewick et al., 2010). Furthermore, the likelihood of having common psychological issues, including anxiety, stress and depression, increases during adolescence and reaches a peak in early adulthood around the age of 25, making university students an especially vulnerable demographic (Shah et al., 2021).
Mental health is recognised as one of the potential components in individual's health. There has been a significant increase in the mental health disorder which is becoming potential concern of public health across the globe. The report of WHO (2021) demonstrated that the mental illness is being increasing rapidly and is impacting majority of health across the world. The research of Mukhtar (2020), illustrates that 450 million
people across the globe suffer from the mental disorder. Moreover, there are 25% of people that extensively experience different type of mental disorder across the globe. According to Davenport et al., (2016) the significant increase in mental health disorders is causing disabilities globally and leading toward poor conditions such as depression, usage of alcohol, bipolar affective disorder, schizophrenia and obsessive-compulsive disorder. The research Ali and Gul (2018) represents global data that among 45 million people across the globe, individual above the age of 15 suffers from schizophrenia at some point of their life. However, there are 340 million people that are currently experiencing numerous depression disorders. Hence, schizophrenia and depression are considered as two potential disorders which are accountable for about 60% of suicide.
In the above context, Pakistan is also experiencing miserable circumstances. The current population of Pakistan is almost 200 million and the country is experiencing distinct health challenges including communicable and non -communicable diseases. Pakistan does not have a strong public-funded primary health care system (PHC) while the majority of the people seek healthcare services in the highly unregulated private sector. Thus, mental health in Pakistan is generally neglected due to scarce health resources. On the other hand, the research of O'Connor et al, (2019) displayed that about 10-16% population of Pakistan suffers from mild to moderate mental illness.
The research conducted by Ungar and Theron (2020) to enhance a positive mental health a person should openly talk about their feeling, worries and it effectively help to deal with times when a person feel trouble. The effective exercise each day will help individual to build self-esteem and significantly help to concentrate (Trompetter, et al, 2017). The physical workout will keep brain and all other part of the body healthy. The research further indicated that it plays significant role in improving mental health. However poor mental health increase risk of developing mental health problems. While, the poor mental health can have negative impact on physical health and it intrinsically increase risk of some conditions (Ungar & Theron, 2020).
According to Wong (2016), young people do not seek professional care or do so only after a long period of time which can minimize the probability of better long-term results as compared to earlier treatment. Improving mental health awareness may be used as a strategy to improve young people's mental health by promoting early detection, help-seeking, and treatment of disorders. The gender difference in mental health among university students observed that women are associated more with a degree of mental health literacy as compare to males.
MENTAL HEALTH LITERACY
The theory of reasoned action, which is in line with the promotion of mental health literacy, emphasizes the significance of one's views as crucial to deciding help-seeking behavior. A person's ability to recognize the signs of mental illness and advocate for themselves in the face of stigma is bolstered by their level of "mental health literacy" (Hurley et al., 2020). Seeking help for mental health issues is correlated with knowledge about the factors that contribute to the development of mental illness, the efficacy of treatments, the rehabilitation process and available resources (Downs & Eisenberg, 2012).
Positive mental health is the foundation of a healthy body, spirit and mind. Schizophrenia, depression and other psychotic and brain-related abnormalities are only a few of the potentially deadly mental illnesses resulting from a breakdown in mental stability. Many things go into determining a person's mental health status. Socioeconomic
and ecological issues play a significant role (Brain, 2013). Biological, psychological and behavioral elements, as well as social interactions, were found to be reliable indicators of mental health in a recent study. Biological causes are typically associated with inherited cognitive deficiencies from one's parents. The importance of environmental stimuli that profoundly impact an individual's personality and mental health is at the heart of the psychological elements. Our own way of living and capacity for self-discipline are two components of the behavioural aspect. Sleep deprivation, poor organization and putting off tasks are three of the most influential lifestyle variables (Dyrbye et al., 2006).
PSYCHOLOGICAL WELL-BEING
When it comes to one's mind, psychological wellness is paramount. According to the World Health Organization, (2012), happiness is achieved when an individual realizes their potential, effectively manages the difficulties of daily life, can give back to society via productive and fulfilling work and feels they are making a difference in the world. Even though psychological health has always been defined as an absence of depression and anxiety (Luo & Hancock, 2020). Some persons are predisposed to mental disease, others can enjoy a higher standard of mental health as a result of their unique personality traits (Wood & Tarrier, 2010).
Different disciplines use various terms to describe psychological health (Gao & Mclellan, 2018; Gartoulla et al., 2015). Life satisfaction on both a material and spiritual level are included and the system can operate at its best (Stamp et al., 2015). The extent to which an individual has command over his or her environment is also an indicator of psychological health. Emotions like frustration, disappointment and melancholy are normal parts of life and are all part of wellness psychology (Stamp et al., 2015). Because of this, it's crucial for one's mental health in the long run to learn to control unpleasant emotions (Huppert, 2009). Having people who care about you and who make you feel good about yourself may significantly impact your mental health and happiness (Siddiqui & Khan, 2016). A person who has achieved a high level of psychological well-being is confident in their abilities and feels they have the support they need to succeed in their personal and professional endeavors (Panahi, 2016). According to proponents of the notion of psychological well-being, a person's level of mental health is measured by how well their minds perform in specific contexts (Udhayakumar & Illango, 2018). A healthy person gets along well with others, cares about the world around them, is at peace with their present self and history, is motivated to achieve their objectives, constructs their path through life and makes their own choices (Siddiqui & Khan, 2016).
Indisputable progress has been made in the sector of positive mental health frameworks. Recently, however, definitions that place too much emphasis on positive emotions and productive functioning as indicators of mental health have been criticized for their potential to discriminate against people who are unable to work productively or function within the environment due to their unique physical characteristics or the constraints of their particular social and/or economic circumstances (Galderisi et al., 2015). Keyes has effectively addressed these concerns by integrating the concepts of mental disease, mental health and well-being into a unified theoretical framework that expands our understanding of mental health as a whole (Keyes and Michalec, 2010). According to the paradigm, a person's mental health cannot be adequately described by either pathogenic techniques emphasizing the negative (such as mental disease) or salutogenic approaches emphasizing the positive (such as well-being) (Keyes and Michalec,
2010). Instead, the concept suggests that mental health and sickness are two distinct latent continuum connected to one another. Specifically, mental health and happiness are on two axes, one ranging from no mental disease to full-blown mental illness and the other from extreme depression to euphoria (Slade, 2010). Therefore, a state of mental health is not synonymous with a state of flourishing simply because of its absence.
The mental health literacy is based on three major skills which are: Understanding of mental health problems, awareness regarding the promotion of mental health positively and knowledge of help-seeking behaviours (Wei et al., 2013). The knowledge regarding the mental health issues among the general public is very low thus, it become the problem for the people who have mental health issues (Thornicroft et al., 2016). The mental health literacy theory believes on the positive psychology and it is based on two important factors such as resilience and mindfulness. However, there are no restrictions which are set to be followed in positive mental health (Spiker & Hammer, 2019). The research aims to determine the mental health literacy among the university students. Moreover, the study also aims to discover the mental health status and psychological well-being among the students of university and the study is based on the university's students of Pakistan.
OBJECTIVES OF THE CURRENT STUDY
This study had following objectives
1. To examine extent of Mental Health Literacy (in terms of maintenance of positive mental health, recognition of mental illness, attitude to mental illness stigma, help seeking efficacy, and help seeking attitude), mental health status ( i.e., Anxiety and Depression) and Psychological Wellbeing among University Students
2. . To find out association between Mental Health Literacy, mental health status and Psychological Wellbeing among University Students
Hypotheses
1. There would be significant relationship of Mental Health Literacy (in terms of maintenance of positive mental health, recognition of mental illness, attitude to mental illness stigma, help seeking efficacy, and help seeking attitude), mental health status ( i.e., Anxiety and Depression) and Psychological Wellbeing among University Students.
2. There would be strong relationship between Mental Health Literacy, mental health status and Psychological Wellbeing among University Students.
METHOD
Research Design
.This study utilized cross sectional survey method approach. Data was collected at one
point in time from students at public sector universities across Pakistan,
Sample
The sample population targeted in this research study was sixteen hundred and twenty eight students (N=1628). University Students (all genders) from all provinces of Pakistan (along with AJK and GB regions) were approached for the present study.
Inclusion criteria
Following was the inclusion criteria
1. Being adolescents and the university students from the selected universities from all over the Pakistan.
2. Ability to understand English and urdu.
3. The participants who were present during the study period.
Exclusion criteria
1. Individuals who faced any traumantic event in last 6 months. Sample size calculation
Sample size formula calculated as per prevalence formula for infinite populations was used.
Study Measures
1. Mental Health Literacy
The MHLS is a 35item measure, which assesses all attributes of mental health literacy . The response categories are organised on a 5-point Likert-scale, ranging from Strongly Disagree to Strongly Agree . The MHLS has shown internal consistency, reliability and content validity
2. Hospital anxiety and depression scale
This scale was originally developed by Zigmond & Snaith (1983) and is commonly used to determine the levels of anxiety and depression that a person is experiencing. Originally developed by Zigmond & Snaith in 1983, Hospital Anxiety and Depression Scale (HADS) is also a 14-item scale generates ordinal data and used to know the levels of anxiety and depression. The HADS offers 7-item anxiety measure and 7-item depression measure. Individual items in both measures can be scored from zero to three, meaning a subject can score 0 to 21 for depression and anxiety combine. Bjelland et al., (2002) identified a cut-off point of 8/21 for anxiety or depression. Their study involved a literature review of a large number of existing studies. The study gave a specificity of 0.78 and a sensitivity of 0.9 for anxiety (HADS-A). However, for depression (HADS-D) the study resulted a specificity of 0.79 and a sensitivity of 0.83.
3. Warwick Eddinburgh Mental well being scale (Appendix H)
The Warwick Eddinburgh Mental well-being scale has 14 items. The reliability of the scale is .82. The response categories are organised on a 5-point Likert-scale, ranging from None of the time to all time.
Procedure
FJWU policy for the PhD was following throughout the PhD. Firstly, approval from AS & RB and Ethics Committee was sought. After clearance, relevant stakeholders (i.e.,registrars of universities from each province) were approached for access to the participants and seeking data sharing agreement. After due process of approvals, data collection may begin in Jan 2021 .The questionnaires were applied to the representative sample of approximately thousand students from different provinces of Pakistan, AJ&K and GilgitBaltistan. For the collection of data researcher will use random sampling technique (lottery method) .Every 5 th student from the attendance list was invited to participate in the study.In order to proceed the project a rapport and understanding was built to create trust among the researcher and the participants. All the Participants were informed about the purpose of the study and asked to complete questionnaire. Ethically, the participants were provided information about the research project and what help they might provide to the researcher to fulfill his/her goal. Firstly, demographic sheet was used to collect basic information. Later, the questionnaire was distributed among the participants to achieve the goals of the study undertaken. Instructions were read to the population along with the encouragement towards to fill out every possible item in the questionnaire that applies to them. The participants were given full trust of the research ethics to be followed. The questionnaires was filled by the participants at the spot and was collected with thanks to the sample population for their cooperation and participation
in the research project. The scores of the samples was statistically analyzed. The data was analyzed by using SPSS.
Ethical Considerations
Ethics have always been an integral part of any field of study especially research. Ethics are even more important when the study follows a primary data collection method. The prime reason behind this is because that particular data collection method involves the participation of variius participants that share their views and opinions in order to benefit the study (Resnik, 2018). However, the researcher for this study have made ethics an utmost priority of the study. The researcher has included students from different universities as participants of the study. The researcher has ensured them that their shared information will not be used for any other purpose apart from this study. It is often observed that students mostly get into such things or participate due to the peer pressure but the researcher for this study have made sure that no participate is forced to participate. Every participant was made comfortable before making them participate in the study. The level of ease was enhanced by consent forms.
The consent was taken from each participant through official consent forms. The reason for using consent form is to give assurity to both the researcher as well as participants. In case of any misunderstanding the form could be used as a legal document to sort out the issue. Consent form not only helped the researcher get the consent of participants but also provide details to participants regarding the study. This included aim and objectives of the study along with the scope of the study. The purpose behind inclusion of this information in the consent form is because the researcher wanted to let participants know more about the study they was contributing their time and efforts for.
Analysis
Quantitative questionnaire survey was used for the study primarily because the researcher wants to engage many participants for this study. Participants have also been diverse as they belong to different provinces of the same country. Data analysis is the most important part of the method because here the collected data is analysed using specific tools and techniques. This is the part where the data is led towards findings of the study. After getting the required information, the data was carefully analyzed and interpreted. In order to quantify the data, the data was coded and processed through software namely SPSS (Statistical Package for Social Science). SPSS statistics is software packages used for statistical analysis. Quantitative questionnaire survey was used for the study primarily because the researcher wants to engage many participants for this study. Participants have also been diverse as they belong to different provinces of the same country. Data analysis is the most important part of the method because here the collected data is analysed using specific tools and techniques. This is the part where the data is led towards findings of the study.
RESULTS
Table 1: Frequency and percentage across demographic variables of university students (n=1628)
Demographic variable F %
Male Gender Female 1163 465 71.4 28.6
19-23 Age 24-28 1413 86.8
215 13.2
Qualificatio BS 1465 90.0
n MSc. 163 10.0
Family Nuclear 808 49.6
System Joint 815 50.1
Single 1330 81.7
Relationshi Engaged 138 8.5
Married 123 7.6
p In
37 2.3
relationship
Disability Yes 686 42.1
No 924 57.9
AJK 25 4 15.6
GB 2 48 15.2
Province Sindh 2 8 2 17.3
Baluchistan 2 8 2 17.3
KPK 2 8 1 17.3
Punjab 281 17.3
Table 1 shows that the sample consisted of 1628 students, of which 1163 were males and 465 were females. Results showed that all students were 19-28. One thousand four hundred forty-three were in the age group of 19-23, and 215 were in the age 24-28. There are two categories of students based on degree level, which showed that 90% of students were in BS and 10% were students of MSc. Level. Table 1 shows that students fall into two categories of the family system as students were included in the study from joint and nuclear family systems. It also shows that students in the study belong to four categories of relationships, students were1330 single, 138 were engaged, 123 were married, and 37 were in a relationship. Of 1628 students added to the study, 628 had disabilities, while 924 had no disabilities. Students from all the provinces of Pakistan were added to the study (AJK 254, GB 248, SINDH 282, BALUCHISTAN 282, KPK 281, PUNJAB 281).
Table 2 : Correlation Matrix with different variables among university students
Mental Mental Mental Psy
Health Literacy is Health Literacy is Health Literacy chology oriented toward oriented by belief oriented by Wellbeing knowledge resources
Mental Health
Literacy is 1
oriented by knowledge Mental Health
Literacy is 0.452** 1
oriented by belief
Mental Health
Literacy 0.347* 0.487* 1
oriented by resources
Psy^ 0.392* 0.364* 0.751* 1
ogy Wellbeing
**. Correlation is significant at the 0.01 level, *. Correlation is significant at the 0.05 level
A student's mental health performance correlates with their knowledge, belief, and resources-oriented mental health literacy levels in Table 4.5. According to the data in the table, university students who worry about performing poorly and have mental health problems tend to experience higher physiological problems. Those who believe in mental health literacy are likelier to have lower mental health and psychological problems. Similarly, a significant positive relationship was found between knowledge, belief, and resources-oriented mental health literacy with psychological well-being. The data in Table 4.5 supports the importance of addressing mental health literacy among university students to promote better mental health outcomes. By increasing students' knowledge, beliefs, and access to resources related to mental health, universities may be able to improve the overall mental health and well-being of their student population.
Table 3: Correlation matrix between MHLS and HADS and WEMWBS.
Variables MHLS HADS WEM
WBS
MHLS -
HADS 0.248 0.088*
*
WEMWBS
Note: MHLS = Mental Health Literacy Scale, HADS = Hospital Anxiety and Depression Scale, WEMWBS = Warwick Mental Well-being Scale. **p < 0.01
Table 4.32 indicates that there is a significant moderate positive correlation between the Hospital Anxiety and Depression Scale (HADS) and the Mental Health Literacy Scale (MHLS). At the same time, there is a very weak positive correlation between the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and the MHLS. A moderate positive correlation between HADS and MHLS suggests that individuals with higher mental health literacy tend to report higher levels of anxiety and depression symptoms. This finding may reflect that people who are more aware of mental health issues and better understand their symptoms are more likely to identify and report anxiety and depression symptoms. Alternatively, it could indicate that anxiety and depression symptoms negatively impact mental health literacy. On the other hand, the very weak positive correlation between WEMWBS and MHLS suggests little relationship between mental well-being and mental health literacy. This finding may reflect that having knowledge and understanding of mental health issues is not necessarily associated with higher levels of well-being. Alternatively, it could also indicate that mental well-being is not significantly contributing to mental health literacy.
DISCUSSION
The pressures of university life can be overwhelming, and it is well known that students are more likely to develop mental health problems than the general population. As Brown, (2018) highlighted, this can be attributed to various factors, including social isolation, stress, depression, mental health illness, and financial pressures. The findings of a recent study have further reinforced this reality, with over half of the university students feeling stress. In addition, the study has also revealed a strong correlation between poor psychological well-being and mental health issues among students. These findings highlight the urgent need for positive measures to support student mental health and promote psychological well-being. In this study, 29.24% of students reported believing that individuals with anxiety disorders have excessive fear or anxiousness, which aligns with earlier research by Ansley et al. (2016), who identified difficulty concentrating as a symptom of anxiety. The current study's findings also contrasted with those reported by Jamieson et al., (2022) and Talib & Zia-ur Rehman, (2012); they also identified stress among the student population.
Depression is one of the leading causes of disability and suffering worldwide (Sarokhani et al., 2013). Modern and traditional civilizations and industrialized and non-developed nations are all affected by this worldwide epidemic of student mental health (Speciale, 2021). Such as several melancholy studies have found that students, compared to the general population, have a disproportionately high rate of mental health issues (Yusoff et al., 2013). More importantly, recent research has shown that student mental health problems are rising (DiPlacito-DeRango, 2016). Despite the widespread depression, few studies have focused on its root causes throughout many cultures. However, it is generally agreed that student depression results from mental and social variables (Lipson et al., 2016).
CONCLUSION
The study found that university students experience high levels of anxiety and depression, indicating the need for mental health services and interventions to address these issues. Furthermore, the study found that social support significantly impacts mental health and psychological well-being. This highlights the importance of promoting and providing social support to students as part of mental health promotion and intervention programs. The study also found that mental health literacy plays a significant role in mediating the relationship between mental health status and psychological well-being
Anxiety and depression are used to measure the mental health status of university students. According to the results of these studies, most university students experience a high-stress level. Students are not only experiencing anxiety but also depression, which can have a negative impact on their social and intellectual development. Anxiety and depression can affect a student's life, including social relationships and overall well-being. High-stress levels can also impact their ability to engage in extracurricular activities and develop social connections with peers, ultimately affecting their personal growth and development. To address these issues, it is essential to identify the sources of stress and promote emotional well-being among students.
The study examined the Mental Health Literacy, mental health status, and psychological well-being of University Students, including gender differences and the impact of social support on mental health status and psychological well-being. The study also identified the most significant predictor of mental health status and psychological
well-being. It determined the role of mental health literacy as a mediator or moderator in mental health status. The findings of this study have significant implications for mental health promotion and intervention. The study found that the mental health literacy of university students is inadequate in maintaining positive mental health, recognition of mental illness, attitude to mental illness stigma, help-seeking efficacy, and help-seeking attitude. Overall this study suggests the need for targeted mental health literacy interventions to improve students' knowledge and understanding of mental health issues.
RECOMMENDATIONS
Firstly, universities should prioritize providing accessible and comprehensive mental health services to students. These services should include counseling, therapy, and other interventions to address anxiety and depression. Universities can also offer stress management workshops and promote physical activity to reduce stress and promote emotional well-being.
Secondly, universities should promote social support networks among students. This can be achieved by creating support groups, mentorship programs, and other initiatives encouraging peer-to-peer support. The study found that social support significantly impacts students' mental health and well-being.
Thirdly, universities should prioritize mental health literacy interventions that address students' lack of knowledge and understanding of mental health issues. These interventions should focus on increasing students' mental health awareness, reducing stigma, and improving their help-seeking efficacy and attitudes. Overall, prioritizing university students' mental health and well-being can contribute to their personal growth and development and create a positive culture that supports their academic success.
The findings of this study provide important insights into the mental health literacy, mental health status, and psychological well-being of university students in Pakistan. The study highlights the need for targeted mental health promotion and intervention programs for university students, including improving mental health literacy, providing social support, and promoting collaboration among various stakeholders. University administrations and policymakers must take immediate action to address university students' mental health needs and ensure they have access to adequate mental health support. Doing so can create a healthier and more resilient future generation that can contribute positively to society.
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