PUB - Publikationen an der Universität Bielefeld

### Background Mental illnesses constitute a significant portion of the global burden of disease (World Health Organization, 2016). However, the scale of their impact on populations is frequently not reflected in governmental spending and policy concerns. Mental health issues have been, and remain, less of a priority in a number of countries across the world (Patel et al., 2016; Whiteford et al., 2013). The limited focus on mental health issues appears to be more profound when viewed from the perspective of inequality of wealth among countries. Developing countries tend to spend lesser on mental health issues than developed countries, even when accounted for their comparative spending on physical health issues (Gadit, 2007; Saraceno et al., 2007). This owes much to the perception that mental illnesses are not life threatening and therefore do not generally gain the political momentum required to direct resources towards their management.
It is only recent that the burden of mental health issues has been measured in terms which reveal the scale of their social as well as economic burden not only in health sector but in other spheres of social activity (Bloom et al., 2011; Centre for Mental Health, 2010; Patel et al., 2016). The introduction of concepts such as Years Lived with Disability (YLDs) and Disability Adjusted Life Years (DALYs) have highlighted the gravity of mental health issues and their relative importance in relation to other more established concerns such as cancer and HIV/AIDS (Murray et al., 2012; Whiteford et al., 2013). Still, the share of mental health issues in the global burden of disease cannot be adequately gauged due to indirect impacts it causes on the progression of physical health conditions.
Mental health issues are not evenly spread across population segments and research suggests that youth are more vulnerable to mental health issues than other age groups (Erskine et al., 2015; Patel, Flisher, Hetrick, & McGorry, 2007).Within the youth segment, students have been shown to be particularly vulnerable to mental illnesses. The reason for this could be that mental health issues are largely dependent on social conditions and students are exposed to stressful conditions not only in wider society but also to those associated with the academic environment.
In view of the above, the present study is conducted in Pakistan which has a 57 million population aged 15 to 29 years. Among these, 1.8 million young people are studying in universities (Government of Pakistan, 2015). Despite challenges at several fronts, Pakistan boasts of its young population and envisions its youth as a driver of socioeconomic development in foreseeable future. However, investment in the development of young population has been minimal which is evident from Pakistan’s dismal literacy rate and rates of transition from schools to universities (Nasir & Nazli, 2010). If any, there is very limited coordination between education and health sector nor are there any robust structures which could cater to the health needs of students (Khan, 2013). The lack of institutional structures for health within universities most adversely affects subtle mental health issues which are less likely to be self-diagnosed.
### Objectives of the Study This study is intended to measure the determinants, prevalence and outcomes of mental health issues among the university students of Pakistan. It considers the influence of health-related behaviors, academic and non-academic stressors on mental health issues. The academic and demographic characteristics of students are taken as confounding variables and their impacts on stressors and mental health issues have been examined. Thereafter, the impacts of mental health issues on academic performance and subjective well-being of students have been measured. Finally, this study describes the coping strategies used by students to mitigate mental health issues and discusses how these are related with their demographic characteristics.
### Theoretical Framework This study is theoretically embedded in stress theory introduced by Selye (Selye, 1950; 1956). The stress theory presents an elaborate process wherein it is argued that the accumulation of stressors might result in stress depending on the context of the occurrence of stress. The stress experienced by an individual may or may not lead to distress depending on the nature and scope of coping resources embodied by that individual. In the context of present study, the university students are assumed to be confronted with several academic and non-academic stressors which may lead to stress. The effect of these stressors may be increased or decreased due to personal circumstances of individual students. However, mental health is also affected by issues which are intrinsic to an individual. These issues include health behaviors, self-rated physical health, psychosomatic complaints and chronic illnesses. In this study, these internal factors are dealt parallel to the stressors explained above. This distinction is based on the effort in this study to independently assess the impact of university related factors and personal factors on mental health issues. The stress theory further states that coping resources of an individual are a mitigating factor in the transition from stress to distress. While, this study has attempted to investigate how the students cope with stress, it has also tried to figure out the coping strategies used by students suffering from distress. Finally, as hypothesized by stress theory, this study examined the outcomes of distress for the students. Given the wide range of outcomes which may arise from distress, these outcomes were limited to students’ academic performance and subjective well-being.
### Methods and Materials This quantitative study adopted a cross sectional design to guide data collection. Using multi-stage cluster sampling technique, the data were collected from 1308 randomly selected students of age (15-29) from three selected public universities in the province of Punjab, Pakistan. The data were collected through a pre-coded self-administered questionnaire. The questionnaire consisted of six distinct sections. The first section of the questionnaire dealt with the demographic details and academic background of the respondents. The second section included questions about self-rated health status, health related behaviors and Psychosomatic Health Complaints (PHCs) of the students. The third section measured academic and non-academic stressors faced by the students. The fourth section comprised of standardized tools to measure perceived stress, depressive symptoms and psychological well-being of students. The fifth segment measured the academic performance and level of satisfaction with the different areas of life whereas the sixth section dealt with coping strategies used by students to mitigate stress. Findings based on the collected data are presented in two sections. Descriptive statistics section includes results presented in the form of frequencies and percentages whereas in the inferential statistics section, simple, binary and multinomial logistic regression analyses are used for hypothesis testing.
### Key Findings The response rate was 91.4%, excluding partially filled questionnaires. The findings revealed that an overwhelming majority of students at the universities were 20-24 years of age with the mean age of 21.5 years. The proportion of male and female students was almost equal and most the respondents (61.5%) in the sample belonged to urban areas. The study sample represented students from diverse family backgrounds in terms of parents’ education, family income etc. A major finding was that gender and income insufficiency were associated with all three types of mental health issues considered in this study. Students living home and those enrolled in Bachelors programs were more affected with mental health issues than their counterparts. General health and health related behaviors had a significant impact on mental health of students across all the selected universities. Academic stressors such as examinations were considered by students as severe stressors. However, in terms of impact, non-academic stressors such as family expectations and problems in interaction with fellow students had a more profound impact on mental health. The prevalence of perceived stress and depressive symptoms were high at 54.1% and 44.2% respectively across the study sample. Students suffering from high levels of distress and depression had poor objective and subjective academic performance. Even students with higher grades were likely to report their subjective academic performance as poor if they were suffering from mental health issues. Depressive symptoms had more impact on subjective well-being of students than perceived stress. Few students used problem focused strategies to cope with mental health issues. The use of religious coping strategies was high in the study sample.
### Discussion The prevalence of distress and depression in this study was like most research conducted elsewhere. However, this study also highlighted those determinants of mental health issues which were rooted in peculiar conditions of the study area. These determinants such as English language as the medium of instruction or interaction with opposite gender were not reported in the studies consulted by the author. Financial dependency of students on their families was significantly higher than what is reported in studies from Western countries. Furthermore, the amount of physical activity undertaken by the students was substantially lower than what most previous studies elsewhere have reported. Consistent with most previous studies, academic performance and subjective well-being were adversely affected by distress and depression. Similarly, some of the coping strategies reported in this study, especially those grounded in religious beliefs, were a novelty in view of previous research.
### Conclusion This study was the first attempt of its kind to measure the prevalence of mental health issues in public sector universities of Pakistan. The high prevalence of mental health issues reported in this study was not matched by the scant health services available at the universities. Students were dissatisfied with the facilities at their universities, and there seemed to be a disconnect between students’ needs and policies devised by universities’ administrations. It is suggested that similar studies may be conducted to inform mental health policies at the university level, which would focus on mental health promotion and disease prevention.