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Improving college student mental health: Research on promising campus interventions

Hiring more counselors isn’t enough to improve college student mental health, scholars warn. We look at research on programs and policies schools have tried, with varying results.

college student mental health

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by Denise-Marie Ordway, The Journalist's Resource September 13, 2023

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If you’re a journalist covering higher education in the U.S., you’ll likely be reporting this fall on what many healthcare professionals and researchers are calling a college student mental health crisis.

An estimated 49% of college students have symptoms of depression or anxiety disorder and 14% seriously considered committing suicide during the past year, according to a national survey of college students conducted during the 2022-23 school year. Nearly one-third of the 76,406 students who participated said they had intentionally injured themselves in recent months.

In December, U.S. Surgeon General Vivek Murthy issued a rare public health advisory calling attention to the rising number of youth attempting suicide , noting the COVID-19 pandemic has “exacerbated the unprecedented stresses young people already faced.”

Meanwhile, colleges and universities of all sizes are struggling to meet the need for mental health care among undergraduate and graduate students. Many schools have hired more counselors and expanded services but continue to fall short.

Hundreds of University of Houston students held a protest earlier this year , demanding the administration increase the number of counselors and make other changes after two students died by suicide during the spring semester, the online publication Chron reported.

In an essay in the student-run newspaper , The Cougar, last week, student journalist Malachi Key blasts the university for having one mental health counselor for every 2,122 students, a ratio higher than recommended by the International Accreditation of Counseling Services , which accredits higher education counseling services.

But adding staff to a campus counseling center won’t be enough to improve college student mental health and well-being, scholars and health care practitioners warn.

“Counseling centers cannot and should not be expected to solve these problems alone, given that the factors and forces affecting student well-being go well beyond the purview and resources that counseling centers can bring to bear,” a committee of the National Academies of Sciences, Engineering, and Medicine writes in a 2021 report examining the issue.

Advice from prominent scholars

The report is the culmination of an 18-month investigation the National Academies launched in 2019, at the request of the federal government, to better understand how campus culture affects college student mental health and well-being. Committee members examined data, studied research articles and met with higher education leaders, mental health practitioners, researchers and students.

The committee’s key recommendation: that schools take a more comprehensive approach to student mental health, implementing a wide range of policies and programs aimed at preventing mental health problems and improving the well-being of all students — in addition to providing services and treatment for students in distress and those with diagnosed mental illnesses.

Everyone on campus, including faculty and staff across departments, needs to pitch in to establish a new campus culture, the committee asserts.

“An ‘all hands’ approach, one that emphasizes shared responsibility and a holistic understanding of what it means in practice to support students, is needed if institutions of higher education are to intervene from anything more than a reactive standpoint,” committee members write. “Creating this systemic change requires that institutions examine the entire culture and environment of the institution and accept more responsibility for creating learning environments where a changing student population can thrive.”

In a more recent analysis , three leading scholars in the field also stress the need for a broader plan of action.

Sara Abelson , a research assistant professor at Temple University’s medical school; Sarah Lipson , an associate professor at the Boston University School of Public Health; and Daniel Eisenberg ,  a professor of health policy and management at the University of California, Los Angeles’ School of Public Health, have been studying college student mental health for years.

Lipson and Eisenberg also are principal investigators for the Healthy Minds Network , which administers the Healthy Minds Study , a national survey of U.S college students conducted annually to gather information about their mental health, whether and how they receive mental health care and related issues.

Abelson, Lipson and Eisenberg review the research to date on mental health interventions for college students in the 2022 edition of Higher Education: Handbook of Theory and Research . They note that while the evidence indicates a multi-pronged approach is best, it’s unclear which specific strategies are most effective.

Much more research needed

Abelson, Lipson and Eisenberg stress the need for more research. Many interventions in place at colleges and universities today — for instance, schoolwide initiatives aimed at reducing mental health stigma and encouraging students to seek help when in duress – should be evaluated to gauge their effectiveness, they write in their chapter, “ Mental Health in College Populations: A Multidisciplinary Review of What Works, Evidence Gaps, and Paths Forward .”

They add that researchers and higher education leaders also need to look at how campus operations, including hiring practices and budgetary decisions, affect college student mental health. It would be helpful to know, for example, how students are impacted by limits on the number of campus counseling sessions they can have during a given period, Abelson, Lipson and Eisenberg suggest.

Likewise, it would be useful to know whether students are more likely to seek counseling when they must pay for their sessions or when their school charges every member of the student body a mandatory health fee that provides free counseling for all students.

“These financially-based considerations likely influence help-seeking and treatment receipt, but they have not been evaluated within higher education,” they write.

Interventions that show promise

The report from the National Academies of Sciences, Engineering, and Medicine and the chapter by Abelson, Lipson and Eisenberg both spotlight programs and policies shown to prevent mental health problems or improve the mental health and well-being of young people. However, many intervention studies focus on high school students, specific groups of college students or specific institutions. Because of this, it can be tough to predict how well they would work across the higher education landscape.

Scientific evaluations of these types of interventions indicate they are effective:

  • Building students’ behavior management skills and having them practice new skills under expert supervision . An example: A class that teaches students how to use mindfulness to improve their mental and physical health that includes instructor-led meditation exercises.
  • Training some students to offer support to others , including sharing information and organizing peer counseling groups. “Peers may be ‘the single most potent source of influence’ on student affective and cognitive growth and development during college,” Abelson, Lipson and Eisenberg write.
  • Reducing students’ access to things they can use to harm themselves , including guns and lethal doses of over-the-counter medication.
  • Creating feelings of belonging through activities that connect students with similar interests or backgrounds.
  • Making campuses more inclusive for racial and ethnic minorities, LGBTQ+ students and students who are the first in their families to go to college. One way to do that is by hiring mental health professionals trained to recognize, support and treat students from different backgrounds. “Research has shown that the presentation of [mental health] symptoms can differ based on racial and ethnic backgrounds, as can engaging in help-seeking behaviors that differ from those of cisgender, heteronormative white men,” explain members of National Academies of Sciences, Engineering, and Medicine committee.

Helping journalists sift through the evidence

We encourage journalists to read the full committee report and aforementioned chapter in Higher Education: Handbook of Theory and Research . We realize, though, that many journalists won’t have time to pour over the combined 304 pages of text to better understand this issue and the wide array of interventions colleges and universities have tried, with varying success.

To help, we’ve gathered and summarized meta-analyses that investigate some of the more common interventions. Researchers conduct meta-analyses — a top-tier form of scientific evidence — to systematically analyze all the numerical data that appear in academic studies on a given topic. The findings of a meta-analysis are statistically stronger than those reached in a single study, partly because pooling data from multiple, similar studies creates a larger sample to examine.

Keep reading to learn more. And please check back here occasionally because we’ll add to this list as new research on college student mental health is published.

Peer-led programs

Stigma and Peer-Led Interventions: A Systematic Review and Meta-Analysis Jing Sun; et al. Frontiers in Psychiatry, July 2022.

When people diagnosed with a mental illness received social or emotional support from peers with similar mental health conditions, they experienced less stress about the public stigma of mental illness, this analysis suggests.

The intervention worked for people from various age groups, including college students and middle-aged adults, researchers learned after analyzing seven studies on peer-led mental health programs written or published between 1975 and 2021.

Researchers found that participants also became less likely to identify with negative stereotypes associated with mental illness.

All seven studies they examined are randomized controlled trials conducted in the U.S., Germany or Switzerland. Together, the findings represent the experiences of a total of 763 people, 193 of whom were students at universities in the U.S.

Researchers focused on interventions designed for small groups of people, with the goal of reducing self-stigma and stress associated with the public stigma of mental illness. One or two trained peer counselors led each group for activities spanning three to 10 weeks.

Five of the seven studies tested the Honest, Open, Proud program, which features role-playing exercises, self-reflection and group discussion. It encourages participants to consider disclosing their mental health issues, instead of keeping them a secret, in hopes that will help them feel more confident and empowered. The two other programs studied are PhotoVoice , based in the United Kingdom, and

“By sharing their own experiences or recovery stories, peer moderators may bring a closer relationship, reduce stereotypes, and form a positive sense of identity and group identity, thereby reducing self-stigma,” the authors of the analysis write.

Expert-led instruction

The Effects of Meditation, Yoga, and Mindfulness on Depression, Anxiety, and Stress in Tertiary Education Students: A Meta-Analysis Josefien Breedvelt; et al. Frontiers in Psychiatry, April 2019.

Meditation-based programs help reduce symptoms of depression, anxiety and stress among college students, researchers find after analyzing the results of 24 research studies conducted in various parts of North America, Asia and Europe.

Reductions were “moderate,” researchers write. They warn, however, that the results of their meta-analysis should be interpreted with caution considering studies varied in quality.

A total of 1,373 college students participated in the 24 studies. Students practiced meditation, yoga or mindfulness an average of 153 minutes a week for about seven weeks. Most programs were provided in a group setting.

Although the researchers do not specify which types of mindfulness, yoga or meditation training students received, they note that the most commonly offered mindfulness program is Mindfulness-Based Stress Reduction and that a frequently practiced form of yoga is Hatha Yoga .

Meta-Analytic Evaluation of Stress Reduction Interventions for Undergraduate and Graduate Students Miryam Yusufov; et al. International Journal of Stress Management, May 2019.

After examining six types of stress-reduction programs common on college campuses, researchers determined all were effective at reducing stress or anxiety among students — and some helped with both stress and anxiety.

Programs focusing on cognitive-behavioral therapy , coping skills and building social support networks were more effective in reducing stress. Meanwhile, relaxation training, mindfulness-based stress reduction and psychoeducation were more effective in reducing anxiety.

The authors find that all six program types were equally effective for undergraduate and graduate students.

The findings are based on an analysis of 43 studies dated from 1980 to 2015, 30 of which were conducted in the U.S. The rest were conducted in Australia, China, India, Iran, Japan, Jordan, Kora, Malaysia or Thailand. A total of 4,400 students participated.

Building an inclusive environment

Cultural Adaptations and Therapist Multicultural Competence: Two Meta-Analytic Reviews Alberto Soto; et al. Journal of Clinical Psychology, August 2018.

If racial and ethnic minorities believe their therapist understands their background and culture, their treatment tends to be more successful, this analysis suggests.

“The more a treatment is tailored to match the precise characteristics of a client, the more likely that client will engage in treatment, remain in treatment, and experience improvement as a result of treatment,” the authors write.

Researchers analyzed the results of 15 journal articles and doctoral dissertations that examine therapists’ cultural competence . Nearly three-fourths of those studies were written or published in 2010 or later. Together, the findings represent the experiences of 2,640 therapy clients, many of whom were college students. Just over 40% of participants were African American and 32% were Hispanic or Latino.

The researchers note that they find no link between therapists’ ratings of their own level of cultural competence and client outcomes.

Internet-based interventions

Internet Interventions for Mental Health in University Students: A Systematic Review and Meta-Analysis Mathias Harrer; et al. International Journal of Methods in Psychiatric Research, June 2019.

Internet-based mental health programs can help reduce stress and symptoms of anxiety, depression and eating disorders among college students, according to an analysis of 48 research studies published or written before April 30, 2018 on the topic.

All 48 studies were randomized, controlled trials of mental health interventions that used the internet to engage with students across various platforms and devices, including mobile phones and apps. In total, 10,583 students participated in the trials.

“We found small effects on depression, anxiety, and stress symptoms, as well as moderate‐sized effects on eating disorder symptoms and students’ social and academic functioning,” write the authors, who conducted the meta-analysis as part of the World Mental Health International College Student Initiative .

The analysis indicates programs that focus on cognitive behavioral therapy “were superior to other types of interventions.” Also, programs “of moderate length” — one to two months – were more effective.

The researchers note that studies of programs targeting depression showed better results when students were not compensated for their participation, compared to studies in which no compensation was provided. The researchers do not offer possible explanations for the difference in results or details about the types of compensation offered to students.

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Denise-Marie Ordway

  • Open access
  • Published: 08 June 2021

Impact of COVID-19 on the mental health of US college students

  • Jenny Lee 1 ,
  • Matthew Solomon 1 ,
  • Tej Stead 1 ,
  • Bryan Kwon 1 &
  • Latha Ganti 2 , 3 , 4  

BMC Psychology volume  9 , Article number:  95 ( 2021 ) Cite this article

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Background/aim

In the beginning of 2020, the novel Coronavirus disease (COVID-19) caused by the SARS-CoV-2 virus, became a public health emergency in the U.S. and rapidly escalated into a global pandemic. Because the SARS-CoV-2 virus is highly contagious, physical distancing was enforced and indoor public spaces, including schools and educational institutions, were abruptly closed and evacuated to ensure civilian safety. Accordingly, educational institutions rapidly transitioned to remote learning. We investigated the impacts of the COVID-19 pandemic on domestic U.S. college students, ages 18–24 years.

Through Pollfish®’s survey research platform, we collected data from 200 domestic U.S. college students in this age range (N = 200) regarding the physical, emotional, and social impacts of COVID-19 as well as key background information (e.g. whether or not they are first-generation or if they identify with the LGBTQIA+ community).

Our results indicate that students closer to graduating faced increases in anxiety (60.8%), feeling of loneliness (54.1%), and depression (59.8%). Many reported worries for the health of loved ones most impacted their mental health status (20.0%), and the need to take care of family most affected current and future plans (31.8%). Almost one-half of students took to exercising and physical activity to take care of their mental health (46.7%). While a third did not have strained familial relationships (36.5%), almost one half did (45.7%). A majority found it harder to complete the semester at home (60.9%), especially among those who had strained relationships with family (34.1%). Seventy percent spent time during the pandemic watching television shows or movies. Significantly more men, first-generation, and low-income students gained beneficial opportunities in light of the pandemic, whereas their counterparts reported no impact. First-generation students were more likely to take a gap year or time off from school.

Conclusions

Although students found ways to take care of themselves and spent more time at home, the clear negative mental health impacts call for schools and federal regulations to accommodate, support, and make mental health care accessible to all students.

Peer Review reports

Introduction

The outbreak of the SARS-CoV-2 virus, originally from Wuhan, China, in December 2019 gave rise to an ongoing global public health crisis addressing the proliferation of the novel Coronavirus disease (COVID-19). The SARS-CoV-2 virus directly targets the respiratory system in humans with characteristic symptoms of cough, fever, sore throat, dyspnea, and fatigue [ 1 ]. As the virus continued spreading over 2020, more findings on the epidemiological characteristics of SARS-CoV-2 have been divulged to the public. A study showed that the COVID-19 disease presents varying lengths of incubation periods, typically an average of 5.2 days, and it is estimated to have a slightly higher basic reproduction number (2.24–3.58) than that of the original SARS-CoV virus [ 1 ]. According to the National Health Commission of China, the virus can be transmitted through aerosols, droplets, contacts, respiratory aspirates, and feces, with both animals (e.g., bats, pangolins) and humans being veritable modes of transmission [ 2 ]. Accurate and accelerated testing is necessary to control this extremely contagious disease in cities, communities, and hospitals.

Due to the sudden outbreak of COVID-19, most universities across the United States were forced to send their students home early for the 2019–2020 academic year to prevent spread and protect students as well as surrounding communities. The sudden change in students’ learning environment, the quality of their education, and other circumstances caused students to face unique challenges, adversely impacting their mental health. The loss of internships, on-campus jobs, and other opportunities also contributed to the stress and declining mental health of students. According to a study done on a cohort of students attending Dartmouth College, there were noticeable differences in behavioral and mental health over the course of the pandemic thus far, with a higher number of self-reported cases of depression and anxiety around final exams [ 3 ].

Other minority communities also faced particular hardship in light of the pandemic. For example, greater proportions of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) population do not have access to health insurance and struggle with poverty compared to the non-LGBTQ population [ 4 ]. Because of their health disparities and social disadvantages, the mental health of LGBTQ students is exacerbated due to the psychological trauma that can come with the COVID-19 pandemic. Furthermore, people of color and those in socioeconomically disadvantaged groups are more likely to be mentally overwhelmed due to the unequal burden of finances, illness, and death. In a study done at a hospital in northern California of COVID-19 patients, non-Hispanic African Americans were found to be 2.7 times more likely to be hospitalized compared to non-Hispanic white patients [ 5 ].

A study of college students from India [ 6 ] found that both anxiety and depression were prevalent in their cohort, with women being affected more. They also noted a disturbed sleeping pattern which aligns with both anxiety and depression. A study that used smartphone-based ecological momentary assessments of anxiety and optimism related to COVID-19 and other generic mental health variables 6 times daily [ 7 ] found widespread mental health impact, especially anxiety, in their cohort of 140 students. Yet another study of college students [ 8 ] found a significant decline in physical activity and mental health occurred as a result of the COVID-19 pandemic.

There are many variables that can further contribute to the mental health status of college students during the pandemic, including their identity, family life, and background. We aimed to investigate the emotional, physical and social impacts on domestic US college students ages 18–24 and determine whether these impacts were significant among particular groups.

Recruitment and data collection

Two hundred (N = 200) domestic U.S. college students ages 18–24 attending a 4-year university in person before the COVID-19 pandemic were surveyed through Pollfish®. Pollfish® is a survey research platform that uses organic sampling built on Random Device Engagement (RDE). [ 9 ] Using artificial intelligence (AI) to track unique respondent identification, RDE reaches users in their natural environments as they participate in their daily activities through any device. [ 10 ] Pollfish®’s partnerships with over 120,000 applications and more than 700 million global users allow for random recruitment of participants fitting the specific inclusion criteria via in-app incentives specific to each user’s real-time activity on their respective devices [ 9 ]. The advanced AI technology and algorithm prevents fraud from single users on multiple accounts (SUMA) and suspicious or illogical responses to specific questions [ 10 ]. Pollfish® uses weighting to match the univariate distributions of age, gender, and geographic region. All results reported use this weighting.

Two screening questions were used to determine survey eligibility. These questions inquired whether participants are male or female aged 18–24 years, and whether they attended a domestic four-year U.S. college or university. The survey then consisted of 14 multiple choice questions. For some of the questions, multiple selections amongst the multiple choices were allowed, so that percentage totals could exceed 100%. The first 3 questions of the 14 inquired about background, including the participants’ year in college, whether they are the first in their family to attend college, and if they identify with the LGBTQIA+ community. The subsequent questions honed in on the physical, emotional, and social impacts of the COVID-19 pandemic. The final question was an open-ended one designed to capture the students’ verbatim feelings.

Statistical analysis

Data were analyzed using JMP Pro 14.1 for Windows [ 11 ]. Participants with a household income less than $50,000 annually were considered “low-income”. For comparing 2 × 2 contingency tables, Fisher’s two-tailed exact test was used. For comparing ordinal data, Wilcoxon’s rank-sum test was used. Ninety-five percent confidence intervals (CI) for odds ratios are Wald-based. All results used weighting generated by Pollfish® to match the univariate distributions of age and gender.

Ethics committee approval

This study (# 2020-966) was considered exempt by our institutional review board manager HCA Centralized Algorithms for Research Rules on IRB Exemptions (CARRIE).

A total of 200 people responded, of whom 50.6% were female (after adding weighting). Twenty three and 3/10% were first-year students, 39.9% were second-year students, 17.8% were third-year, 12.6% were fourth-year (seniors), and seven and one half percent were taking additional semesters (fifth or higher year). Fifty eight percent were first-generation students, and 36% considered themselves to be “a member of the LGBTQIA+ community.” The distributions of responses to each question are summarized in the Appendix, and each question is explored in detail in this section.

How has COVID-19 impacted your mental health?

For this question, multiple responses were allowed. Increased anxiety, depression, and feeling of loneliness were found in 60.8%, 54.1%, and 59.8% of the weighted population, respectively (Fig.  1 ). More than eighty percent (83.8%) reported an increase in at least one of these three symptoms. On the other hand, decreased anxiety, depression, and feelings of loneliness were respectively found in only 9.1%, 5.3%, and 4.6% of the population. For 10.7%, their mental health was unaffected. Using Fisher’s exact test, we found no significant differences in the prevalence of having at least one increased mental health symptom across first-generation status, gender, or LGBTQIA+ status. A general trend of decreased prevalence of symptoms as students drew closer to graduation was noticed. Using Fisher’s exact test, academic year and prevalence of mental health symptoms are not independent, with p  < 0.0001.

figure 1

Prevalence of mental health symptoms by academic year, and whether they increased

If you are not feeling at ease, what contributes MOST to your mental health status?

Twenty percent of respondents said that worries about the health of loved ones was their primary concern, 19.2% were most concerned about school/continuing education, 19.0% had anxiety about lack of proactivity, 15.9% were worried about finances, 10.8% were worried about future job offers, and 5.0% feared contracting the virus. Only 6.8% said that they were feeling at ease. Interestingly, there was no significant association between the proportion of respondents who were most worried about finances and income level (Fig.  2 ).

figure 2

Causes of worry among students

Was it easier or harder to complete this semester away from campus?

Almost sixty-one percent of students found it harder to complete the semester away from campus, while 32.7% found it easier and 6.4% reported no change. There was no significant difference across age, gender, income level, LGBTQIA+ status, or first-generation status in this response.

How has COVID-19 affected your physical health?

Fifty percent of respondents indicated that they gained weight due to increased eating, while 20.2% reported that they felt/looked better due to exercise or dieting, 13.3% lost weight due to a lack of appetite, and 16.6% reported no changes. Among the students who reported an increased feeling of loneliness (59.8%), 57% reported that they gained weight, compared with just 39.4% of those who did not experience symptoms. Using Fisher’s exact test, this was significant with a p -value of 0.0301. The odds ratio (OR) is 2.04 (95% CI 1.15–3.62).

How has COVID-19 impacted your current and future plans?

COVID-19 disrupted the lives of most students, with only 26.4% stating the pandemic has not impacted their current or future plans. 27.1% lost an internship or job offer, 22.9% are taking a gap year or time off from school, and 31.8% need to support family. Only 16.6% say that the pandemic has given them other beneficial opportunities.

The groups of people most likely to have other beneficial opportunities due to the pandemic were men (OR 3.18, 95% CI 1.41–7.22, p = 0.0039), first-generation students (OR 2.27, 95% CI 0.99–5.19, p  = 0.0329), and low-income students (OR 3.05, 95% CI 1.35–6.99, p  = 0.0042). First-generation students were significantly more likely to take a gap year/time off from school (OR 2.42, 95% CI 1.17–5.02, p  = 0.0251).

On the other hand, the groups that were significantly more likely to report no impact on future plans were women (OR 2.05, 95% CI 1.07–3.92, p  = 0.0159), non-first-generation students (OR 3.12, 95% CI 1.62–5.97, p  = 0.0003), and non-low-income students (OR 3.77, 95% CI 1.89–7.53, p  < 0.0001). Given that these three groups correspond exactly to those which were least likely to say they gained beneficial opportunities, we investigated the rate at which gender, first-generation status, and low-income status affects having either a beneficial opportunity or no change in future plans. When performing this analysis, we found no significant differences across any of the three groups. Combined with the other evidence, this suggests that the key difference between demographic groups lies in the rate at which they gained beneficial opportunities in light of the pandemic.

How has COVID-19 impacted your relationships with your family?

29.4% of students had improved relationships with family, while 34.1% had strained relationships with family and 36.5% had no impact on relationships with family. The people who had strained relationships were significantly more likely to consider it harder to complete the semester at home (OR 2.59, 95% CI 1.36–4.94, p  = 0.0036) compared to those who had improved relationships or no change.

How has COVID-19 impacted your relationships with your friends?

27.8% of students had improved relationships with friends, while 45.7% had strained relationships with friends and 26.5% had no impact on relationships with friends.

How have you specifically taken care of your mental health amidst COVID-19?

29.0% of students engaged in mindfulness activities (meditation, yoga, journaling, etc.). 46.7% were exercising or engaging in physical activity, 22.0% were using a health app, 17.7% were obtaining mental health care from a professional, and 30.3% were not taking any specific actions to take care of their mental health. Of the people who were exercising, 35.9% gained weight while 32.0% said they felt/looked better due to exercise or dieting. In contrast, of those who were not exercising, 62.2% gained weight and only 9.8% said they felt or looked better. Using Fisher’s exact test, this effect was significant with p  < 0.0001.

At what point was your concern about COVID-19 heightened?

29.8% of students had their concern first heightened when college campuses sent students home, whereas 29.0% were first alarmed by states beginning lockdown guidelines. For 10.5%, they became more concerned when a friend or relative was diagnosed with COVID-19. For just 6.4%, the turning point was that friends or relatives were taking prevention measures seriously. Only 4.1% of the population indicated that they were not concerned about COVID-19. The distribution of responses was roughly equal across demographic groups.

How are you spending most of your time during the pandemic?

71.0% were watching TV shows or movies, 30.5% were reading books, 39.6% were exercising, 34.9% were learning new skills or picking up new hobbies, 33.6% were cooking or baking, 29.5% were working or interning, and 8.0% said they were not doing very much at all (Fig.  3 ). Note that the 39.6% figure of those exercising does not conflict with the 46.7% figure above, as some of the respondents may not be devoting very much time to exercise, and do not consider it a major use of their time during the pandemic.

figure 3

How college students spent their time during the COVID-19 pandemic

Is there anything else you would like to share about the effect of COVID-19 on your mental health?

As this was a free-form text box, we used JMP’s text analysis suite to identify keywords. However, neither keyword identification nor singular value decomposition provided very much insight into the sentiments expressed. Given that this was an optional question, there was not enough information for numerical patterns to emerge. Instead, we have included a few quotes that demonstrate the range of ways that the COVID-19 pandemic has affected people’s mental health (not ordered by frequency).

“Everything has been so uncertain and has made me increasingly anxious”

“It is comforting to know that every college student in the country, and most around the world, are dealing with the same struggles that I am, and I am not alone in being fearful and anxious.”

“I smoke more”

“Its very hard to hold it together knowing the world as we once knew is no longer in existence..”

“Not getting help from my college financially has really drained me from even thinking about returning to college for FALL semester 2020.”

“One good thing is that it's given me more time to sleep, which has been one of the only benefits of the lockdown/pandemic.”

“It has increased productivity in approaching music & business”

The COVID-19 pandemic has brought severe educational and social repercussions, including the closure of college campuses as well as the introduction of online learning and social distancing at universities for the foreseeable future. College students were forced to abandon the social advantages of the so-called “college experience” (i.e. social gatherings, group studying, and in-person classes and meetings) to return home mid-semester. As reported by our survey, this triggered a decline in mental health measured by self-reported increased anxiety, depression, and loneliness. Consistent with these results, reports indicate that people of student status and ages 18–24 are at higher risk of anxiety and depression [ 12 ]. The stress associated with this abrupt social change, the disruptive factors that may exist at one’s home, and the fear of potentially contracting or spreading COVID-19 likely contributed to the development of trauma or stress-related disorders [ 13 ]. This accounts for the worsening mental health of domestic U.S. college students as shown by this survey, with significantly greater prevalence of symptoms among underclassmen that decreases with students closer to undergraduate completion. In line with the impacts we will discuss, this is likely due to the challenge of transitioning to college amidst a pandemic, the limited opportunities to form solid friendships, as well as a lack of human contact and in-person support.

Based on our survey’s results, the mental health status of the respondents has been most affected by their worries about the health of their loved ones amidst the COVID-19 pandemic. On top of that, many respondents feel uneasy about their plans for their continuing education, anxious about their lack of productivity at home, concerned about their finances and losing job and internship prospects, and worried about contracting the virus. These factors likely made it harder for students to complete the Spring 2020 semester at home, as many respondents have indicated. Indeed, most respondents indicated that their concern about the ongoing pandemic largely began when college campuses began to shut down or when states issued lockdown guidelines shortly after. These events evidently served as a turning point in the mental health of the respondents. As the pandemic ensued, the respondents reported that their lives were disrupted in significant ways. For instance, many reported to have lost an internship or job offer. Others reported the need to take a gap year. In addition, many respondents indicated that they now have the added responsibility of supporting their family in some way. Of the respondents who claimed that the COVID-19 pandemic strained family relationships, most admitted that it has been harder to work from home than at school. These results are summarized in Fig.  4 .

figure 4

Ways in which COVID-19 has affected the mental health of college students

More than one third of first-generation students experienced increased anxiety and a quarter found it harder to complete the semester at home. Accordingly, significantly more first-generation students reported taking a gap year or time off from school. First generation students were more likely able to take advantage of opportunities due to the pandemic, indicating access to support systems that may have allowed these students to take time off from school in the first place. Men and low-income students were also more likely to benefit from opportunities due to the pandemic while women, non first-generation, and non low-income students were more likely to report no impacts. However, there were no significant differences across these three demographic statuses, indicating that the main differences were solely in whether or not they gained beneficial opportunities due to the pandemic. Taken together, it appears that first generation and low-income students likely sought out more support during the pandemic, which has helped them overcome pre-pandemic anxiety regarding communicating with campus faculty and staff and utilizing support services [ 14 ]. In regards to male students who benefitted from these opportunities, they likely took time off from school as the number of men who have enrolled in college this Fall 2020 declined by seven times compared to the number of women enrolled [ 15 ], potentially due to the increased mental health issues experienced by all. The key difference is that men are less likely to seek help for mental health difficulties compared to women even pre-pandemic [ 16 ].

On the other hand, there were mixed experiences (albeit statistically insignificant) for LGBTQIA+ students with regard to anxiety, with a quarter reported increased levels and a similar number reporting decreased levels of anxiety. There were similarly mixed experiences in completing the semester from home. This may be due to LGBTQIA+ students accessing necessary resources as sixty-two percent of U.S. colleges and universities have LGBTQIA+ support groups [ 17 ] that likely serve as a valuable resource for these students throughout the pandemic.

Presumably due to increased stress factors at home and distance barriers, most respondents indicated that the COVID-19 pandemic strained relationships with their friends. While communications with friends declined, most respondents reported to be spending most of their free time watching TV because of widespread state and local lockdown orders. According to a health survey in England from 2012, watching TV for two hours or more on a daily basis is associated with mental health disorders, measured by a poor performance on the General Health Questionnaire and Warwick-Edinburgh Mental Well-being Scale [ 18 ]. On the other hand, nearly 40% of respondents indicated that they spent time exercising. Physical exercise has been proven to alleviate anxiety and depression, while increasing one’s mood and cognitive function [ 19 ]. Roughly half of the respondents claimed that they used exercise to take care of their mental health. Of those people, most reported feeling better. However, over 30% of respondents admitted to not specifically taking care of their mental health. Most people reported that they gained weight, particularly those who reported increased loneliness. The isolation and lack of contact may have led affected students to seek comfort food or decrease their daily activity levels, whether it may be training on a sports team or walking to classes and other commitments.

Similar to our findings that the COVID-19 pandemic has led to an overall reduction in the mental health of US college students, a study in China reported that about 40% of female adolescents have suffered from depression. The study cited distance learning, concern about the pandemic, and a decrease in physical exercise and sleep as independent factors causing this increase in depression [ 20 ]. Undoubtedly, the pandemic has caused many to experience feelings of loneliness and isolation. Furthermore, it has caused many individuals’ pre-existing mental health conditions to deteriorate without access to the appropriate services [ 21 ].

These services are offered on most college campuses but are more difficult to access in the world of online learning. According to a study in the New York City metropolitan area, only about half of the surveyed colleges offered information about remote counseling on their website and less than 60% of college counseling websites even offered directions for students experiencing a mental health emergency [ 22 ]. Furthermore, many news outlets report that out-of-state students have been unable to receive mental health services from their schools due to state-dependent licensures—some of which require psychologists to apply for a temporary license or receive special permission to practice [ 23 ]. Although some policies have been relaxed, students still face geographic, time, and financial barriers to access these necessary mental health services [ 23 , 24 , 25 ]. Additionally, the flexibility extended for telemedicine providers due to the pandemic being a public health emergency began to expire in Fall 2020, and navigating these policies is time-consuming and confusing for healthcare providers [ 25 ]. All of these obstacles have contributed to out-of-state students losing their mental health support completely in the face of the clear decline in mental health we have found, as supported by recent similar studies [ 26 , 27 , 28 , 29 ].

To combat the mental health challenges experienced by many US college students amidst the COVID-19 pandemic, colleges and universities across the country could take steps to expand access to virtual mental health resources and professional guidance. Some institutions have taken to a 24/7 crisis support line as well as virtual resources and emergency funding provided by the CARES Act distributed through the Higher Education Emergency Relief Fund [ 30 ]. Some universities were able to refund costs from room and board, which likely contributed to easing financial distress [ 31 ]. At the federal level, the PSYPACT agreement was passed—allowing interstate practice within the fourteen states it has been enacted in [ 32 ]ーand the TREAT Act that would allow healthcare professionals to render services anywhere during the COVID-19 pandemic was proposed but has yet to be implemented [ 33 ].

Limitations

The survey results are limited by the fact that only students who are registered with Pollfish® as publishers have the opportunity to participate in this survey. Potentially due to the monetary incentive given by Pollfish® to the respondents of their surveys, first generation and low income students are slightly overrepresented. In this survey, 61.0% of students are first generation, 35.5% being low income which is higher than the national average of 56.0% first generation students [ 34 ]. However, a study by Haenz et al. at the University of California, Los Angeles reports that roughly 50.0% of first generation students are low-income [ 35 ], which may be accounted for by the additional 10.5% of students who preferred not to reveal their income status in our study. Additionally, there are more students who identify as a member of the LGBTQIA+ community (36.5%) compared to the national average of 18.2% [ 36 ]. Our slightly disproportionate sample indicates that our findings may not be fully representative of all U.S. college students.

Future avenues of investigation include looking into specific experiences of these groups as well as other factors, such as the experiences of international students, of associate degree program students, community college students, or students completing online degrees and areas of improvement for the specific support systems in place at these educational institutions for these students since the pandemic.

The outbreak of COVID-19 has taken a universal toll on almost all aspects of life. As cases rapidly increased with great incidence, dense areas and indoor public spaces were closed and physical distancing as well as other preventative measures were enforced. These safety measures led to abrupt closures of schools and educational institutions, and a rushed transition to remote learning. Many reported worries for the health of loved ones most impacted their mental health, and the need to take care of family most affected current and future plans. Given that most students’ concerns were heightened when college campuses sent students home as well as the detrimental effects of the COVID-19 pandemic on students’ mental health, it is crucial for colleges as well as federal regulations to provide the appropriate accommodations and access to mental health care to ensure well-being and safety are prioritized as much asーif not more thanーeducation.

Availability of the data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Abbreviations

Confidence interval

2019 Novel Coronavirus

Lesbian, gay, bisexual, transgender, queer or questioning, intersex, and asexual or allied

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Agender, Asexual and other queer-identifying community

Psychology Interjurisdictional Compact, an interstate compact facilitated by the Association of State and Provincial Psychology Boards (ASPPB)

Coronavirus Aid, Relief, and Economic Security Act, S.3548 bill introduced in 19 March 2020 by Senator McConnell

Temporary Reciprocity to Ensure Access to Treatment Act, S.4421 bill introduced in 04 August 2020 by Senator Murphy

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A qualitative assessment of mental health literacy and help-seeking behaviors among male college students

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Although the number of students receiving care from college counseling centers has increased, engaging male college students to seek help presents a unique challenge. This qualitative study explored mental health literacy and help-seeking behaviors among undergraduate college men. Semi-structured interviews (n = 26) based on three vignettes (anxiety, depression, stress) were employed to assess mental health literacy. Analysis revealed three general themes and associated sub-themes: (a) knowledge of signs and symptoms (physiological, behavioral, and emotional); (b) recommended help-seeking behaviors (do nothing, self-care, seek help); and (c) barriers to help-seeking (social stigma, self-stigma, masculinity). Findings present a triadic interplay between the person, help-seeking behavior, and environment. Future research should explore this dynamic relationship to inform interventions aimed at improving college male mental health help-seeking behavior.

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1 Introduction

Due to various unique stressors, emerging adulthood, the age group for most college students, is a critical period of the life course [ 1 ]. Poor mental well-being among young adults is an important public health issue as mental health symptoms have doubled among college students [ 2 ]. Prevalence data (2013–2021) from a large national study of students from 373 colleges/universities revealed worsening trends in flourishing (− 32.5% change), depression (+ 134.6% change), anxiety (+ 109.5% change), eating disorders (+ 95.6% change), suicidal ideation (+ 64% change), and non-suicidal self-injury (+ 45% change) [ 3 ]. Addressing mental well-being among college students is particularly important as poor mental health has been identified to be associated with binge drinking, physical inactivity, poor diet, high stress, anxiety, loneliness, poor body image, interpersonal issues, co-occurring mental health concerns, and discrimination [ 4 , 5 ]. If left untreated, mental health disorders have been indicated as a risk factor for decreased academic productivity and a two-fold increased risk of dropping out without graduation [ 6 , 7 , 8 ]. As such, the American College Health Association identified several objectives to improve college student mental health such as reducing attempts as suicide, reducing disordered eating, and increasing diagnoses of mental health issues [ 9 ].

1.1 Mental health help-seeking behaviors among college males

While data point towards an increase in the number of students receiving care from college counseling centers [ 10 ], engaging college men to seek help is a unique challenge [ 11 , 12 ].

Data from the 2022 American College Health Association-National College Health Assessment reveal that there was little difference in the percentage of male and female college students who reported experiencing moderate/severe psychological distress, loneliness, or a positive screening for suicidal ideation. However, only 36% of male undergraduate college students reporting ever receiving psychological or mental health services as compared to 54% of females [ 13 ].

Alternatively, male college students are more likely to engage in unhealthy coping mechanisms in place of seeking care [ 4 , 12 , 14 ]. Chuick and colleagues [ 15 ] noted a cyclical relationship between symptoms of a mental health concern, external consequences, and coping mechanisms in that males who participated in negative coping strategies further exacerbated their mental health symptoms [ 15 ]. Interestingly, although men have lower reported rates of depression [ 16 ], males have also been observed with a higher suicide rate (12.6 per 100,000) as compared with females (5.4 per 100,000) [ 17 ].

1.2 Mental health literacy among college males

Mental health literacy (MHL), defined as “knowledge and beliefs about mental disorders which aid their recognition, management, or prevention,” [ 18 ] has been identified as an avenue to increase students mental well-being and help-seeking behaviors [ 19 , 20 ]. Despite multiple studies assessing mental health literacy among young adults and college students, few have focused solely on males residing in the U.S. Of those that have examined MHL among college students using survey methodology, studies contained low sample sizes for male participants [ 14 , 21 , 22 , 23 , 24 , 25 , 26 ], focused on a single mental health issue (e.g., depression) [ 27 , 28 , 29 , 30 , 31 ], or were conducted outside of the United States [ 12 , 14 , 22 , 23 , 24 , 26 , 29 ].

Nonetheless, current research suggests low MLH among males as compared to their female counterparts [ 11 , 32 , 33 , 34 , 35 , 36 ]. Aspects of MHL identified as barriers to male mental health help-seeking behaviors include: (a) male gender norms, including masculinity [ 12 , 15 , 27 , 37 , 38 , 39 , 40 , 41 ]; (b) stigma [ 11 , 12 , 27 , 40 , 42 , 43 , 44 , 45 ]; and (c) attitudes regarding mental health [ 12 , 42 , 45 ]. Additional factors revealed in the current literature include discounting the severity of their mental health concern or feeling as though professional treatment was not necessary; (b) confidentiality, lack of trust, and fear; (c) self-reliance and seeking help from other resources; and (d) accessibility, time, and cost [ 6 , 46 , 47 , 48 , 49 , 50 , 51 ]. For example, a cross-sectional study assessing depression-specific help seeking behaviors among 313 college males attending a Midwestern university, revealed relationships between gender role conflict, self-stigma, and help-seeking behaviors [ 27 ]. More specifically, self-stigma predicted a decreased willingness to engage in formal and informal (e.g., family, friends) help-seeking while gender role conflict was found to be associated with decreased willingness to engage in informal help-seeking behaviors and increased avoidant behaviors [ 27 ]. A meta synthesis of studies published from 2010 to 2013 which focused on men’s perspectives of mental health (n = 26), revealed the following themes regarding mental health literacy (a) pressure to subscribe to dominant masculine ideals; (b) inability to recognize and articulate mental health issues; and (c) a desire to manage the issue as opposed to help-seeking [ 30 ]. Nonetheless, due to limitations in participant sampling (e.g., middle class, educated male populations diagnosed with depression) the authors recommend future research that explores the perspective of men who are not sampled solely on their experience of having diagnosed or self-reported depression [ 30 ]. Similarly, the authors of a scoping review of male mental health published between 2010 and 2020 (n = 21) note that although stigma was a common experience among male participants, the literature regarding male mental health literacy remains undeveloped [ 40 ]. To that end, the authors emphasize the need for qualitative research exploring the nature and mechanisms regarding stigma and mental health literacy among diverse groups of males across the life course [ 40 ].

Addressing above-described recommendations for future male mental health research, the purpose of the current qualitative study was to gain a better understanding of the multiple facets of mental health literacy among emerging adult males attending a U.S. based university. As mental health literacy is embedded in various cultural contexts, qualitative methodology was employed to further explore dimensions of mental health literacy within the context in which they occur [ 52 ].

2 Materials and methods

2.1 participants.

This study utilized a purposive sample of undergraduate males at a large southern research university in the United States. Inclusion criteria for the study included: (a) ≥ 18 years old; (b) self-identify as male; and (c) currently enrolled in an undergraduate degree. Data collection occurred from June to September 2017. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

2.2 Recruitment

Participants were recruited through e-mail and university-specific social media which are moderated by university administrators. In addition to a description of the study, recruitment materials included a link to an online survey to assess if interested males met inclusion criteria. If inclusion criteria were met, additional contact information was gathered to enable researchers to schedule 30- to 60-min in-person interviews.

Prior to each interview, participants were asked to read and sign an informed consent form; the procedures and purpose were explained by the moderator; and participants were given an opportunity to ask questions. All interviews were audio-taped and later transcribed verbatim, excluding identifying information, by an experienced transcriptionist. Those who participated in the study were compensated with a $10 University Dining Services meal voucher. Research integrity and compliance approval was granted through the University’s Institutional Review Board prior to study implementation.

2.3 Conceptual framework

An expanded definition of mental health literacy, offered by Jorm [ 53 ] served as the conceptual framework for this study. Originally defined as “knowledge and beliefs about mental disorders which aid in their recognition, management, or prevention” [ 54 ], Jorm indicated that although knowledge and beliefs regarding mental health are necessary for prevention, recognition, and management of mental health issues, they are not sufficient for improving mental health as the knowledge must be linked to mental health help-seeking behaviors to assist self and other [ 53 ]. Translation of this expanded definition of mental health literacy informed the following research questions: (a) what are college male students’ perceptions regarding mental health (e.g., knowledge, beliefs, attitudes, susceptibility, severity); and (b) what are college male students’ perceptions regarding mental health help-seeking behaviors (e.g., for self, friend, other).

2.4 Measures and procedures

Although, there has been disagreement regarding the proper way to conceptualize and study mental health literacy [ 55 , 56 ], one method that has been used widely among young adults is the use of vignettes illustrating the mental health symptoms and asking the participant to identify the disorder [ 14 , 21 , 22 , 24 , 25 , 26 , 29 , 57 ].

Interviews utilized three vignettes representing a male college student presenting with anxiety, depression, or stress. Guided by diagnostic criteria according to the Diagnostic and Statistical Manual of Mental Disorders-5 [ 58 ] vignettes were developed by a member of the research team who is a licensed psychologist experienced in working with university students. Three additional licensed psychologists reviewed each vignette for face (i.e., the extent to which the vignettes appear to be assessing signs and symptoms of generalized anxiety disorder, depression, stress) and content validity (i.e., extent to which the vignettes contain samples of signs and symptoms of generalized anxiety disorder, depression, stress) with respect to a college student population [ 59 ]. Table 1 includes the vignettes and accompanying text representing DSM-5 [ 58 ] mental health disorders.

The vignettes comprised of text and accompanying photo were presented to each participant. Photos were included for the purposes of increasing identification of each vignette to a typical male college student attending the university-specific setting (e.g., photo of a college male (varying in race/ethnicity) wearing university-specific logo with the university-specific setting).

Interviews were conducted in a semi-structured manner; the same series of questions were asked for each of the three vignettes and probing for additional information was left to the discretion of the interviewer. Interview questions were arranged in a funneling pattern according to protocol outlined by Hawe and colleagues [ 60 ]. Key questions included: (a) Given what I just described about *name from vignette*, what do you think *name from vignette* is experiencing; (b) Explain why you answered that way; (c) Describe how *name from vignette* can best be helped; (d) Where do you think he could get more information about this concern; (e) Imagine *name from vignette* is someone you’ve known for a long time and you know him well. You want to help him. What do you think is appropriate to do; (f) Have you or any of your friends ever experienced this? What did you do/tell them to do; and (g) If you were *name from vignette* what would you do? As a means to increase respondent cooperation and data quality regarding this “sensitive” topic, interviews were conducted by one male researcher as it has been noted that interviewer characteristics such as sex can affect respondent-interviewer rapport; thus matching interviewers with respondents on that characteristic as to increase comfort, rapport, and trust [ 61 ].

At the end of each interview, participants were asked to complete a paper–pencil questionnaire to assess perceived helpfulness of various mental health resources [ 62 ]. Sources of mental health help included parents, friends, mental health specialists, religious leaders, academic personnel, and telephone/text help lines, among others. Answer categories presented on a five-point Likert type scale ranging from very helpful to very unhelpful. An “I don’t know” answer category was also included. A second questionnaire captured participant’s demographic information and included race, ethnicity, age, and college of study.

2.5 Data analysis

Throughout the data collection process interview audio files were transcribed and reviewed for accuracy by the study team. Three independent coders who were members of the research team initially hand-coded the interview transcripts. Individual codes within the code families were garnered through inductive investigation of the data. Members of the research team were responsible for determining which codes presented in a code family. The research team then met and discussed individual codes until consensus was reached. This process was repeated to reduce the number of individual codes such that themes might present more readily. To ensure inter-rater reliability at least three research team members had to completely agree on the code for each quotation. Coding of the study transcripts was performed using Atlas.Ti v6.2 where axial coding was then performed to identify overarching themes and sub-themes.

Descriptive statistics were run to examine the frequency of all quantitative survey responses using SPSS 24. For the perceived helpfulness scale, because of the small sample size, the answer categories for the 5-point Likert scales were collapsed into three categories, helpful, neutral, and not helpful. Prior use questions were scored as dichotomous yes/no variables.

Twenty six in-person interviews were conducted reaching data saturation (i.e. the ability to no longer gain any new information [ 63 ]). Table 2 depicts demographic and behavioral characteristics of the sample. Among participants, the majority were non-Hispanic (76.9%), white (53.8%), and non-international students (92.3%). Participants’ year in college ranged from first to 15 + years, but most students were either in their second (38.5%) or third (38.5%) year. The college of study of participants was diverse and included art, arts and science, behavioral science, business, engineering, and public health. The mean age of the sample was 20.6 years old. The student health center was reported to be the only campus health resource used by over half of the sample (57.7%). With regard to correctly identifying the mental health concern for each of the vignettes, 14 participants (53.8%) correctly identified anxiety, 25 (96.2%) correctly identified depression, and 19 (73.1%) correctly identified stress.

Analysis of qualitative data yielded three general themes: (1) knowledge of signs and symptoms; (2) recommended help-seeking behaviors, and (3) barriers to mental health help-seeking behaviors. Table 3 depicts a summary of general themes and associated sub-themes. Themes and sub-themes are described in detail within the following sections.

3.1 Theme one: knowledge of signs and symptoms

Analyses revealed that for all three mental health issues presented via the vignettes, participants demonstrated knowledge regarding identification and descriptions of signs and symptoms of poor mental well-being. Three sub-themes emerged in that knowledge of signs and symptoms were described by three types including: (a) physiological; (b) behavioral; and (c) emotional. Moreover, comparable sub-themes were revealed when comparing participants who correctly identified the mental health issue portrayed in the vignette to those who did not correctly identify the presenting mental health issue. That is to say, the majority of male participants identified and described physiological, behavioral, and emotions signs and symptoms indicating “the person in the vignette is experiencing something”, but as presented previously, not all participants were able to identify the issues as either anxiety, depression, or stress. Furthermore, most participants who did not describe vignettes as experiences of poor mental health described the signs and symptoms displayed in the vignette as “normal” to the college experience.

Signs and symptoms: physiological For all three vignettes, physiological signs and symptoms were identified recurrently as compared to behavioral and/or emotional. Physiological indicators included heart palpitations, sweating palms, trembling, dizziness, fatigue, loss of appetite, and weight loss. Examples of participant quotes representative of this subtheme include the following:

[Anxiety] “The physical symptom, dizziness, heart palpitations, sweating palms, trembling, sounds like an indication of anxiety … it sounds like his physical symptoms match his mental state.” [Depression] “He's losing weight, he does not feel like eating, he's constantly tired … he just lacks the energy.” [Stress) “Major stress. … his body is starting to show the physical signs of being overwhelmed and overworked. Upset stomach … and the headaches too.”

Signs and symptoms: behavioral The second sub-theme emerged from the analyses revealed the expression of behavioral signs and symptoms of poor mental well-being. Behavioral signs and symptoms included lack of self-care, trouble sleeping, lack of focus, avoidance, and social isolation. Examples of participant quotes representative of this subtheme include the following:

[Anxiety] “He talks about wanting to be isolated and introverted, staying low profile at work, and he doesn't want to go out with his friends and meet new people.” [Depression] “…constantly wanting to sleep, but when he does try to sleep, he can't.” [Stress) “It seems like he's got a lot on his mind, which I guess is causing him not to be able to sleep well”

Signs and symptoms: Emotional The third sub-theme emerging from the analyses revealed emotional signs and symptoms of poor mental health. Although emerging as a sub-theme, emotional signs and symptoms were expressed the least out of the three sub-themes. Emotional signs and symptoms identified among the three vignettes included worry, irritation, on edge, and pressure. Examples of participant quotes representative of this subtheme include the following:

[Anxiety] “‘Wound up, edgy.’ I guess he has anxiety all the time…he's just constantly worried all the time.” [Depression] “He's unusually sad and miserable” [Stress] “Feeling irritable and pressured”; “It seems like he's got a lot on his mind…and he says he's feeling pressured”

Additionally, although not a sub-theme per-se, specific to the depression vignette, participants identified and described suicidal ideation was an indication of depression. Examples of participant quotes representative of this subtheme include the following:

“Thinking of ways to end his life. That would be the big highlight right there.” “Suicidal thoughts and tendencies, that's kind of one of the big signs I guess.” “You start thinking about ways to end your life … It's definitely symptoms of that [depression].”

3.2 Theme two: recommended help-seeking behaviors

The second general theme that emerged from analysis pertains to the discrepancy between what the participant would recommend for a male stranger exhibiting signs and symptoms of poor mental health versus what he would advise for a male friend versus what he would advise for himself. Participants advocated distinct help-seeking strategies contingent upon their association with the person in question. Accordingly, this theme comprised of two sub-themes including: (a) Intrapersonal (Self); and (b) Interpersonal (Male Friend, Unknown Male).

3.2.1 Recommended help-seeking behaviors for self

With reference to recommended intrapersonal help-seeking behaviors, participants conveyed three main strategies for addressing presenting mental health issues in the vignettes. Although differences were observed depending on the presenting mental health issue, recommended strategies included: (a) do nothing; (b) engage in self-care; (c) seek mental health services. When presented with the anxiety and/or the depression vignette, participants expressed that they would “do nothing.” The self-recommendation to “do nothing” was supported by the belief that described signs and symptoms were not severe and they believed they would be able to work through it on their own. Frequent terms to express this belief included “pushing through” and “waiting it out.” Examples of participant quotes representative of this subtheme include the following:

“Just kept working through it … Things are going to get tough in life, and I just kind of ended up dealing with it. Pushed through. Grass is always greener on the other side.” “I would just wait until I had some free time or if until things got kind of serious.”

Engaging in self-care was articulated when presented with the anxiety and/or stress vignette. Self-care practices suggested by participants covered a broad range of items including wellness activities such as breathing exercises, physical exercise, relaxation methods, and organizing one’s schedule. Examples of participant quotes representative of this subtheme include the following:

“…reset my diet, my sleep schedule, you know, spend more time just meditating and just thinking about what I can do to positively benefit my life.” “And I would make sure that I've not overworked myself. That I had time … an hour or an hour and a half to myself just relaxing.” “I would definitely start cutting back on some activities to just try to remove some of that load from my life.”

Seeking mental health services was only expressed when presented with the depression vignette. As depicted in Table 4 , participants indicated the usefulness of different mental health services included peers, family members, and healthcare providers. Examples of participant quotes representative of this subtheme include the following:

“That's the way it feels, but if you actually put in the time to go to counseling and try to help yourself, then you can get out of it.” “I would probably try to seek help in the wellness center or a therapist’s office or something.”

3.2.2 Recommended help-seeking behaviors for a male friend

The interpersonal sub-theme encompasses recommendations participants would present to their male friends and other males. With regard to recommendations to their male friends, in general across mental health concerns, participants conveyed that they would either “do nothing” or talk to their friend about signs and symptoms, and/or suggest that the friend seek assistance from healthcare or a mental health provider. When presented with the depression and anxiety vignettes, most participants expressed that they would not provide any recommendations for help-seeking to a friend. When data were compared by those who correctly identified the depression and anxiety vignettes to those who did not, the recommendation remained consistent. The majority of participants expressed that due to a stated lack of qualifications, they did not believe they were in the position to intervene or were unsure of how to appropriately handle such a situation. Since the depression vignette indicated suicidal ideation, many participants conveyed concern in that if they said the wrong thing it would make the situation worse. Examples of participant quotes representative of this subtheme include the following:

“I personally believe that I shouldn't be telling people what to do.” “It's his life so I feel like it's his responsibility to improve his wellbeing.” “I don't know what I can do personally, since I wouldn't really know how to deal with this.” “If I give him some suggestion and he takes it the other way, it will just be bad for him.”

Irrespective of mental health issues presented in the three vignettes, participants expressed that they would talk with their friend about signs and symptoms. For example, participants expressed that their friend may have been suppressing signs and symptoms of the mental health concern, and by addressing these with their friend, could provide useful. Examples of participant quotes representative of this subtheme include the following:

“For me to do as a friend, would be to listen to how he's feeling.” “Just tell him straight up, "Hey, you've been saying you have all these symptoms going on. I think you may have a bit of high anxiety.” “Maybe talking with him … and working through it, and trying to make him feel a little better.”

Lastly, when talking with their friend, most participants expressed that they may also recommend that the friend seek assistance from a medical professional as a way to address physiological issues. Males recommending mental health services described this recommendation as a measure for suicide ideation. Examples of participant quotes representative of this subtheme include the following:

“I'd talk to him and say, You know. First thing, seek medical professional help. The doctors.” “I think the first thing would definitely be, make sure he gets to a doctor, gets checked up, make sure that everything physically is fine.” “If he's been talking about ending his life he should see a counselor of some sort.”

3.2.3 Recommended help-seeking behaviors: unknown male

Across all three mental health concerns, when the person described was an unfamiliar male, participants conveyed that the male should seek assistance from a mental health provider. This recommendation held true whether the participant correctly or incorrectly identified the mental health issue presented in the vignette. Examples of participant quotes representative of this subtheme include the following:

“I think John could use maybe some counseling services.” “He should go visit a psychiatrist or something so that they can go through what's happening to his day-to-day life” “If this thing continues, then he should go visit a doctor”

3.3 Theme three: barriers to help-seeking behavior

The third general theme represented barriers to mental health help-seeking behaviors. This theme comprised of three sub-themes including social stigma, self-stigma, and masculinity.

3.3.1 Social stigma

Social stigma accounted for participants beliefs regarding how they would be perceived by others and society if they were to seek help for a mental health concern. Participants were most concerned with perceptions stemming from family and friends. The stigma associated with mental health may not only influence a person’s beliefs and attitudes towards them, but can also influence their behaviors (e.g., being out casted, losing friends). Participants frequently used terms such as “crazy” and “normal” when describing someone with or without a mental illness, respectively. Examples of participant quotes representative of this subtheme include the following:

“Stigma. … If people figure out you're talking to someone … then you get the crazy label.” “Oh, and fear of being outed, I guess, per se . Like if your friends find out that you're going to counseling they're like, what's wrong with you?” “The stigma associated with them if someone found out like, ‘Oh you went to a mental health place. So you must be crazy or you're not stable. Don't talk to me. I need friends who are normal.’”

3.3.2 Self-stigma

Another barrier identified was the self-stigma associated with a mental illness. Self-stigma captured how participants would view themselves should they receive help for a mental health issue. Participants questioned whether a mental health diagnosis made them unstable or out-of-control of their life. Analysis of this subtheme presented in multiple ways including perceptions of vulnerability. Examples of participant quotes representative of this subtheme include the following:

“The biggest mental block would simply be going there [to get help] admits you have a problem. That you don't have control of what you're doing. That's a scary thing to admit.” “I feel like it's probably kind of scary … ‘Maybe I'm like having a mental illness. … Does that make me stupid? Does that make me dangerous? Does that make me this or that?’” “Pride. … you don't want to be known as one of the people who has to go get help. You want to feel like you can work things out yourself.”

3.3.3 Masculinity

The third subtheme within the barriers theme was masculinity. This subtheme accounted for participants’ expressed beliefs regarding how males “should function in society.” Analyses revealed that traditional gender norms were a salient concern when males considered seeking mental health services and that they were a major obstacle to help-seeking. Most participants discussed males needing to be perceived as strong by hiding their feelings and by figuring out their own problems. Admitting a problem, not being able to solve one’s own problems, and even talking about one’s feelings meant that males were not manly and thus were weak and socially undesirable. Males’ perception was that females do not have the same societal pressures placed on them pertaining to mental health help-seeking. Examples of participant quotes representative of this subtheme include the following:

“There's a stigma against men going to get mental healthcare, because it's perceived as some kind of weakness. It's expected for women to be, say, open with their feelings. With men, it's the complete opposite.” “Especially among men, it's considered a weakness in a lot of groups of people (pause) it's not masculine to receive help.” “Society tells us we have to be manly and just hold it in, and you can't be talking about your emotions. You're supposed to be the man of the house, the man of the family. You're not supposed to show any sign of weakness.” “There's a lot of societal pressure … that males don't really have to seek help, you just figure it out on your own.”

4 Discussion

Attending to mental health literacy among male college students is critical for improving student health, well-being, and success as males are more likely to adopt maladaptive coping behaviors as opposed to mental health help-seeking behaviors. The purpose of the current study was to address noted gaps in the literature by exploring the multiple facets of mental health literacy among male college students in the U.S. By means of qualitative methodology grounded in Jorm’s mental health literacy conceptual framework, the current study explored undergraduate males’ knowledge of signs and symptoms, attitudes, beliefs, and perceived susceptibility to depression, anxiety, and stress, in addition to recommended help-seeking behaviors and barriers to care. The current study revealed three general themes including (a) knowledge of signs and symptoms (physiological, behavioral, and emotional); (b) recommended intra- and interpersonal help-seeking; and (c) barriers to help-seeking behaviors. Individually, these themes present with enlightening sub-themes; yet, when triangulated, findings present an interesting triadic interplay that provides insight for practice translations. Each theme will be discussed individually followed by a discussion regarding the triadic interplay between themes and sub-themes.

First, the identification with physiologic and behavioral signs and symptoms of anxiety, depression, and stress as opposed to emotional provides insight as to key indicators of poor mental health from the college male perspective. Participants expressed the familiarity of physical issues such as headaches, digestive issues, and rapid heart rate, in addition to behaviors such as inability to sleep, eat, irritability (i.e., yes, this happens to me). On the other hand, participants expressed an unfamiliarity to anxiety, depression, and stress as a mental health issue (i.e., no, this has not happened to me). However, although these physiologic and behavioral indicators were identified in the presenting vignettes, many were perceived as “normal” to the college experience. This was especially true for diagnoses that seemed common to the college experience, such as stress and anxiety. This is troublesome as identification of symptoms is a predictor of help-seeking [ 20 ].

Second, despite knowledge of signs and symptoms of mental health issues, participants varied on recommended care strategies based on (a) proximity to self and (b) the perceived mental health issue. For example, the current study reveals that the further removed the male is to himself, the more likely they were to recommend seeking professional services. College males are more likely to recommend to themselves “do nothing” and “wait it out”, as compared to recommending a medical provider for their friend, and a mental health provider to a stranger. This is supported by the findings of Rickwood and colleagues [ 19 ] where participants were more likely to recommend services to others than to use them themselves. College males in the current study revealed that talking to their male friend about physical and behavioral issues and advising him to seek a medical provider is much easier and less worrisome than discussing mental health. This finding also brings to light the importance of involving the university medical health services in the screening of mental health issues.

Further, results of the current study reveal that seeking professional mental health services for themselves was only expressed when presented with the depression vignette. These results support the work of others in that males tend to seek care only when in crisis [ 4 ]. Alternatively, as described previously, male college students are more likely to engage in unhealthy coping mechanisms in place of seeking care [ 4 , 12 , 14 ]. Subsequently, the adopting of maladaptive coping strategies may increase the likelihood of potential conduct violations. Similar to university student health services, university behavioral intervention teams and conduct offices should consider mental health screening when addressing student alcohol, drug, and behavioral conduct issues.

Third, the current study points to the importance of stigma and masculine motifs as barriers to help-seeking behaviors in addition to interpersonal help-seeking. A recent study by DeBate et al. [ 45 ] supports this point in that they found stigma negatively mediates the relationships between knowledge, motivation, and help-seeking among male college students. The work of Chuick and colleagues [ 15 ] and Oliffe and colleagues [ 38 ] support this idea by indicating that traditional ideas of masculinity negatively impact males help-seeking behavior in a cyclical fashion. Decreasing the role of masculinity and stigma in dictating males experience with mental health is paramount to successful programs; however, it is difficult to parse the exact effect of both.

Finally, interpreting these themes independently should be done with caution as the current study reveals an interesting triadic interplay between the person (i.e., male college student), their help-seeking behavior, and their environment. As depicted in Fig.  1 , these three themes all influence each other; whereas, improving mental well-being among college males cannot be achieved by solely focusing and attending to one or two of these components. For example, masculine norms influence what males identify as indicators of poor health, in addition to influencing their intention to seek care. The choice of help-seeking behavior is influenced by self-stigma and social stigma. This also hold true for recommendations for help-seeking for their male friends. Engaging in self-care or “doing nothing” reinforces the masculine norms and self-stigma. The triadic interplay creates a persistent pattern that may be considered too difficult to break.

figure 1

Male mental health literacy triadic interplay

This study sought to better understand the factors impacting mental health literacy among male undergraduate college students and the analysis provides a detailed description of their knowledge, perception towards help-seeking, and barriers. As with most qualitative studies, the generalizability of this study is limited, and the findings cannot be extended beyond this population (e.g., females, males not attending university, males residing outside of the U.S.). This has been well-documented in qualitative research, thus generalizability beyond this population is not the purpose of the current study [ 64 ]. For example, the population was comprised of males who have access to resources due to being students, location can only be generalized to local university, and the vignettes were only specific to depression, anxiety, suicide ideation, and stress. Further, although the authors took note in data collection via a trained male interviewer, due to the level of trust and comfort in discussing mental health, there may have been socially desirable responses as well as self-censorship. Second, considerations of study results should note limitations presented by the vignettes. As development of the vignettes employed DSM-5 criteria as a guide, they should not be interpreted as representative of an individual diagnosed with generalized anxiety disorder nor depression. This may have limited the ability for participants to correctly identify representative mental health issues. To that end, translation of DSM-5 criteria for generalized anxiety disorder may have provided a better reflection of how these disorders manifest in a U.S. population. Nonetheless, despite certain limitations, the current study adds to the current literature regarding mental health literacy among college males in addition to translation to practice in institutions of higher education.

Despite limitations, the current qualitative study adds additional literature regarding college male mental health literacy. Moreover, a triadic interplay (person, environment, and behavior) may be noted to provide avenues for improving mental health literacy among male college students. In addition to addressing mental health literacy among male college students, perhaps improvements could be made by improving mental health literacy of college student healthcare providers. By re-perceiving this triadic interplay from an asset-based approach instead of a deficit-based approach, implications for practice can be made. For example, social marketing programs could be developed that are grounded in positive masculinity and provide action items to confidential on-line therapy assessments, modules, and programs such as TAO (Therapy Assistance Online [ 65 ]). Another recommendation is to develop paradigms for mental health around the physiological and behavioral signs of poor mental health. Mental health literacy training programs could be implemented for student health providers whereas they can be identified as first-line providers to secondary prevention of mental health issues. Future research should be implemented to further explore the dynamic relationships between these concepts in addition to development and evaluation of interventions aimed at improving mental health literacy and help-seeking behaviors among male college students.

Data availability

The datasets generated during and/or analyzed for the current study are not publicly available due to IRB approval criteria but are available from the corresponding author on reasonable request.

Code availability

Not applicable.

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DeBate, R., Gatto, A., Rafal, G. et al. A qualitative assessment of mental health literacy and help-seeking behaviors among male college students. Discov Ment Health 2 , 23 (2022). https://doi.org/10.1007/s44192-022-00028-9

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MENTAL HEALTH PROBLEMS IN COLLEGE FRESHMEN: PREVALENCE AND ACADEMIC FUNCTIONING

Ronny bruffaerts.

Research Group Psychiatry, Department of Neurosciences, KU Leuven University, Universitair Psychiatrisch Centrum – KU Leuven, Leuven, Belgium

PHILIPPE MORTIER

Research Group Psychiatry, Department of Neurosciences, KU Leuven University, Leuven, Belgium

GLENN KIEKENS

Randy p auerbach.

Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, MA, USA

PIM CUIJPERS

Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam

KOEN DEMYTTENAERE

Jennifer g green.

School of Education, Boston University, Boston, MA, USA

MATTHEW K NOCK

Department of Psychology, Harvard University, Cambridge, MA, USA

RONALD C KESSLER

Harvard Medical School, Department of Health Care Policy, Harvard University, Boston, MA, USA

1. INTRODUCTION

The college years are a developmentally crucial period when students make the transition from late adolescence to emerging adulthood (Arnett, 2000). Epidemiological studies suggest that 12–50% of college students meet criteria for one or more common mental disorders ( Blanco et al., 2008 ; Hunt & Eisenberg, 2010 ; Verger et al. 2010 ). Differences between college students and their non-college peers are generally understudied but the available evidence shows that college students are somewhat at lower risk of mental disorders ( Auerbach et al., 2016 ; Blanco et al., 2008 ). In any case, mental disorders in early adulthood are associated with long-term adverse outcomes in later adulthood, including persistent emotional and physical health problems ( Scott et al., 2016 ), relationship dysfunction ( Kerr & Capaldi, 2011 ), and labor market marginalization ( Niederkrotenthaler et al., 2014 ; Goldman-Mellor et al., 2014 ). These long-term adverse outcomes may be mediated by mental health problems that exist during the college years, as these years constitute a peak period for the first onset of a broad range of mental disorders ( Ibrahim et al., 2013 ).

In Belgium, around roughly 70% of high school graduates attains higher education after graduating from high school ( Dehon & Ortiz, 2008 ), but only 37–39% will succeed and even 28% will never obtain any diploma ( Declercq & Verboven, 2014 ). Reasons for dropout are comparable to international literature, and include: lower socio-economic status ( Walpole, 2003 ), male gender ( Dehon & Ortiz, 2008 ), or the overall lack of social resources ( Tinto, 1998 ). Also mental disorders may contribute to college dropout. Most of the research so far discussed the role of pre-matriculation mental disorders on subsequent academic functioning ( Kosidou et al., 2014 ; Eisenberg et al., 2009 ; Gunnell et al., 2009). Previous studies show that college students with mental disorders are twice as likely to drop out without obtaining a degree ( Kessler et al., 1995 ; Hartley, 2010 ). Consistent with this finding, between 15% and 23% of college students with mental disorders suggest that they confer a negative academic impact ( Kernan et al., 2008 ). Studies that investigate the association between mental health distress and academic performance in college are much scarcer. Most evidence exists for the finding that depression and suicidal thoughts and behaviours are related to a lower grade point average ( De Luca et al., 2016 ; Mortier et al., 2015 ; Hysenbergasi et al., 2009; Andrews & Wilding, 2009). In addition, most studies focus on the impact of just one disorder (e.g. Meda et al., 2017; Arria et al., 2015), leading to uncertainties as to the overall associations of a broad range of mental health problems with academic outcomes. Prior studies also mostly relied on self-reported academic performance or were based on reports from students presenting to the student (mental) health center.

We address these shortcomings in the current report by using data obtained in the Leuven College Surveys. These surveys were carried out as part of the International College Student project (WMH-ICS; http://www.hcp.med.harvard.edu/wmh/college_student_survey.php ) of the WHO World Mental Health Surveys. The WMH-ICS aims to obtain accurate cross-national information on the prevalence, incidence, and correlates of mental, substance, and behavioral problems among college students worldwide, to describe patterns of service use and unmet need for treatment, to investigate the associations of these disorders with academic functioning, and to evaluate the effects of a wide range of preventive and clinical interventions on student mental health, social functioning, and academic performance. The current study builds on earlier work on academic functioning in college students ( Mortier et al., 2015 ; Kiekens et al., 2016; Auerbach et al., 2016 ). The aim is to investigate the prevalence of mental health problems in the past year and the extent to which these problems in freshmen in the Leuven College Surveys were associated with objectively-assessed measures of academic performance obtained from official university records at the end of the freshman year. We also go beyond previous studies in investigating the possibility that these associations vary by academic departments (like bio-engineering, law school,…) using analysis methods that take into account clustering of students within departments so as to avoid over-generalizing conclusions.

2. MATERIAL AND METHOD

2.1. procedures.

As part of the WMH-ICS project, the Leuven College Surveys consist of a series of ongoing web-based self-report surveys of KU Leuven students. As Belgium’s largest university, KU Leuven has an enrollment of over 40,000 students, with 7,527 Dutch-speaking incoming freshmen aged 18 years or older in the 2012 and 2013 entering classes eligible for the baseline survey. The sample was recruited in three stages. In the first stage, the baseline survey was included in a routine medical check-up organized by the university student health center early in the academic year. All incoming freshmen from all university departments were sent a standard invitation letter for the check-up. Students who arrived at their check-up were invited to complete the study survey on a desktop computer in the waiting room of the student health center. In a second stage, non-respondents to the first stage were personally contacted using customized emails containing unique electronic links to the survey. The third stage was identical to the second stage, but additionally included an incentive to complete the survey (i.e., a raffle for 20 euro store credit coupons). Each stage used reminder emails, setting the maximum amount of contacts at eight. The study’s protocol was approved by the University Hospital Leuven Biomedical Ethical Board (B322201215611) and by the Belgian Commission for the Protection of Privacy (VT005053139). We used the code for a pure epidemiological study (in contrast to an intervention study) and have permission to include baseline samples until September 2018. The ethical board adopts the International Conference on Harmonisation – Guidelines of Good Clinical Practice) principles. Students who reported any 12-month suicidality or non-suicidal self-injury were presented with links to local mental health resources.

We obtained freshman departmental status from the KU Leuven administration office. The KU Leuven is divided in 40 departments based on the academic content offered to the enrolled students within that department (e.g., bio-engineering, law, romance languages – for a full list, see https://www.kuleuven.be/english/faculties_schools ). A department is a micro-unit within the larger campus environment, with shared structural (e.g., classrooms), interpersonal (e.g., sense of belongingness), and social (e.g., sports participation) elements. The clustering of students in academic departments enabled us to estimate multilevel models that investigated the possibility of between-department variability in prevalence and associations of 12-month mental disorders with subsequent academic performance. Such an approach may be especially valuable given that students’ wellbeing and performance are known to be is linked to peer-group characteristics, student–faculty interactions, and general institution characteristics ( Astin, 1993 ; Fink, 2014 ).

2.2. Measures

The WMH-ICS survey instrument was developed by the World Mental Health Survey Consortium and includes multiple screening instruments for a wide range of mental health problems. For each respondent, survey data were linked to unique administrative unit-level data obtained from the KU Leuven students’ administration office, including academic year functioning, and sociodemographic variables.

Sociodemographic variables

Socio-demographics included gender, age, and parental educational level. Parental education was divided in three levels: both parents completed a high academic degree (i.e., college bachelor degree or more), only one parent obtained a high academic degree, and neither parent obtained a high academic degree. Parental education was included as covariate because it is a reliable proxy variable for socio-economic status ( Hauser & Warren, 1997 ), as well as for young people’s educational success and achievement-related behaviors ( Eccles et al., 2004 ).

Mental health problems were assessed using the Global Appraisal of Individual Needs Short Screener (GAIN-SS), a well-validated screening instrument for 12-month mental health problems in adolescent and adult populations ( Dennis et al., 2006 ). The 20-item instrument is developed to provide a quick and accurate screening of emotional and behavioural problems in order to identify groups of adolescents and young adults with a possible need for referral or treatment, and thus to aid in clinical referral, treatment planning, and program evaluation ( Dennis et al., 2006 ). It is used by more than 1,700 agencies in both clinical services and research communities ( Conrad et al., 2012 ). The GAIN-SS is one of the few screening instruments that effectively addresses mental health and substance abuse problems. The instrument has been used in a variety of populations (primary care, school, criminal justice system, homeless populations, college populations, and general population samples - e.g. Truman et al., 2012 ; Shinn et al., 2007 ; Sacks et al., 2008 ; Mortier et al., 2015 ). It has also been used to screen for various mental health problems such as major depression, psychotic problems, substance abuse problems, or bipolar disorder (Peters et al., 2008; Rush et al., 2013). The GAIN-SS consists of four sub-screeners, each indicative for one type of mental health problems, including: internalizing mental health problems (depression, anxiety, sleep problems, post-traumatic stress, and suicidal ideation), externalizing mental health problems (inattentiveness, hyperactivity, impulsivity, and conduct disorder), problems with substance use (problematic use, substance abuse, and dependence), and crime/violence-related problems (interpersonal, property, and drug related crimes). Sub-screeners show good internal consistency (Cronbach α=0.65–0.81), and they are highly correlated with the original corresponding subscales of the 60–120 min DSM-IV-TR based GAIN structured interview (Pearson r=0.84–0.93; Dennis et al., 2006 ). For each type of mental health problems the recommended cut-off score of three or more positive symptoms in the past 12 months. The GAIN-SS does not allow us to assign diagnoses or identify disorders in se; the instrument is developed and used in order to identify 4 types of mental health problems.

Academic year percentage (AYP)

The AYP is the final grade percentage (range 0.0–100.0%), as objectively calculated by the KU Leuven administration office. The AYP is the mean result of all final course grades (in terms of percentages) obtained from the examination periods in June and September, and is an expression of the academic achievement of the individual student in a given academic year. The AYP is calculated after the September retakes. If students do not participate in an examination, the obtained grade for this particular course is zero. For reasons of comparability with other studies, we also provide grade point average (GPA) apart from the AYP.

2.3. Statistical analyses

All analyses were performed with SAS (version 9.3) and MLwiN software (version 2.24; Rasbash et al., 2009 ). First, non-response propensity weighting techniques were applied on the data to adjust for socio-demographic differences between survey respondents and non-respondents using de-identified socio-demographic data for the population obtained from university administrative records. These techniques were applied to account for non-response bias and missingness of data. This approach enables us to obtain estimates representative for the full student population of incoming freshmen with respect to the post-stratification variables. Since response rates can be poor indicators of data representativity ( Groves, 2006 ), we also calculated representativity indicators (R-indicators; Schouten et al., 2009 ) for each additional inclusion stage. These are calculated as 1 - (2 x the standard deviation of the response propensities). Response propensities are the probability of response, as calculated here by a logistic regression model, with response as the outcome variable and all sociodemographic variables as predictors. The more variability there is in the response probabilities, the better the sociodemographic variables actually explain the response (or non-response). In other words, the higher the standard deviation of the response propensities, the more likely there is nonresponse based on sociodemographic variables. Hence, subtracting 1 by 2 times the standard deviation of the response propensities results in a multivariate determined indicator of representativity. Values of R-indicators vary between 0 and 1, the latter indicating data are fully representative of the population under study with respect to the population parameters investigated.

Generalized linear modeling (GLM; using SAS GENMOD procedure) was used initially to estimate the associations of 12-month mental health problems with AYP adjusting for gender, age, and parental education. Two-level linear regression models were subsequently fitted, with students (level one) nested within academic departments (level two). We estimated between- and within-department random slopes for the associations of 12-month mental health problems with AYP, again adjusting for individual-level socio-demographics in the fixed part of the model. Significance testing from zero of fixed effects and (co)variances was performed using the univariate Wald test. Finally, we estimated Spearman’s ranking correlation coefficients (using SAS PROC CORR procedure) between the predicted slopes of AYP on mental health problems from the multilevel models and departmental proportions in gender, age, parental educational level, 12-month mental health problems, and departmental mean values in AYP, and number of students enrolled.

Prevalence estimates are reported as weighted numbers (n), weighted proportions (%), and standard errors (SE), corrected for finite population sampling without replacement (SAS PROC SURVEYFREQ procedure). To describe between-department variance in variables, median values and interquartile range (IQR) were calculated. Model parameters are reported as weighted unstandardized regression coefficients (β), associated standard errors (SE), and 95% confidence intervals (95%CI).

3.1. Sample description

Sample and department characteristics are presented in Table 1 . The final sample consisted of 4,921 freshmen (with a response rate of 73.2% after correction for college dropout). R-indicators increased from 0.803 after inclusion stage 1 to 0.815 after inclusion stage 3, suggesting a good socio-demographic representativeness of the weighted sample. Freshmen survey respondents were distributed over 38 different departments (two departments were left out of the analysis due to n<10). The median number of students per department was 64 (IQR=36–164). The median departmental response rate was 67.4% (IQR=59.7–73.2) and the mean AYP across departments was 50.1% (corresponding to a GPA of 1.7).

SAMPLE DESCRIPTION OF THE LEUVEN COLLEGE SURVEY (n=4,921)

3.2. Twelve month mental health problems

Mental health problems in the past year were estimated at 34.9% (SE=0.45) of college freshmen, with higher estimates for internalizing (23.7%) and externalizing (18.3%) problems than for either substance use (5.4%) or antisocial (0.1%) problems. Mental health problems were frequently co-occurring as 36.1% of those who had one type of problems also had another type of mental health problems. That means that mutual exclusive types of mental health problems were much lower, with estimates of 14.2% (SE=0.56) for internalizing problems, 8.6% (SE=0.46) for externalizing, 1.7% (SE=0.21) for substance use, and 0% for antisocial problems.

3.3. Associations between 12-month mental health problems and academic functioning

Table 2 shows the generalized linear model parameters estimating the association between mental health problem and academic functioning in two statistical models, i.e. a model for each of the mental health problem separately (left pane) and a full-factorial model (right pane) (bivariate analyses upon request). Two out of the four types of mental health problems (internalizing and externalizing problems) were associated with significant decreases in academic functioning (after adjusting for socio-demographics) of 2.9% and 4.7% in AYP, corresponding to a decrease of 0.2–0.3 in GPA, respectively. Substance abuse and antisocial problems were not significantly associated with academic functioning, although power to detect an association involving antisocial problems was low due to the small number of students with that disorder (n=5). Being older than 18 years old and having parents without academic degrees were also significantly associated with decreased academic functioning (with AYP reductions of 4.0–7.4%, corresponding to GPA reductions of 0.5–0.7).

Impact of past year risk for mental disorders on academic year percentage

In addition, we have also tested whether gender, age, or SES moderates the interaction between mental health problems and academic functioning. None of these interactions reached significance (tables upon request). We have also tested whether multicollinearity in the multivariate model may be an issue by calculating tolerance and variance inflation factors (VIF – Kutner et al., 2004 ). These statistics were very reassuring, with tolerance values in the range 0.880–0.992, and VIF values in the range 1.008–1.137. In fact, the Pearson correlations between the four types of mental health problems were rather low, i.e. all in the range 0.080–0.240 (4 out of 6 correlations significant).

3.4. Between-department variance in impact of 12-month mental health problems academic functioning

Table 3 shows summary results of the multilevel linear models that estimated between-department variance in the associations of mental health problems with academic functioning. The main finding is that the associations of internalizing and externalizing mental health problems remain significant when taking into account the between-departmental variability in the multilevel analyses, with externalizing mental health problems associated with a 4.3% (95%CI= −5.8 to −2.7) decrease and internalizing problems a 2.3% (95%CI= −4.1 to −0.6) decrease in AYP. We also found a significant interaction (p=0.005) between mean departmental academic functioning and the individual-level association between mental health problems and academic functioning: the negative individual-level association between mental health problems and academic functioning was stronger among freshmen in departments with a lower departmental AYP or GPA average. Indeed, these departments showed a higher decrease in AYP/GPA associated with externalizing mental health problems compared to those in higher performing departments, with within-department reductions of on average 4.1% in AYP (corresponding to 0.3 drop in GPA). Department membership explained 6.5% of the variance in the AYP/GPA among students with 12-month externalizing mental health problems compared to 3.7% among students without externalizing problems.

MULTILEVEL ANALYSIS OF THE ASSOCIATION BETWEEN 12-MONTH MENTAL DISORDERS AND ACADEMIC YEAR PERCENTAGE

Spearman’s ranking correlation coefficients between the estimated departmental decrease in AYP associated with externalizing problems (38 departments) and other departmental characteristics are presented in Table 4 . Spearman’s ρ between decrease in AYP associated with externalizing disorders and departmental AYP was 0.784 (p<.001). Decreases in AYP associated with externalizing problems were positively correlated with the proportion of males (Spearman’s ρ=0.324, p<0.05) and the proportion of students with highly educated parents (Spearman’s ρ=0.484, p<0.01) but negatively correlated with 12-month internalizing problems (Spearman’s ρ= −0.384, p<0.05). After calculating partial Spearman ranking correlation coefficients (adjusting for all other departmental mean values and proportions in Table 4 ), the departmental decrease in AYP associated with 12-month externalizing problems remained significantly correlated with departmental AYP (ρ=−0.747; p<0.001).

SPEARMAN RANK CORRELATION BETWEEN DEPARTMENT CHARACTERISTICS

4. DISCUSSION

This is the first study that investigated the extent to which a broad range of 12-month mental health problems are associated with objectively-measured academic performance among college freshman. We addressed several shortcomings of previous studies in the field, by including a large sample, using propensity weights that enable to draw population-based conclusions, and by using multivariate multilevel equations to investigate effects of the departments in the research questions. These elements make the innovation or impact of this paper above and beyond what has been done in the field of college mental health before. Two main findings stand out. First, freshmen with internalizing and externalizing mental health problems have significant lower academic functioning than other students. Second, the association of internalizing problems with academic functioning is consistent across departments, whereas the association of externalizing problems with academic functioning varies significantly across departments as an inverse function of mean department-level AYP or GPA.

Approximately one in three indicated having mental health problems in the past year, a finding that is consistent with prior studies, although the estimate of alcohol problems is somewhat to the lower end ( Auerbach et al., 2016 ; Aertgeerts et al., 2002). More importantly, externalizing mental health problems (other than Attention Deficit Hyperactivity Disorder; ADHD) in college students have been rarely examined, largely because of the assumption that persons with childhood onset externalizing problems are at high risk for dropping out in high school and thus never make it to college ( Alexander et al., 1997 ). Still, we estimate the proportion of freshmen students with externalizing problems is one in five, higher than full ( Lee et al., 2008 ) or subthreshold ADHD (around 7–8%) ( Weyandt & DuPaul, 2006 ). The exact reason for such high numbers is unclear, and may be the result of the fact that we use a low-threshold screening instrument for mental health problems. It may also be explained by an increasing number of adolescents with mental health problems entering tertiary education ( Gallagher, 2007 ).

Students who have mental health problems in the past year have, on average, a decrease of 2.9–4.7% of their AYP (or 0.2–0.3 decrease in GPA) at the end of the academic year compared to those without these problems. That means that a student who functions on an academic level in the 50 th percentile will make a drop to the 38 th and 35 th percentile in the presence of internalizing or externalizing mental health problems, respectively, comparable to the Eisenberg et al. (2009) data, although the average GPA in US universities is higher than the one in our study (2.6 vs. 1.7, respectively – Zwick, 2004 ; Cabrera et al., 2013 ). A new finding is that a wide range of emotional problems – not just depression – have a significant association with lower academic functioning, even after adjusting for a broad set of confounders. Specifically freshmen with externalizing problems had a marked decrease in academic functioning. The role of externalizing problems in college is far from settled, mostly confined to studies of ADHD ( Green & Rabiner, 2012 ) and high-risk health behaviors ( Adams & Moore, 2007 ), and our data point to the need of studying these problems among college students in the future.

That externalizing problems play an important role in freshmen college life is further reflected by the fact that we found that context-specific features may moderate the associations of externalizing problems with academic functioning. Similar to what was found for suicide attempts (see Mortier et al., 2015 ), the association of 12-month externalizing problems with academic functioning was stronger in departments with lower academic functioning. The most plausible interpretation here is that academic programs that are more rigorous may increase student distress and may lead to higher mental health problems, and eventually to lower academic functioning. An alternative interpretation may be that academically poor educational environments have lower sense of connectedness or social support, and that this, in turn, may temper the academic impact of externalizing mental health problems (Tinto et al., 1993).

The results of this study should be interpreted in light of several limitations. First, the relatively low number of cases precluded simultaneous tests of level 2 effects for all covariates, as such analyses require very large sample sizes (e.g., N>4,000,000 - Jablonska et al., 2009 ). However, a low amount of level 2 units comes mainly at the cost of underestimating level 2 variances ( Hox, 2010 ), leaving other estimates unbiased. Second, we did not have exact information on pre-college functioning of the freshmen in our sample. This may have led to the possibility that the associations we found could be partially driven by so-far unmeasured factors (such as social or intellectual functioning). However, the fact that we adjusted for the fixed effects of both age and parental educational level (i.e. proxies for fall-behinds in high school – Spera et al., 2009 ) in the multilevel models limits the possibility of a selection effect that explains away the observed interaction effect between departmental academic functioning and the individual-level association of externalizing problems with AYP. Third, because of limited statistical power we were unable to add additional covariates (such as family environment or peer relationships) in the regression models. Further research with larger cohorts or pooled data from the WMH-ICS surveys carried out in other universities may focus on adding these in statistical models because these variables may explain the association between mental health problems and academic performance. This is also the case for an extensive examination of comorbidity which is beyond the scope of the current study. Fourth, our data are based on the results of a screening instrument that assesses mental health problems. Despite the fact that this is a well-validated screener with good internal reliability and external validity, the use of a screening instrument implies that findings might have been different if we used full diagnostic interviews. Related to this, the GAIN-SS may not be the best instrument to identify antisocial personality in college freshmen. The information gathered on the proportion of students with antisocial problems is more likely to be informative than conclusive, because the lack of any statistical power for this type of mental health problems. Fifth, although nonresponse bias might limit the generalizability of our findings, we showed high socio-demographic representativeness of our final sample and non-response propensity weighting was used to adjust to the extent possible for sample bias. Finally, our findings are based on data from one university, and may therefore not be generalized to other universities or to college students in general.

The need to understand patterns of mental health problems among college students is important. Around 1/3 of college freshmen endorses problems with mental health in the previous 12 months, and our data also suggest that mental health problems are directly associated with lower academic performance. Low academic performance, in turn, is associated with dropout in the short-term and loss of human capital for societies in the longer term ( Freudenberg & Ruglis, 2007 ). This means that emotional problems among college students are not just a theoretical, clinical, or educational problem but also a societal problem.

Our study suggests a potential role of the college environment as a target for treatment and prevention interventions. The best way to resolve that uncertainty definitively is to carry out experimental effectiveness trials that evaluate the effects of treating emotional problems on academic functioning. We plan to carry out such trials in subsequent phases of the WMH-ICS. Prior to implementing such interventions, though, it would be valuable to add longitudinal data and focus on potential level-2 explanatory variables (such as connectedness to college) that might provide insights that could be used either to refine or target preventive and clinical interventions.

Acknowledgments

The Leuven College Survey was carried out in conjunction with the World Health Organization World Mental Health (WMH) survey initiative and is a part of the World Mental Health International College Student project. The WMH survey is supported by the National Institute of Mental Health (NIMH; R01MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, GlaxoSmithKline, and Bristol-Myers Squibb. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centers for assistance with instrumentation, fieldwork, and consultation on data analysis. None of the funders had any role in the design, analysis, interpretation of results, or preparation of this paper. A complete list of all within-country and cross-national WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/ . In Belgium specifically, these activities were supported by the Belgian Fund for Scientific Research (11N0514N/11N0516N), the King Baudouin Foundation (2014-J2140150-102905), and Eli Lilly (IIT-H6U-BX-I002). We also thank the Student Health Centre and the Administration Offices of the KU Leuven for their support in the data collection.

Contributor Information

RONNY BRUFFAERTS, Research Group Psychiatry, Department of Neurosciences, KU Leuven University, Universitair Psychiatrisch Centrum – KU Leuven, Leuven, Belgium.

PHILIPPE MORTIER, Research Group Psychiatry, Department of Neurosciences, KU Leuven University, Leuven, Belgium.

GLENN KIEKENS, Research Group Psychiatry, Department of Neurosciences, KU Leuven University, Leuven, Belgium.

RANDY P AUERBACH, Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, MA, USA.

PIM CUIJPERS, Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam.

KOEN DEMYTTENAERE, Research Group Psychiatry, Department of Neurosciences, KU Leuven University, Universitair Psychiatrisch Centrum – KU Leuven, Leuven, Belgium.

JENNIFER G GREEN, School of Education, Boston University, Boston, MA, USA.

MATTHEW K NOCK, Department of Psychology, Harvard University, Cambridge, MA, USA.

RONALD C KESSLER, Harvard Medical School, Department of Health Care Policy, Harvard University, Boston, MA, USA.

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  • Published: 11 February 2024

Mental health disorders among medical students during the COVID-19 pandemic in the area with no mandatory lockdown: a multicenter survey in Tanzania

  • Deogratius Bintabara 1 , 2 ,
  • Joseph B. Singo 1 ,
  • Mathew Mvula 1 ,
  • Sichone Jofrey 1 &
  • Festo K. Shayo 2 , 3  

Scientific Reports volume  14 , Article number:  3451 ( 2024 ) Cite this article

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The COVID-19 pandemic brought about a major public health concern worldwide. It forced many countries to enforce lockdowns, leading to the closure of higher learning institutions. The abrupt shift in the lifestyle of students had a profound impact on their mental health. This study aims to determine the prevalence and factors associated with mental health conditions among university students in Tanzania during the COVID-19 pandemic. A sample of 425 students from six medical universities and colleges in Tanzania completed an online survey and was included in the analysis. The questionnaire consisted of validated Depression, Anxiety and Stress Scale—21 Items (DASS-21) questions (Cronbach’s alpha = 0.92) assessing the presence of mental health symptoms: depression, anxiety, and stress. Multivariable logistic regression models were fitted to explain the factors associated with mental health conditions. A P -value < 0.05 was considered statistically significant in all inferential analyses. The median age (interquartile range) of the participants was 24 (22–26). The prevalence of mental health conditions was 28.94%, 54.12%, and 15.06% for depression, anxiety, and stress, respectively, while the prevalence of having any mental health condition was 58.59%. In an adjusted regression model, being in the fourth and fifth years of study and living with a spouse were significantly associated with increased odds of depression: AOR = 5.99 (1.31–27.47), AOR = 5.52 (1.18–25.81), and AOR = 1.84 (1.08–3.15), respectively. Moreover, studying in private universities and living with a spouse were significantly associated with an increased likelihood of anxiety: AOR = 2.35 (1.72–2.76), and AOR = 2.32 (1.20–4.50), respectively. The likelihood of stress was only among participants studying in private universities; AOR = 2.90 (1.60–5.27). The study revealed alarmingly high rates of mental health conditions among medical students in Tanzania during the COVID-19 pandemic. The findings suggest the need for regular checkups for medical students regarding their mental health status. Additionally, it recommends that the government and other stakeholders establish mental health services within the universities for the effective prevention of the rising burden of mental health problems among universities in Tanzania and other countries with similar settings.

Introduction

The spread of the coronavirus disease 2019 (COVID-19) pandemic worldwide in early 2020 had an immense impact on all socioeconomic sectors, including education 1 . Following the declaration of the COVID-19 pandemic in March 2020 by the World Health Organization (WHO), world leaders were faced with the challenge of maintaining the normal operation of different sectors amid the pandemic 2 . The first approach used by both heavily and minimally affected countries was to impose a total or partial lockdown in order to minimize the spread of COVID-19 3 . Education institutions, including universities and colleges, were among the most affected as the students were caught by surprise with the sudden halt of classes and the requirement to stay at home for an unknown period of time 1 , 4 , 5 . However, in most developed countries, teaching and assessments were shifted online 1 . This was not the case in most developing countries due to the lack of developed and resilient digital technology at universities 4 , 5 . As a results, students in developing countries faced uncertainty regarding the continuation of their studies and when they would be able to resume their academic life 6 .

During the COVID-19 pandemic, the younger population including university students were clinically not regarded as a risky or vulnerable population, however, there was a great concern about their mental health as a result of the pandemic 7 , 8 , 9 , 10 . To date, in various parts of the world, especially in developed countries, studies have shown that there is an increase in mental health conditions, such as stress, anxiety, and depression 11 , 12 , 13 , 14 , 15 , 16 , 17 . Given the fact that mental health conditions among university students were also prevalent even before the COVID-19 pandemic 18 , 19 , 20 , the evidence shows that the pandemic has increased its prevalence and magnitude 21 , 22 .

Since the onset of the COVID-19 pandemic, the study of mental health among students has been given great attention in social science research. Various studies conducted around the globe have documented the detrimental effect of the pandemic on diverse aspects of mental well-being among students of from diverse groups. According to these studies, stress, anxiety, and depression were the main mental health conditions reported among students in higher learning institutions during the pandemic 23 . For instance, a cross-sectional study conducted in countries of Eastern Europe, the Middle East, and South America, involving 2349 university students revealed that the average prevalence of stress, depression, and generalized anxiety symptoms was 61.3%, 40.3%, and 30%, respectively 12 . In the United Kingdom, one study found that more than 50% of university students experienced high levels of anxiety and depression above the clinical cut-offs. This was due to low levels of resilience as a result of lockdown-related isolation and restrictions 13 . In China, a large cross-sectional survey during early 2020 among 821,218 college students reported that the prevalence rates of acute stress, depression, and anxiety symptoms were 34.0%, 21.1%, and 11.0, respectively 14 . Furthermore, a systematic review and meta-analysis of cross-sectional studies in China revealed that the pooled prevalence of anxiety symptoms was 25.0% (95% CI 21–29%, p < 0.001) among college students 15 . In Africa, there have been few studies that reported the mental health impact of to COVID-19 pandemic among university students 24 , 25 . In South Africa, the prevalence of anxiety and depression during lockdown was 45.6% and 35.0%, respectively 16 . In Uganda, one study reported a significantly higher prevalence of depression (80.7%), anxiety (98.4%), and stress (77.9%) as a result of the pandemic 17 .

The majority of the research on the mental health impact due to COVID-19 pandemic has been carried out in Europe, China, and North America compared to African countries including Tanzania 24 , 25 . Furthermore, few African countries including Tanzania imposed partial or total lockdowns in the first wave of the pandemic and lifted the lockdown in the subsequent waves 3 . This was because the federal government was unable to support and maintain the socioeconomic activities of the citizens due to poverty 3 . In this accord, together with other factors, the prevalence and magnitude of mental health among students of higher learning institutions due to the impact of the pandemic in African countries have been different from other countries across the world 25 , 26 .

Tanzania had a unique approach to the COVID-19 pandemic: a brief total lockdown in the first wave of the pandemic followed by unscientific denial of the pandemic and resuming of normal life 27 , 28 , 29 . The denial of the existence of the pandemic had a strong political influence and enforcement and hence it was very difficult to conduct social science studies on the impact of the COVID-19 pandemic 27 , 28 , 29 . It was then, in late 2021 when the government re-declared the existence of the pandemic and implemented the rollout of the COVID-19 vaccines 30 . Therefore, the impact of the COVID-19 pandemic on mental health among university students in Tanzania can have a different picture if compared to other countries context within Africa and across the world. To date, less is known about the impact of the COVID-19 pandemic on the mental health of the general population including students in higher learning institutions in Tanzania. Therefore, the current study sought to determine the prevalence and the factors associated with mental health conditions among university students in Tanzania during the COVID-19 pandemic.

Materials and methods

Study design.

A descriptive-analytical cross-sectional study (online survey) was conducted from January to March 2022.

Study participants and study setting

Medical students were recruited from six (three public and three private) medical universities in Tanzania. The public universities are (i) The University of Dodoma (UDOM), (ii) Muhimbili University of Health and Allied Sciences (MUHAS), (iii) University of Dar Es Salaam (UDSM-Mbeya) while the private universities are (iv) Catholic University of Health and Allied Sciences (CUHAS), (v) Hubert Kairuki Memorial University (HKMU) and (vi) St. Francis University College of Health and Allied Sciences (SFUCHAS). These medical universities are located in the five major cities in Tanzania which are Dar es Salaam, Dodoma, Mbeya, Morogoro, and Mwanza.

Sample size and sampling procedures

The sample size was determined by using a single population proportion by taking the prevalence of mental distress 45.9%; a study reported from University of Gondar, Northern Ethiopia 31 with; a 5% margin of error, 95% confidence, population size of 5010 and assuming 20% nonresponse rate. Finally, a sample size of 426 medical students were achieved.

Recruitment, enrolment, and data collection

In Tanzania, each medical university enroll about 135 to 200 student per year (an average of 167 students per year). As medical school in Tanzania taking 5 years, therefore a total average of 835 students per each university was estimated. For the six universities involved in this study brings a total population size of 5010 medical students. To determine the representative sample, authors considered sending email invitation to at least 1/10th of the medical students in Tanzania (0.1 × 5010 = 501). Therefore. email invitations with a link to a voluntary, de-identified survey were sent to 501 medical students. The information from all medical students remained anonymous to ensure the confidentiality and reliability of the data. Medical students who accepted the invitation to take part in the study clicked the link to complete the online questionnaire.

Data collection and tools

The online questionnaire consisted of three sections; university students’ demographic information, academic profile (type of university and students’ current academic year), and information regarding symptoms of mental health disorders during the COVID-19 pandemic., DASS 21 questions were used to assess for the presence of symptoms related to mental health disorders. The original DASS comprised 42 items on a four-point Likert scale to assess the negative emotional states of depression, anxiety, and stress, with 14 questions for each subscale. However, Henry and Crawford in 2005, developed and validated a shorter version of the DASS, known as DASS 21, which comprised 21 items, where each of its sub-scales of depression, anxiety, and stress contained seven items.

The online English version of self-administered questionnaires was used during data collection because the study population used the English language which is the media of communication for medical training in Tanzania. The use of online questionnaires helps simplify the process of data collection as it saves time, is cheap, more affordable, and easily accessible.

This questionnaire included two sections. The first part contained the personal characteristics of the study participants such as age, marital status, year of the study, name of university, etc. The second section included information on the short form of the Depression, Anxiety, and Stress scale (DASS-21) which consists of 21 items that have been divided into three subscales of anxiety, stress, and depression, each with seven items. The subscale for depression assessed inadequacy, dissatisfaction, hopelessness, devaluation, and inertia. The subscale for anxiety is used to assess acute responses to fear as well as physical and mental symptoms of anxiety, while the stress subscale evaluates tension, restlessness, irritability, and difficulty relaxing. Questions 3, 5, 10, 13, 16, 17, and 21 form the depression scale; questions 2, 4, 7, 9, 15, 19, and 20 form the anxiety scale while questions 1, 6, 8, 11, 12, 14, and 18 are covered in stress scale. The sum of the scores for each sub-seven scale’s items was used to assess the presence and absence of depression, anxiety, and stress. The presence of depression, anxiety, and stress were indicated by a sum of scores ≥ 10, ≥ 8, and ≥ 15 respectively. The details regarding DASS 21 cut-off points for conventional severity labels are indicated in Table 1 .

Validity and reliability of DASS 21

The reliability was tested by calculating the overall Cronbach’s alpha of the DASS 21 which was 0.92, indicating excellent internal consistency, while the Cronbach’s alpha of each sub-scale (Depression = 0.76, anxiety = 0.86, and stress = 0.87 (Supplementary Table 1 ).

Measurement of variables

Outcome variables.

Mental health disorders were considered if study participants were identified to have symptoms related to (i) Depression, (ii) Anxiety, and (iii) Stress based on DAS 21. Each of these three had a sub-seven scale containing seven factors rated from 0 to 3 on a Likert scale (0: “Did not apply to me at all,” 1: “Applied to me to some degree or some of the time,” 2: “Applied to me to a considerable degree or a good part of the time,” and 3: “Applied to me very much or most of the time”).

Medical students who fall under moderate, severe, or extremely severe groups in each sub-seven scale were considered as having depression, anxiety, or stress. In addition, medical students with any of these three were regarded as having mental health disorders.

Independent variables

In this study age was grouped into four categories which are “18–21,” “22–25,” “26–29” and “30 or more”. Year level of study was grouped into “first,” “second,” “third,” “fourth,” and “fifth”. Marital status was categorized as “single” and “married/cohabiting”. The university type was categorized as “public” for government-owned universities and “private” for private and faith-based universities. Clinical rotation “Yes” for medical students in the fourth or fifth year (attached in the hospital) and “No" for first, second, and third year who doing basic sciences. Lastly, vaccination status was coded as vaccinated for those who reported having been vaccinated with any type of vaccine against COVID-19.

Data processing and statistical analysis

Data was cleaned, edited, coded, and analyzed by using STATA version 17. During descriptive analysis, continuous variables were summarized using median and interquartile (IQR) while categorical variables were summarized using proportions, then presented in tables and graphs. Furthermore, a series of individual unadjusted logistics regression analyses were constructed across all three outcome variables; depression (model 1a), anxiety (model 2a), and stress (model 3a). Thereafter, all independent variables that showed an association with P < 0.2 from each unadjusted model were eligible for inclusion in their corresponding multivariable logistics regression analyses (model 1b, 2b, and 3b). All models were fitted using a stepwise (backward) elimination method and P < 0.05 was taken to indicate statistical significance. The odds ratio (OR) and 95% confidence interval (95% CI) for each variable were computed and used to measure the association with the outcome variables.

Ethical statement

The ethical approval to conduct this study was obtained from the Ethical Research Committee of the University of Dodoma (reference MA.84/261/02 dated 17th January 2022). All study participants signed written informed consent and agreed to the publishing of their anonymized data. This study did not expose study participants to unnecessary risks. Confidentiality was kept at all levels of the study; it was assured by excluding names and identifiers in the questionnaire and the data were used only for this study purpose. The study was conducted by the guidelines and regulations of the Declaration of Helsinki.

Respondents’ characteristics

As presented in Table 2 , out of 501 who were invited a total of 425 medical students responded, completed the online questionnaire and their information was included in the analysis. The median age (IQR) of the respondents was 24 (22–26) years. More than a quarter (27.3%) of the respondents were living with their spouse at the time of the pandemic. Nearly 80% of the respondents were from publicly owned universities. Furthermore, more than half of the respondents reported having been vaccinated against COVID-19.

Prevalence of mental health disorder

Table 3 shows the percentage distribution of depression, anxiety, stress, and any form of mental health disorders among medical students in Tanzania. Most of the respondents presented with normal ranges for depression (44%), anxiety (36%), and stress (77%) compared to other ranges. However, a significant proportion of 29%, 54% and 15% of respondents clinically presented with depression, anxiety, and stress respectively. Furthermore, nearly 60% of respondents clinically presented with any form of the above mental disorders.

Predictors of mental health disorders

Table 4 shows the results of a series of logistic regression models to examine the associations between selected independent variables and mental health disorders. For depression, model 1a and the corresponding model 1b that adjusted for all selected factors from model 1a, the odds of having depression were nearly six times higher for years four and five and two times higher for married/cohabiting respondents compared to their counterparts. For anxiety, model 2a and the corresponding model 2b that adjusted for all selected factors from model 2a, the odds of having anxiety were two times higher for married/cohabiting respondents and those from privately owned universities compared to their counterparts. For stress, model 3a and the corresponding model 3b that adjusted for all selected factors from model 3a, the odds of having stress were three times higher for respondents from privately owned universities compared to their counterparts. For having any mental disorders, model 4a and the corresponding model 4b that adjusted for all selected factors from model 4a, the odds for having any mental health disorders were almost three times higher for married/cohabiting respondents, two times higher for those from privately owned universities and those who are in clinical rotations compared to their counterparts.

In general, the academic life and job descriptions of medical students necessitate the utilization of patients who sometimes present with infectious conditions to comprehend diverse medical conditions and their appropriate management. This exacerbates their vulnerability to mental health disorders such as depression, anxiety, and stress. In addition, situations such as pandemic of highly infectious and fatal diseases such as COVID-19 may augment the detrimental effects experienced by medical students during their learning process 32 , 33 . Therefore, the current study aimed to assess the mental health status among medical students in Tanzania during the COVID-19 pandemic. The findings from the current study revealed high proportions (nearly 60%) of respondents had clinical symptoms related either to depression, anxiety, or stress. Furthermore, it revealed that being in the fourth/fifth year (clinical rotation), living with a partner, and studying in private universities were significant predictors of presenting symptoms related to mental health disorders.

The observed high proportion of symptoms related to mental health disorders among medical students in the current study is lower than that observed in other studies conducted in Egypt 32 and Sudan 34 . The observed disparities in findings between current and previous studies might be due to differences in the type and number of tools used to assess symptoms of mental health disorders. The current study assessed depression, anxiety, and stress using single tool namely DASS-21, while the study in Egypt utilized two tools DASS-21 and the Impact of Event Stress Scale-Revised (IES-R). Hence, the aforementioned approach increased the sensitivity to identify individuals with symptoms related to mental health disorders. Furthermore, it is plausible that the disparity in findings between these studies may be attributable to the absence of lockdown as a measure to prevent the spread of COVID-19 infection in Tanzania, as compared to Egypt, Sudan, and other African nations. This assertion is substantiated by the findings of previous studies that have demonstrated that the implementation of a lockdown strategy to fight against COVID-19 infection has been associated with reported instances of mental health disorders such as depression, anxiety, and stress 35 , 36 . Furthermore, it is possible that the disparities may be attributable to variations in the socio-political context. The medical students in Sudan were subjected to social instability, economic suffering, and changes in the political environment. All of these situations, together with the COVID-19 pandemic, resulted in frequent and prolonged closures of public institutions including universities and colleges. The high proportion of symptoms related to mental health disorders among medical students in these studies calls on local authorities and international agencies to design appropriate immediate interventions for curbing this burden.

The current study shows that of the three assessed mental health disorders, the majority of medical students had symptoms related to anxiety (54%). This pattern is similar to that reported in previous studies conducted in Palestine, although it reported a high proportion of anxiety (89%) 37 and Pakistani (88%) 38 . The patterns of anxiety being highly prevalent compared to depression and stress might be observed even in the general population. This has been demonstrated by previous systematic and meta-analyses, which observed similar patterns in the general population 39 . Furthermore, the current and previous studies utilized the psychometric scale DASS-21 to assess symptoms related to mental health disorders. As a results, they are more likely to capture a similar tendency irrespective of the settings or study populations. These findings suggest that anxiety is more prevalent than depression and stress not only among medical students or during COVID-19 but also among the general population and even before the pandemic.

The current study also assessed the factors associated with having symptoms of mental health disorders among medical students during the COVID-19 pandemic. The findings showed that being in clinical rotation during the pandemic was associated with having symptoms related to mental health disorders. In Tanzania, the majority of these students are in the fourth and fifth years of their studies, and as a result, they are six times more likely to experience depression compared to pre-clinical students (first to third year). Nonetheless, this observation contrasts with from the findings of previous study conducted among medical students in Peru, which revealed that pre-clinical students were more likely to experience symptoms related to mental health disorders 40 . This is supported by the findings from other study that suggested that mental health problems in medical students are more frequent during the early years of their schooling and decreases as their education progresses 41 . The observed differences may be due to differences in the medical school lifestyles between the study areas. In Tanzania, medical students are easily adapting the teaching styles during the pre-clinical that is not much different from high school education. However, previous studies have indicated that pre-clinical medical students may encounter certain challenges, possibly owing to relocation and a lack of medical school experience, which may have been negatively impacted by the COVID-19 pandemic, resulting in prominent symptoms related to mental health disorders even during the initial stage of their university schooling 40 , 42 .

Furthermore, the current study revealed that living with a partner (married/cohabiting) was significantly associated with having symptoms related to depression and anxiety. to the reason for this could be that being closer to someone such as a spouse increases the risk of COVID-19 transmission, as spouses spend more time together. This might have increased the fear of being contracted with this disease for medical students who were living with partners considering there was no lockdown in Tanzania during the pandemic. Therefore, were more likely to present with symptoms related to depression and anxiety during the COVID-19 pandemic compared to single individuals. This finding is supported by previous studies 43 , 44 which suggested that living with close family members such as a spouse increases the risk of depression and anxiety among healthcare workers. However, these findings contradict those reported from other previous studies which suggested that single individuals were more likely to present with symptoms related to depression and anxiety 45 , 46 .

Last but not least, our study has highlighted that being medical students in private universities increased the likelihood of having symptoms related to anxiety and stress. This might be due to fear of freezing or lockdown which could have resulted in repayment of tuition fees which are nearly four times higher in private universities compared to public ones. Several previous studies have reported similar findings 47 , 48 .

To the best of our knowledge, this is the first study in Tanzania to assess mental health status among medical students who were required to continue learning even in a terrifying situation such as the COVID-19 pandemic. The inclusion of both private and public universities across all zones of Tanzania ensures that the collected data is representative. This implies a high degree of generalizability and accuracy in characterizing the mental health status among medical students during the COVID-19 pandemic in Tanzania.

Nonetheless, the cross-sectional nature of the study presents a limitation, as it failed to document whether the exposures occurred prior to the outcome, which could have affected the observed association. Furthermore, the utilization of the validated DASS-21 tool based on general populations of the United Kingdom (UK) possible might have introduced measurement variance owing to the absence of cross-cultural equivalence of the items. Therefore, it is important to interpret the present findings with caution. In addition, there might be possibility of misclassification bias due to the use of an arbitrary approach to dichotomize the outcome variables. This might have either under or overestimated the prevalence of outcome variables and their associations with independent variables.

Conclusions

The findings from the current study indicate the need for regular checkups for medical students regarding their mental health status. Additionally, it recommends to the government and other stakeholders to establish mental health services within the universities to effectively mitigate the rising burden of mental health problems among universities in Tanzania and other countries with similar settings. Furthermore, medical students especially those in their clinical rotations (fourth and fifth year) should be given mental health education to expand their sense of self-esteem so that they can easily adapt in case they face difficult situations during their medical school programs such as the COVID-19 pandemic. This might be an effective way to manage symptoms related to mental health disorders among medical students in Tanzania.

Data availability

The dataset used for this study is restricted by the Ethical Research Committee of the University of Dodoma, as it contains sensitive patient information. However, it can be accessed upon reasonable request from the Directorate of Research Publication and Consultancy, University of Dodoma, P.O. Box 259, Dodoma, Tanzania ([email protected]).

Abbreviations

Coronavirus disease 2019

Catholic University of Health and Allied Sciences

Depression, anxiety, and stress scale

Hubert Kairuki Memorial University

Interquartile range

Muhimbili University of Health and Allied Sciences

St. Francis University College of Health and Allied Sciences

The University of Dodoma

University of Dar es Salaam

World Health Organization

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Acknowledgements

The authors wish to thank the study participants and the universities for agreeing and participate in this study.

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D.B., J.B.S., M.M., and S.J. conceptualized, designed the study, and collected data. D.B. and F.K.S. supervised the data collection and assisted J.B.S., M.M., and S.J. in performing data analysis. D.B., J.B.S. and F.K.S. interpreted data and drafted the manuscript. All authors critically reviewed the manuscript and approved the final version for submission.

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Bintabara, D., Singo, J.B., Mvula, M. et al. Mental health disorders among medical students during the COVID-19 pandemic in the area with no mandatory lockdown: a multicenter survey in Tanzania. Sci Rep 14 , 3451 (2024). https://doi.org/10.1038/s41598-024-53885-5

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Mental Health Research Topics

College and university students pursuing psychology studies must write research papers on mental health in their studies. It is not always an exciting moment for the students since getting quality mental health topics is tedious. However, this article presents expert ideas and writing tips for students in this field. Enjoy!

What Is Mental Health?

It is an integral component of health that deals with the feeling of well-being when one realizes his or her abilities, cope with the pressures of life, and productively work. Mental health also incorporates how humans interact with each other, emote, or think. It is a vital concern of any human life that cannot be neglected.

How To Write Mental Health Research Topics

One should approach the subject of mental health with utmost preciseness. If handled carelessly, cases such as depression, suicide or low self-esteem may occur. That is why students are advised to carefully choose mental health research paper topics for their paper with the mind reader. To get mental health topics for research paper, you can use the following sources:

  • The WHO website
  • Websites of renowned psychology clinics
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However, we have a list of writing ideas that you can use for your inspiration. Check them out!

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  • Is the psychological treatment of mental disorders working for all?
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  • The contribution of coronavirus pandemic to mental disorders
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  • Does religion play a part in propagating mental disorders?
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Mental Illness Research Questions

  • The role of antidepressant medicines in treating mental illnesses
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  • The role of nutrition and diet in causing mental illness
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  • Evaluate the effectiveness of mental health promotional activities in schools

Hot Mental Health Topics For Research

  • Do stress prevention programmes on TV work?
  • The role of anti-discrimination laws and campaigns in promoting mental health
  • Discuss specific psychological and personality factors leading to mental disorders
  • How can biological factors lead to mental problems?
  • How stressful work conditions can stir up mental health disorders
  • Is physical ill-health a pivotal contributor to mental disorders today?
  • Why sexual violence has led many to depression and suicide
  • The role of life experiences in mental illnesses: A case of trauma
  • How family history can lead to mental health problems
  • Can people with mental health problems recover entirely?
  • Why sleeping too much or minor can be an indicator of mental disorders.
  • Why do people with mental health problems pull away from others?
  • Discuss confusion as a sign of mental disorders

Research Topics For Mental Health Counseling

  • Counselling strategies that help victims cope with the stresses of life
  • Is getting professional counselling help becoming too expensive?
  • Mental health counselling for bipolar disorders
  • How psychological counselling affects victims of mental health disorders
  • What issues are students free to share with their guiding and counselling masters?
  • Why are relationship issues the most prevalent among teenagers?
  • Does counselling help in the case of obsessive-compulsive disorders?
  • Is counselling a cure to mental health problems?
  • Why talking therapies are the most effective in dealing with mental disorders
  • How does talking about your experiences help in dealing with the problem?
  • Why most victims approach their counsellors feeling apprehensive and nervous
  • How to make a patient feel comfortable during a counselling session
  • Why counsellors should not push patients to talk about stuff they aren’t ready to share

Mental Health Law Research Topics

  • Discuss the effectiveness of the Americans with Disabilities Act
  • Does the Capacity to Consent to Treatment law push patients to the wall?
  • Evaluate the effectiveness of mental health courts
  • Does forcible medication lead to severe mental health problems?
  • Discuss the institutionalization of mental health facilities
  • Analyze the Consent to Clinical Research using mentally ill patients
  • What rights do mentally sick patients have? Are they effective?
  • Critically analyze proxy decision making for mental disorders
  • Why some Psychiatric Advance directives are punitive
  • Discuss the therapeutic jurisprudence of mental disorders
  • How effective is legal guardianship in the case of mental disorders?
  • Discuss psychology laws & licensing boards in the United States
  • Evaluate state insanity defence laws

Controversial Research Paper Topics About Mental Health

  • Do mentally ill patients have a right to choose whether to go to psychiatric centres or not?
  • Should families take the elderly to mental health institutions?
  • Does the doctor have the right to end the life of a terminally ill mental patient?
  • The use of euthanasia among extreme cases of mental health
  • Are mental disorders a result of curses and witchcraft?
  • Do violent video games make children aggressive and uncontrollable?
  • Should mental institutions be located outside the cities?
  • How often should families visit their relatives who are mentally ill?
  • Why the government should fully support the mentally ill
  • Should mental health clinics use pictures of patients without their consent?
  • Should families pay for the care of mentally ill relatives?
  • Do mentally ill patients have the right to marry or get married?
  • Who determines when to send a patient to a mental health facility?

Mental Health Topics For Discussion

  • The role of drama and music in treating mental health problems
  • Explore new ways of coping with mental health problems in the 21 st century
  • How social media is contributing to various mental health problems
  • Does Yoga and meditation help to treat mental health complications?
  • Is the mental health curriculum for psychology students inclusive enough?
  • Why solving problems as a family can help alleviate mental health disorders
  • Why teachers can either maintain or disrupt the mental state of their students
  • Should patients with mental health issues learn to live with their problems?
  • Why socializing is difficult for patients with mental disorders
  • Are our online psychology clinics effective in handling mental health issues?
  • Discuss why people aged 18-25 are more prone to mental health problems
  • Analyze the growing trend of social stigma in the United States
  • Are all people with mental health disorders violent and dangerous?

Mental Health Of New Mothers Research Topics

  • The role of mental disorders in mother-infant bonding
  • How mental health issues could lead to delays in the emotional development of the infant
  • The impact of COVID-19 physical distancing measures on postpartum women
  • Why anxiety and depression are associated with preterm delivery
  • The role of husbands in attending to wives’ postpartum care needs
  • What is the effectiveness of screening for postpartum depression?
  • The role of resilience in dealing with mental issues after delivery
  • Why marginalized women are more prone to postpartum depression
  • Why failure to bond leads to mental disorders among new mothers
  • Discuss how low and middle-income countries contribute to perinatal depression
  • How to prevent the recurrence of postpartum mental disorders in future
  • The role of anti-depression drugs in dealing with depression among new mothers
  • A case study of the various healthcare interventions for perinatal anxiety and mood disorders

What Are The Hot Topics For Mental Health Research Today

  • Discuss why mental health problems may be a result of a character flaw
  • The impact of damaging stereotypes in mental health
  • Why are many people reluctant to speak about their mental health issues?
  • Why the society tends to judge people with mental issues
  • Does alcohol and wasting health help one deal with a mental problem?
  • Discuss the role of bullying in causing mental health disorders among students
  • Why open forums in school and communities can help in curbing mental disorders
  • How to build healthy relationships that can help in solving mental health issues
  • Discuss frustration and lack of understanding in relationships
  • The role of a stable and supportive family in preventing mental disorders
  • How parents can start mental health conversations with their children
  • Analyze the responsibilities of the National Institute for Health and Care Excellence (NICE)
  • The role of a positive mind in dealing with psychological problems

Good Research Topics On Refugees Mental Health

  • Why do refugees find themselves under high levels of stress?
  • Discuss the modalities of looking after the mental health of refugees
  • Evaluate the importance of a cultural framework in helping refugees with mental illnesses
  • How refugee camp administrators can help identify mental health disorders among refugees
  • Discuss the implications of dangerous traditional practices
  • The role of the UNHCR in assisting refugees with mental problems
  • Post-traumatic Stress Disorder among refugees
  • Dealing with hopelessness among refugees
  • The prevalence of traumatic experiences in refugee camps
  • Does cognitive-behavioural therapy work for refugees?
  • Discuss the role of policy planning in dealing with refugee-mental health problems
  • Are psychiatry and psychosomatic medicine effective in refugee camps?
  • Practical groups and in‐group therapeutic settings for refugee camps

Adolescent Mental Health Research Topics

  • Discuss why suicide is among the leading causes of death among adolescents
  • The role of acting-out behaviour or substance use in mental issues among adolescents
  • Mental effects of unsafe sexual behaviour among adolescents
  • Psychopharmacologic agents and menstrual dysfunction in adolescents
  • The role of confidentiality in preventive care visits
  • Mental health disorders and impairment among adolescents
  • Why adolescents not in school risk developing mental disorders
  • Does a clinical model work for adolescents with mental illnesses?
  • The role of self-worth and esteem in dealing with adolescent mental disorders
  • How to develop positive relationships with peers
  • Technology and mental ill-health among adolescents
  • How to deal with stigma among adolescents
  • Curriculum that supports young people to stay engaged and motivated

Research Topics For Mental Health And Government

  • Evaluate mental health leadership and governance in the United States
  • Advocacy and partnerships in dealing with mental health
  • Discuss mental health and socio-cultural perspective
  • Management and coordination of mental health policy frameworks
  • Roles and responsibilities of governments in dealing with mental health
  • Monitoring and evaluation of mental health policies
  • What is the essence of a mental health commission?
  • Benefits of mental well-being to the prosperity of a country
  • Necessary reforms to the mental health systems
  • Legal frameworks for dealing with substance use disorders
  • How mental health can impede the development of a country
  • The role of the government in dealing with decaying mental health institutions
  • Inadequate legislation in dealing with mental health problems

Abnormal Psychology Topics

  • What does it mean to display strange behaviour?
  • Role of mental health professionals in dealing with abnormal psychology
  • Discuss the concept of dysfunction in mental illness
  • How does deviance relate to mental illness?
  • Role of culture and social norms
  • The cost of treating abnormal psychology in the US
  • Using aversive treatment in abnormal psychology
  • Importance of psychological debriefing
  • Is addiction a mental disease?
  • Use of memory-dampening drugs
  • Coercive interrogations and psychology

Behavioural Health Issues In Mental Health

  • Detachment from reality
  • Inability to withstand daily problems
  • Conduct disorder among children
  • Role of therapy in behavioural disorders
  • Eating and drinking habits and mental health
  • Addictive behaviour patterns for teenagers in high school
  • Discuss mental implications of gambling and sex addiction
  • Impact of maladaptive behaviours on the society
  • Extreme mood changes
  • Confused thinking
  • Role of friends in behavioural complications
  • Spiritual leaders in helping deal with behavioural issues
  • Suicidal thoughts

Latest Psychology Research Topics

  • Discrimination and prejudice in a society
  • Impact of negative social cognition
  • Role of personal perceptions
  • How attitudes affect mental well-being
  • Effects of cults on cognitive behaviour
  • Marketing and psychology
  • How romance can distort normal cognitive functioning
  • Why people with pro-social behaviour may be less affected
  • Leadership and mental health
  • Discuss how to deal with anti-social personality disorders
  • Coping with phobias in school
  • The role of group therapy
  • Impact of dreams on one’s psychological behaviour

Professional Psychiatry Research Topics

  • The part of false memories
  • Media and stress disorders
  • Impact of gender roles
  • Role of parenting styles
  • Age and psychology
  • The biography of Harry Harlow
  • Career paths in psychology
  • Dissociative disorders
  • Dealing with paranoia
  • Delusions and their remedy
  • A distorted perception of reality
  • Rights of mental caregivers
  • Dealing with a loss
  • Handling a break-up

Consider using our expert research paper writing services for your mental health paper today. Satisfaction is guaranteed!

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Mental health and the pandemic: what u.s. surveys have found.

research questions about mental health and college students

The coronavirus pandemic has been associated with worsening mental health among people in the United States and around the world . In the U.S, the COVID-19 outbreak in early 2020 caused widespread lockdowns and disruptions in daily life while triggering a short but severe economic recession that resulted in widespread unemployment. Three years later, Americans have largely returned to normal activities, but challenges with mental health remain.

Here’s a look at what surveys by Pew Research Center and other organizations have found about Americans’ mental health during the pandemic. These findings reflect a snapshot in time, and it’s possible that attitudes and experiences may have changed since these surveys were fielded. It’s also important to note that concerns about mental health were common in the U.S. long before the arrival of COVID-19 .

Three years into the COVID-19 outbreak in the United States , Pew Research Center published this collection of survey findings about Americans’ challenges with mental health during the pandemic. All findings are previously published. Methodological information about each survey cited here, including the sample sizes and field dates, can be found by following the links in the text.

The research behind the first item in this analysis, examining Americans’ experiences with psychological distress, benefited from the advice and counsel of the COVID-19 and mental health measurement group at Johns Hopkins Bloomberg School of Public Health.

At least four-in-ten U.S. adults (41%) have experienced high levels of psychological distress at some point during the pandemic, according to four Pew Research Center surveys conducted between March 2020 and September 2022.

A bar chart showing that young adults are especially likely to have experienced high psychological distress since March 2020

Young adults are especially likely to have faced high levels of psychological distress since the COVID-19 outbreak began: 58% of Americans ages 18 to 29 fall into this category, based on their answers in at least one of these four surveys.

Women are much more likely than men to have experienced high psychological distress (48% vs. 32%), as are people in lower-income households (53%) when compared with those in middle-income (38%) or upper-income (30%) households.

In addition, roughly two-thirds (66%) of adults who have a disability or health condition that prevents them from participating fully in work, school, housework or other activities have experienced a high level of distress during the pandemic.

The Center measured Americans’ psychological distress by asking them a series of five questions on subjects including loneliness, anxiety and trouble sleeping in the past week. The questions are not a clinical measure, nor a diagnostic tool. Instead, they describe people’s emotional experiences during the week before being surveyed.

While these questions did not ask specifically about the pandemic, a sixth question did, inquiring whether respondents had “had physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart” when thinking about their experience with the coronavirus outbreak. In September 2022, the most recent time this question was asked, 14% of Americans said they’d experienced this at least some or a little of the time in the past seven days.

More than a third of high school students have reported mental health challenges during the pandemic. In a survey conducted by the Centers for Disease Control and Prevention from January to June 2021, 37% of students at public and private high schools said their mental health was not good most or all of the time during the pandemic. That included roughly half of girls (49%) and about a quarter of boys (24%).

In the same survey, an even larger share of high school students (44%) said that at some point during the previous 12 months, they had felt sad or hopeless almost every day for two or more weeks in a row – to the point where they had stopped doing some usual activities. Roughly six-in-ten high school girls (57%) said this, as did 31% of boys.

A bar chart showing that Among U.S. high schoolers in 2021, girls and LGB students were most likely to report feeling sad or hopeless in the past year

On both questions, high school students who identify as lesbian, gay, bisexual, other or questioning were far more likely than heterosexual students to report negative experiences related to their mental health.

A bar chart showing that Mental health tops the list of parental concerns, including kids being bullied, kidnapped or abducted, attacked and more

Mental health tops the list of worries that U.S. parents express about their kids’ well-being, according to a fall 2022 Pew Research Center survey of parents with children younger than 18. In that survey, four-in-ten U.S. parents said they’re extremely or very worried about their children struggling with anxiety or depression. That was greater than the share of parents who expressed high levels of concern over seven other dangers asked about.

While the fall 2022 survey was fielded amid the coronavirus outbreak, it did not ask about parental worries in the specific context of the pandemic. It’s also important to note that parental concerns about their kids struggling with anxiety and depression were common long before the pandemic, too . (Due to changes in question wording, the results from the fall 2022 survey of parents are not directly comparable with those from an earlier Center survey of parents, conducted in 2015.)

Among parents of teenagers, roughly three-in-ten (28%) are extremely or very worried that their teen’s use of social media could lead to problems with anxiety or depression, according to a spring 2022 survey of parents with children ages 13 to 17 . Parents of teen girls were more likely than parents of teen boys to be extremely or very worried on this front (32% vs. 24%). And Hispanic parents (37%) were more likely than those who are Black or White (26% each) to express a great deal of concern about this. (There were not enough Asian American parents in the sample to analyze separately. This survey also did not ask about parental concerns specifically in the context of the pandemic.)

A bar chart showing that on balance, K-12 parents say the first year of COVID had a negative impact on their kids’ education, emotional well-being

Looking back, many K-12 parents say the first year of the coronavirus pandemic had a negative effect on their children’s emotional health. In a fall 2022 survey of parents with K-12 children , 48% said the first year of the pandemic had a very or somewhat negative impact on their children’s emotional well-being, while 39% said it had neither a positive nor negative effect. A small share of parents (7%) said the first year of the pandemic had a very or somewhat positive effect in this regard.

White parents and those from upper-income households were especially likely to say the first year of the pandemic had a negative emotional impact on their K-12 children.

While around half of K-12 parents said the first year of the pandemic had a negative emotional impact on their kids, a larger share (61%) said it had a negative effect on their children’s education.

research questions about mental health and college students

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Most americans who go to religious services say they would trust their clergy’s advice on covid-19 vaccines, what we know about online learning and the homework gap amid the pandemic, unvaccinated americans are at higher risk from covid-19 but express less concern than vaccinated adults, americans who relied most on trump for covid-19 news among least likely to be vaccinated, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

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REPORT: Universities compounded the student mental health crisis during the pandemic

A new report from boston university researchers found that nearly 60% of college students qualify for at least one mental illness., university responses to the pandemic took a toll on student mental health..

In study from Boston University (BU), researchers found that mental health is worsening among college students in the United States. 

A majority of college students have at least one mental health problem including depression and anxiety, according to the findings.

“College is a key developmental time; the age of onset for lifetime mental health problems also directly coincides with traditional college years—75 percent of lifetime mental health problems will onset by age 24,” Sarah K. Lipson , BU School of Public Health assistant professor and co-author of the study, told BU research newspaper The Brink .

[RELATED: ‘The Trend is a lot of Mental Illness’]

Lipson is one of nine researchers that conducted the study. The researchers evaluated data from over 350,000 students from 373 college campuses who participated in the Healthy Minds Study between 2013 and 2021. 

The results found that over 60% of the respondents met the qualifying criteria for “one or more mental health problems, a nearly 50% increase from 2013.”

The study’s “[f]indings have important implications for campus mental health programming” and pinpoint an alarming problem for the student population. The researchers called for “best practices’’ to be used in “clinical settings and…system-level change” to “reduce mental health inequalities.”

Declining mental health among students has been compounded since the start of the COVID-19 pandemic. 

A 2020 study of students at Texas A&M University, for example, found that 48.1% of students “showed...moderate-to-severe level[s] of depression,” and “[a] majority of participants...indicated that their stress/anxiety levels had increased during the pandemic.”

[RELATED: OSU survey: More students are burned out, unhealthier]

Campus Reform spoke with students in the nation’s capitol in January of this year to gauge how they were coping with the effects of the pandemic. Several suggested lockdowns were contributing to depression and isolation.

Lockdown policies and heavy social restrictions also impacted students’ grades, a Missouri University of Science and Technology study found. According to its research, remote learning correlated with a decline in both students’ grades and mental health.

In 2021, a study by Pennsylvania State University reported that 72% of respondents said the pandemic had affected their mental health. 66% claimed the pandemic negatively impacted their academic performance.

As such, the U.S. Department of Education ordered colleges and universities to shift their unspent COVID-19 relief funding to increase mental health resources on campus. 

U.S Secretary of Education stated in a press release that colleges must provide resources for campus members to “heal from the grief, trauma, and anxiety they endured amid the pandemic.”

Campus Reform contacted Lipson and BU for comment. This article will be updated accordingly.

Follow @Alexaschwerha1 on Twitter.

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Alexa Schwerha

Alexa Schwerha is a Reporter at the Daily Caller News Foundation. Previously, she was Campus Reform's Assistant Editor. She graduated Kent State University with a degree in Communication Studies and Political Science.

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Key influences on university students’ physical activity: a systematic review using the Theoretical Domains Framework and the COM-B model of human behaviour

  • Catherine E. B. Brown 1 ,
  • Karyn Richardson 1 ,
  • Bengianni Halil-Pizzirani 1 ,
  • Lou Atkins 2 ,
  • Murat Yücel 3   na1 &
  • Rebecca A. Segrave 1   na1  

BMC Public Health volume  24 , Article number:  418 ( 2024 ) Cite this article

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Physical activity is important for all aspects of health, yet most university students are not active enough to reap these benefits. Understanding the factors that influence physical activity in the context of behaviour change theory is valuable to inform the development of effective evidence-based interventions to increase university students’ physical activity. The current systematic review a) identified barriers and facilitators to university students’ physical activity, b) mapped these factors to the Theoretical Domains Framework (TDF) and COM-B model, and c) ranked the relative importance of TDF domains.

Data synthesis included qualitative, quantitative, and mixed-methods research published between 01.01.2010—15.03.2023. Four databases (MEDLINE, PsycINFO, SPORTDiscus, and Scopus) were searched to identify publications on the barriers/facilitators to university students' physical activity. Data regarding study design and key findings (i.e., participant quotes, qualitative theme descriptions, and survey results) were extracted. Framework analysis was used to code barriers/facilitators to the TDF and COM-B model. Within each TDF domain, thematic analysis was used to group similar barriers/facilitators into descriptive theme labels. TDF domains were ranked by relative importance based on frequency, elaboration, and evidence of mixed barriers/facilitators.

Thirty-nine studies involving 17,771 participants met the inclusion criteria. Fifty-six barriers and facilitators mapping to twelve TDF domains and the COM-B model were identified as relevant to students’ physical activity. Three TDF domains, environmental context and resources (e.g., time constraints), social influences (e.g., exercising with others), and goals (e.g., prioritisation of physical activity) were judged to be of greatest relative importance (identified in > 50% of studies). TDF domains of lower relative importance were intentions, reinforcement, emotion, beliefs about consequences, knowledge, physical skills, beliefs about capabilities, cognitive and interpersonal skills, social/professional role and identity, and behavioural regulation. No barriers/facilitators relating to the TDF domains of memory, attention and decision process, or optimism were identified.

Conclusions

The current findings provide a foundation to enhance the development of theory and evidence informed interventions to support university students’ engagement in physical activity. Interventions that include a focus on the TDF domains 'environmental context and resources,' 'social influences,' and 'goals,' hold particular promise for promoting active student lifestyles.

Trial registration

Prospero ID—CRD42021242170.

Peer Review reports

Physical activity (PA) has a powerful positive impact on all aspects of health. Regular PA can prevent and treat noncommunicable diseases [ 1 , 2 ], build resilience against the development of mental illness [ 3 ], and attenuate cognitive decline [ 4 ]. Given these pervasive health benefits, increasing participation in PA is recognised as a global priority by international public health organisations. Indeed, a core aspect of the World Health Organisation’s action plan for a “healthier world” is to achieve a 15% reduction in the global prevalence of physical inactivity by 2030 [ 5 ].

Despite international efforts to reduce physical inactivity, university students frequently do not meet the recommended level of PA required to attain its health benefits. Approximately 40–50% of university students are physically inactive [ 6 ], many of whom attribute their inactivity to unique challenges associated with university life. For many students, the transition to university coincides with new academic, social, financial, and personal responsibilities [ 7 ], disrupting established routines and imposing additional barriers to the initiation or maintenance of healthy lifestyle habits such as regular PA [ 8 ]. Students’ PA tends to decline further during periods of high stress and academic pressure, such as exams and assignment deadlines [ 9 ]. This pattern has been observed across diverse university populations and cultural contexts [ 10 , 11 , 12 ], highlighting the importance of understanding the factors that contribute to physical inactivity among this cohort globally.

Understanding the barriers and facilitators to PA in the context of the university setting is an important step in developing effective, targeted interventions to promote active lifestyles among university students. A recently published systematic review found that lack of time, motivation, access to places to practice PA, and financial resources were primary barriers to PA for undergraduate university students [ 13 ]. A corresponding and complementary synthesis of the facilitators of PA, however, has not yet been conducted. Such a synthesis would be valuable in enabling a comprehensive understanding of the factors that influence students' PA and identifying facilitators that could be leveraged in intervention design. Furthermore, applying theoretical frameworks to understand barriers and facilitators to PA can guide the development of theory-informed, evidence-based interventions for university students that purposely and effectively target factors that influence their participation in PA.

The Theoretical Domains Framework (TDF) [ 14 , 15 , 16 ] and the COM-B model of behaviour [ 17 ] are two robust, gold-standard frameworks frequently used to examine the determinants of human behaviour. The TDF is an integrated framework of 14 theoretical domains (see Additional file 1 for domains, definitions, and constructs) which provide a comprehensive understanding of the key factors driving behaviour. The TDF was developed through expert consensus, synthesising 33 psychological theories (such as social cognitive theory [ 18 , 19 ] and the theory of planned behaviour [ 20 , 21 ] and 128 theoretical constructs (such as ‘competence’, ‘goal priority’, etc.) across disciplines identified as most relevant to the implementation of behaviour change interventions. Identifying the relative importance of theoretical domains allows intervention designers to triage which behaviour change strategies should be prioritised in intervention development [ 22 , 23 ]. The TDF has been widely applied by researchers and practitioners to systematically identify which theoretical domains are most relevant for understanding health behaviour change and policy implementation across a range of contexts, including education [ 24 ], healthcare [ 25 ], and workplace environments [ 26 ].

The 14 TDF domains map onto the COM-B model (Fig.  1 ), which is a broader framework for understanding behaviour and provides a direct link to intervention development frameworks. The COM-B model posits that no behaviour will occur without sufficient capability, opportunity, and motivation. Where any of these are lacking, they can be strategically targeted to support increased engagement in a desired behaviour, including participation in PA. Within the COM-B model, capability can be psychological (e.g., knowledge to engage in the necessary processes) or physical (e.g., physical skills); opportunity can be social (e.g., interpersonal influences) or physical (e.g., environmental resources); and motivation can be automatic (e.g., emotional reactions, habits) or reflective (e.g., intentions, beliefs). The COM-B model was developed through a process of theoretical analysis, empirical evidence, and expert consensus as a central part of a broader framework for developing behaviour change interventions known as the Behaviour Change Wheel (BCW) [ 17 ].

figure 1

The TDF domains linked to the COM-B model subcomponents

Note. Reproduced from Atkins, L., Francis, J., Islam, R., et al. (2017) A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science 12, 77.  https://doi.org/10.1186/s13012-017-0605-9

Using the TDF and COM-B model to understand the barriers and facilitators to university students’ participation in PA is valuable to inform the development of effective evidence-based interventions that are tailored to address the most influential determinants of behaviour change. As such, this systematic review aimed to: a) identify barriers and facilitators to university students’ participation in PA; b) map these factors using the TDF and COM-B model; and c) determine the relative importance of each TDF domain.

Study design

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 27 ]. The review protocol was registered on PROSPERO (CRD42021242170).

Search strategy

Search terms and parameters were developed in collaboration with a Monash University librarian with expertise in systematic review methodology. The following databases were searched on 15.03.2023 to identify relevant literature: MEDLINE, PsycINFO, and SPORTDiscus. Key articles were also selected for citation searching via Scopus. In consultation with a librarian, these databases were selected due to their unique scope, relevance, broad coverage, and utility. This process ensured the identified literature aligned with the aim and research topic of our systematic review. A 01.01.2010—15.03.2023 publication period was purposefully specified to account for the significant advancements in digital fitness support and tracking tools within the past decade [ 28 ], All available records were searched using the following combination of concepts in the title or abstract of the article: 1) barriers, facilitators, or intervention, Footnote 1 2) physical activity, 3) university, and 4) students. Each search concept was created by first developing a list of search terms relevant to each concept (e.g., for the ‘physical activity’ concept search terms included ‘physical exercise’, ‘physical fitness’, ‘sports’, ‘inactive’, ‘sedentary’, etc.). To create each concept, search terms were then searched collectively using the operator ‘OR’. Each search concept was then combined into the final search by using the operator ‘AND’. Search terms related to concepts 1, 2 and 3 included indexed terms unique and relevant to each database (i.e., Medical Subject Heading Terms for MEDLINE, Index Terms for PsycINFO, and Thesaurus terms for SPORTDiscus). The search was performed according to Boolean operators (e.g., AND, OR) (see Additional file 2 for the complete search syntax for MEDLINE). Unpublished studies were not sought.

Selection criteria

Articles were included if they: (a) reported university students’ self-reported barriers and/or facilitators to physical activity or exercise Footnote 2 ; (b) were written in English; and (c) were peer-reviewed journal articles. Articles encompassed studies directly investigating barriers and/or facilitators to students’ participation in PA and physical exercise intervention studies, where the latter reported participants’ self-reported barriers and/or facilitators to intervention adherence (see Table  1 below for full criteria).

Study selection

Identified articles were uploaded to EndNote X9 software [ 30 ]. A duplication detection tool was used to detect duplicates, which were then screened for accuracy by CB prior to removal. The remaining articles were uploaded to Covidence to enable blind screening and conflict resolution. Articles were screened at the title and abstract level against the inclusion and exclusion criteria by author CB, and 25% were independently screened by BP. The full text of studies meeting the inclusion criteria was then screened against the same criteria by CB, and 25% were again independently screened by BP. Differences were resolved by an independent author (KR). Inter-rater agreement in screening between CB and BP was high (0.96 for title and abstract screening, 0.83 for full-text screening). The decision to dual-screen 25% of studies was strategically chosen to balance thoroughness with efficiency, ensuring both the validity of the screening criteria and the reliability of the primary screener’s decisions. This approach aligns with the protocols used in similar systematic reviews in the field (e.g., [ 31 , 32 ]).

Data extraction

Key article characteristics were extracted, including the author/s, year of publication, country of origin, participant characteristics (e.g., enrolment status, exercise engagement [if reported]), sample size, research design, methods, and analytical approach. Barriers and facilitators were also extracted for each article and subsequently coded according to the 14 domains of the TDF and six subcomponents of the COM-B model. Quantitative data were only extracted if ≥ 50% of students endorsed a factor as a barrier or facilitator. This cut-off criterion was applied to maintain focus on the most common variables of influence and aligns with other reviews synthesising common barriers and facilitators to behaviour change (e.g., [ 26 , 33 ]).

A coding manual was developed to guide the process of mapping barriers and facilitators to the TDF and COM-B. All articles were independently coded by at least two authors (CB and BS, BP or KR). The first version of the manual was developed a priori, based on established guides for applying the TDF and COM-B model to investigate barriers and facilitators to behaviour [ 14 , 34 ], and updated as needed via regular consultation with a co-author and TDF/COM-B designer LA to ensure the accuracy of the data extraction. Barriers and facilitators were only coded to multiple TDF domains if deemed essential to accurately contextualise the core elements of the barrier/facilitator, and when the data in individual papers was described in sufficient detail to indicate that more than one domain was relevant. For example, if ‘lack of time due to competing priorities’ was reported as a barrier to PA, this encompassed both the ‘environmental context and resources’ (i.e., time) and ‘goals’ (i.e., competing priorities) domains of the TDF. Coding conflicts were resolved via discussion with LA.

Data analysis

The following three-step method was utilised to synthesise quantitative and qualitative data:

Framework analysis [ 35 ] was conducted to deductively code barriers and facilitators onto TDF domains and COM-B subcomponents. This involved identifying barriers and facilitators in each article, extracting and labelling them, and determining their relevance against the definitions of the TDF domains and COM-B subcomponents. This process involved creating tables to assist in the systematic categorisation of barriers and facilitators into relevant TDF domains and COM-B subcomponents.

Within each TDF domain, thematic analysis [ 36 ] was conducted to group similar barriers and facilitators together and inductively generate summary theme labels.

The relative importance of each TDF domain was calculated according to frequency (number of studies), elaboration (number of themes) and the identification of mixed barriers/facilitators regarding whether a theme was a barrier or facilitator within each domain (e.g., if some participants reported that receiving encouragement from their family to exercise was a facilitator, and others reported that lack of encouragement from their family to exercise was a barrier). The rank order was determined first by frequency, then elaboration, and finally by mixed barriers/facilitators.

This methodology follows previous studies using the TDF and COM-B to characterise barriers and facilitators to behaviour change and rank their relative importance [ 22 , 23 ].

Study characteristics

Following the removal of duplicates, 6,152 articles met the search criteria and were screened based on title and abstract. A total of 5,995 articles were excluded because they did not meet the inclusion criteria (see Fig.  2 below for the PRISMA flowchart). After the title and abstract screening, 157 full-text articles were retrieved and assessed for eligibility. One additional article was identified and included following citation searching of selected key articles. Thirty-nine articles met the inclusion criteria (see Additional file 3 for a summary of these studies). Eight studies were conducted in the USA, seven in Canada, three in Germany, two each in Qatar, Spain, the United Arab Emirates, and the United Kingdom, and one each in Australia, Belgium, Columbia, Egypt, Ireland, Japan, Kuwait, Malaysia, New Zealand, Saudi Arabia, South Africa, Sri Lanka, and Uganda.

figure 2

PRISMA flowchart illustrating the article selection process

Relative importance of TDF domains and COM-B components

Twelve of the 14 TDF domains and all six subcomponents of the COM-B model were identified as relevant to university students' PA. The rank order of relative importance of TDF domains and associated COM-B subcomponents are presented in Table  2 . The three most important domains were identified in at least 54% of studies.

Barriers and facilitators to student’s physical activity

Within the TDF domains, 56 total themes were identified, including 26 mixed barriers/facilitators, 18 facilitators and 12 barriers (Table  3 ). The barriers and facilitators identified within each TDF domain are summarised below (with associated COM-B subcomponent presented in parentheses), in order of relative importance:

1. Environmental context and resources (Physical Opportunity) ( n  = 90% studies)

The most frequent barrier to PA across all TDF domains was ‘lack of time’, most often in the context of study demands. Time constraints were exacerbated by long commutes to university, family responsibilities, involvement in co-curricular activities, and employment commitments. Students’ need for ‘easily accessible exercise options, facilities and equipment’ was a recurring theme. PA was deemed inaccessible if exercise facilities and other infrastructure to support PA, such as bike paths and running trails, were situated too far from the university campus or students’ residences, or if fitness classes were scheduled at inconvenient times. ‘Financial costs’ emerged as a theme. The costs associated with accessing exercise facilities, equipment and programs consistently deterred students from engaging in PA. The desire for ‘safe and enjoyable’, ‘weather appropriate’ environments for PA were frequently reported. Participating in outdoor PA in green spaces or near water increased enjoyment, provided the environment felt safe and weather conditions were suitable for PA. Factors related to students’ home, work, and university environment impacted their participation in ‘incidental PA’. Incidental PA was influenced by whether students engaged in domestic house chores, and manual work, and actively commuted to university and between classes on-campus. Students’ ‘access to a variety of physical activities’ and ‘information provision regarding on-campus exercise options’ impacted their PA. Students most often had access to a wide variety of physical activities, however, it could be difficult to access information about what types of activities were available on-campus and how to sign up to participate. The ‘lack of personalised physical activities to cater to individual fitness needs’ was a barrier, particularly for students with low levels of PA who required beginner-oriented programs. Another barrier was the ‘lack of university policy and promotion to encourage PA’, which led students to perceive that there was no obligation to participate in PA and that the university did not value it. ‘Health-concerning behaviours associated with university’, including poor diet, increased alcohol intake and sedentary behaviour, negatively impacted students’ PA. ‘Listening to music while exercising’ was a facilitator.

2. Social influences (Social Opportunity) ( n  = 72% studies)

Within social influences, ‘exercising with others’ emerged as the most frequent theme. Doing so increased students’ accountability, enjoyment and motivation, and helped them to overcome feelings of intimidation when exercising alone. Having a lack of friends to exercise with was a particular concern for students who were new to exercise or infrequently participated in PA. Receiving ‘encouragement from others to be physically active’, such as family members, friends, peers, and fitness instructors, shaped students’ values toward PA and enhanced their motivation and self-efficacy. Students’ family members, friends and teachers discouraged PA if it was not valued, or in favour of other priorities, such as academic commitments. Another recurrent theme was ‘competition or relative comparison to others’. While most students were motivated by competition, a minority felt demotivated if they compared themselves to others with higher PA standards, especially if they failed to achieve similar PA goals. Sociocultural norms influenced barriers/facilitators to PA across different cultures, and between various groups, such as international versus domestic students, and women versus men. Students from Japan and Hawaii viewed PA as an important part of their culture, in contrast to students from the Philippines who described the opposite. Participation in PA enabled international students to integrate with domestic students and learn about the local culture, however cultural segregation was a barrier to participation in university team sports. For female students from some middle-eastern countries, including Saudi Arabia, the UAE and Qatar, cultural norms made it impermissible for women to engage in PA, particularly compared to men. Religion also differentially impacted barriers/facilitators between women and men. Muslim women reported that Islamic practices, such as needing to engage in PA separately from men, be accompanied by a male family member while going outdoors, or dress modestly, posed additional barriers to PA. However, one study reported that Islamic teachings generally encouraged PA for both women and men by emphasising the importance of maintaining good health. Other gender-specific barriers were identified. Women often felt unwelcome or intimidated by men in exercise facilities, partly due to the perception that these facilities were tailored toward “masculine” sports and/or dominated by men. ‘Being stared at while engaging in PA’ was another barrier, impacting both women and students with a disability. A less common facilitator was the influence of both positive and negative ‘exercise role models’. For example, students practiced PA because they aspired to be like someone who was physically active, or because they did not want to be like someone who was not physically active.

3. Goals (Reflective Motivation) ( n  = 54%)

‘Prioritisation of PA compared to other activities’ was the most common theme within goals. Students frequently prioritised other activities, such as study, social activities, or work, over PA. However, those who played team sports or regularly practiced PA were more inclined to prioritise it for its recognised health benefits (i.e., stress management), and its role in enhancing confidence. Additional facilitators included ‘engaging in PA to achieve an external goal’, such as improving one’s appearance, and ‘setting specific PA-related goals’ as a means to enhance accountability.

4. Intentions (Reflective Motivation) ( n  = 44%)

Within intentions, ‘motivation to engage in PA’ was the most common theme. Students most often noted a lack of self-motivation for PA. Less frequent barriers included perceiving PA as an obligatory or necessary "chore", and ‘failing to follow through on intentions to engage in PA’. Conversely, ‘self-discipline to engage in PA’ emerged as a facilitator that assisted students in maintaining a regular PA routine.

5. Reinforcement (Automatic Motivation) ( n  = 38%)

The most frequent facilitator within reinforcement was ‘experiencing the positive effects of PA’ on their health and wellbeing. These included physical health benefits (i.e., maintaining fitness), psychological benefits (i.e., stress reduction), and cognitive health benefits (i.e., enhanced academic performance). Conversely, barriers arose from ‘experiencing discomfort during or after PA’ due to pain, muscle soreness or fatigue. ‘Past and current habits and routines’ was a theme. Students were more likely to participate in PA if they had established regular exercise routines, and that forming these habits at an early age made it easier to maintain them later in life. However, maintaining a regular PA routine was difficult in the context of inflexible university schedules. Students’ ‘sense of accomplishment in relation to PA’ was a theme. Students were less likely to feel a sense of accomplishment after participating in PA if it was not physically challenging. Consistent facilitators were ‘receiving positive feedback from others’ after engaging in PA, such as compliments, and ‘receiving incentives’, such as reducing the cost of gym memberships if students participated in more PA. ‘Experiencing a sense of achievement’ after reaching a PA-related goal or winning a sports match also served as a facilitator.

6. Emotion (Automatic Motivation) ( n  = 38%)

‘Enjoyment’ was the most frequently cited emotional theme. Most students reported that PA was fun and/or associated with positive feelings, however, a minority described PA as unenjoyable, boring, and repetitive. Students’ ‘poor mental health and negative affectivity’ (such as feeling sad, stressed or self-conscious, as well as fear of injury and pain), adversely impacted their motivation to be physically active.

7. Beliefs about consequences (Reflective Motivation) ( n  = 31%)

‘Beliefs about the physical health consequences of PA’ was the most recurrent barrier/facilitator. Most students understood that PA was essential for maintaining good health and preventing illness. However, some students who rarely or never engaged in PA believed they could delay pursuing an active lifestyle until they were older without compromising their health. Participating in PA to ‘maintain or improve one’s physical appearance’ acted as a facilitator. This motivation was most often cited in contexts such as increasing or decreasing weight, changing body shape or enhancing muscle tone. Beliefs about the positive environmental, occupational and psychological impacts of PA also served as facilitators. Students were motivated to participate in PA due to the environmental benefits of using active transport. They also acknowledged the importance of being physically fit for work and believed that being active was beneficial for mental health. ‘Receiving advice to participate in PA from a credible source’, such as a health professional, further facilitated students’ motivation to be active.

8. Knowledge (Psychological Capability) ( n  = 28%)

'Knowledge about the benefits of PA’, encompassing an understanding of the various types of benefits (i.e., physical, mental, or cognitive) and the biological mechanisms by which PA brings about these changes was identified as the most common knowledge theme. Being aware of these benefits positively influenced students’ motivation to be physically active. Conversely, students’ lack of knowledge about the gym environment and the programs available were barriers to PA. Regarding the gym environment, students’ ‘lack of knowledge about how to navigate through the gym, what exercises to do, and how to use exercise equipment’ amplified feelings of intimidation. Likewise, ‘lack of knowledge about the types of exercise programs and activities that were available on-campus, and how to sign up to participate’ were all barriers. A unique theme emerged concerning ‘knowledge about how to adapt physical activities for students with a disability’. Students with a disability described how fitness instructors often had a limited understanding of how to modify activities to enable them to participate. However, students with a disability were able to overcome this barrier if they possessed their own knowledge about how to tailor physical activities to meet their specific needs.

9. Physical skills (Physical Capability) ( n  = 21%)

The most prevalent theme within physical skills was ‘having the physical skills and fitness to participate in PA’. A lack of physical skills was most frequently a hindrance to PA. Additional obstacles to PA included being physically inhibited due to a ‘lack of energy’ or ‘physical injury’.

10. Beliefs about capabilities (Reflective Motivation) ( n  = 18%)

Within beliefs about capabilities, ‘self-efficacy to participate in PA’ was the most recurrent theme. Students who doubted their success in becoming physically active or who lacked confidence in their ability to initiate PA or participate in sport were less motivated to take part. A less frequent facilitator was students’ ‘self-affirmation to participate in PA’, often referring to positive cognitions about one’s own physical abilities.

11. Cognitive and interpersonal skills (Psychological Capability) ( n  = 15%)

‘Time-management’ was the only theme identified within cognitive and interpersonal skills. Students who struggled to manage their time effectively found it difficult to incorporate regular PA into their daily routine.

12. Social/professional role and identity (Reflective Motivation) ( n  = 8%)

The most frequent theme within social/professional role and identity was ‘perceiving PA as a part of one’s self-identity’. Students who engaged regularly in PA often considered it integral to their identity. Conversely, students who perceived they did not align with the aesthetic and superficial stereotypes commonly associated with the fitness industry felt less motivated to be active. A specific facilitator emerged among physiotherapy students, who were motivated to be active due to the emphasis on PA within their profession.

13. Behavioural regulation (Psychological Capability) ( n  = 3%)

Within the domain of behavioural regulation, two facilitators were equally prevalent: ‘self-monitoring of PA’ and ‘feedback on progress towards a PA-related goal’. By keeping track of their step count and receiving feedback on walking goals, students were motivated to exceed the average number of daily steps or achieve their personal PA targets.

14. Memory, attention, and decision process (Psychological Capability); Optimism (Reflective Motivation) ( n  = 0%)

No barriers or facilitators relating to the TDF domains of memory, attention and decision process, or optimism were identified.

This systematic review used the TDF and COM-B model to identify barriers and facilitators to PA among university students and rank the relative importance of each TDF domain. It is the first review to apply these frameworks in the context of increasing university students’ participation in PA. Twelve TDF domains across all six sub-components of the COM-B model were identified. The three most important TDF domains were ‘environmental context and resources’, ‘social influences’, and ‘goals’. The most common barriers and facilitators were ‘lack of time’, ‘easily accessible exercise options, facilities and equipment’, ‘exercising with others’, and ‘prioritisation of PA compared to other activities’.

The most common barrier to PA was perceived lack of time. This is consistent with previous findings among university students [ 13 , 74 ] and across other populations [ 24 ], For students, lack of time was frequently attributed to a combination of competing priorities and underdeveloped time management skills. Students predominantly prioritised study over PA, as performing well at university is a valued goal and there is a common perception that spending time exercising (at the expense of study) will impede their academic success [ 53 , 58 ]. Evidence from cognitive neuroscience research, however, suggests that this is a mistaken belief. In addition to its broad physical and mental health benefits, a growing body of evidence demonstrates regular PA can change the structure and function of the brain.

These changes can, in turn, enhance numerous aspects of cognition, including memory, attention, and processing speed [ 4 , 75 , 76 , 77 ], and buffer the negative impact of stress on cognition [ 78 ], all of which are important for academic success. However, students are typically unaware of the brain and cognitive health benefits of PA and its potential to improve academic performance, particularly compared to the physical health benefits [ 37 , 40 , 64 ]. Interventions that position participating in PA as a conduit for helping, rather than hindering, academic goals could increase the relative importance of PA to students and therefore increase their motivation to regularly engage in it. The impact that interventions of this nature have on students’ PA is yet to be empirically assessed.

Ineffective time management also contributed to students’ perceived lack of time for PA. Students reported tendencies to procrastinate in the face of overwhelming academic workloads, which left limited time for PA [ 53 ]. Additionally, students lacked an understanding of how to organise time for PA around academic timetables, social and family responsibilities, co-curricular activities, and employment commitments [ 9 , 44 , 53 , 59 ]. To address these challenges, efforts to develop students’ time management skills will be useful for enabling students to regularly participate in PA. Goal-setting and action planning are two specific examples of such skills that can be integrated into interventions to help students initiate and maintain a PA routine [ 79 ]. For example, goal-setting could involve setting a daily PA goal, and action planning could involve planning to engage in a particular PA at a particular time on certain days.

While the most common determinants of university students’ PA levels were not influenced by specific demographic characteristics, several barriers disproportionately impacted women and students with a disability. These findings are in keeping with evidence that PA is lower among these equity-deserving groups compared with the general population [ 68 , 80 ]. For women, particularly those from Middle Eastern cultures, restrictions were often tied to religious practices and sociocultural norms that limited their opportunities to engage in PA [ 45 , 48 , 66 ]. Additionally, a substantial number of women felt intimidated or self-conscious when exercising in front of others, especially men [ 48 , 49 ]. They also felt that exercise facilities were more often tailored towards the needs of men, leading to a perception that they were unwelcome in exercise communities [ 45 , 48 ]. Consequently, women expressed a desire for women-only spaces to exercise to help them overcome these gender-specific barriers to PA [ 47 , 48 , 66 ]. Furthermore, students with a disability faced physical accessibility barriers and perceived stigmatisation that deterred them from PA [ 50 , 52 ]. The lack of accessible exercise facilities and suitable equipment, programs, and education regarding how to adapt physical activities to accommodate their needs limited their opportunity and ability to participate [ 52 ]. Moreover, students with a disability felt stigmatised by others for not fitting into public perceptions of ‘normality’ or the aesthetic values and beauty standards often portrayed by the fitness industry [ 50 ]. These barriers for both equity-deserving groups of students are deeply rooted in historical stereotypes that have traditionally excluded women and people with a disability from engaging in various types of PA [ 81 , 82 ]. Despite growing awareness of these issues, PA inequalities persist due to narrow sociocultural norms, and a lack of diverse representation and inclusion in the fitness industry and associated marketing campaigns [ 83 , 84 ]. A concerted effort to address PA inequalities across the university sector and fitness industry more broadly is needed. One approach for achieving this is to develop interventions that are tailored to the unique needs of equity-deserving groups, emphasise inclusivity, diversity, and empowerment, and feature women and people with a disability being active.

The “This Girl Can” [ 85 ] and “Everyone Can” [ 86 ] multimedia campaigns are two examples of health behaviour interventions that were co-developed with key stakeholders (i.e., women and people with a disability, respectively) to tackle PA inequalities. The “This Girl Can” campaign has reached over 3 million women and girls, projecting inclusive and positive messages that aim to empower them to be physically active. Following the widespread reach of the “This Girl Can” campaign, the “Everybody Can” campaign was launched to support the inclusion of people with a disability in the PA sector. Although not tailored for university students, these campaigns provide a useful example for developing interventions that are specifically designed to address key barriers preventing women and people with a disability from participating in PA.

Across the tertiary education sector globally, efforts to elevate opportunities and motivation to include PA as a core part of the student experience will be beneficial for promoting students’ PA at scale. Two intervention approaches that can be implemented to facilitate such an endeavour are environmental restructuring and enablement [ 17 ]. These intervention approaches should involve the provision of accessible low-cost exercise options, facilities, and programs, integrating PA into the university curriculum, and mobilising student and staff leadership to encourage students’ participation in PA [ 9 ]. Although there is evidence that these approaches can be effective in promoting sustained PA throughout students’ university years and beyond [ 87 ], implementation measures such as these are complex. Implementation requires aligning student activity levels with broader university goals and is further complicated by having to compete with other funding priorities and resource allocations. Notably, due to the negative impact of the COVID-19 pandemic on university students’ physical and mental health [ 88 , 89 ], the post-pandemic era has seen many universities prioritise enhancing student health and wellbeing alongside more traditional strategic goals like academic excellence and workforce readiness. Despite the potential for PA to be used as a vehicle for supporting these strategic goals there is an absence of data on the extent to which this is occurring in the university sector. The limited evidence in this area suggests that some universities have made efforts to support students’ mental health by referring students who access on-campus counselling services to PA programs [ 90 ]. However, the uptake and efficacy of such initiatives is rarely assessed, and even less is known about whether PA is being used to support other strategic goals, such as academic success. Therefore, while the potential is there for the university sector to use PA to support students’ mental health and academic performance, to be successful this needs to become a strategic university priority. Given that these strategic priorities are set at the senior leadership level, engaging senior university staff in intervention design and promotion efforts is important to enhance the value of PA in the tertiary education sector.

Implications for intervention development

The current findings provide a high-level synthesis of the most common barriers and facilitators to university students’ physical activity. These findings can be leveraged with behavioural intervention development tools and frameworks (e.g., the BCW [ 17 ], Obesity-Related Behavioural Intervention Trials model [ 91 ], Intervention Mapping [ 92 ], and the Medical Research Council guidelines for developing complex interventions [ 93 , 94 ]) to develop evidence-based interventions and policies to promote PA. Given that the TDF and COM-B model are directly linked to the BCW framework, applying this process may be particularly useful to translate the current findings into an intervention.

Additionally, current findings can be triangulated with data directly collected from key stakeholders to assist in the development of context-specific interventions. Best practice principles for developing behavioural interventions recommend this approach to ensure a deep understanding of the barriers and facilitators that need to be targeted to increase the likelihood of behaviour change [ 17 ]. Consulting stakeholders directly (i.e., university students and staff) to understand their perspectives on the barriers and facilitators to students’ PA also enables an intervention to be appropriately tailored to the target population’s needs and implementation setting. Studies continue to demonstrate the effectiveness of this approach, especially when framed within the context of frameworks directly linked to intervention development frameworks, such as the TDF [ 95 ].

Strengths and limitations

The findings of this review should be considered with respect to its methodological strengths and limitations. The credibility and reliability of the research findings are supported by a systematic approach to screening and analysing the empirical data, along with the use of gold-standard behavioural science frameworks to classify barriers and facilitators to PA. The inclusion of qualitative, quantitative, and mixed-methods studies of both barriers and facilitators to students’ PA allowed for a comprehensive understanding of the factors that influence students’ PA that have not previously been captured.

While the present review elucidates students’ own perspectives of the factors that influence their activity levels, other stakeholders such as university staff, will also influence the adoption, operationalisation, and scale of PA interventions in a university setting. It will be important for future research to explore factors that influence university decision-makers in these roles to inform large-scale strategies for promoting students' PA.

Additionally, only one study included in the review used the TDF to explore barriers and facilitators to PA [ 47 ]. Therefore, it is possible that certain TDF domains may not have been identified because students were not asked relevant questions to assess the influence of those domains on their PA. For instance, domains such as ‘memory, attention, and decision process’, and ‘optimism’ are likely to play a role in understanding the barriers and facilitators to PA despite not being identified in this review.

Moreover, quantitative data were only extracted if ≥ 50% of students endorsed the factor as a barrier or facilitator to PA. This threshold was purposefully applied to maintain a focus on the TDF domains most universally relevant to the broad student population in the context of understanding their barriers and facilitators to PA. It is possible that less frequently reported barriers and facilitators, which may not be as prominently featured in the results, could be relevant to specific groups of students, such as those identified as equity-deserving.

Lastly, a quality appraisal of the included studies was not undertaken. This decision was informed by the aim of the review, which was to describe and synthesise the literature to subsequently map data to the TDF and COM-B rather than assess the effectiveness of interventions or determine the strength of evidence. However, this decision, combined with dual screening 25% of the studies and excluding unpublished studies and grey literature, may introduce sources of error and bias, which should be considered when interpreting the results presented.

PA is an effective, scalable, and empowering means of enhancing physical, mental, and cognitive health. This approach could help students reach their academic potential and cope with the many stressors that accompany student life, in addition to setting a strong foundation for healthy exercise habits for a lifetime. As such, understanding the barriers and facilitators to an active student lifestyle is beneficial. This systematic review applied the TDF and COM-B model to identify and map students’ barriers and facilitators to PA and, in doing so, provides a pragmatic, theory-informed, and evidence-based foundation for designing future context-specific PA interventions. The findings from this review highlight the importance of developing PA interventions that focus on the TDF domains ‘environmental context and resources’, ‘social influences’, and ‘goals’, for which intervention approaches could involve environmental restructuring, education, and enablement. If successful, such strategies could make a significant contribution to improving the overall health and academic performance of university students.

Availability of data and materials

The review protocol is available on PROSPERO. The datasets used and/or analysed during the current study and materials used are available from the corresponding author on reasonable request.

The term ‘intervention’ was included to identify student barriers and facilitators to engaging in implemented physical activity interventions.

Physical exercise is defined as “a subset of physical activity that is planned, structured, and repetitive”, and purposefully focused on the improvement or maintenance of physical fitness, whereas physical activity is defined as “any bodily movement produced by skeletal muscles that results in energy expenditure” [ 96 ].

Abbreviations

Behaviour Change Wheel

Capability, Opportunity, Model-Behaviour

  • Physical activity

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

International Prospective Register of Systematic Reviews

Theoretical Domains Framework

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Acknowledgements

The authors extend their gratitude to the funder, the nib foundation, for its financial support, which was instrumental in facilitating this research. We are also indebted to the Wilson Foundation and the David Winston Turner Endowment Fund for their generous philanthropic contributions, which have supported the BrainPark research team and facility where this research was conducted. Special thanks are owed to the library staff at Monash University for their expertise in conducting systematic reviews, which helped inform the selection of databases and the development of the search strategy.

This research was supported by nib foundation. The nib foundation had no role in the design of the study and collection, analysis, and interpretation of data, and in writing the manuscript. The views expressed are those of the authors and not necessarily those of the nib foundation.

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Catherine E. B. Brown, Karyn Richardson, Bengianni Halil-Pizzirani & Rebecca A. Segrave

Centre for Behaviour Change, University College London, London, UK

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CB, KR, BP, LA and RS developed the review protocol. CB and BP conducted the search and screened articles, and KR resolved conflicts. CB, KR, BP, LA and RS extracted the barriers and facilitators, mapped barriers and facilitators to the TDF and COM-B model, and interpreted the results. CB drafted the paper. All authors read, revised, and approved the submitted version.

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Theoretical Domains Framework domains, definitions, and constructs.

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Brown, C.E.B., Richardson, K., Halil-Pizzirani, B. et al. Key influences on university students’ physical activity: a systematic review using the Theoretical Domains Framework and the COM-B model of human behaviour. BMC Public Health 24 , 418 (2024). https://doi.org/10.1186/s12889-023-17621-4

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research questions about mental health and college students

ORIGINAL RESEARCH article

A participatory study of college students’ mental health during the first year of the covid-19 pandemic.

Chulwoo Park&#x;

  • Department of Public Health and Recreation, San José State University, San José, CA, United States

Introduction: The COVID-19 pandemic has negatively impacted college students’ mental health and wellbeing. Even before the pandemic, young adults reported high mental health morbidity. During the pandemic, young adult college students faced unprecedented challenges, including campus closure and a pivot to fully online education.

Methods: This study employed a novel participatory approach to a Course-based Undergraduate Research Experience (CURE) in an introductory epidemiology course to examine factors students considered important regarding their experience during the pandemic. Two groups of undergraduate students enrolled in this course (one in Fall 2020 and another in Spring 2021) and participated in the CURE. A sub-group of these students continued after the class and are authors of this article. Through repeated cross-sectional surveys of college students’ peer groups in northern California in October 2020 and March 2021, this student/faculty collaborative research team evaluated depression, anxiety, suicidal ideation and several other topics related to mental health among the students’ young adult community.

Results: There was a high prevalence of anxiety (38.07% in October 2020 and 40.65% in March 2021), depression (29.85% in October 2020 and 27.57% in March 2021), and suicidal ideation (15.94% in October 2020 and 16.04% in March 2021). In addition, we identified the significant burden of loneliness for college students, with 58.06% of students reporting feeling lonely at least several days in the past two weeks. Strategies that students used to cope with the pandemic included watching shows, listening to music, or playing video games (69.01%), sleeping (56.70%), taking breaks (51.65%), and connecting with friends (52.31%) or family (51.21%). Many reported distressing household experiences: more than a third reporting loss of a job or income (34.27%) in the first year of the pandemic. We explain the participatory research approach and share empirical results of these studies.

Discussion: We found this participatory CURE approach led to novel, experience-based research questions; increased student motivation; real-world benefits such as combatting imposter syndrome and supporting graduate school intentions; integration of teaching, research, and service; and development of stronger student-faculty relationships. We close with recommendations to support student wellbeing and promote student engagement in research.

Introduction

The global COVID-19 pandemic has been devastating for many communities. In the United States, while young adults have had lower mortality rates from COVID-19 than older adults, this age group has experienced massive disruptions to their education, living situations, and livelihoods. Throughout the pandemic, young adults have consistently reported the highest levels of depression and anxiety of any age group ( 1 ) and experienced the highest unemployment rates of any age group ( 2 ).

Young adult college students have faced unprecedented challenges, including campus closure and a pivot to fully online education. National surveys of college students from March through May 2020, at the start of the pandemic, showed that two-thirds of college students were very or extremely concerned about how long the pandemic would last, and a similar proportion experienced an increase in financial stress ( 3 ). In surveys of California college students, a majority reported that they changed their living situation, nearly half lost work, and 40% took on household caregiving responsibilities ( 4 ). Over 70% of California college students reported missing class because of personal stress ( 4 ).

According to a large, multi-campus study in the summer of 2020, first generation college students were more likely than continuing generation college students to experience financial hardships, food and housing insecurity, encounter technological barriers to online education, and to experience adverse mental health outcomes ( 5 ). Black, Latinx, and low-income students were also more likely to experience financial hardships, increased caregiving responsibilities, and have inadequate access to technology to support online learning ( 4 ).

While these burdens have been well-documented in a series of reports and articles, little research has been conducted by and for diverse college students, centering students’ concerns about their experiences during the pandemic. For example, although previous research measured mental health among diverse college students in Israel ( 6 ) and the United States ( 7 ), these studies did not emphasize students engagement in the study design and data collection, or provide an opportunity for students to draw on their experiential knowledge of mental health to generate research questions. Such participatory research has the potential to identify new aspects of wellbeing that have not been previously described, through engaging students to reflect on their experiences in a way that supports meaning-making and purposeful action for improving student wellbeing. The present study aims to fill this gap by describing a Course-based Undergraduate Research Experience (CURE) to conduct participatory research on college student wellbeing during the COVID-19 pandemic at a large, diverse public university in northern California.

This article employs a novel structure: while presenting findings from an empirical epidemiologic study, it documents the participatory methods and presents qualitative evaluative comments from members of the collaborative research team. In addition, using a participatory CURE approach, we illustrate the impacts of conducting this epidemiology research. We share the empirical results of this study which, though limited in their generalizability, produce valid estimates of the burden of various mental health challenges in the peer group of the student research partners. We argue that participatory CURE approaches are an under-utilized methodology in public health and social science disciplines. We encourage more wide-spread adoption focusing on adolescent mental health in school and university settings.

Participatory course-based undergraduate research experience

CUREs are a form of experiential learning where students gain hands-on research experience within a credit-bearing course. CUREs share five key attributes: they (1) engage students in scientific research, (2) emphasize collaboration, (3) produce new knowledge, (4) focus on broadly relevant topics, and (5) are scaffolded or iterative, allowing for multiple learning opportunities ( 8 – 10 ). While originally promoted in STEM education as a way to scale student involvement in research ( 11 , 12 ), CUREs have been increasingly recognized as high impact practices for diverse college students to increase retention, promote a sense of belonging in higher education, and enhance diversity in the academic pipeline ( 9 ). Empirical research is scant in social sciences and public health on the use of CUREs ( 10 ).

Because of their emphasis on engagement, focus on topics relevant to students, orientation toward students as collaborators, and scaffolded learning opportunities, CUREs are a natural fit for participatory research methodologies. Participatory methodologies have been employed in fields as diverse as education, international development, and public health for the past five decades. While the specific methods used in these fields vary, they share a common approach, centering partnership, mutual learning, application/action, and real world impact ( 13 ). Within the field of public health, the most commonly used participatory research approaches are Community-Based Participatory Research (CBPR), Participatory Action Research (PAR), and Youth Participatory Action Research (YPAR) ( 14 ).

Participatory research methodologies are collaborative and seek to equitably involve academic and non-academic research partners through all phases of a study, from identification of a problem to research design and implementation to analyzing and disseminating the study results. Many participatory studies aim to improve health and health equity ( 15 ). Participatory methodologies build on the resources and strengths of community members or participants, valuing lived experience in addition to other forms of knowledge. These methodologies often result in context-specific research and action projects. In addition, participatory methods often use multiple strategies for dissemination of knowledge produced through a study, including forms that are most accessible to community members as well as more traditional academic products or policy/advocacy reports ( 16 ).

The present study employed a participatory approach to a CURE study within a public health course. We considered college students as the participants or community of interest, situating the faculty member teaching the course as the “academic partner,” recognizing that, in reality, often participatory research partners occupy multiple, complex positions within a study ( 17 ). The CURE design encouraged student co-researchers to draw on the knowledge gained not only in their academic studies, but also from their lived experiences as members of the affected population. In addition, this participatory CURE provided an opportunity for continued involvement in this study after the course had concluded. Indeed, student co-researchers participated in all aspects of the study, including the writing of this manuscript. While all authors participated in the research and writing, we chose to italicize reflections of individual research team members. While there is rich history to this multi-voiced approach in qualitative research ( 18 ), this approach is less common in quantitative public health research, and we are not aware of any CURE studies that incorporate student voice as explicitly. We hope that this innovative approach deepens the reader’s experience in learning about this participatory course-based study and provides context to the experience of college students during the COVID-19 pandemic.

Materials and methods

Study design.

The study took place at a large, diverse, urban public university in northern California. Two linked cross-sectional studies were designed, implemented, and analyzed by college students as part of a CURE embedded in a required junior-level public health introductory epidemiology course. The course instructor (last author) encouraged students to think about their own lives, what they were learning about the pandemic through their classes, news and social media, and the experiences and concerns of their family and friends in order to identify topics that they wanted to explore through a survey.

Working in small groups, students discussed what topics they were generally interested in and then conducted literature reviews to identify what was already known on the topics they selected. With guidance from the instructor, students then developed survey questions on their topic, which were integrated into a single survey assessing their peers’ experiences during the COVID-19 pandemic. When topics examined constructs where standardized scales were available (e.g., depression), the instructor encouraged students to use these standard scales; when topics were novel or no prior scale could be found, original survey questions were developed based on student experiences and perspectives.

The present article describes the work of two different classes, with a focus on results related broadly to mental health. In the fall semester, the class had 25 students working in five teams; in the spring semester, the class had 26 students working in six teams. Each class produced one survey, which pulled together the research questions developed by each of the student teams: one survey conducted during fall semester of 2020 (“October 2020 survey”) and one survey conducted during spring semester of 2021 (“March 2021 survey”). Topics fell broadly under the heading of wellness during COVID-19. Both surveys assessed demographics and mental health. In this pre-vaccine era, students in the fall semester also examined attitudes toward COVID-19 vaccination, employment characteristics, access to personal protective equipment and social distancing at work, and coping strategies that participants were using to deal with the pandemic. In the spring, students added questions focusing on different aspects of mental health, food insecurity, adverse household experiences during the pandemic, as well as use of legal and illicit drugs. The rest of this article focuses on the survey constructs related to mental health. Both study protocols were written by students, edited by the faculty member, and approved by the University’s Institutional Review Board.

The student-faculty collaboration continued after the class ended with five undergraduate students (authors 3–7) joining the instructor, a colleague (first author), and a graduate student (second author) in further data analysis and dissemination. These continuing students led a process where they identified which findings they thought were important to share with the college community and their peers and disseminated these findings to university stakeholders through on-campus presentations, email to the director of the campus health center and other campus leaders, and through a blog. 1 The study team also collaborated on developing conference abstracts, which they presented in November 2021 at the American Public Health Association annual meeting, and in writing the present article.

Data collection

Both surveys employed a non-probability sampling design, disseminating a link to an anonymous online Qualtrics xm (Qualtrics International Inc., Provo, UT) survey through email and social media. The October 2020 survey was opened on October 14, 2020 and closed on November 4, 2020; the March 2021 survey was opened on March 23, 2021 and closed on April 13, 2021.

Each class developed their own sampling strategy and inclusion/exclusion criteria. For the October 2020 survey, the class decided to include all adults over the age of 18 who were California residents. This decision was made because many of the students were in their first semester at the university after transferring from community college and students were concerned that if they restricted participants to college students at their university, they might not be able to obtain a sufficiently large sample to examine the questions of interest. However, in documenting where they distributed the survey link, it was apparent that most people who received the survey link were contacted through campus lists (e.g., class lists, student organizations and clubs, and sports teams) and the sample was predominantly college students. For the March 2021 survey, the class decided to only include students over the age of 18 at the university where the study took place. Similar strategies were employed to disseminate the survey link.

Both surveys began by assessing the eligibility criteria. If a participant did not meet either of the criteria, they were taken to the end of the survey. If a participant met the criteria, they were asked a series of demographic questions including their age, gender identity, sexual orientation, and racial or ethnic identity.

Both surveys used the Patient Health Questionnaire-4 (PHQ-4) to assess depression and anxiety. These two constructs were coded according to the scale conventions with a total score ≥ 3 for questions 1 and 2 suggesting anxiety and a total score ≥ 3 for questions 3 and 4 suggesting depression ( 19 ). The PHQ-4 consists of a 2-item depression scale (PHQ-2) and a 2-item anxiety scale (GAD-2) and has good psychometric properties to measure depression and anxiety in the general population ( 19 , 20 ).

Both surveys included item 9 of the PHQ-9, which assesses thoughts of self-harm or suicidal ideation. This single item has been found to be a strong predictor of future suicide attempt or completion in large, population-based studies ( 21 , 22 ). Consistent with other studies of college student mental health, we used this single item as a proxy for suicidal ideation ( 23 – 25 ). We classified responses of “not at all” to this question as not having suicidal ideation and responses of “several days” or more frequently as having suicidal ideation to make it a binary variable.

The October 2020 survey assessed experiences of loneliness by asking how often participants felt lonely or isolated. This question was modified from the CES-D ( 26 ), which uses a reference time of 7 days, to use the same 2 week time frame as the PHQ-4 and PHQ-9 item 9. In addition, the survey asked “What are some of the ways you are coping with the COVID-19 pandemic?” and offered the following options: Taking breaks; Sleeping; Mindfulness practice or breathing exercises; Using alcohol or cannabis; Using other drugs; Exercise or spending time outdoors; Art, music, journaling, or another creative expression; Connecting with friends; Connecting with family; Watching shows, listening to music, or playing video games; Taking care of a pet; or Other (specify).

The March 2021 survey asked participants “Overall, how would you say your mental health has been since the start of the pandemic?” with the options of reporting that their mental health had gotten worse, stayed the same, gotten better, or that they were unsure. For participants who reported their mental health had gotten worse, they were asked the follow up question “Do you believe that your worsening mental health is due to the pandemic?” with options to state “Yes, largely due to the pandemic and its associated challenges,” “Somewhat, the pandemic has contributed, but there are other factors, too,” “No, my experience is not really because of the pandemic,” or “Unsure.” In addition, this survey asked participants “In the last 2 weeks, how often have you felt that you were on top of things?” with response options mirroring those available for the PHQ survey items. The March 2021 survey also assessed whether participants or members of their household had any of several distressing experiences during the COVID-19 pandemic.

Statistical methods

First, we described the demographic characteristics of the population. We then estimated the overall prevalence of each primary outcome and the distribution of these outcomes by demographic characteristic, testing for differences. Second, we assessed differences in the level of mental health pathology (anxiety, depression, and suicidal ideation) across the two time periods by using a qui-square test. We used generalizable linear regression models with robust standard errors to examine hypothesized relationships between variables. All analyses were performed using Stata/MP 14.2 (StataCorp, College Station, TX).

Study findings

There were 457 and 245 survey responses, respectively, in October 2020 and March 2021. After excluding respondents who did not meet eligibility criteria or who did not provide answers to any of the survey questions after opening the survey, we were left with analytic samples of 394 participants in October 2020 and 222 participants in March 2021, resulting in a total analytic sample of 616. Demographic characteristics of the samples are provided in Table 1 and show similar distributions by gender, sexual orientation, and race across the two different time frames. More than 70% of participants were female, three-fourths were heterosexual, the majority were Asian or Latinx, and ~75% were aged 18–25.

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Table 1 . Mental health status during COVID-19.

Anxiety and depression were common in this primarily young adult population ( Table 1 ). In October 2020, 38.07% met the criteria for anxiety and 29.85% met the criteria for depression; in March 2021, 40.65% met the criteria for anxiety and 27.57% met the criteria for depression. Suicidal ideation was also high with 15.94% of participants in October 2020 and 16.04% in March 2021 reporting suicidal thoughts. The prevalence of anxiety was higher among women compared to men in both time periods (43.94% vs. 20%, χ 2 (2) = 19.1, p  < 0.001 in October 2020 and 44.83% vs. 20.45%, χ 2 (2) = 13.31, p  = 0.003 in March 2021). Compared to heterosexual participants, non-heterosexual participants (combining gay, lesbian, bisexual, mostly heterosexual, and other) showed significantly higher prevalence in anxiety (54.41% vs. 34.78%, χ 2 (1) = 9.16, p  = 0.002), depression (55.88% vs. 24.53%, χ 2 (1) = 25.91, p  < 0.001), and suicidal ideation (33.82% vs. 11.8%, χ 2 (1) = 20.02, p  < 0.001) in October 2020. Participants aged 18–25 showed significantly higher prevalence of suicidal ideation compared to older adults (18.18% vs. 8.25%, χ 2 (1) = 4.91, p  = 0.027) in October 2020.

Examining differences in mental health outcomes across the two time periods, we found that the prevalence of anxiety, depression, and suicidal ideation were not significantly different (chi-square tests, respectively, p  = 0.533, 0.555, 0.975). We present data on the comorbidity of these mental health outcomes in Figure 1 . Among participants who answered all questions in the PHQ-4 and item 9 of the PHQ-9 across the two different time periods ( N  = 601), 50 of them (8.32%) were classified as meeting the criteria for all three outcomes ( Figure 1 ).

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Figure 1 . Comorbidity of anxiety, depression, and suicidal ideation. This graph displays the proportion of participants classified with each of the three mental health disorders in October 2020 and March 2021 (Total: 601).

In addition to anxiety, depression, and suicidal ideation, the October 2020 survey assessed loneliness and coping strategies that students were employing to manage the challenges of the pandemic. More than half the participants reported loneliness for several days, more than half the days, or nearly every day ( Table 2 ). Participants provided multiple answers for their coping strategies. The most common coping strategy was watching shows, listening to music, or playing video games (69.01%). More than half of the participants reported sleeping (56.70%), taking breaks (51.65%), connecting with friends (52.31%), and connecting with family (51.21%) to help them manage the pandemic. Other coping strategies are described in Table 2 .

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Table 2 . Additional mental health survey results from October 2020 ( N = 394) and March 2021 ( N = 222).

Using a generalizable linear regression model with robust standard errors, we found that students who experienced anxiety or depression were less likely to report taking breaks (Prevalence Ratio 0.73, 95% CI 0.56, 0.97, p  = 0.029 for anxiety and PR 0.68, 95% CI 0.49, 0.94, p  = 0.021 for depression) than students without anxiety or depression. Students who experienced depression, suicidal ideation, or reported feeling lonely nearly every day were less likely to report connecting with family (PR 0.69, 95% CI 0.49, 0.95, p  = 0.027 for depression; PR 0.49, 95% CI 0.30, 0.80, p  = 0.004 for suicidal ideation; PR 0.32, 95% CI 0.15, 0.67, p  = 0.003 for loneliness nearly every day). Those who reported feeling lonely nearly every day had more than twice the prevalence of coping by sleeping than students who did not report feeling lonely (PR 2.25, 95% CI 1.19, 4.23, p  = 0.012).

The March 2021 survey asked participants to report on their overall mental health: almost half of the participants’ reported that their mental health had become worse since the pandemic (46.40%), with 96.05% reporting that this was due fully or partially to the COVID-19 pandemic ( Table 2 ). Participants reported feeling on top of things for several days (43.40%), more than half the days (21.23%), and nearly every day (8.49%). Student researchers also inquired about various distressing experiences that participants or someone in their household may have had because of the COVID-19 pandemic in the March 2021 survey ( Table 2 ). Almost half of the participants reported that they or someone in their household had experienced mental health problems (43.95%). Additional stressors reported included loss of a job or income (34.27%), working without PPE or social distancing (21.77%), becoming sick with COVID-19 (19.35%), delaying necessary medical care (12.50%), experiencing violence or abuse (5.24%), reducing work to care for children (4.84%), and experiencing eviction, foreclosure, or being required to move to save money (3.63%).

Reflections on the research process

Through use of this participatory CURE, the student-faculty research team was able to obtain answers to original research questions of interest to the team members, campus stakeholders, and the broader public health community. Topics across the two semesters of the CURE were different, reflecting the CURE principle that new research questions and directions be generated each semester, in collaboration with the students in the course. In fact, there is an expectation in CURE research that work in a CURE is “unlikely to look the same from year to year” ( 27 ).

Students reported increased motivation to work on this participatory CURE than projects for other courses. One student reported: “ the prospect of collecting meaningful data and promoting change through our analysis motivated us to choose a topic that would interest us for the next 4+ months. We were all very interested in mental health and knew we would find shifts in wellness during COVID-19 because of our own experiences .” Another student reflected that the participatory CURE “ allowed me the chance to practically apply concepts we were learning in class. ” The graduate research assistant shared, “ I started this work at a time where I was feeling uninspired in my internship and struggling with motivation in grad school. Collaborating with this team helped me cope with my own isolation and loneliness. ”

While highly motivating, working on research that had potential for application outside the classroom context also made students feel nervous. One student shared that she experienced imposter syndrome and felt her “ excitement being quickly overtaken by anxiousness and doubt in my capability to keep up with the rest of the team .” The regular meeting structure, conversations with her peer co-researchers, and candid talks with the graduate student assistant working on the study all helped allay this student’s concerns. She noted that the faculty created “ an open space to speak out, for us to ask questions ” and encouraged students to “ step outside of our comfort zone .” Another student researcher shared “ The level of professionalism required for this project was honestly such a new experience for everybody involved! ”

As others have reported, participating in a CURE made some students more interested in pursuing graduate education. One student co-researcher shared, “ I really enjoyed how the curriculum changed to reflect that semester’s cohort. Working on this study and actively exploring epidemiology made me much more interested in public health. Now I want to pursue an MPH with a concentration in epidemiology/biostatistics. ”

As with other participatory methodologies, this study made use of the participant’s lived experiences to guide the research questions, strengthening their relevance. For example, loneliness was a topic that students selected because it resonated with their own experiences. One student shared “ I already had an idea what isolation can do to a person’s mental wellbeing from my job working at a 55+ aged community for skilled nursing and memory care… I witnessed elderly residents’ mental health decline from isolation because they were unable to receive social support from their family due to the lockdown protocol…. I was also isolating myself in my room and encountering loneliness myself. When speaking to other people my age they reported they were also experiencing similar feelings. I wondered how these experiences were being felt by my own community of college students. ” Working on this topic allowed this student to draw on her professional experience, her personal experience, and her academic knowledge. Students were similarly encouraged to decide for themselves what they thought the most valuable means of disseminating the study findings would be and selected a public-facing blog where they could write findings in lay language and post videos of short professional presentations of the research findings.

As other faculty engaged in CUREs have reported, the faculty collaborating in this participatory CURE reported that it was highly satisfying ( 28 ). One faculty member shared: “ I find doing student-partnered research incredibly meaningful. I love having the opportunity to more closely integrate my teaching, research, and mentorship. While I sometimes feel like the stakes for a CURE are higher than for other teaching approaches and it requires a deeper investment of time, that additional work is offset by the joy of seeing students motivated to do work for the science itself rather than for a grade. ” The other faculty member pointed out that employing a participatory CURE approach was an effective way to “ pursue research productivity and teaching effectiveness at the same time. ”

These perspectives highlight the potential for transformative experiences for students and faculty engaged in participatory CURE, especially on topics related to adolescent mental health and wellbeing in schools and universities. The Course-Based Undergraduate Research Experiences Network (CUREnet) database provides details on 25 CUREs across 24 campuses in multiple countries; despite the diverse topics and contexts, all of the courses are in STEM fields ( 29 ). This article extends the CURE literature by providing an example of a CURE within the public health field.

In our study of diverse young adults, we found that 46.93% had evidence of clinical levels of either anxiety or depression. This is consistent with the Healthy Minds Study from Fall 2020, which sampled over 30,000 college students on campuses across the country and found 47% met criteria for depression and/or anxiety disorders ( 30 ). While the Healthy Minds Study used different measures for anxiety and depression than we used in our study, these data are also similar to the findings from the U.S. Census Household Pulse survey, which, like the present study, used the PHQ-4. Throughout the pandemic, the Household Pulse survey has found that young adults ages 18–24 have the highest level of anxiety and depression of any age group ( 31 ). In December, midway between our two surveys, 56.2% of 18–24-year old’s surveyed reported symptoms of anxiety and/or depression. Depression and anxiety were more common in households that had experienced job loss and among racial and ethnic minority populations ( 31 ).

The level of depression in our study was slightly higher than has been reported in this specific student population previously and higher than most prior studies of college student mental health ( 32 ), likely reflecting the increase in depression in the population during the COVID-19 pandemic ( 33 ). However, these prior studies used the PHQ-9, a different measure of depression, rather than the PHQ-4, and thus observed differences might also reflect these different scales.

Compared to the Fall 2020 Healthy Minds Study, our participants reported more suicidal ideation in both time periods (Healthy Minds found 13% past year suicidal ideation vs. 15.94% and 16.04% past 2 weeks suicidal ideation in our study) ( 30 ). Our participants reported less loneliness than students in the Healthy Minds Study (41.94% of participants in our study reported not feeling lonely at all vs. 34% of students in the Healthy Minds Study reported feeling isolated from others hardly ever) ( 30 ). Suicidal ideation and loneliness are critical factors to track as even before the pandemic, suicide was the second leading cause of death in young people and the social isolation brought on by the pandemic is expected to exacerbate this problem ( 34 ).

Similar to surveys of Canadian students in the early months of the pandemic, over half of students in our October 2020 survey reported connecting with family or friends to help them cope with the pandemic and students who used these social strategies had better mental health ( 35 ). While a similar proportion of participants also reported using exercise to cope (our study: 46.81% vs. Canadian study 54.5%), twice as many participants in our study used mindfulness (27.69%) compared to students in the Canadian study (12.0%). More than half of our participants reported sleeping to cope, compared to just 17.5% of Canadian students.

The adverse mental health impacts of the COVID-19 pandemic are likely to be felt for years after the pandemic ends ( 36 ). Recognizing the extensive mental health challenges faced by young adult college students, we suggest that Universities proactively employ universal approaches to improving mental health, rather than relying on counseling and psychological services within health centers to treat all students who could potentially benefit from mental health care ( 37 ). Universal approaches target mental health interventions to all students through multiple, overlapping strategies rather than rely on the typical client/therapist mental health care model. Such approaches might focus on building the skills of resilience, which research shows can be actively taught ( 38 ). To combat loneliness and improve general emotional wellbeing, universities might also consider programming specifically aimed at reducing loneliness, including pedagogy training for faculty on teaching strategies that promote connections between students ( 39 ).

The strengths of this study include its participatory design, use of valid and reliable scales in addition to novel constructs, and good sample sizes for the research questions examined. The study quality benefits from the strong voice of students, members of the population under study, and the collaborative nature of the study. Survey questions reflected students’ interests, representing community members’ interests as well. From the students’ perspective, this study closed the gap between knowledge learned in the course and actual research and application. From the course instructors’ perspective, the CURE synergizes teaching and research, and require high commitment, creativity, investigativeness, and critical analysis ( 40 ).

Limitations

The study findings are limited by the non-probability sampling approach, decreasing generalizability. As students in the CURE were public health majors and minors, it is likely that the study sample overrepresented students in this field of study compared to other disciplines. Students were also mostly juniors and seniors, who might have different experiences than first-year students ( 41 ). However, our empirical findings are very similar to contemporaneous larger studies, such as the non-representative Healthy Minds Study and the nationally representative Household Pulse Survey. Regarding data from two time periods, the study represents a repeated cross-sectional survey rather than a longitudinal design and so changes in variables do not reflect changes at the individual level, but rather at the population level. Although the respondents of the first survey in October 2020 were not the same respondents of the second survey in March 2021 survey, the two samples were drawn from overlapping source populations and by comparing results in the two time periods, we could observe how mental health among this college student population changed. In addition, we did not specify a priori how we would evaluate the process or outcomes related to using this participatory CURE approach. Future participatory CURE studies would be strengthened from a priori specification of the design to assess process and CURE outcomes such as student motivation and graduate school intentions.

Course-Based Undergraduate Research Experiences are ripe locations for integrating participatory research approaches, such as Community-Based Participatory Research. This participatory CURE gave rise to a deeper understanding of college students’ mental health burden and highlighted both areas of risk and factors that are protective for this population. Students who engage in CUREs can be strong advocates for the application of research findings, bringing their youthful passion to solve complex problems. In the case of these findings, we hope that colleges and universities take seriously their obligation to serve and protect their student population by increasing mental health services, given the high need in this young adult population. While CUREs have been slow to be adopted outside of STEM fields, this study adds to a growing body of literature demonstrating the feasibility of CUREs in public health and other social sciences.

Data availability statement

The datasets presented in this article are not readily available because of concerns that privacy of research participants may be compromised when variables are combined. Requests to access the datasets should be directed to [email protected] .

Ethics statement

The studies involving human participants were reviewed and approved by San José State University IRB approval (IRB protocol tracking numbers 20251 and 21069). Exempt registration was received. Waiver of signed consent was approved. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author contributions

MW developed the CURE and taught the course. KN, DP, HM, TA, and the PH 161 cohorts of Fall 2020 and Spring 2021 designed the study and collected the data. CP, MMF, TME, KN, DP, HM, TA, and MW conducted initial data analysis. CP further analyzed the data and produced the tables and figures. CP, MW, KN, TME, and MMF conceived of the manuscript. MW drafted the manuscript, with contributions from KN, TME, CP, and MMF. All authors contributed to the article and approved the submitted version.

This work was supported by the Thoracic Foundation.

Acknowledgments

The authors would like to thank students from Worthen’s PH 161 Epidemiology classes in Fall 2020 and Spring 2021 at San José State University.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: course-based undergraduate research experience, depression, anxiety, loneliness, COVID-19, participatory research

Citation: Park C, McClure Fuller M, Echevarria TM, Nguyen K, Perez D, Masood H, Alsharif T and Worthen M (2023) A participatory study of college students’ mental health during the first year of the COVID-19 pandemic. Front. Public Health . 11:1116865. doi: 10.3389/fpubh.2023.1116865

Received: 05 December 2022; Accepted: 02 March 2023; Published: 21 March 2023.

Reviewed by:

Copyright © 2023 Park, McClure Fuller, Echevarria, Nguyen, Perez, Masood, Alsharif and Worthen. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Miranda Worthen, [email protected]

† ORCID: Chulwoo Park, https://orcid.org/0000-0003-0667-6549 Miranda Worthen, https://orcid.org/0000-0002-6494-7098

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Emerging issues that could trouble teens

Stanford Medicine’s Vicki Harrison explains the forces impacting youth mental health today, and why it’s so important to involve teens in solutions.

research questions about mental health and college students

Image credit: Getty Images

One of the most alarming developments across the United States in recent years has been the growing mental health crisis among children and adolescents.

The already dire situation is evolving 2024 already presenting a new set of challenges that Vicki Harrison, the program director at the Stanford Center for Youth Mental Health & Wellbeing , is closely monitoring and responding to.

Stanford Report sat down with Harrison to find out what concerns her the most about the upcoming year. Harrison also talked about some of the promising ways she and her colleagues are responding to the national crisis and the importance of bringing the youth perspective into that response.

Challenging current events

From the 2024 general election to evolving, international conflicts, today’s dialed-in youth have a lot to process. As teens turn to digital and social media sources to learn about current events and figure out where they stand on particular issues, the sheer volume of news online can feel overwhelming, stressful, and confusing.

One way Harrison is helping teens navigate the information they consume online is through Good for Media , a youth-led initiative that grew out of the Stanford Center for Youth Mental Health & Wellbeing to bring teens and young adults together to discuss using social media in a safe and healthy way. In addition to numerous youth-developed tools and videos, the team has a guide with tips to deal with the volume of news online and how to process the emotions that come with it.

Harrison points out that the tone of political discourse today – particularly discussions about reining in the rights a person has based on aspects of their identity, such as their religion, race, national origin, or gender – affects adolescents at a crucial time in their development, a period when they are exploring who they are and what they believe in.

“If their identity is being othered, criticized, or punished in some way, what messages is that sending to young people and how do they feel good about themselves?” Harrison said. “We can’t divorce these political and cultural debates from the mental health of young people.”

Harrison believes that any calls for solving the mental health crisis must acknowledge the critical importance of inclusion, dignity, and respect in supporting the mental health of young people.

Talking about mental health

Adolescence is a crucial time to develop coping skills to respond to stressful situations that arise – a skill not all teens and youth learn.

“It hasn’t always been normalized to talk about mental health and how to address feeling sad or worried about things,” Harrison said. “It’s not something that all of us have been taught to really understand and how to cope with. A lot of young people aren’t comfortable seeking professional services.”

The Stanford Center for Youth Mental Health & Wellbeing is helping young people get that extra bit of support to deal with problems before they get worse.

This year, they are rolling out stand-alone “one-stop-shop” health centers that offer youth 12-25 years old access to a range of clinical and counseling services with both trained professionals and peers. Called allcove , there are three locations open so far – Palo Alto, Redondo Beach, and San Mateo. More are set to open across the state in 2024.

“If we can normalize young people having an access point – and feeling comfortable accessing it – we can put them on a healthier track and get them any help they may need,” Harrison said.

Another emerging issue Harrison is monitoring is the growing role of social media influencers who talk openly about their struggles with mental health and well-being.

While this is helping bring awareness to mental health – which Harrison wants to see more of – she is also concerned about how it could lead some teens to mistake a normal, stressful life experience for a mental disorder and incorrectly self-diagnose themselves or to overgeneralize or misunderstand symptoms of mental health conditions. Says Harrison, “We want to see mental health destigmatized, but not oversimplified or minimized.”

“We can’t divorce these political and cultural debates from the mental health of young people.” —Vicki Harrison Program Director at the Stanford Center for Youth Mental Health & Wellbeing

Eyes on new technologies

Advances in technology – particularly generative AI – offer new approaches to improving teen well-being, such as therapeutic chatbots or detecting symptoms through keywords or patterns in speech.

“Digital solutions are a promising part of the continuum of care, but there’s the risk of rolling out things without the research backing them,” Harrison said.

Social media companies have come under scrutiny in recent years for inadequately safeguarding young adult mental health. Harrison hopes those mishaps serve as a cautionary tale for those applying AI tools more broadly.

There’s an opportunity, she says, to involve adolescents directly in making AI applications safe and effective. She and her team hope to engage young people with policy and industry and involve them in the design process, rather than as an afterthought.

“Can we listen to their ideas for how to make it better and how to make it work for them?” Harrison asks. “Giving them that agency is going to give us great ideas and make a better experience for them and for everyone using it.”

Harrison said she and her team are hoping to engage young people with policy and industry to elevate their ideas into the design process, rather than have it be an afterthought.

“There’s a lot of really motivated young people who see potential to do things differently and want to improve the world they inhabit,” Harrison said. “That’s why I always want to find opportunities to pass them the microphone and listen.”

IMAGES

  1. College students and mental health: an outlook

    research questions about mental health and college students

  2. ≫ Mental Health Issues Among College Students Free Essay Sample on

    research questions about mental health and college students

  3. (PDF) Mental Health and College Students

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  4. Issues in Mental Health: OCR A Level Psychology

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  5. 10 Simple Questions To Ask About Someone's Mental Health

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  6. Ultimate Guide to College Student Mental Health

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COMMENTS

  1. Key questions: research priorities for student mental health

    UK university students ( N = 385) submitted 991 questions, categorised into seven themes: epidemiology, causes and risk factors, academic factors and work-life balance, sense of belonging, intervention and services, mental health literacy and consequences.

  2. Student mental health is in crisis. Campuses are rethinking their approach

    During the 2020-2021 school year, more than 60% of college students met the criteria for at least one mental health problem, according to the Healthy Minds Study, which collects data from 373 campuses nationwide ( Lipson, S. K., et al., Journal of Affective Disorders, Vol. 306, 2022 ).

  3. A qualitative study of mental health experiences and college student

    Students participated in one hour-long interviews that focused on students' conceptions of mental health in relation to their identity, students' actions related to mental health and students beliefs about the role of mental health in their sense of mattering.

  4. Academic Stress and Mental Well-Being in College Students: Correlations

    According to a 2015 American College Health Association-National College Health Assessment survey, three in four college students self-reported feeling stressed, while one in five college students reported stress-related suicidal ideation (Liu, C. H., et al., 2019; American Psychological Association, 2020 ).

  5. College Students: Mental Health Problems and Treatment Considerations

    Mental health problems are very common among college students [ 1 ]. This may be due to the fact that attending college corresponds to a challenging time for many traditional and non-traditional undergraduate students.

  6. Factors that influence mental health of university and college students

    Poor mental health of students in further and higher education is an increasing concern for public health and policy [1,2,3,4].A 2020 Insight Network survey of students from 10 universities suggests that "1 in 5 students has a current mental health diagnosis" and that "almost half have experienced a serious psychological issue for which they felt they needed professional help"—an ...

  7. PDF Mental Health and Academic Performance of First-Year College Students

    Abstract The prevalence and severity of mental health issues are increasing among college students, and such issues pose a threat to health and academic performance. Purpose: The primary purpose of the study is to examine differences in mental health diagnoses and their related academic impact with a special focus on classification year in college.

  8. Emotional Intelligence, Belongingness, and Mental Health in College

    Introduction Mental Health Problems. High rates of mental health problems have been documented amongst college students (for a discussion see Auerbach et al., 2016; Xiao et al., 2017).For example, one study reported that 17% of surveyed students met diagnostic criteria for major depressive disorder (Selkie et al., 2015).Using the Depression, Anxiety, Stress Scale (DASS-21) Mahmoud et al. (2012 ...

  9. Improving college student mental health: Research on promising campus

    Advice from prominent scholars The report is the culmination of an 18-month investigation the National Academies launched in 2019, at the request of the federal government, to better understand how campus culture affects college student mental health and well-being.

  10. Mental Health, Academic Self-Efficacy and Study Progress Among College

    A secondary aim was to examine mental health help seeking for students with mental distress. Data was derived from the Norwegian Students' health and welfare survey 2014 (SHOT 2014) which is the first major survey comprising questions of both mental health, academic self-efficacy and psychosocial factors amongst students.

  11. Full article: Mental health among first-generation college students

    Introduction. In 2022, there were roughly 19 million undergraduate students enrolled in U.S. postsecondary education National Center for Education Statistics, (Citation 2022).A mounting body of evidence reveals that college student mental health outcomes are worsening over time; in the 2020-2021 academic year, over 60% of students were experiencing at least one clinically-significant mental ...

  12. Impact of COVID-19 on the mental health of US college students

    Impact of COVID-19 on the mental health of US college students Jenny Lee, Matthew Solomon, Tej Stead, Bryan Kwon & Latha Ganti BMC Psychology 9, Article number: 95 ( 2021 ) Cite this article 81k Accesses 106 Citations 71 Altmetric Metrics Abstract Background/aim

  13. A qualitative assessment of mental health literacy and help-seeking

    Although the number of students receiving care from college counseling centers has increased, engaging male college students to seek help presents a unique challenge. This qualitative study explored mental health literacy and help-seeking behaviors among undergraduate college men. Semi-structured interviews (n = 26) based on three vignettes (anxiety, depression, stress) were employed to assess ...

  14. PDF Frequently Asked Questions About College Student Mental Health Data and

    (1) How many students are experiencing mental health problems? (2) Are mental health problems increasing in college populations? If so, why? (3) Are college students at higher risk for mental health problems than young adults not in college? (4) What is the economic case for investing in student mental health?

  15. Student mental health: some answers and more questions

    June S. L. Brown. Public concern for the mental health of university students has been rising. University counselling services in the UK and USA are reporting increases in helpseeking, with more students presenting with more severe problems (Avotney, 2014; Flatt, 2013 ). Several reasons probably explain this increase.

  16. Frontiers

    The SCL-90 has been widely used to screen for mental health issues and is commonly used to assess the subjective mental health symptoms of college students (Xie and Dai, 2006). According to Ren (2009) , the SCL-90 was used in 63.8% of the published articles regarding the mental health of college students, illustrating its strong validity and ...

  17. College Student Mental Health in the COVID-19 Era: Results of an

    problems. Alarmingly, students without preexisting mental health concerns were most likely to report deteriorating mental health and distressing anxiety and depression symptoms (Hamza et al., 2021). Psychosocial Impact of COVID-19 on Undergraduate Students . COVID-19 has contributed to numerous adverse mental health outcomes for students

  18. College Student Mental Health and Well-Being

    According to the latest research on college students and mental health, three out of 10 students have struggled with depression in the last two weeks, and over one in four have expressed issues with anxiety. Even more distressing is the one in 20 college students who had created a suicide plan in the past year.

  19. Mental Health Problems in College Freshmen: Prevalence and Academic

    The WMH-ICS aims to obtain accurate cross-national information on the prevalence, incidence, and correlates of mental, substance, and behavioral problems among college students worldwide, to describe patterns of service use and unmet need for treatment, to investigate the associations of these disorders with academic functioning, and to evaluate...

  20. Student involvement, mental health and quality of life of college

    The third research instrument will measure the students' health status using the mental health inventory (MHI-38) by the Australian Mental Health Outcomes and Classification Network (AMHOCN). MHI-38 is composed of 38 questions which require an answer from five to six-point scale.

  21. Mental health disorders among medical students during the ...

    The prevalence of mental health conditions was 28.94%, 54.12%, and 15.06% for depression, anxiety, and stress, respectively, while the prevalence of having any mental health condition was 58.59%.

  22. 207 Great Mental Health Research Topics For Students

    How do substance-use disorders impede the healing process? Discuss the effectiveness of the mental health Gap Action Programme (mhGAP) Are non-specialists in mental health able to manage severe mental disorders? The role of the WHO in curbing and treating mental disorders globally The contribution of coronavirus pandemic to mental disorders

  23. The impact of socialization on college student thriving

    The 2023 Thriving College Student Survey was conducted in October 2023 by Ipsos, commissioned by the College Student Mental Wellness Advocacy Coalition and the Hi, How Are You Project, with support from the Jed Foundation. The survey was distributed through housing providers that are members of the coalition, with 29,791 students participating.

  24. Mental health and the pandemic: What U.S. surveys have found

    On both questions, high school students who identify as lesbian, gay, bisexual, other or questioning were far more likely than heterosexual students to report negative experiences related to their mental health. Mental health tops the list of worries that U.S. parents express about their kids' well-being, according to a fall 2022 Pew Research ...

  25. Campus Reform the #1 Source for College News

    August 29, 2022, 1:00 pm ET. In study from Boston University (BU), researchers found that mental health is worsening among college students in the United States. A majority of college students ...

  26. Key influences on university students' physical ...

    Physical activity (PA) has a powerful positive impact on all aspects of health. Regular PA can prevent and treat noncommunicable diseases [1, 2], build resilience against the development of mental illness [], and attenuate cognitive decline [].Given these pervasive health benefits, increasing participation in PA is recognised as a global priority by international public health organisations.

  27. Frontiers

    Through repeated cross-sectional surveys of college students' peer groups in northern California in October 2020 and March 2021, this student/faculty collaborative research team evaluated depression, anxiety, suicidal ideation and several other topics related to mental health among the students' young adult community.

  28. Emerging issues that could trouble teens

    February 20, 2024 Emerging issues that could trouble teens. Stanford Medicine's Vicki Harrison explains the forces impacting youth mental health today, and why it's so important to involve ...

  29. Deleting social media: How it transformed my mental health as a college

    Unfortunately, college students are going through a mental health epidemic. Right now, according to the Healthy Mind survey, which surveyed over 96,000 U.S. students across 133 campuses during the 2021-22 academic year, mental health problems are at the highest rates in the survey's 15-year history. Specifically, 44 percent of students ...