Mental health awareness and literacy among health university students in Southern Karnataka

INTRODUCTION

The importance of mental health as a component of overall well-being has grown significantly in recent years. Its effects extend beyond the lives of individuals to many social arenas, including academic institutions. The World Health Organization describes mental health as a state of well-being in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Mental health is a fundamental human right and is essential for personal, communal and socio-economic development.¹

Students may encounter a variety of concerns in their new academic setting after schooling, such as hostel living and coursework stress, and may develop unhealthy eating habits, sleep disturbances, smoking, excessive internet use and sedentary behaviour. Owing to the demanding nature of their studies and anxiety about the future, health university students, who will be at the forefront of healthcare delivery, are particularly vulnerable to mental health problems.² Academic pressure, financial difficulties, the transition to university life and loneliness have been identified as important influences on the mental health of university students.³ A review of undergraduate students in the United States reported a high prevalence of mental health disorders, particularly depression and anxiety.⁴

In 2022, as many as 77% of college students reported moderate to severe psychological distress; anxiety was reported by 35% and depression by 27% of students. Further, 89% of students who faced academic difficulties reported that these difficulties affected their mental well-being, underscoring the close link between academic struggles and mental health among college students.⁵

Adolescence and young adulthood form a pivotal phase in which social and emotional patterns that are vital for good mental well-being are established. Mental well-being of young people is influenced by many factors, and potential impact increases as they encounter more risk factors such as exposure to adversity, peer pressure and exploration of identity. Mental health problems affect a considerable proportion of young people and are a leading cause of health-related disability in this age group.⁶

The term “mental health literacy” was introduced to describe knowledge and beliefs about mental disorders which aid their recognition, management or prevention.⁷ Raising mental health literacy enables people to identify problems early and to seek appropriate treatment.⁸ Its components include the ability to recognise specific disorders, knowing how to seek mental health information, knowledge of risk factors and causes, knowledge of self-treatment and of the professional help available, and attitudes that promote recognition and appropriate help-seeking.^8,9 Higher mental health literacy has been associated with better positive mental health among adolescents.¹⁰

Conversely, many members of the public are unable to correctly recognise mental illness, and stigmatising attitudes towards people with mental disorders remain common among young people.^11,12 Stigma, embarrassment and difficulty in recognising symptoms are among the most important barriers to help-seeking in young people, and personal stigma has been shown to reduce young people’s intentions to seek professional help.^13,14 Young people also frequently prefer informal sources of help, such as family and friends, over professional services.¹⁵ Despite major advances in India’s healthcare infrastructure, studies on mental health literacy remain limited, and the available Indian studies among college and university students have reported gaps in knowledge and persisting stigma.^16,17

Students who seek admission to a health university come from the general community, and their knowledge, beliefs and literacy levels are therefore likely to be similar to those of society at large. This may leave them with little ability to deal with problems that they or their peers face in daily life, or to act as professionals assisting those in need. Health professional students will be better equipped to take care of themselves and others if their current level of mental health awareness and literacy is known and steps are taken to raise it during their professional training.

Nearly three-quarters of all lifetime mental disorders have their onset by the mid-twenties, and mental disorders in young people contribute substantially to the global burden of disease measured in disability-adjusted life years (DALYs).^6,18 Recognizing the vulnerability of specific groups such as adolescents and young people, the World Health Organization, in its Mental Health Action Plan 2013-2020, emphasised promoting mental health and preventing mental disorders in the general population rather than focusing only on individuals with established mental illness.^19,20

Although mental health literacy has been studied among university students in several countries, including medical students, evidence comparing Medical, Dental and Pharmacy students in India is scarce.^21,22 Understanding the level of awareness and literacy in these groups, and the factors associated with them, is essential for designing targeted curricular interventions.

Objectives

Objectives were to assess the level of mental health awareness and mental health literacy among health university students (Medical, dental and pharmacy students) and to identify the factors associated with mental health awareness and mental health literacy among these students.

METHODS

Study design, setting and period

This cross-sectional study was conducted in the JSS Medical College, JSS Dental College and JSS College of Pharmacy, constituent colleges of the JSS Academy of Higher Education and Research, Mysuru, Karnataka, India, from January 2023 to June 2023.

Study population and eligibility criteria

All students enrolled in the first and second professional years of the medical, dental and pharmacy courses were eligible. Students who gave informed consent were included. Students who were long-term absentees in any batch were excluded.

Sample size and sampling technique

Universal sampling (complete enumeration) was adopted, and no formal a priori sample size calculation was performed, because the entire eligible population was invited to participate. The sampling frame comprised all 828 first- and second-year students of the three colleges (Medical 449, dental 168 and pharmacy 211). Of these, 348 students (42.0%) completed the questionnaire and were included in the analysis. The achieved sample exceeds the minimum of 263 participants that would be required to estimate a proportion of 50% with 5% absolute precision at 95% confidence after applying the finite population correction; the obtained sample of 348 corresponds to a margin of error of about ±4.0%.

Study tools

A pretested, semi-structured proforma was used to collect socio-demographic details (age, gender, course and year of study).

MHAS

A structured 17-item scale was developed by the investigators after a review of the literature to assess awareness of the nature, causes, treatment and social aspects of mental illness, including common misconceptions (for example, attribution of mental illness to black magic, karma or divine punishment) and stigmatising beliefs. Each item was rated on a five-point Likert scale from “strongly disagree” to “strongly agree”, giving a possible total score of 17 to 85. The internal consistency of the scale in the present study was acceptable (Cronbach’s α=0.776).

MHLS

The MHLS developed by O’Connor and Casey was used to assess mental health literacy.²³ The scale was developed following a review of existing scale-based measures, which found that most assessed only some of the attributes of mental health literacy.⁹ It consists of 35 items covering six attributes: the ability to recognise disorders, knowledge of where to seek information, knowledge of risk factors and causes, knowledge of self-treatment, knowledge of professional help available, and attitudes that promote recognition and appropriate help-seeking. Items are scored on four- or five-point Likert-type scales, giving a total score of 35 to 160, with higher scores indicating better mental health literacy. A validated, multi-attribute instrument was preferred because tools measuring mental health knowledge vary widely in the quality of evidence supporting their measurement properties.²⁴

Data collection

Data were collected using a self-administered Google Form, which was shared with students of each batch. The first section of the form explained the purpose of the study and obtained informed consent; only students who consented could proceed to the questionnaire. Participation was voluntary and anonymous, and no incentive was provided.

Operational definitions

Students scoring below the overall mean score of the study population were categorised as having low mental health awareness (mean 66.39) or low mental health literacy (mean 111.85), and those scoring above the mean were categorised as having high awareness or high literacy, respectively.

Statistical analysis

Data were entered and coded in Microsoft Excel 2010 and analysed using SPSS version 25 (licensed to JSS AHER). Categorical variables were summarised as frequencies and percentages, and scores as mean and standard deviation. Associations between categorical variables (age group, gender and course) and levels of awareness and literacy were tested using the chi-square test. A p value below 0.05 was considered statistically significant. The internal consistency of the MHAS was assessed using Cronbach’s alpha; a value above 0.70 was considered to indicate acceptable reliability.

Ethical considerations

The study was approved by the Institutional Ethics Committee of JSS Medical College, Mysuru (JSSMC/IEC/240123/22 NCT/2022-23, dated 25.01.2023). Informed consent was obtained from all participants before data collection, and the confidentiality of responses was maintained.

RESULTS

Socio-demographic characteristics

Of the 828 eligible students, 348 (42.0%) completed the questionnaire. The majority were female (200, 57.5%), and 148 (42.5%) were male. Most students were aged 17–19 years (195, 56.0%), followed by 20-22 years (142, 40.8%) and 23-25 years (11, 3.2%). Pharmacy students constituted 44.8% of participants, and Medical and Dental students 27.6% each (Table 1).

Level of mental health awareness

The mean mental health awareness score of all participants was 66.39±7.29. Medical students had the highest mean score (68.76±6.84), followed by dental (66.86±7.82) and pharmacy students (64.63±6.78) (Table 2). Overall, 168 (48.3%) students had high and 180 (51.7%) had low mental health awareness.

Level of mental health literacy

The mean mental health literacy score of all participants was 111.85±14.70. Medical students had the highest mean score (118.19±13.12), followed by dental (114.03±15.07) and pharmacy students (106.61±13.55) (Table 3). Overall, 146 (42.0%) students had high and 202 (58.0%) had low mental health literacy.

Factors associated with mental health awareness

Age, gender and course were significantly associated with mental health awareness (Table 4). All students aged 20-22 years (142, 100%) and 23-25 years (11, 100%) had high awareness, compared with only 15 (7.7%) of those aged 17-19 years (χ²=292.55, p<0.001). Higher proportion of male students (87, 58.8%) than female (81, 40.5%) had high awareness (χ²=11.39, p=0.001). High awareness was most frequent among medical students (61, 63.5%), followed by dental (53, 55.2%) and pharmacy students (54, 34.6%) (χ²=22.47, p<0.001).

Factors associated with mental health literacy

Age, gender and course were also significantly associated with mental health literacy (Table 5). High literacy was found in 132 (93.0%) students aged 20-22 years and all 11 (100%) aged 23-25 years, compared with only 3 (1.5%) of those aged 17-19 years (χ²=297.70, p<0.001). High literacy was more frequent among male (73, 49.3%) than female students (73, 36.5%) (χ²=5.74, p=0.017), and among medical (57, 59.4%) and dental (47, 49.0%) than pharmacy students (42, 26.9%) (χ²=28.37, p<0.001).

Reliability of the MHAS

The 17-item MHAS showed acceptable internal consistency, with a Cronbach’s alpha of the 0.776 (Table 6).

*Possible score range: 17-85.

*Possible score range: 35-160.

*Percentages are row percentages. Low/high awareness: score below/above the overall mean (66.39).

*Percentages are row percentages. Low/high literacy: score below/above the overall mean (111.85).

DISCUSSION

The present study assessed mental health awareness and literacy among first- and second-year medical, dental and pharmacy students of a health university in Mysuru. Overall awareness and literacy were satisfactory, with medical students scoring highest, and both outcomes were significantly associated with age, gender and course of study.

Socio-demographic characteristics of the participants

In the present study, the majority of participants were female (57.5%). This contrasts with a study among university students in Bangladesh, in which the majority of participants were male (67.7%).² On the other hand, a systematic review of university and college students in the United Kingdom noted a higher representation of female students.³ A study among university students in Delhi reported an equal distribution of male and female participants.¹⁷

The majority of students in the present study were aged 17-19 years (56.0%), and only 3.2% were aged 23-25 years, reflecting the inclusion of first- and second-year students only. Similarly, most participants in the Bangladeshi study were aged 17-22 years, whereas participants in the studies included in the United Kingdom review were largely aged 19-28 years and 65% of the postgraduate participants in the Delhi study were aged 20-24 years.^2,3,17

Level of mental health awareness

In the present study, medical students displayed higher mental health awareness than students of other disciplines (mean 68.76±6.84), which may reflect a greater interest in, and earlier exposure to, physical and mental health issues. In a study involving 2036 university students in Bangladesh, 85.1% of participants had a higher level of awareness of mental health problems.² Similarly, a study among university students in Delhi found that about 46% of the participants had adequate knowledge and identified more positive outcomes, while 71% had sufficient knowledge and identified more negative outcomes.¹⁷ In contrast, a community-based study from a rural district of Bangladesh found that more than half of the respondents were not aware of any mental health condition, indicating that awareness is considerably lower in the general population than among university students.²⁵

Level of mental health literacy

Mental health literacy was also highest among medical students (mean 118.19±13.12), and overall literacy was acceptable. A study from Delhi similarly reported acceptable mental health literacy among university students with respect to awareness of warning signs and the ability to recognise a mental health condition.¹⁷ In contrast, a study among pre-university students in South India reported very low mental health literacy; adolescents preferred informal sources of help, such as their mothers, over formal sources, reflecting the pervasive stigma against mental disorders.²⁶ Low knowledge of depression and suicide has also been reported among undergraduate medical students in Egypt, leading the authors to recommend mental health education early in medical curriculum.²² A community-based study among college students in Gujarat likewise emphasised need for educational campaigns to improve knowledge about mental illness and reduce stigma.¹⁶ Because teachers are often the first adults to notice mental health problems among students, their perspectives on and understanding of mental health disorders are also important for early identification and referral.²⁷

Factors associated with mental health awareness and literacy

In the present study, awareness and literacy increased markedly with age: all students aged 20 years and above had high awareness, compared with only 7.7% of those aged 17-19 years, and a similar gradient was seen for literacy. These differences were statistically significant. Comparable findings were reported in Bangladesh, where age was significantly associated with awareness and participants aged over 22 years were 1.47 times more likely to be aware of mental health issues than younger participants.²⁵ The low literacy observed among youngest students is also consistent with the very low literacy reported among pre-university adolescents in South India, which was attributed to their age and insufficient exposure to, and first-hand knowledge of, mental health disorders.²⁶ These findings suggest that students may lack sufficient knowledge about mental illness in the earliest years of their education and become more knowledgeable as they progress. Since age closely follows year of study in this population, the age gradient probably reflects a combination of maturity and academic exposure.

Gender was significantly associated with both outcomes in the present study; 58.8% of male students had high awareness compared with 40.5% of female students, and 49.3% of male students had high literacy compared with 36.5% of female students. In contrast, female students in Bangladesh were more likely than male students to be in the higher knowledge category, and among parents of young people with mood disorders, mental health literacy was higher among women.^2,28 A study among college students in the United States also reported important differences between men and women in mental health literacy and help-seeking.²¹ The direction of the gender difference observed in the present study may be influenced by differences in the gender composition of the three courses and should be confirmed using multivariable analysis in larger samples.

The course of study was significantly associated with both awareness and literacy, with pharmacy students having the lowest proportion with high scores. In contrast, a study from Bangladesh found that the students’ course, academic year and type of university were not significantly associated with mental health awareness.²⁵ Our finding on literacy is supported by a study in which students with a background in psychology had higher mental health literacy than students of other academic courses.²⁹ However, health-science training alone does not guarantee favourable attitudes; in a study of Chinese college students, a high proportion showed stigma and a desire for social distance from people with depression, and medical students showed higher stigma on some items than non-medical students.³⁰

Implications

Improving mental health literacy is an important step towards improving help-seeking. A systematic review found that interventions including mental health literacy content improved help-seeking attitudes, although evidence for changes in actual help-seeking behaviour was limited.³¹ As stigma lowers young people’s willingness to seek professional help, educational programmes for health professional students should address stigmatising beliefs as well as factual knowledge.¹⁴ Introducing such content from the first year of the course would target the group with the lowest awareness and literacy in the present study.

Limitations

The study was conducted in a single university, which limits the generalisability of the findings. Although all eligible students were invited, only 42.0% completed the questionnaire, and response rates differed between courses; non-response bias therefore cannot be excluded, as students who were more interested in mental health may have been more likely to respond. The cross-sectional design does not allow changes in knowledge and attitudes over time to be assessed. The MHAS was self-designed, and only its internal consistency was assessed. The analysis was limited to bivariate associations, so the independent effects of age, gender and course could not be separated. Finally, self-reporting may have introduced social desirability bias in responses to questions on mental health.

CONCLUSION

Mental health awareness and literacy among health university students in Mysuru were satisfactory overall but not uniform. Medical students had higher awareness and literacy than Dental and Pharmacy students, and awareness and literacy were significantly associated with age, gender and course of study, with the youngest students showing the largest gaps. Increasing mental health literacy and awareness should be viewed as a key preventive intervention for the mental health problems of young people.

Recommendations

Periodic mental health awareness sessions, with evaluation of improvement in knowledge and attitudes and access to professional counselling and medical care when required, should be included in the curriculum from the time of admission, irrespective of the course or discipline. This would help students become well informed, take self-help measures and lead physically and mentally healthy lives. Future multicentric studies with multivariable analysis and validated awareness tools are recommended.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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