Barriers to Student Engagement in Online Self-Help Programs

A Student’s Perspective: Exploring the Barriers to University Students’ Engagement in Extra-curricular Online Self-Help Programs

Abstract

Technology-based, online self-help mental health services are not used widely, despite growing evidence of their effectiveness. Students need access to proven intervention strategies to improve their relational versatility, endurance and well-being.

This thesis aims to identify several vital barriers influencing students’ decisions to complete extra-curricular online self-help well-being programs. The study’s three research areas are:

a) Defining the key factors influencing university students to complete internet-based self-help well-being programs;

b) clarifying the significant barriers university students have when completing online psychological well-being services and

c); and determining whether there were differences between mature-aged and recent school-leavers in key factors they believed were barriers to completion of these programs.

Data collected was derived from two primary sources; recent year 12 school leavers and mature-aged students enrolled in first-year psychology classes at the University of Southern Queensland. Participants’ non­verbal and verbal behaviours are observed throughout the Nominal Groups Technique (NGT) sessions.

From the standpoint of self-determination theory (SDT), autonomy (feeling uncoerced), ability (competency), and relatedness are fundamental psychological needs of being connected to others. Optimal well-being occurs where these needs are met. Preliminary evidence supported the reliability and validity of previous research and shed further light on the factors that influence individuals’ decisions to complete these self-help programs.

Keywords: University students, mental Health, Self-Determination Theory, Nominal Groups Technique.

Table of Contents

Abstract

Chapter 1: Introduction………………………………………………………………………

Purpose of the Study………………………………………………………………………4

Research Questions……………………………………………………………………5

Self-Determination Theory…………………………………………………………………5

Universities' promotion of mental health skills made a priority......................7

A Dual factor model of mental health

Graduate Student mental health……………………………...…………………………9

Mental Health Literacy (MHL)……………..………………………………….…………12

What is help-seeking? ……………………………………………………………………16

Chapter 1: Introduction

In today’s awareness atmosphere on mental health problems, students need access to proven intervention strategies to improve their relational endurance and well-being. Previous research suggests that university students are increasingly experiencing mental health problems (Blanco et al., 2008; Stallman, 2010; Bewick et al., 2010). This previous research shows that these problems are becoming more complex, and in both academic and personal fields, mental health problems can have severe and harmful consequences for university students.

Psychology graduate students are a group that faces a unique set of challenges in the course of a higher degree. The main sources of stress cited in previous studies among psychology graduate students were time and financial constraints (Goplerud, 2001).A recent study by Doran et al. (2016, p. 05) found that almost 68% of recent doctorates in psychology have a significant debt for their education, with a median of $80,000 for health service providers (HSP; defined as doctorates in clinical, counselling, and school psychology). Failure to promote students’ mental health can later lead to burnout, stress, and adult mental health problems. In turn, burnout may lead to psychological distress, depression, suicidal ideation, and other personal and professional problems (Smith & Moss, 2009).This stress can have consequences for student success because it can constitute a considerable impediment to retention, completion and achievement. Also, students of HSP face additional responsibilities and time demands for clinical work, education and supervision. As novices without well-established support systems and coping strategies, trainees may find it more difficult to manage clinical stress skilfully (Shen-Miller et al., 2011).

In addition to academic requirements, which can contribute to the development or exacerbation of mental health problems, university students can face many other stressors (Sarmento, 2015). These may include developmental challenges for younger students, such as increased freedom, decision-making, challenging family beliefs through risky actions, or pushing them to do well (Kadison & Di Geronimo, 2005, p. 08).

For mature students, study, family, and work commitments may also be competing demands. The majority of Australian students also contribute to tertiary education through financial payments (Australian Bureau Statistics [ABS], 2008). In addition to social isolation and homesickness, international students face the challenges of cultural and linguistic differences. There are also increases in the number of students who have been most vulnerable to higher education stress, such as students from a diverse cultural and linguistic background, students with physical or mental disabilities; or backgrounds in which they are the first family member to attend university (Connell et al., 2007).

The impact of psychological stress management during the study period goes beyond university life, with research linked to results such as employability and well-being at work, both now and in the future. For instance, Carter et al. (2017) suggested that mental health difficulties follow students when they transition to work and lead to adverse effects for a lifetime. Given this, it may not be surprising that students see their mental health as a means of achievement; and as the primary outcome that measures their success (O’Shea & Delahunty, 2018).

Psychological distress, focusing on depression, anxiety or stress symptoms, has been associated with significant academic decreases in performance and engagement (Stallman, 2010). Research shows that students who experience high psychological distress are, on average, prevented from working or studying for 8-day periods over four weeks due to stress, which overall affects their ability to study (Stallman, 2010).

Given the high percentage of psychology students experiencing disruptive levels of stress during graduation, programs and faculties should take further steps to educate and assist students in developing skills management and addressing barriers to their well-being, ensuring that unique differences between different demographic groups are addressed (El-Ghoroury et al., 2012).

Two recent studies in Australia reported that university students had psychological distress significantly higher than their collective peers (Stallman, 2010). Using the Kessler Psychological Distress Scale (K10) with a ≥ 22 score (high to very high distress) in a sample of undergraduate students at Adelaide University, Leahy et al. (2010) evaluated the prevalence of psychological distress. They determined that their prevalence was significantly higher than its age-compared community peers (48% vs 11% ).

In a second study that used K10, Stallman’s (2010) study, from two major Australian universities, also looked at how the prevalence of psychological stress in universities was considerably higher (age range: 16-30) and mature (age range: 30-50) than their community colleagues (84% vs 29% and 19% vs 3%).

Transdiagnostic mental health programs are well adapted to students’ diverse mental health problems and provide them with skills to handle university stresses. Acceptance and Commitment Therapy is one transdiagnostic, empirical-oriented procedure (ACT; Hayes et al., 2011) used successfully to reduce mental health problems and improve well-being (Pakenham, 2015).

The majority of university environments address students’ needs by providing on-campus services such as health and medical and counselling assistance. University environments provide a unique opportunity to reach many students using these existing university services; otherwise, they cannot seek help (Hunt & Eisenberg, 2010). However, given that university students already rely heavily on the internet for study purposes, the online delivery of promotional programs for mental health is conveniently a form of practical and easily accessible intervention. The combination of treatment-seeking and the resources of mental health services are a promise of online self-help. In recent decades, a wide range of student-related problems such as depression, anxiety, eating disorders and addictions have shown the effectiveness of internet self-help psychological measures (Andersson, 2016).               Research has begun to show the possible effectiveness of such mobile self-help interventions (Donker et al., 2013). These modals are self-guided, online in format and can be disseminated widely with minimal costs per new user. Supporting this, a total of around 40% of university counselling centres are now providing university students with psycho-educational information on their website, in order to address the growing demand for mental health services (Gallagher, 2014). To address how to meet the increasing demand for services by providing an alternative, cost-effective format, online self-help can also be particularly promising.

Purpose of the Study

Mental health, mental illness and distress on Australian university campuses are genuine problems (Connell et al., 2007; Leahy et al., 2010; Stallman, 2010; Sarmento, 2015). While statistics point to the seriousness of student psychological concerns (2018–19 ABS Annual Report, 2019), universities struggle to understand how to support them effectively (Stallman & Shochet, 2009).

Worldwide research shows numerous barriers to student-aid research (Eisenberg et al., 2011; Golberstein, 2008), and a small group is identifying new ways to restructure support services to address these barriers, and to help the increasing number of students who seek support (Ryan et al., 2010).

This study aims to gain a student perspective on barriers that prevent students from seeking psychological assistance and understand how university support services – including health centres, can help remove these barriers and serve the increasing numbers more effectively. The overarching objective is to provide an overview of the barriers encountered by first-year psychology students (both recent school leavers and mature-aged) in Queensland, that prevent psychological problems from being addressed and outline ways to modify support services to overcome these obstacles in order to meet the growing requirements.

Research Questions

The study asked three questions from the viewpoints of university students in order to better understand the barriers that students encounter in the field of help-seeking; and then generate practical suggestions as to how support services can be modified to overcome help-seeking barriers:

1. What are the key factors influencing university students to complete extra­              curricular internet-based self-help psychological well-being programs?

2. What are the main barriers to university students completing these programs?

3. Are there any differences between mature-aged and recent school-leavers, in the key factors they believe are barriers to completing these internet-based self-help well-being programs?

Self-Determination Theory

Given the high-stress costs for physical and mental health, there are theoretical and clinical significances to understand how stress is caused and managed. Self-determination theory is the only theory of motivation, which explicitly identifies autonomy as a human need that, once encouraged, facilitates a more autonomous form of behavioural regulation (SDT; Deci & Ryan, 2000). The theory of self-determination applies to areas like health, education, work and sport. SDT health research thus focuses on students’ perception about supporting autonomy (as well as the other basic psychological needs of competence and relatedness). Some have theorised that more autonomic support and satisfaction of basic needs lead to the adaptive auto-regulations of healthy behaviours (i.e., more physical activity, medication prescribed, help-seeking) (Kasser & Ryan, 1996).             

Experimental field studies and clinical trials (Niemiec et al., 2009) have typically trained physicians to support clients’ psychological requirements, and have documented significant changes in behaviour, motivation, and well-being. The follow-up periods in post-treatment studies extend to 24 months and generally have supported the long-term effects. The studies described by Ryan et al. (2008) in SDT models, explain why SDT is building interconnecting and predicting mental and physical health indices (Fig. 1). There are three fundamental psychological needs: autonomy (the feeling that one’s behaviours are their own), skills (feeling effective); and relatedness (being cared for by others) are central to the model.

The support for these needs and their subsequent satisfaction provides a better psychological energy quality that is predicted to motivate the introduction and long-term maintenance of health behaviour and has been empirically confirmed (Ryan et al., 2008). Given the importance of psychological needs for health satisfaction and optimal performance, the SDT model identifies contextual and individual factors which optimise this satisfaction. These factors include a healthcare climate that supports independence, a high degree of autonomy and an intrinsic life-expectancy.

Figure. 1. The SDT model of health behaviour change adapted from Ryan, Patrick, Deci, and Williams (2008).

The more autonomous the person’s motivation, the greater his persistence, performance and well-being in an activity or within a domain are shown by SDT research (Ryan, 2009).

Universities’ promotion of mental health skills made a priority

The increased prevalence of mental health problems and stress among a range of students (Blanco et al., 2008; Gallagher, 2014; Ryan et al., 2010) indicates an urgent need for university mental health education. According to the National Health Survey (Australian Bureau of Statistics, 2019), 4.8 million Australians (20.1%) suffer from mental illness, an increase from 4 million Australians (17.5%) in 2014-15; with an estimated 49.1% (age range 18-24), 59.1 % (age range 25-34), and 60.1% (age range 35-44) of the population experiencing low levels of psychological distress; 25.7% (age range 18-24), 23.5 % (age range 25-34), and 24.8% (age range 35-44) moderate distress; and 3.2% -12.4% (age range 18-24), 3.1% -11.8 % (age range 25-34), and 2.5% - 10.3% (age range 35-44) experiencing very high to very-very high distress levels. Females aged 55-64 reported higher levels of distress than any other group. Besides, reviews of epidemiological studies show that 50-75% of all life-long mental disorders are likely to develop between mid-teens and 25 years of age (Kessler et al., 2007) – the age range of most university students. These statistics highlight the crucial need for targeted interventions to enhance mental health skills in younger adults and potentially minimise or prevent mental health problems later in life (Burns & Rapee, 2006).

The typical age range for most students at university is also a critical development period. Unresolved mental health problems can influence social, emotional and cognitive factors and have lasting effects on adults’ lives (Bewick et al., 2010; Rickwood et al., 2005). Most university students are also linked to other milestones that can aggravate stress, such as parental separation, financial independence, increasing academic responsibility, decision-making in education and career, intimate relations, and balancing work, study, and social life (Rickwood et al., 2005).

Inadequate mental health skills can have a significant impact on academia, physical and emotional health and overall quality of life (Bewick et al., 2010; Ryan et al., 2010), with significant long-term health challenges and adaptation challenges (Bewick et al., 2010; Rickwood et al., 2005). Because these effects for university students are more pronounced than those of the general public of the same age (Stallman & Shochet, 2009), there is a dire need for university-based mental health promotion. To attain the most significant reach, mental health support must include mental health aspects: providing mental illness management strategies and encouraging positive psychological states.

The dual-factor model of mental health

University students’ needs have moved from more benign development and information to more severe psychological problems (Gallagher et al., 2001; Eklund et al., 2011). Traditional psychological assessment practises, with diagnoses connected to behavioural symptoms and associated levels of impaired functioning, focus on the presence or lack of psychopathology. With a focus on pathology, the challenge faced by universities’ mental health services is how the needs of students with more involved psychological problems and other students can be addressed. Positive psychology models of mental health incorporate risk and pathology with human adaptation and development (Masten, 2001; Keyes, 2005). In this light, individuals adapt to life’s challenges and face a mental health orientation that is particularly applicable to students’ broader health and development needs on university campuses.

The dual-factor model was proposed as co-occurring, distinct factors that contribute to mental health's overall functioning. In the dual-factor model of mental health, ‘mental health’ is defined as the lack of psychology and the presence of a flourishing disease (Keyes, 2005). In other words, a person is not classified as ‘mentally healthy’ simply because they do not have a mental illness (Keyes, 2005). Unlike treatment models that focus only on pathology, treatment modalities such as ACT work dualistically. They do this by decreasing the vulnerabilities of psychopathology while at the same time teaching strategies to thrive (Hayes et al., 2011).

Focusing on positive mental health through education and skills building, combined with evidence-based pathology strategies, could lead students to greater well-being and prosperity. Positive mental health is of great importance to university students, particularly in refining their university studies’ values, academic goals and performance, and career guidance decisions (Levin et al., 2014). The use of a dual-factor mental health model to guide intervention development is likely to facilitate a range of skills designed to enhance participants’ positive mental health attributes. These include psychological flexibility, valued living, and the minimisation of psychology. Another critical aspect of promoting mental health is educating students about their mental health. This is referred to as ‘mental health literacy’ (MHL).

Graduate student mental health

There has been growing international concern about university students’ mental health and the unrecognised and untreated mental illness that may impact individual students, institutions, and sometimes other students (Shuchman, 2007). Graduate students experience more serious psychological distress than the general public, and severe mental illness (SMI) signs and symptoms are also higher (Stallman, 2010; Australian Bureau of Statistics, 2019). With over 1.3 million Australian university students at present and an estimated 20% of those with mental illness, it is time for universities to focus more on this issue (Carter et al., 2017, p. 01). These conditions’ costs vary from suicidality (Drum et al., 2009) to academic failure (Eisenberg et al., 2009). Large-scale epidemiological studies in North American and Australian university students indicated that 19.2 to 50% of students satisfy criteria for one or more disorders in mental health (Blanco et al. 2008; Hunt & Eisenberg, 2010; Stallman, 2010). Students’ ability to do their work for 10 to 15 days a month on average decreases when high levels of psychological distress, compared with 1.7 days for those with low stress (Stallman & Shochet, 2009). However, increasing numbers of specific disciplines, such as Psychology and Counselling, have been associated with increased stress and distress among university students (El-Ghoroury et al., 2012).

Research from university counselling health services indicates that there are not enough services nationally to meet student needs and that the complexity and severity of problems presented by students have increased (Stallman, 2011). A study by Stallman from on-campus counselling centres in Australia and New Zealand (2011) indicated that students’ mental health needs are significantly lacking, with one counsellor assigned to 4,340 students. Depression, stress, anxiety, and academic and relationship problems are critical issues for Australian university students (Ryan et al., 2010).

Previous research has identified several subgroups of students with an increased risk of mental health problems. International students are more likely to suffer from mental health problems than domestic students (Khawaja & Stallman, 2011). Gender was also recognised as a factor; males are at higher risk than female students (Blanco et al., 2008; Hunt & Eisenberg, 2010). In 2012-2013, after age adjustment, Indigenous people were 2.7 times as likely as non-Indigenous people to experience high or very high levels of psychological distress (Australian Indigenous Health Info Net, 2018).

Furthermore, social and lifestyle factors; like low social support (Blanco et al., 2008; Hefner & Eisenberg, 2009); difficulties/lost relationships (Blanco et al., 2008); increased stressful life over 12 months (Blanco et al., 2008). Studies indicated that first-year students are at greater risk of mental well-being issues (Bewick et al., 2010). Students from higher education institutions in Australia that neglect mental health problems and stress-induced disorders are more likely to experience mental health problems than general population members (Ryan et al., 2010). The additional stress of high fees and university students’ performance expectations can cause or acerbate pre-existing conditions. Poor mental health is also related to risky actions such as excessive alcohol, unprotected sexual activity, and illegal substance use (Sarmento, 2015).

In higher education, multiple barriers challenge students who experience mental health difficulties that negatively affect successful completion (Orygen, 2017). Successful integration and engagement with student life are disrupted for these students, along with fluctuations in concentration, lower academic confidence levels, mood variability, motivational spikes, adverse drug effects, and difficulty in social relations (Venville et al., 2016). University students’ poor mental health can also adversely affect universities. An extreme example is the 2007 Virginia Polytech incident, which claimed 27 students and five faculty members (Shuchman, 2007).

Compared to males and the general population, female university students are also at an increased risk of severe mental illness. In the 18–24-year age category, 22.2% of females reported high distress levels, indicating severe mental illness. This risk, compared to 16.4% of males and 3.5% of the general population for females and 3.3% for males (Stallman, 2010).

Mental Health Literacy (MHL)

Mental Health Literacy (MHL) refers to public awareness of the measures that people can take to prevent, respond to, and treat mental illness at an early stage. The prevalence rate of MHL among university students is low and indicates a lack of awareness of mental health among the population. It is an essential element to tackle issues of mental health and is gaining momentum in universities. From a social perspective, education in the prevention, intervention and treatment of most physical diseases is widely accepted; however, mental health is not yet the case (Jorm, 2012). MHL has different elements, such as recognising developmental disorders, knowledge of mental disorder prevention, and knowledge of the availability of treatment options (including effective self-help strategies for the less severe disorder) (Jorm, 2012).

The promotion of MHL at the university level offers benefits. In university, students develop MHL (e.g., through exposure to programs teaching them mental health) as a regular part of their mental health development. In turn, the skills they have developed are more likely to be used (Dossett et al., 2013). These skills are fundamental since studies with university students on behavioural care have identified a perceived lack of necessity as a significant reason for not seeking mental health treatment (Golberstein et al., 2008).

Universities provide students with limited psychological assistance to help students with mental illness support and fight attrition. Research in university counselling and health services on campus indicates a lack of resources to meet student needs and increase the complexity and severity of students’ problems (Stallman, 2011).

Poor mental health also leads to increased university attrition rates, with research suggesting that students with mental health issues are double the risk of leaving before their studies are completed (Auerbach et al., 2016). This attrition affects universities; reputations suffer and financially from the loss of tuition fees and alumni donations(Berge and Huang, 2004). Besides, the higher the university’s retention rates, the greater the likelihood that it will be ranked higher, secure more bonds, and accredit more smoothly (Thammasiri et al., 2014). It is, therefore, in the interests of universities to make sure that students graduate.

Although MHL interventions have shown that their attitudes to help seekers in adults are significantly enhanced(Lo, Gupta and Keating, 2018), the use of MHL in universities is scarce and has had mixed results. Reavley et al. (2014) tested the ‘Mind Wise’ MHL intervention in nine Australian universities to assess whether it could improve MHL and help-seeking and reduce psychological distress and alcohol abuse. Mind Wise included e-mails, posters, campus events, fact sheets, and first aid mental health courses. Results indicated that there were no effects on psychological distress compared to the waitlist group; however, participants in the intervention group were more likely to recall interventional elements two years later and indicated that they would attend a drug and alcohol centre for problems with alcohol (J.Reavley et al., 2014).

Despite the considerable amount of work done to improve MHL, the population of young Australian university students still lacks qualitative research which considers social perceptions of mental health (Jorm, 2012). Australian universities should pay serious attention to their student’s mental health and well-being. The Higher Education Support Act 2003 (HESA) mandated that adequately qualified staff provide advice services free of charge to domestic students (Jorm, 2012).

In June 2018, the Australian Federal Government released the final report of the Higher Education Standards Panel on Improving Retention, Completion and Success in Higher Education, recommending that all universities should have a mental health strategy supported by genuine commitment and appropriate resourcing, including appropriate staffing levels of university counselling services (Australian Government Department of Education and Training, 2017). Not only does psychological distress negatively affect the individual student, but emotional or behavioural problems can also sometimes result in disturbing, disruptive or aggressive behaviour affecting student peers and university staff (Shuchman, 2007).

Severe psychological distress can lead to self-harm and suicide in the end. For ethical reasons alone, universities are responsible for promoting and ensuring all students and staff's safety and well-being (Stallman, 2011). Support for student well-being is also essential to fulfil universities’ core missions to provide a high-quality educational experience and positive graduate outcomes. A variety of projects and initiatives aiming at students with programs to improve mental health education, develop the abilities to self-identify and manage stress, and encourage aid seeking have recognised universities' unique potential to support students’ mental health (Stallman, 2011). This approach recognises the significance of the student's mental health and well-being of the university context's educational and learning environment (Stallman, 2011).

Australia has improved MHL among its population through various national initiatives (Kessler et al., 2005). In the Australian national survey, Kessler et al. (2005) found that 67.3% of participants (n = 910) recognised significant depression described in a case vignette correctly. Young tertiary education students need to tackle mental health problems, be it with professional aid or searching for self-help. Many factors affect the search for and interaction of help to determine when and how people seek mental health problems (Rickwood et al., 2007).

In the last decade, Australia was a leader in the policy and investment of youth in mental health. Not just the fact that the Australian Government’s favourite evidence-based platform for early intervention has developed ‘Headspace’; the early psychosis service model, but also templates international efforts to tackle the mental health of youth (Orygen, 2017).

Universities are in the ideal position for identifying and providing information, resources and ways of early interventions on mental health to students at risk of mental illness. Universities are also in an excellent position to develop and implement policies programs and support ‘in-house’ programs, and support students with high-stress levels (Orygen, 2017).

A critical approach to this problem understands better students’ social context and relationships with mental health. Friends, family and other important people can give instrumental, informative or emotional support. This support is commonly called social support and is considered a psychosocial resource for managing stress, positively affecting individuals' reserves, such as self-appreciation and self-efficacy (Thoits, 1995).

Australian students’ MHL needs to be investigated to develop appropriate interventions in higher education settings. Young people’s reluctance to seek professional assistance for mental health problems is increasingly recognised as a challenge to practice early intervention approaches (Orygen, 2017).

Decreased MHL can also impact help-seeking behaviour, with research showing that students do not often perceive a need for treatment even in situations of distress (Golberstein et al., 2008; Eisenberg et al., 2009). Research suggests that stress is simply part of studying (Golberstein et al., 2008; Stallman, 2010). The effect of decreased MHL levels and negative mental health attitudes concerning help-seekers behaviours were investigated in university populations. The most critical barriers to help-seekers included a low awareness of mental health conditions, symptoms and treatment options, and negative attitudes to help-searching, including a recommendation on help-seeking for others (Cheng et al., 2018). In contrast, students with higher MHL rates showed increased intention for assistance, as did students who had previously sought professional help in the face of an issue of mental health (Cheng et al., 2018).

Overall, these studies point out that, although important, MHL alone is not sufficient to improve mental health outcomes. It does, however, play a role in increasing awareness of mental health problems and encouraging assistance-seeking behaviour.

What is Help-Seeking?

A way for students to access resources themselves would be to engage in the search for help actively. Help-seeking behaviour has been conceived as a multi-stage process among mental health researchers (Eisenberg et al., 2009). According to Eisenberg et al. (2009), individuals begin by experiencing a specific health problem, followed by a need for professional assistance. They then assess the costs and benefits of receiving treatment (within the context of social standards for seeking assistance) and take action to receive care by choosing one of several types of mental health assistance.

Tertiary students are a unique demographic. The transition from high school to post-secondary education is characterised by changes, adjustments, and ambiguity concerning the disruption of routines, security, predictability, and loss of control during high school (Versaevel, 2014). A way to support students is by offering different resources in terms of mental health, academia, physical activities and finance to university institutions.

Student perceptions of help-seeking can also vary. Chew-Graham et al. (2003) looked at medical students' perceptions about the help available to mental health students and their attitudes towards help-seeking at a British university. The authors had semi-structured interviews with twenty-two medical students. The authors found that most students sought assistance from family and friends in their mental health concerns instead of clinical professionals on campus (Chew-Graham et al., 2003).

Students also had limited knowledge of existing on-campus mental health services. Most importantly, students reported that their future qualifications would have been affected by perceived stigma regarding mental health concerns. The student’s perceived stigma would prevent them from trusting clinical professionals on campuses because of the fear of not keeping their information confidential. The results of this study indicated that the lack of knowledge concerning support on campus and the belief that a clinical professional is trusted can be attributed to students' unmet need (who is associated with the university), would negatively impact their future aspirational goals (Chew-Graham et al., 2003).

Mental health approaches available to university students

Several approaches to mental health intervention have been employed, both at the clinical level and in the prevention of mental health of university students. Interventions vary with the problem being approached (e.g., alcohol consumption; depression or anxiety) or the emphasis on teaching (e.g., in a self-help format). Diverse delivery formats such as individual and face-to-face treatment, online assistance and a combination of both have been adopted. The treatments used also vary and include cognitive behavioural treatment (CBT), ACT, mindfulness, social skills training, psychoeducation, interpersonal psychotherapy and relaxation (Conley et al., 2017).

This thesis’s importance lies in its ability to determine if the behaviour of students seeking assistance in universities determines the use of university support services and if those services ultimately address the needs of students. In particular, the effects of university support services on psychological distress, as outlined in the purposes above, contributes considerably to learning outcomes. Can this information also contribute to influencing the design of university support systems and services? A more comprehensive understanding of student experience and the impact on mental health issues can help university administrators understand the practical support for students’ actual and targeted needs. Potential new measures are being developed to support distressed students and, consequently, enhance overall learning, performance, and tertiary training interaction.

In past studies, the quantification and qualification of behavioural and psychological distress among university students have been central (Jorm, 2012; Stallman, 2008, 2010; Stallman & Shochet, 2009). While these two questions are essential as individual characteristics and an indicator of the performance and interaction of students in the university environment, they have not focused on ways these measurements can contribute to the design and configuration of university support systems. This study is intended to understand the demographics of students accessing support services by interpreting information collected from a sample of local university students. This research aims to determine whether the psychological distress and behaviour of students who have access to the support services change significantly. Further insight into student’s understanding of health literacy and related health actions will be given to understand the relationship between psychological stress and behavioural care.