Mental distress is among the most common type of mental health problems characterized by a mixture of different complaints and short duration [1]. This consisted of non-psychotic mental health problems including depression, anxiety, and somatoform disorders that can adversely affect the day to day activities of most individuals across the world [2, 3]. According to World Health Organization (WHO) 2015 report, over 300 million (4.4%) and 264 million (3.6%) of the total population of the world are estimated to suffer from depressive and anxiety disorders respectively [4].
In low- and middle-income countries (LMICs), the prevalence of depression and anxiety is high, which is mostly associated with the risk factors of poverty and socio-economic problems [5]. The contribution of these disorders to the global mental health burden from LMICs is high [6]. However, the accessibility of mental health service is still very low, which accounts for 76-85% treatment gap [7]. This gap is linked to the lack of skilled human powers, policy gap, lack of access to mental health services, economic, preferring to informal treatments, lack of mental health literacy, and fear of stigma [8-10]. As a result, the majority of people living with depression and anxiety in LMICs do not receive professional mental health care [11]. But, there is significant engagement with traditional and religious healers believing that mental illnesses are caused by spirit and demon possession [9].
Like in any other LMICs, large numbers of people in Ethiopia are affected by depression and anxiety; they are slightly higher among women compared to men [12]. These disorders are highly prevalent in the community that accounts for the pooled prevalence of 22% [12]. Depression and anxiety are associated with risk factors such as food insecurity [13], low socioeconomic status, violence, migration, and substance use [14]. The burden of these disorders in Ethiopia is increasing. For example, depression alone contributes to about 6.5% of the burden of diseases [14]. However, only few people receive professional mental health service. For instance, a meta-analysis reported that the pooled prevalence of formal mental health help-seeking behaviors and intention of people with depression is 38% and 48% respectively [15]. In Ethiopia, most people with mental illness first contact non-professional care providers such as religious leaders and herbalists [16]. But, when the problem remains untreated by these traditional healers and when it becomes more severe, they go to psychiatric care providers [16].
Barriers to receive professional mental health services in Ethiopia include lack of accessibility of psychiatric care, low awareness about mental health literacy, low commitment from funders to access the service, preferring informal treatments, poverty, and stigma [16-18]. Even the existing professional mental health services are mainly concentrated in the capital city of Ethiopia, Addis Ababa [19]. To scale-up the limited mental health services across the country, the government has planned to expand 100% of mental health care by 2020 [20]. National Mental Health Strategy which was developed in 2012 by the Federal Ministry of Health aimed to decentralize and integrate mental health care at primary health care level to make the service accessible, acceptable, and affordable for all Ethiopians [19]. It is currently under revision.
The prevalence of mental distress (depression and anxiety) is relatively higher among university students compared to the general population [21]. A research evidence shows that anxiety and depression are emerging public health problem among university students because of a range of challenging stressors they experience [22]. For instance, a cross-cultural web-based survey of 17,348 university students from 23 (high, middle, and low-income) countries reported an average depression prevalence of 20% [23]. A cross-sectional study in the Chinese university showed that the prevalence of depression and anxiety are 68.5% and 54.4% respectively [24]. Similarly, the prevalence of depression and anxiety among Ethiopian university students ranges from 21.6-49% [25, 26].
There are several explanations for the high prevalence of anxiety and depression among university students including because of: (i) vulnerability of these age groups for early onset of most mental health problems including depression and anxiety [27]; (ii) new identity formation (e.g., new peer relations, physical and social changes) and changes in emotional, behavioral, sexual, and social aspects [28]; (iii) transition from adolescence to early adulthood, with challenges of being away from home for the first time, and the balancing of emerging autonomy and independence [29]; and (iv) several stressors e.g., academic pressure, problematic substance use [30], and financial difficulties [31]. Similary, the prevalence of mental distress among university students in Ethiopia is also associated with various risk factors such as exposure to the new environment, low social support, family history of mental illness, conflict with friends, academic stressors, peer pressure, economic problems, lack of break, loneliness, not attending religious services, being freshman, being female, and substance use [32-34]. On the other hand, there are protective factors from mental distress among these students that include: having high social support, having an interest in the field of study, having good religious practice, having a sound relationship with roommates, being male, free from substance use, and having enough pocket money [33].
Depressive and anxiety disorders may harm university students’ academic performance, their physical and psychological well beings [30], and affect their overall quality of life [31]. Clinically depressed and anxious college students have significantly poorer performance on examinations compared to non-clinically depressed and anxious students [35]. The prevalence of depression and anxiety among undergraduate students is alarmingly high. At the same time, the proportion of professional mental health treatment gap is large ranging from 37% to 84% [36] , where the majority do not receive any professional mental health service [37]. This treatment gap is similarly high among university students in Ethiopia, where majority of the students receive treatment from informal sources such as family, friends, relatives, herbalists, and religious leaders [38].
Previous studies reported various reasons for not receiving formal health service by undergraduate university students with mental distress [36, 39, 40]. For instance, a study which was conducted in St. Catherine University, US, reported the main reasons for not using university counseling center were receiving help from friends or family, preference for self-management, considering their problems as not serious enough, and thinking the problem would get better by itself [39]. In addition, commonly reported barriers to receive mental health service were lack of perceived need, being unaware of the existence of such services, fear of stigma, concerns about privacy, lack of time, skepticism about treatment effectiveness, socioeconomic problem [36], denial and not wanting to be labeled as “crazy” [40].
Research findings about relationship between demographic factors (e.g., gender) and receiving mental health care are inconsistent. For example, studies showed that female students have more positive attitudes toward the utilization of mental health services compared with male students [41]. On the contrary, evidence showed that being male is more likely to seek mental health care compared with being female [42]. There is a study finding reporting that gender is not a predictor for seeking mental health care [43]. Similarly, there is also no significant difference between males and females in reporting barriers to receive mental health care [44].
In the same vein, research findings about the relationship between age and attitude to receive mental health care are not consistent. For example, older students are more likely to have positive attitudes toward seeking mental health care than younger students [45]. Contrary to this, another study reported that younger people have more positive attitudes toward seeking mental health care compared with older people [42]. There is also a finding reporting that there is no significant difference in barriers to access mental health services based on age [44]. Class years are also reported as a predictor to receive mental health services. For instance, due to treatment-related barriers, first-year and fourth-year students are less likely to use mental health services compared with second-year and third-year students [46]. But, rural-urban backgrounds are not predictors to access mental health services [47].
Furthermore, a previous study has reported that university students who had personal contact with a family with mental illness had a significant association with the non-help-seeking intention [48]. This could be because of the family with a history of mental illness experience high perceived public stigma [49]. Moreover, students with mental distress use substance to medicate the symptoms and get out of the feeling of discomfort [50] which might hinder them to receive professional mental health treatment.
Even though the existence of mental distress, associated risk factors, predictors, and barriers to receive mental health care among university students could be similar across the world, there might be higher prevalence, more complex risk factors, lower help-seeking behavior, and higher treatment gap in LMICs compared with developed countries [51]. For example, although the prevalence of mental distress is high among university students in LMICs, the majority of them do not receive professional mental health care, due to lack of skilled human and financial resources [52, 53].
Higher education in Ethiopia began in 1950 with the establishment of the University College of Addis Ababa [54]. At present, there are 45 public universities within the nine regions and the two City Administrations (Addis Ababa and Dire Dawa) in the country. According to the Annual abstract report of the Ethiopian Ministry of Education in 2017, there were 679,299 undergraduate students enrolled in the public universities. Of these, 392,788 students (255,657 male and 137,131female) were enrolled in regular undergraduate programs. The majority of the students were adolescents, single, economically dependent on their family, live in the university dormitory, full-time learner, and they came from rural and urban areas of all-over Ethiopia. Moreover, these students came from diversified cultures, religions, languages, and ethnicity.
A number of universities in Ethiopia are increasing and most of the studies conducted in these universities are primarily focused on assessing the prevalence of mental distress than looking at the possible barriers to receiving professional help. Besides this, there is a literature gap on identifying the perceived need for mental health service and the potential demographic factors associated with barriers to receive mental health care among university students in Ethiopia. Therefore, the current study aimed to assess the prevalence of mental distress, perceived need for mental health care, and to identify barriers to receive professional mental health care among regular undergraduate university students in Wolaita Sodo University (WSU).The present study also investigated demographic predictors for perceived barriers to receive professional mental health care. The findings from the current study will contribute to the existing literature by filling the literature gap on professional help-seeking intention for mental distress, predictors, and barriers to receive mental health service among regular undergraduate university students in LMICs. In addition to this, the current findings inform to adapt and study feasibility of psychological intervention for students with mental distress within Ethiopian universities with potential implication for other LMICs universities.