INTRODUCTION
A person's mental health is something that needs to be paid as much attention as physical health, moreover mental illness cannot be seen and identified easily [1]. Mental health is defined by the World Health Organization (WHO) as a condition of individual well-being who realizes one's potential, can cope with the stresses of normal life, carries out productive and fruitful activities, and is able to contribute to the surrounding environment. Another definition of mental health is a condition where an individual can develop physically, mentally, spiritually and socially so that the individual is aware of his own abilities, can handle pressure, can work productively and is able to contribute to their community [2].
Mental illness is a huge burden on health services in whole. In 2019, there were an estimated 970 million people in the world living with a mental disorder, 82.0% of whom were in low- and middle-income countries (LMIC), while between 2000 and 2019, there were an estimated 25.0% more people living with a mental disorder [3,4]. WHO estimates that neuropsychiatric conditions contribute to 10.7% of the global disease burden [5]. With the direct economic impacts of mental illness (such as spending on treatment) and indirect impacts (such as lost productivity) it costs the global economy an estimated $2.5 trillion annually. It is estimated that this number is increasing rapidly and will increase by around $6 trillion or a third of the global economic burden due to non-communicable diseases by 2030 [5].
Specific data regarding mental illness and symptoms of depression in Indonesia is still limited. One study in 2013 which was located in 26 low-, middle- and high-income countries (including Indonesia) showed that 24.4% of students experienced symptoms of depression, including 8.9% with severe depression and 28.4% with moderate depression. This figure is much higher than other Asian countries such as China (2.4% in 2017), Korea (11% in 2017), Nepal (4.2% in 2016) and Vietnam (2.8% in 2011) [6]. Meanwhile, based on 2018 Basic Health Research (Riskesdas) data, the population aged over 15 years who experienced mental health problems in Indonesia reached 9.8%, where there was an increase of 3.8% from the previous 6% in 2013 [7].
The highest prevalence of depression is found in the adolescent or adult age range and decreases with increasing age. Nationally, the prevalence of depressive symptoms is high in Indonesia, experienced by adults at 21.8% in 2014~2015 [8]. The age range of 18~25 years is a period when individuals no longer feel like they are teenagers but are not yet fully adults, which is then referred to as the emerging adulthood stage. This stage is generally felt when entering a university or college environment after graduating from Senior High School. Students in the first year as new students will experience various situations that are different from before, both in terms of the lecture system, learning methods, a wider circle of friends and a new living environment [9]. The various changes that occur require students to be able to adapt to the environment around them. The inability to adapt will certainly have a significant impact, especially mental and psychological problems, such as feelings of disappointment, failure, lack of self-confidence and feelings of depression due to not being able to overcome the problems that occur. This is what often triggers mental health problems among students [10].
Related with that more specific scope, the urgency of this research is the increasing number of suicide cases among students who are thought to be due to depression in the Semarang City university environment in the immediate period. Where the suicide case of a 20-year-old student was found in a downtown shopping center and a 23-year-old student at his boarding house, both of whom left a will about what they experienced [11]. Before deciding to end his life, one of the victims showed changes in behavior that were symptoms of depression [12]. This incident is considered a signal that society, especially students, increasingly needs to increase awareness of mental health conditions. The university already has a Health Service Center (Puslakes) and a Counseling Center, but in fact it is not effective enough in dealing with mental health problems.
The lack of knowledge and awareness of mental health in social life, even stigma and discrimination against people with mental disorders, results in someone who actually has a mental disorder refusing to get psychological help from professional services and even denying that he or she does not have a mental disorder. Large costs and limited time are also obstacles to someone refusing help from experts such as psychologists [13]. Therefore, early detection is needed as a preventive measure to determine mental health conditions, symptoms and factors as well as triggers for the emergence of mental health problems as early as possible [10]. This needs to be done because there is a lack of awareness in society, individuals and the social environment regarding mental health, resulting in delays in treatment which can make mental conditions worse and even end life. It is hoped that the results of this study will be able to detect the mental health conditions of students in general and take the necessary efforts to prevent more serious conditions. This study aims to detect the mental health conditions of college students and identify the factors influencing their reluctance to seek psychological help, in order to prevent the progression of more serious mental health issues.
METHODS
1. Study Design and Participants
The study used quantitative with a descriptive survey design. It was chosen with the aim of describing and identifying the phenomena found in terms of the respondent’s mental health state. The population in this study were active undergraduate students who fall into the late teenage age category, the age in question is 18~24 years. Based on available data, the population in question for first year and second year students is 20,733 students [14]. Sample requirements in this study were calculated using the Slovin formula where the margin of error used was 5%. The results of these calculations showed that the number of respondents' needs was at least 400 people. The inclusion criteria for respondents were aged between 18~24 years who were registered as active students and were willing to be respondents in this research. Questionnaire forms were distributed online to all students who met the inclusion criteria, and during the specified filling time limit of one month, a total of 835 forms were returned. This research has been approved by the Ethics Committee of the Faculty of Medicine, Universitas Negeri Semarang with number (442/KEPK/FK/KLE/2024).
2. Measures and Instruments
The online questionnaire was developed using Google Form with a compilation of questions asked using the Indonesian version of the Mental Health Inventory (MHI38) and the Indonesian version of Health Seeking Behavior as well [15,16]. MHI-38 is a measuring tool that has been developed to assess various perspectives in mental health, namely explicit assessment of psychological distress and well-being. The MHI-38 instrument has been proven to be a valid and reliable instrument in mental health research and has been translated into various language versions. Meanwhile, this research uses the Indonesian version of the MHI-38 which shows relatively adequate reliability with a Cronbach’s ⍺ coefficient of 0.89 [15]. This research used The Mental Health Literacy and Help-Seeking Behavior questionnaires by Stan Kutcher et al., which have been translated and developed Fransisca Kaligis et al. [16]. The questionnaire consists of three parts, namely Mental Health Knowledge, Attitude Toward Mental Health, and Help-Seeking Behavior questionnaires, but this research only focuses on the Help-Seeking Behavior for adolescent’s section.
This research questionnaire form is divided into five parts, namely respondent characteristics, namely MHI-38 which consists of two parts: Psychological Well-being (PW) and Psychological Distress (PD) and Health Seeking Behavior sections consisting of the first, second and third parts. All questionnaires asked were closed questions so that none of the respondent forms returned were excluded from the research.
First section, to collect information on respondents' characteristics, four question items were used, there are age, gender, region of origin and study program taken. There were 75 study program options recorded which were then grouped back into 9 faculty groups. Furthermore, for the region of origin section, there are a choice of 416 districts and 98 cities in 38 provinces in Indonesia. Next, the regions of origin were grouped into two different groups, namely (1) Central Java Province and (2) outside Central Java Province. This grouping was carried out based on the research location in that province.
Second section, the Mental Health Inventory (MHI-38) measures mental health consisting of 38 self-report items divided into two dimensions, namely psychological wellbeing (PW) and psychological distress (PD). Three psychological well-being (PW) subscales with 14 question items, namely General Positive Affect (GPA) 11 items, emotional ties (ET) 2 items and life satisfaction (LF) 1 item. Like PW, psychological distress (PD) also consists of three subscales with 24 question items, namely anxiety (AN) 9 items, depression (DP) 6 items, and loss of emotional control (LOE) 9 items. The MHI-38 assessment uses a 5-point Likert scale, there are 1=Never, 2=Rarely, 3=Sometimes, 4=Often and 5=Always with each answer having a value of 1-5. Therefore, the total score on the MHI-38 ranges from 38 to 190 consisting of PW 14 to 70 and PD 24 to 120. A higher score on the MHI-38 corresponds to better mental health whereas for the PD scale, which reverses the score on the item.
Last section, Health Seeking Behavior questionnaires refer to individuals' patterns and actions in seeking help or support when facing mental health problems in various ways such as seeking information or contacting mental health professionals. Factors that influence this behavior include the individual’s level of awareness about their mental condition, social stigma, accessibility of services, as well as the availability of social support. This questionnaire consists of 16 question items. The first five questions are questions assessing individual attitudes towards seeking and providing support for mental health problems based on different situations in each question item. The form of answer to this question is a five-point Likert scale (Strongly Disagree=1, Disagree=2, Neutral=3, Agree=4, Strongly Agree=5). The result of this section of questions are categorized into one category group. One question is in the form of a self-assessment (self-report) regarding the current condition of your need for help seeking mental health. Consists of four answer choices in the form of I have no problems or concerns regarding mental health, I am waiting to see a mental health professional, I chose not to talk to mental health professional even though I am worried about my mental health, and I have spoken to mental health professionals. Nine questions regarding respondents' statements of attitude during the last three months towards parties who can help. The answer form is in the form of 3 statement items, there are asking for help=1, Wanting, but not asking for help=2 and Don’t need for help=3. One last question asked about the respondent's plans in the future to ask for help from these parties (parents, siblings, distant relative, close friend, collage friend, lecturer, religious leaders health workers in primary health care, mental health professionals).
3. Statistical Analysis
The first analysis carried out was descriptive analysis for respondent characteristics and mental health inventory. The results of the overall psychological well-being data analysis are grouped into 3 categories, namely low, moderate and high, where the group is determined based on the total score, where the bottom edge to the top edge is in the moderate group, while scores less than the bottom edge are in the low group and vice versa, more than the top edge is in the high group. This grouping also applies to psychological distress. Apart from that, descriptive analysis was also carried out for Health Seeking behavior so that the frequency of each respondent’s condition could be known. The bivariate crosstab x2 test was carried out to determine the relationship between variables and determine the correlation value. All statistical tests were carried out using IBM SPSS 25.
RESULTS
1. Respondents’ Characteristics
Respondents in this study are 835 people consisting of 509 (61.0%) women and 326 (39.0%) men, all of whom were active students in their first and second year of study. Respondents’ ages were categorized into two groups, namely 18~19 years and more than 20 years, while respondents’ regional origins were categorized into Central Java (local area) and non-Central Java. More details characteristics of respondents can be seen in Table 1.
2. Psychological Well-Being and Psychological Distress
The obtained psychological well-being and psychological distress scores were then grouped into three categories. Based on data analysis, the lowest score for the psychological well-being assessment was 22 points and the highest was 70 points with a mean value of 48.24. Percentile values are used as a benchmark for grouping psychological well-being conditions with details of obtaining scores below <43=Low well-being, 43~53=Moderate wellbeing, and >53=High well-being. Likewise, psychological distress scores are grouped into three categories <50=Mild Distress, 50~69=Moderate Distress, and >69=Severe Distress. In this study, we detailed in more detail the items of psychological well-being (General Positive Affective, Emotional Ties, Life Satisfaction) and psychological distress (Anxiety, Depression, Loss of Emotional) so that the relationship between other variables is known. More details can be seen in Tables 2 and 3 of the results of the bivariate crosstabs Kendal’s tau test between variables.
Based on Table 2, it is known that the percentage of psychological well-being for women and men is similar, where the moderate well-being group has a score of 52.8% and the p-value for gender comparison is .989. This shows that there is no significant difference in the level of psychological well-being between women and men or in other words they have similar patterns of well-being. If we look at it based on age, there is a significant relationship (.001) between age and psychological well-being, specifically General Positive Affective which is also .001, and Life Satisfaction 0.005. Where the Correlation Coefficient value shows -.12 (p=.000), which means that as age increases, overall psychological well-being tends to decrease, including general positive affective and life satisfaction, although this relationship is not very strong. Related with the age, the regional origin variable is significantly related (p=.024) to psychological well-being with a correlation coefficient value of -.07. This data can be interpreted as individuals from outside the region (migrating) tend to have slightly lower psychological well-being than those from within the region (not migrating).
Table 3 shows that gender is significantly related (p<.001) to overall psychological distress. Meanwhile, the correlation coefficient value is negative with a weak level of relationship between the two variables (-.14) for all dimensions of psychological distress, meaning that women do not have more anxiety, depression and emotional loss than men even though they have a weak relationship. Furthermore, psychological distress is significantly related to age, where the older age group (20~24 years) is more prone to depression and emotional loss than the younger age group (18~19 years). Levels of anxiety (p=.050) and depression (p<.001) of the respondents within the region are higher than those from outside the region.
3. Health Seeking Behaviour
Table 4 shows self-report mental health in seeking health assistance. It can be seen that regional origin is the only one that is significantly related (p=.007) to seeking health assistance. As many as 68.4% of individuals in the region (not abroad) have spoken with professional health workers.
Figure 1 shows the frequency distribution of various sources of support chosen by respondents for mental health problems, as well as patterns of requests for help. Data shows that the parties who asked for help the most or were invited to discuss their mental health were close friends 403 (48.0%), followed by parents 330 (40.0%) and siblings 220 (26.0%). In the Wanting, but not asking for help category, the highest preferences were parents 265 (32.0%), mental health professionals 261 (31.0%) and health workers in PHC 230 (28.0%). Meanwhile, those deemed in Don't Need Help were lecturers 589 (71.0%), relative distance 517 (62.0%) and religion leaders 507 (61.0%).
DISCUSSION
This research identified that levels of anxiety, depression and emotional loss tend to be higher in men than women. These findings support the results of previous studies showing that men often experience greater emotional challenges although they are less likely to report them openly and often experience more severe forms [17]. Furthermore, men often feel pressured to meet standards of masculinity which can prevent them from seeking mental health help making proper detection and diagnosis difficult [18]. This worsens their emotional state and hinders effective treatment.
We found that teenagers in the older age group (20~24 years) had better levels of general positive affective and life satisfaction than the younger age group (18~19 years). In line with these findings older individuals often report higher positive affectivity and lower negative affectivity than younger individuals [19]. One key factor that could explain this difference is improved coping skills and greater life experience as well as greater emotional maturity in older individuals, so they are better able to manage stress and enjoy the positive aspects of life. At the age of 18~19 years, many individuals are still in the process of exploring their identity and life goals [20]. This transition period is often accompanied by uncertainty and pressure as well as facing new stressors, which can affect levels of life satisfaction.
This research shows that teenagers who migrate have a higher level of life satisfaction compared to those who do not migrate. These results are consistent with previous findings showing that migrating often brings psychological and emotional benefits. Adolescents who migrate often encounter new challenges and opportunities that encourage them to develop personally, which in turn can increase their life satisfaction [21]. Adolescents who migrate may experience a greater sense of independence and autonomy compared to those who remain in their home area. In addition, going abroad can help teenagers develop adaptation skills that contribute to their psychological well-being. Although migrating is sometimes not stressful, a lack of adequate preparation and social support can exacerbate the challenges faced and can make individuals vulnerable to mental health problems, especially due to feelings of insecurity and loss of community support before migrating [22].
Close friends (48.0%) are the ones most often used as story partners, which indicates that strong interpersonal relationships can provide comfort for individuals facing mental health problems. In line with these findings, several previous findings reveal that interactions with close friends can influence an individual's psychological wellbeing, lower stress levels and better cope with emotional challenges [23,24]. Meanwhile, parents and siblings are the other parties seeking mental health assistance. Individuals who have strong social support, especially from friends and family, tend to experience lower levels of anxiety and depression and can increase the individual's resilience and ability to deal with stress [25].
Several studies have shown that students, who are in the transition from adolescence to young adulthood, tend to seek informal help from relatives or friends, rather than professional help when they experience psychological distress [16,22]. A systematic review study reported that there are several barriers for adolescents in seeking and accessing professional help for mental health problems, namely limited knowledge, reluctance to seek help, uncertainty about the effectiveness of professional help, adolescent concerns regarding sharing personal secrets with unknown people and preference for informal support from family or friends [26]. In addition, the influence of social stigma and shame, fear of losing status in the peer group and making their family angry or upset [27]. Moreover, there are also obstacles related to the costs that must be paid to obtain mental health services, in general they do not have personal income apart from what their parents send [26,28].
The limitations of this study are that the results showed that adolescents rely more on friends and family than professional services, this limitation did not further investigate how the quality or effectiveness of informal support compared to professional support. Therefore, further research is needed, especially qualitative studies for emotional or psychological factors that affect the mental health conditions of students. In addition, it is necessary to explore the role of masculinity that prevents men from seeking mental health help in more detail. It is also necessary to examine the comparison of support from friends or family compared to professional support in dealing with mental health problems in students.
CONCLUSION
This research contributes to the knowledge of the determinants of the psychological well-being, psychological distress and help-seeking behavior among students in first and second year. On the other hand, although no significant gender differences were noted in psychological wellbeing, age and regional origin were significantly associated with both well-being and distress. We found that older students and those from outside the region exhibited slightly lower well-being and were more prone to distress, particularly depression and emotional loss. Concerning health-seeking behavior, students mainly sought help from close friends and relatives while seeking help from professionals was much more common among the local students. Our finding supports the need for focused mental health care that is relevant to age, region, and identified sources of support in order to meet the mental health needs of students.
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