Int J Adv Counselling

DOI 10.1007/s10447-013-9203-y

ORIGINAL ARTICLE

Perceived Causes of Mental Health Problems

and Help-Seeking Behavior among University
Students in Ethiopia

Yirgalem Alemu

# Springer Science+Business Media New York 2013

Abstract The study examined perceived causes of mental health problems and professional
help-seeking behavior among university students in Ethiopia. Data were collected from 370
students from four randomly selected colleges. The results revealed that the majority of the
participants were able to recognize major mental health problems such as schizophrenia and
major depressive disorder. They attributed mental health problems to psychosocial and
biomedical factors and most of the participants had positive attitudes toward seeking profes-
sional psychological help.

Keywords Help-seeking . University students . Ethiopia . Mental health

Introduction

Mental health is an integral component of total health; however, in many countries it is not
accorded the same degree of importance as physical health. Although it is ignored or given
little attention, mental health problems are prevalent across the world. A review of European
studies found that about 27 % of adults were affected by at least one mental health disorder
(OECD 2008) and a similar number of people in Europe suffer from mental health problems
(Wittchen and Jacobi 2005). The actual prevalence rate for mental health disorders in Canada
is approximately 20 %; that is, about one in five Canadians will experience mental health
disorders that range from mild to severe in their lifetime (Jorm et al. 2006). A systematic
review of 10 studies of child mental health problems in 6 countries of Sub-Saharan Africa
indicated a prevalence rate of 14.3 % (Cortina et al. 2012).
Whereas in Ethiopia malnutrition and preventable infectious diseases are very common,
mental health problems are not given due attention (Deribew and Shiferaw 2005). The
prevalence of mental health disorders in Ethiopia is reported as 15 % for adults and 11 %
for children (WHO Reports 2000 & 2008; cited in Susuman 2010). The same reports indicated

Y. Alemu (*)
College of Education and Behavioral Sciences, Haramaya University, Alemaya, Ethiopia
e-mail: [email protected]
 Int J Adv Counselling

that from 2000 to 2008, the rates increased by 3 % for adults and 4 % for children. At such
rates, among every five persons, at least one will be affected by a mental health disorder at
some stage of his or her life (WHO Reports 2000 & 2008; cited in Susuman 2010).
Different researchers have indicated that mental health problems impact on socioeconomic
development of nations and the quality of life of individuals. For example, the WHO Book on
Mental Health (2002) has indicated that about four out of six people that suffer from some
form of disability have their concerns due to certain kinds of neuropsychiatric disorders. Other
research has indicated that mental health problems cost the global economy approximately
US$44 billion per year (Human Resources and Training in Mental Health 2006). The
economic burden of mental illness in the U.S. was estimated at $317.6 billion and over
£105.2 billion a year in England (Kessler et al. 2008; Centre for Mental Health 2010).
The impact of a mental health problem can be profound during adolescence and young
adulthood in particular. According to Rickwood et al. (2005), even a relatively mild mental
health problem can cause social, emotional, or cognitive changes that in turn disrupt educa-
tional and vocational achievements that have a major effect on later adult life. Several decades
of mental health research has revealed that adolescence is the stage in which most mental
health problems first manifest (Patel et al. 2007) and delays in seeking help for mental health
problems typically lead to poorer treatment outcomes (Boyd et al. 2011).
Many students entering university tend to hide maladjustment, emotional illness, or
psychological distress that warrant mental health care. For instance, in the UK, around, 60–
70 % of children and adolescents who experience clinically significant mental health problems
have not been offered any interventions (Meltzer 2003; cited by the Royal College of
Psychiatrists 2010). In Canada, only 30 % of people with mental health problems ever seek
help, and many delay seeking help until their condition becomes severe (Centre for Addiction
and Mental Health 2003). Furthermore, using data from the 2001–2002 U.S. National
Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Blanco et al. (2008)
found that in a one-year period only 18 % of 18–24-year-old college students with a
psychological disorder sought treatment.
The literature also indicates that there are gender differences in help-seeking behavior
among adolescents. In general, female adolescents are more likely to seek help for mental
health problems than males (Ciarrochi et al. 2003). On the contrary, a recent study by Boyd
et al. (2011) in rural Australia indicated that around 55.7 % of their sample of adolescents
indicated that they would seek help if they suffered from a mental health problem and gender
differences were observed, such that males had a higher preference indication for seeking help
from a psychologist than females; though the difference was not statistically significant.
Most undergraduate university students in Ethiopia are at the stage of adolescence and early
adulthood, and as previously indicated, mental health research has revealed that adolescence is
the stage in which most mental health problems first manifest (Patel et al. 2007). According to
Rickwood et al. (2005), even mild mental health problems can disrupt educational and
vocational achievements of this age group. To mitigate the negative impact of mental health
problems on university students, different universities internationally have established guid-
ance and counseling centers. Haramaya University in Ethiopia has recently established such a
center. To the author’s knowledge no study has been undertaken on help-seeking behavior of
university students in Ethiopia. The first aim of this study was, therefore, to undertake such an
investigation.
There are different reasons for the discrepancy between the number of individuals who have
a diagnosable psychological disorder and the number who utilize mental health counseling
services. Researchers have indicated that the perceived cause of a mental health problem
influences help-seeking behavior (Clarke 2004; Gureje and Alem 2000). According to
Int J Adv Counselling

Beverley and Richard (2007), there are three common models that provide explanations for the
causes of mental health problems and possible recommendations about treatment procedures.
The ‘Supernatural model’ attributes mental health problems to magic, evil spirits, demons, and
witchcraft. The ‘Biomedical model’ attributes mental health disorders to brain disease, genetics
heritability, and biochemical imbalances in the body. The ‘Psychosocial model’ attributes
mental health disorders to different psychosocial factors such as environmental stressors or
traumatic childhood events, or substance abuse (Beverley and Richard 2007). The attributed
causes of mental health problems vary from place to place and from culture to culture. Most
people in Canada prefer psychosocial explanations to mental health disorders (Beverley and
Richard 2007), while most nursing staff in Nepal (Shyangwa et al. 2003) and the general
public in the U.S. attribute mental health disorders to combinations of stressful circumstances
with biological and genetic factors (Link 1999).
Attribution of mental health disorders to supernatural forces is rampant in various parts of
the world. In Papua New Guinea in the South Pacific, spirits and supernatural agents are
believed to cause illness when an individual or a group has violated social taboos and norms or
failed to fulfill culturally expected obligations (Koka et al. 2004). The majority of mentally ill
patients in Malaysia attributed their illnesses to supernatural agents such as witchcraft and
possession by evil spirits (Razali et al. 1996). Also, such traditional notions whereby super-
natural powers are attributed to controlling the state of an individual’s mind are widespread in
all ethnic or religious groups in Ethiopia (Samuel 1999; Deribew and Shiferaw 2005).
Knowledge regarding perceived causes of mental health problems among university stu-
dents in Ethiopia is very limited. Hence, the second aim of this study was to assess perceived
causes of mental health problems among university students in that setting. Recognition about
the prospect for recovery from mental health disorders is another important determinant of
treatment-seeking behavior. The concept of recovery has received little attention in both
practice and research in regard to people who have a severe and persistent mental illness
(Whitley et al. 2011). Slade (2010) described recovery as a deeply personal, unique process of
changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a
satisfying, hopeful, and contributing life even with limitations caused by illness (Mancini et al.
2005). The belief that mental illness is incurable can be damaging, preventing patients from
being referred for appropriate mental health care. Therefore, to provide effective services in the
already established guidance and counseling centers, it is important to investigate university
students’ knowledge about the prospect of recovering from mental health problems.

The Present Study

The present study sought to address information gaps in the literature about perceived causes
of mental health problems and help-seeking behavior among university students in Ethiopia.
The research also investigated factors such as knowledge of mental health problems, fields/
colleges of study, perceived recovery from mental health problems and gender as predictive
variables of help-seeking behavior. The objectives of the study were, in regard to Ethiopian
university students, to:

1. Explore their knowledge of mental health problems.

2. Identify perceived mental health problems of university students.
3. Identify perceived causes of mental health problems.
4. Assess attitudes toward seeking professional psychological help.
5. Determine if there is a significant relationship between perceived levels of recovery from
mental health problems and attitudes toward seeking professional psychological help.
 Int J Adv Counselling

Method

Participants and Design

The study employed a survey design and was conducted across four colleges of Haramaya
University in Ethiopia. The participants were 370 third-year students from the Colleges of
Agriculture and Environmental Sciences (CAES), Business and Economics (CBE), Natural
and Computational Sciences (CNCS), and Social Sciences and Humanities (CSSH). While
random sampling was employed to select the participants and the colleges, purposive sampling
was used to select the year-level. Third-year (senior) students were purposefully selected for
the reason that they would have had more experience of university and they would be assumed
to understand more fully university students’ psychosocial conditions.

Instruments

The following instruments were utilized in the study:

Attitudes Toward Seeking Professional Psychological Help. To measure attitudes towards
seeking professional psychological help, a short and revised version of the Attitudes Toward
Seeking Professional Psychological Help Scale (Ang et al. 2007) was used. The scale has 9
items scored according to a 4-point Likert scale ranging through agree, partly agree, partly
disagree, to disagree. The items are scored 0, 1, 2, 3 and the range of possible total scores is 0–
27. Scores less than 13 are deemed to indicate positive attitudes, while scores higher than that
indicate negative attitudes toward seeking professional psychological help.
For the present study, some minor modifications were made to the wording of the
ATSPPHS items in order to avoid local misunderstandings. The term ‘psychotherapy’ was
replaced by ‘mental health services’ and ‘psychologists’ with ‘mental health professionals’.
The instructions included definitions of ‘mental health professional’ and ‘professional mental
health services’ as including services provided by counselors, psychologists, and psychiatrists.
Vignettes. Knowledge and perceived seriousness of some mental health problems were
addressed by the use of three vignettes. The vignettes were adopted from Deribew and
Shiferaw (2005) with no modifications. These authors established the psychometric property
of the vignettes (validity and reliability). The selected mental health problems were
Schizophrenia, Generalized Anxiety Disorder, and Major Depressive Disorder, chosen for
their prevalence, severity, and potential consequences of misidentification (Deribew and
Shiferaw 2005).
The participants in the study were asked if the person described in the vignettes had mental
health problems and, if they responded ‘yes’, the level of severity was asked using scales (1 =
not serious at all, to 5 = very serious). The previous researchers and vignette constructers
(Deribew and Shiferaw 2005) did not ask the severity of the mental health problems described
in their vignettes, but the present researcher added the severity issue to further elicit knowledge
of participants about different mental health problems.
Perceived causes of mental health problems. Perceived causes of mental health problems in
general were measured by listing different components of biomedical, psychosocial and
supernatural factors that people often believe to cause mental health problems. For example,
participants were asked if a chemical imbalance in the brain (an example of a biomedical
factor), possession by evil spirits (an example of a supernatural factor), and stressful circum-
stances in life events (an example of a psychosocial factor) caused mental health problems.
Then, participants were asked to indicate their choices from the list. After that the responses
were categorized under each model; i.e., biomedical, supernatural, psychosocial. Finally, the
Int J Adv Counselling

responses under each model/category were added together (multiple responses were also
possible) leading to a summation of perceived causes of mental health problems.
Perceived recovery from mental health problem measure. Students’ perceptions of likely
recovery from serious mental health problems in general was measured by one item. “In your
opinion, how likely is it that a person with a serious mental health problem can recover/that is,
can resume employment, independent living, community participation, social relations and
others?” It was scored on a 5-point Likert scale from 1 = Not likely at all, to 5 = Very likely.
The collected data were analyzed using percentages, t-tests, ANOVA and correlation
analysis.

Procedure

The participants of the study were 370 students from four Colleges of the University. To select
these students, first, four Colleges out of seven were randomly selected. Then students at each
College were classified based on their departments. Finally, two departments from each
College were randomly selected. The researcher checked the class schedule of the selected
group of students. Then, the instructor of each class was communicated with about the purpose
of the research and asked if he/she was willing to allow 20–30 min of the class time to collect
data, and, fortunately, all instructors showed such a willingness. The participants were
informed about the rationale of the research, issues of confidentiality, anonymity, voluntary
participation and method of completing the questionnaires. Verbal informed consent was
obtained and data were collected during class hours by the researcher.

Results

The first objective of this study was to investigate the awareness/knowledge of Ethiopian
university students about mental health problems. Students were provided with three case
vignettes that described different mental health problems. The vignette about schizophrenia
was well recognized as being a mental health problem by 86.2 % of the participants, while
major depressive and generalized anxiety disorders were recognized by 71.2 % and 48.6 % of
the participants respectively. Compared to the other two disorders, generalized anxiety disor-
ders were considered as mental health problem by less than half of the participants.
Multivariate analysis of variance was performed to investigate the perceived seriousness of
the mental health problems described in the vignettes in relation to gender and field of study/
college. The result revealed that there was no statistically significant difference between males
and females - F (3,195)=1.11, P=.347; Wilkes lambda = .983. However, there were signif-
icant differences among the different colleges - F (9,474)=1.96, P=.42; Partial Eta squared
.029. This significant difference was evident only in regard to major depressive disorder, with
the mean score of students at the College of Social Science and Humanities on perceived
seriousness of major depressive disorder (M=4.07) SE, .238) being significantly higher than
students at the other colleges - CAES (M=3.47, SE=1. 88, P=.05) and CNCS (M=2.88,
SE=.199, P=.000).
After participants’ knowledge of selected mental health problems and their level of severity
had been investigated, the next question considered was about perceived prevalence of mental
health problems. Among the lists of health problems presented, most of the participants
(65.7 %) considered substance/drug abuse as the most prevalent health problem. The second
largest number of participants (54.6 %) identified HIV/AIDS as a prevalent health problem.
Only 28.33 % considered mental health as a prevalent health problem of university students.
 Int J Adv Counselling

There seemed to be a difference between genders and across colleges in considering mental
health problems as a prevalent health concern −30.9 % of male participants and 22 % of female
participants considered mental health problems to be a prevalent concern among university
students in Ethiopia. Similarly, participants of the Colleges of Social Science and Humanities
(60 %), Agriculture and Environmental Sciences (42 %), Business and Economics (67 %) and
Natural and Computational Sciences (48.4 %) labeled mental health problems as prevalent
among university students in Ethiopia.
Chi-square analysis was conducted to test whether the difference in responses between the
sexes and among the colleges was significant. The result showed no significant differences - X2
(1)=2.53, P=.11. This means that the proportion of males that considered mental health as a
prevalent health problem was not significantly different from females, as was also the case
across the colleges - X2 (3)=.86, P=.83.
Participants were also asked about the possible causes of mental health problems, and the
results are presented in Fig. 1.
As indicated in the Figure, the majority of students (over 87 %) attributed mental health
disorders to psychosocial factors. This response did not differ between males and females and
among the different colleges. However, there were big differences in the beliefs about
supernatural causes of mental health problems between the genders and among respondents
of the different colleges. Accordingly, 31.2 % of female respondents attributed mental health
problems to supernatural causes compared to 23.3 % of their male counterparts. The largest
difference in response in this regard was found between respondents of the College of Natural
and Computational Sciences where only14.7 % attributed mental health problems to super-
natural factors compared to 34.4 % of respondents of the College of Social Science and
Humanities.
Participants were also asked about the possibility of recovery of people who suffer from
mental health problems. Accordingly, female respondents had higher mean scores of perceived
recovery from severe mental health problems (M=3.46) compared to their male counterparts
(M=3.44). Also, respondents of the College of Social Science and Humanities had the highest
mean score of perceived recovery from mental health problems (M=3.62) compared to
respondents from other colleges.
An independent sample t-test was conducted to test whether the difference was significant
or not. The result showed that there was no significant difference in mean scores between

Fig. 1 Perceived causes of mental health problems among university students by gender and by college
Int J Adv Counselling

males (M=3.44, SD=1.31) and females (M=3.46) - SD=1.38: t (350)=−.090, p=.462).

There was no significant difference either among the different colleges.
It was also investigated whether Ethiopian university students were likely to seek profes-
sional help if they experienced mental health problems. The results indicated that the average
professional help-seeking behavior score on the ATSPPH was 11.23. According to the
ATSPPH short version scale (Ang et al. 2007), scores less than 13 indicate positive attitudes
to this issue, and, therefore, it seems that the participants in this study overall had positive
attitudes toward seeking professional psychological help.
In this regard there were no significant differences between males - M=11.23, SD=3.97
and females - M=11.02, SD=3.91 - t (318)=.57, p=.57. However, there was a statistically
significant difference in the scores of attitude toward seeking professional psychological help
among the different colleges - F (3, 322)= 5.19, p= .002. Post- hoc comparisons
indicated that the mean score for students in the College of Agricultural and
Environmental Sciences - M=12.59, SD=3.41 - was significantly less positive (al-
though still in a positive direction) from those in the Colleges of SSH (M=10.44,
SD=4.25), NCS (M=10.92, SD=4.19) and BE (M=10.83, SD=3.57). There were no
significant differences among comparisons of the other colleges.
Pearson product moment correlation was used to investigate if there was a relationship
between perceived level of recovery from mental health problems and attitude toward seeking
professional psychological help (ATSPPH). There was a significant correlation between the
two variables (r=−.12, n=355, p=.034), with a high level of perceived recovery being
associated with a positive attitude toward seeking professional psychological help.

Discussion

As hypothesized, the majority of the participants had a relatively sound knowledge of major
mental health problems. The vignettes about schizophrenia and major depressive disorder were
well recognized (by 86.2 % and 71.2 % of the participants respectively) as being mental health
problems. However, less than half of the participants considered the case vignette of general-
ized anxiety disorder as being a mental health problem.
Somewhat similar results in regard to schizophrenia were observed by Deribew and
Shiferaw (2005) in other parts of Ethiopia, where the majority of the respondents (74 %)
identified that disorder as a mental health problem. However, unlike in Deribew and
Shiferaw’s study, 71.2 % and 48.6 % of the present study participants were able to recognize
major depressive disorder and generalized anxiety disorder as being mental health problems
respectively, compared to only 15 % and 29 % respectively in Deribew and Shiferaw’s study.
Such difference could be attributed to participants’ levels of education, with those in the
present study being senior university students. As such, they could acquire greater mental
health literacy from general reading or from course materials they studied compared to less
mental health literate participants.
The participants labeled schizophrenia and major depression disorders as being very serious
mental health problems, but generalized anxiety disorder was considered as the least serious.
There was no gender difference in labeling the seriousness of mental health problems.
Nevertheless, there was a significant difference among the different colleges on perceived
seriousness of major depressive disorder, with the mean score of the CSSH on perceived
seriousness of that disorder (M=4.07) being significantly higher than the CAES (M=3.47) and
the CNCS (M=2.88). This significant difference could perhaps be attributed to the courses
taken by students. Students at the College of Social Sciences and Humanities (CSSH)
 Int J Adv Counselling

presumably take more courses related in general terms to mental health and social behavior
compared to students at the College of Agriculture and Environmental Sciences (CAES) and
the College of Natural and Computational Sciences (CNCS).
The fact that only about a quarter of the participants considered mental health as a prevalent
health problems of university students suggests that the participants might have considered
minor psychological manifestations as not being signs of mental health problems. For exam-
ple, less than half of the participants considered generalized anxiety disorder as being a mental
health problem, compared to 86.2 % for schizophrenia. According to Rickwood et al. (2005),
even a relatively mild mental health problem can cause social, emotional, or cognitive changes
that in turn can disrupt educational and vocational achievements. If less severe forms of mental
health problems such as mild anxiety and mood disorders were considered problematic by the
participants, the above figure could have been increased. On the other hand, substance/drug
use could also be regarded as manifestations of mental health problems. As Ferdinand et al.
(2001) stated, the use of substances, such as alcohol and drugs, could be associated with the
onset and simultaneous presence of psychiatric disorders. Emotional conflicts may also be
expressed in terms of environmental factors like striking over “poor” cafeteria conditions, or
ethnic or religious conflicts. It could be assessed that mental health problems were less
emphasized or were under reported by the present participants. Therefore, further studies are
needed to explore this issue more intensively.
Unlike other studies conducted in Ethiopia (e.g., Deribew and Shiferaw 2005; Samuel
1999), in some parts of Africa (Gureje and Alem 2000; Roberts 2001) and in Papua New
Guinea (Koka et al. 2004) that attribute mental health problems to supernatural forces, the
majority of the present participants (over 87 %) attributed mental illness to psychosocial
factors. This belief goes with the scientific wisdom of the field, and education can enlighten
people and aid in resisting more traditional and primitive notions about mental illness. The
present study involved senior university students, being a likely reason for the results in this
regard differing from other studies involving the general public in other parts of the country.
Generally, the participants’ attitude toward seeking professional psychological help
(ATSPPH) was positive, with the average score of ATSPPH (11.23) being regarded as
favourable. There was no significant difference between male and female participants.
However, the mean ATSPPH score of students at the CAES (12.59) was significantly higher
than in other colleges. This study is in general agreement with that conducted by Boyd et al.
(2011) in rural Australia, which found that there was no significant gender difference in the
ATSPPH. Studies indicate that perceived causation of mental health problems influence help-
seeking behavior and the type of help that is sought (Clarke 2004). Most of the participants in
the present study attributed mental health problems to psychosocial and/or biogenetic factors,
and this seems to have affected students’ ATSPPH scores positively.
Generally, it is expected that the more education a person has received, the more enlight-
ened he or she would be with regard to ways of resolving problems, and the more likely they
would be to seek help from professionals when faced with psychological problems. However,
as the present results indicated, that is not necessarily the case across all fields of study. For
example, students at the College of Agriculture and Environmental Sciences (CAES) showed
significantly lower ATSPPH scores compared to students at other colleges. The possible
explanation for this could be the nature of likely courses that students take at each college.
Students at the CAES would presumably take fewer human-related topics, and this might have
impacted the results. Further studies are needed to clearly indicate the relationship between
education and ATSPPH.
Recognition about the prospect for recovery from mental health disorders is another important
determinant of treatment-seeking behavior. The present study found a significant relationship
Int J Adv Counselling

between ATSPPH scores and perceived recovery from mental health disorders (r=−.12, n=355,
p=.034). That is, a high level of perceived recovery from mental health problems was associated
with positive attitudes toward seeking professional psychological help. In this study higher score of
perceived recovery from mental health problems was associated with lower scores of ATSPPH, and
that is why r tended to be negative. Therefore, it can be said that the higher the scores of perceived
recovery from serious mental health problems, the more positive the attitude will be toward seeking
professional psychological help.

Implications

Information is very pertinent for the effective provisions of guidance and counseling services.
Haramaya University in Ethiopia has recently opened a guidance and counseling center, but
the center is not providing services as expected, with this being one motive for conducting this
study. Clearly the use of mental health services is related to different factors. In this study it
was deemed relevant to see if students knew what mental illness was, if mental health was
considered as a prevalent health problem among university students, to find out perceived
causes and perceived recovery of mental health problems, and to investigate help-seeking
behavior of university students.
To this end, this study is believed to have practical implications for the newly established
guidance and counseling programs of the University. First, most of the participants did not
recognize minor mood and anxiety disorders as being mental health problems. This notion
might hinder students’ help-seeking behavior. The impacts of even minor anxiety disorders can
be revealed through different behaviors, such as substance abuse, interpersonal conflict, and
related problematic behaviors. Therefore, the guidance and counseling center might well seek
to improve mental health literacy of university students, with a view to helping them recognize
likely problems and their effects and to seeking help towards improved functioning.
Secondly, most participants in the study attributed mental health problems to psychosocial
factors and most of them had a positive attitude toward seeking professional psychological
help. This suggests that the conditions are in place for students to seek help from the guidance
and counseling center for mental health problems, and the center should work to strengthen
itself in every aspect to accommodate potential service seekers, with an emphasis on acces-
sibility and increased awareness of services available.

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