Sara N. Johnson1, Katie Vukelich2, Tamnnet Kidanu3, Lauren Eldridge4, Keith A. Mays1, and Michael H. Kim5
1School of Dentistry, University of Minnesota
2 College of Pharmacy, University of Minnesota
3 Center for Health Interprofessional Programs, University of Minnesota
4 School of Public Health, University of Minnesota
5 Medical School, University of Minnesota
Author Note
Sara N. Johnson https://orcid.org/0000-0002-4284-0492
Katie Vukelich https://orcid.org/0000-0002-5475-7143
Lauren Eldridge https://orcid.org/0000-0002-4219-5665
Keith A. Mays https://orcid.org/0000-0001-7695-3359
Michael H. Kim https://orcid.org/0000-0001-5339-9631
Tamnnet Kidanu is now employed at the Office of Health Promotion, Carleton College.
We have no known conflict of interest to disclose.
Correspondence regarding this article should be addressed to Sara N. Johnson, School of Dentistry, University of Minnesota, 15-106 Moos Tower, 515 Delaware St SE, Minneapolis, MN 55455, Email: [email protected]
Introduction
Student mental health is a concern on college and university campuses in the United States (Xiao et al., 2017). 45.1% of college students who participated in a national survey indicated they felt so depressed that it was difficult to function within the last 12 months, 65.7% felt overwhelming anxiety, and 13.3% seriously considered suicide (American College Health Association, 2019). Increasing numbers of students are seeking campus counseling services (Lipson et al., 2019), and the demand for counseling and mental health resources may continue to grow as post-secondary education becomes more accessible for students with mental health diagnoses due to treatment improvements (Novotney, 2014).
Research on post-secondary student mental health exists at the undergraduate and advanced degree levels. Barriers to care (Yorgason et al., 2008; Rafal et al., 2018) and student health within academic disciplines (Harrison et al., 2016; Walter et al., 2013) have been prominent topics in the literature. However, fewer studies exist exploring the mental health needs and barriers to care experienced by students in the academic health sciences, often referred to as academic health centers (AHCs). AHCs include “all the health-related components of universities, including their health professions schools, patient care operations, and research enterprise” (Association of Academic Health Centers, 2020, Academic health centers: Defined, para 1). There are 95 AHCs in North America composed of a medical school and one or more additional health professions programs such as pharmacy, dentistry, nursing, public health, and graduate programs (Association of Academic Health Centers, 2019). Many students in these programs have already completed an undergraduate degree and are seeking advanced education.
Research indicates that health professions students’ mental health can be negatively impacted by academic and financial concerns (Walter et al., 2013), imposter syndrome (Henning et al., 1998), satisfaction with their selected school and program (Payakachat et al., 2014), and struggles adapting to the learning demands of professional programs, clinical responsibilities, and faculty relationships (Murphy et al., 2008). Students in health professions programs experience higher levels of stress than the general adult population (Bidwal et al., 2015), and graduate students, who are often members of AHCs, also experience significant mental health concerns (Evans et al., 2019).
Educators in health professions programs have implemented strategies to support students. One study proposed promoting online programs and apps for relaxation, mindfulness, meditation, web-based cognitive therapy, and suicide prevention (Pospos et al., 2018). Schools have also implemented mindfulness-based stress reduction training (Barbosa et al., 2013) and have counselors based in schools (Adams, 2017) in order to positively impact health professions students’ mental health.
Health professions student awareness and use of mental health resources and barriers to care within health disciplines, particularly in medicine, have also been explored in the literature. First- and second-year medical students at one U.S. institution reported the top five barriers to seeking mental health care were “lack of time, lack of confidentiality, concern that ‘no one will understand my problems,’ stigma of mental health care, and feeling that ‘my problems are not important’” (Givens and Tija, 2002, p. 919). One in five respondents in a survey of 475 Australian medical students felt a need to conceal emotional and mental health concerns because they felt their concerns would be dismissed or invalidated or already had a negative experience related to mental health (Walter et al., 2013). The same study found students had concerns about discrimination, judgement, stigma, privacy, and embarrassment (Walter et al., 2013) related to sharing mental health issues. Perfectionism and stigma were also noted as reasons medical and dental students avoided mental health treatment (Ey et al., 2000). Students are hesitant to use mental health resources and are calling upon schools to organize curricula to keep students engaged, encouraged, and supported (Huot, 2017).
A comprehensive understanding of health professions students’ awareness and use of mental health resources in an AHC is missing from the literature. This information is essential to educators and student affairs professionals working in AHCs as they determine how to invest in, structure, and publicize mental health support for this unique student population. The purpose of this paper is to (1) understand health professions students’ awareness, use of, and barriers to using mental health resources in an AHC and (2) share data with decision-makers to inform the development of support services and programming.
Methods
This project was reviewed by an Institutional Review Board (IRB) and determined not to be human research and not under its purview. The population in this study was health professional students enrolled in a large, public research university with an AHC structure. It included approximately 1,500 students from seven schools and programs across two campuses that are part of a state system. Campus #1 is in a large, metropolitan city where all seven programs are present, and Campus #2 is in a smaller city with two of those seven programs.
A team of student affairs and health professionals developed a survey of 11 questions to assess students’ awareness and use of existing mental health resources and interest in potential resources. The survey defined mental health:
as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. (World Health Organization, 2014, Mental health: A state of well-being, para 1)
There were two versions of the survey with slight variations in questions based on the campus of the students’ program and the different resources available on each campus. Responses to all survey questions were not required. The survey did not gather respondent demographic information other than the student’s college or academic program of study.
The survey asked respondents to indicate familiarity with existing mental health resources. Answers were allowed through a Likert-type scale (extremely familiar, very familiar, moderately familiar, slightly familiar, not familiar at all). This scale is described in Figure 1.
Figure 1
Familiarity Likert Descriptions
| Extremely Familiar | Know this office/program exists and use or have used their services |
| Very Familiar | Know this office/program exists, have reviewed their services and contact information |
| Moderately Familiar | Know this office/program exists, could independently find information about its services and contact information |
| Slightly Familiar | Know this office/program exists, but do not know where to find information about its services or contact information |
| Not Familiar at All | No knowledge of this office or program |
Respondents were then asked to indicate the likelihood that they would consult with those resources if they needed assistance with a mental health concern. Answers to this question were allowed using a second Likert-type scale with answers of extremely likely, somewhat likely, neither likely or unlikely, somewhat unlikely, and extremely unlikely.
The survey then asked respondents to select from a list what barriers, if any, prevented them from accessing existing resources. Listed barriers were not being aware of resources, in person appointments do not fit in my schedule, mental health is not a concern of mine, resources locations are inconvenient, I cannot pay for care, and I do not face any barriers. This question included a free-text box, marked “Other” for respondents to describe barriers not listed. Respondents were then presented with an open-response question asking them to describe other resources they had used for support and an additional question asking them to indicate their likelihood of using proposed new resources if they were available using the extremely likely to extremely unlikely Likert-type scale mentioned previously.
The survey closed with two open-ended questions: one asking what services or support respondents would like to see available and a second that provided respondents with an opportunity to share other information regarding student mental health. The survey included an optional item where respondents could enter their name and email to be entered in a drawing for $50 Visa gift cards for completing the survey.
The survey was created in Qualtrics, an online survey software. Student affairs leaders in each school and program emailed their students an invitation and link to complete the survey online. Most students received the invitation in fall 2017, while students in the medical school on Campus #1 received the invitation in spring 2018. These different timelines were based on staff availability to coordinate the survey’s deployment. Responses to the survey were reviewed for each campus and descriptively analyzed.
Results
A total of 1,513 students responded to the survey: 1,346 from Campus #1, 167 from Campus #2. Each of the seven schools and programs were represented in responses. Campus #1 respondents were extremely familiar or very familiar with campus mental health medical offices, college or school-based student services offices, and student counseling services as resources for mental health support. Students from this campus were also likely to consult with these resources for assistance with mental health concerns. Table 1 details the percent of respondents who indicated they were extremely or very familiar with campus resources as well as if they were extremely or somewhat likely to use a resource.
Table 1
Campus #1 Familiarity with Mental Health Resources and Likelihood of Use
| Resource |
n |
Extremely Familiar (%) | Very Familiar (%) |
n |
Extremely Likely (%) | Somewhat Likely (%) |
| Campus Mental Health Medical Offices | 1200 | 18 | 24 | 1149 | 22 | 42 |
| College/School Student Services Offices | 1200 | 17 | 19 | 1149 | 11 | 33 |
| Campus Student Counseling Services | 1200 | 8 | 13 | 1149 | 12 | 36 |
| University Disability Resource Center | 1200 | 8 | 10 | 1149 | 7 | 17 |
| Informal Peer-to-Peer Support | 1200 | 8 | 12 | 1149 | 11 | 23 |
| Community Based Resources | 1200 | 8 | 11 | 1149 | 14 | 24 |
| Peer-led Wellbeing Initiatives | 1200 | 6 | 8 | 1149 | 5 | 16 |
| University Spirituality Center | 1200 | 4 | 8 | 1149 | 4 | 18 |
| Campus Alcohol and Chemical Dependency Services | 1200 | 1 | 4 | 1149 | 2 | 10 |
Note. n numbers from the table do not match the number of survey respondents referenced in the previous paragraph as respondents were not required to answer every question.
an numbers in the second and fifth columns of the table are different as they represent the number of respondents to two separate questions. One question was regarding familiarity of resources (n = 1200) the other regarding likelihood of using resources (n = 1149). Respondents were not required to answer to every question.
Respondents from Campus #2 were most familiar with college student services offices, informal peer-to-peer support, and campus counseling services as resources for mental health support. These students were likely to consult with college or school-based student services offices, campus counseling services, and community-based resources for mental health assistance. Table 2 details the percent of respondents who indicated they were extremely or very familiar with a campus resource as well as the percent of respondents who were extremely or somewhat likely to use that resource.
Table 2
Campus #2 Familiarity with Mental Health Resources and Likelihood of Use
| Resource | n | Extremely Familiar (%) | Very Familiar (%) | n | Extremely Likely (%) | Somewhat Likely (%) |
| College/School Student Services Staff | 164 | 17 | 30 | 164 | 19 | 37 |
| Campus Student Counseling Services | 165 | 9 | 11 | 163 | 18 | 36 |
| Informal Peer-to-Peer Support | 165 | 5 | 18 | 164 | 14 | 21 |
| University Disability Resource Center | 165 | 7 | 10 | 164 | 6 | 19 |
| Community Based Resources | 165 | 5 | 9 | 164 | 10 | 27 |
| Peer-led Wellbeing Initiatives | 165 | 1 | 8 | 163 | 5 | 19 |
| Resources within a Profession | 165 | 2 | 7 | 164 | 5 | 24 |
| Drop-in Counseling | 165 | 1 | 7 | 164 | 6 | 24 |
Note. n numbers from the table do not match the number of survey respondents referenced in the previous paragraph as respondents were not required to answer every question.
an numbers in the second and fifth columns of the table are different as they represent the number of respondents to two separate questions. One question was regarding familiarity of resources (n = 165) the other regarding likelihood of using resources (n = 164). Respondents were not required to answer to every question.
Respondents from both campuses had similar responses when asked about the likelihood of using proposed new resources for mental health support. Suggested resources students (n=1113 for Campus #1, n = 165 for Campus #2) were most likely to use were evening or early morning appointment times with a mental health counselor, counselors based in buildings with student programs, and online wellbeing options. Students also expressed the desire for these resources in their open text responses. Respondents also noted in open text comments that social support from peers and family is important and beneficial to their mental health.
When responding to questions regarding barriers to care, respondents from both campuses most frequently noted not being aware of resources and appointment times not fitting schedules as dominant barriers. Students on both campuses also indicated the stigma associated with seeking care and not having enough time to seek or schedule care as being significant barriers. For some students there were no barriers (13% at Campus #1 and 7% at Campus #2).
Discussion
This study identifies in gap in existing student affairs literature. Study respondents were aware of college or program-based student services offices and likely to use them in support of their mental health which indicates that student affairs plays a role in the experiences of AHC students. There are limited studies reporting on health professions students on any topics (Bresciani, 2003) or about their mental health in student affairs literature and journals such as The Journal of Student Affairs Research and Practice or the Journal of College Student Development. Studies that do exist exploring the mental health needs of health professions students are from the lens of each health program (e.g., dentistry, medicine, pharmacy) (Pospos et al., 2018; Barbosa et al., 2013; Adams, 2017). Student affairs research on health professions students and those learning in AHC environments would be beneficial in understanding how student affairs professionals can effectively support these populations. AHC health professions students are looking to student affairs professionals for guidance and support, and student affairs faculty and staff working in these areas must be prepared to provide it.
Implications for Student Affairs Practice
The results of this survey provide an understanding of health professions students’ awareness, use of, and barriers to using mental health resources in an AHC. The findings may inform the development of services and programming for this unique student population. Operationally, when structuring mental health services for AHC students, appointments should be available at times that complement academic schedules (health professions students are often in class and clinic from 8:00 AM to 5:00 PM with only a break over the lunch hour). Early morning or evening appointment times with providers in buildings where students’ academic programs are based and online wellbeing programming may be of interest to students.
Institutions working with AHC students may also want to consider investing in mental health communication campaigns. These campaigns should focus on increasing student awareness of resources and communicating institutional support of students seeking assistance, including what school resources are available, to help students remove barriers to seeking care. Given the important role peers and families play in supporting AHC students, the campaign should also include information to be shared with peers and families about students’ programs and institutional resources. Each of these strategies must be intentionally constructed to remove the stigma associated with seeking assistance noted by many students.
AHCs are acknowledging the need to restructure education based on the changing needs of society (Wartman, 2015). Although this statement may have been written with patients in mind, the increasing mental health needs of students is clear. The structure of AHCs lends itself to creating efficient, effective partnerships to serve these learners. AHC health professions students often have shared buildings or facilities close to one another. Mental health services that are embedded in these buildings or in easily accessible locations would remove barriers to students seeking care. Sharing the costs associated with new programs and resources could also potentially result in savings, or at least minimal investment, for schools and programs at a time when AHCs are looking for ways to optimize resources due to funding constraints (Wartman, 2015). Shared resources could be used to not only hire staff and pay for space, but to implement programming (e.g., support groups, online tools, wellness activities, resources for family members, etc.) that could lead to students creating mental health habits and self-care strategies that would serve them well as they pursue careers in stressful professions.
A model of shared services for the mental health support of health professions students in an AHC learning environment is also consistent with a national call for interprofessional practice and education. An important component of health education is teaching students to collaborate in practice (e.g., teaching medical, nursing, dental, and pharmacy students to provide care as a team) in order to improve patient health outcomes (National Center for Interprofessional Practice and Education, 2020). New definitions of interprofessional education and health care include the “fourth aim” (Bodenheimer & Sinsky, 2014, p. 575) and acknowledge that the care of providers themselves is a critical part of health systems. These definitions call for practice that, “intentionally supports people – including health professionals, health workers, students, residents, patients, families and communities – to learn together every day to enhance collaboration and improve health outcomes while reducing costs” (National Center for Interprofessional Practice and Education, 2020, About IPE, para 6).
Creating new models of care that address the mental health needs of AHC students may present opportunities for students to learn and support one another in interprofessional ways. Students may realize that as they pursue their careers, the mental health challenges associated with working in healthcare are shared by others working in health professions, and interprofessional colleagues may be able to provide guidance and support. Making mental health services more accessible to health professions students may lead to better long-term health for these providers, allowing them to provide the best possible care and outcomes for their patients.
Campuses and student affairs professionals across the nation have recently had to adjust their approaches to working with students in all functional areas, including mental health support, due to COVID-19. This disruption of services has been exceptionally challenging. In the context of this paper, the innovative work that has been done to continue meeting student needs during this global pandemic provides an opportunity for student affairs professionals to think about how these new strategies can improve access to student mental health care. How can new virtual models for student engagement, advising, academic support, health care, and other areas remove barriers to students seeking assistance and ultimately improve their mental health? The current disruption provides a unique opportunity for student affairs professionals to test new strategies that can benefit students now and in the future.
Implications for Future Research
The findings of this study suggest multiple areas for additional student affairs research. As mentioned previously, health professions students in AHCs are not present in current student affairs literature. Additional research regarding the unique needs of AHC students based in student affairs research and practice would better prepare student affairs professionals to work with this unique student group and better inform institutional leaders of the needs of this population. In addition, research related to access to mental health care for health professions students of color and/or based on other aspects of identity (e.g., gender, socioeconomic status, disability) would also better inform institutions on how to remove barriers and support all students seeking mental health care.
Limitations
There are a few limitations to this survey. Additional questions to determine if respondents had experienced mental health concerns may have been helpful in understanding variation in student responses. Questions to better understand students at the individual, interpersonal, and institutional levels (Byrd & McKinney, 2012) may have also provided a deeper understanding of challenges faced by students related to their mental health concerns. Requesting student demographic data may have also increased understanding of responses in different student populations. Finally, a survey question should have been included in each survey for respondents to identify their campus. Some programs had a very small student presence on more than the two campuses identified in the survey (i.e., on a third campus in the state system), and a small group of students from the small campus completed the large city campus survey. All students received the survey through their student services offices, and the survey should have allowed them to identify their campus.
Conclusion
This paper adds to the literature an understanding of health professions students’ awareness, use of, and barriers to using mental health resources and provides decision-makers with data to inform investment in support services and programming for this unique student population. AHCs are uniquely positioned to develop mental health support programs and resources for students, and student affairs professionals must be a part of this strategic investment. Student affairs professionals working in health professions programs must advocate for health professions students’ needs and be prepared to do so in an environment where fellow student affairs professionals may not understand health professions programs given the absence of this population in student affairs literature. Campus student affairs leaders must seek to understand and consider the unique needs of health professions students and include these students when making decisions about strategic student affairs initiatives to support student mental health as well as when making operational decisions (e.g., hours of counseling available on campus) in order to remove barriers to care. Unique circumstances exist in programs and a “one size fits all” approach to mental health services may limit the ability for some student populations, such as health professions students, to seek support. Evaluation of student mental health needs must go beyond the institutional level and consider program specific information in order to best serve all students, including those in health professions programs, on campus.
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