PhD- Dissertation- Nauman -Ali-Chaudary

231 Pages·2017·4.2 MB·English

by  Nauman Ali Ch

Prevalence and Determinants of Mental Health Issues
among the University Students and its Impact on their
Academic Performance and Well-being in Punjab,
Pakistan
Dissertation Submitted in Fulfillment of the Requirements for the Degree of
Doctor of Philosophy (Public Health) to the School of Public Health,
University of Bielefeld, Germany

Submitted By:

Nauman Ali Chaudary, M. Phil (Sociology)

Dissertation Supervisors:

Fist Supervisor: Prof. Dr. med. Alexander Krämer
School of Public Health,
University of Bielefeld, Germany

Second Supervisor: Prof. Dr. Claudia Hornberg
School of Public Health,
University of Bielefeld, Germany

Bielefeld, December, 2016
School of Public Health
University of Bielefeld, Germany
Doctor of Philosophy (PhD) in the Discipline of Public Health

Declaration
I hereby declare that this dissertation represents my independent and original work and that I
have used no other sources except as noted by citations. All data, tables, figures and text
citations which have been reproduced from any other source have been explicitly
acknowledged as such. This dissertation has not been accepted in substance for any other
degree, nor is it currently being submitted in candidature or achievement of any other degree
at any other university. I further declare that I have not previously made attempts to do a
doctorate at any national or international university.

Signed: ___________________________ Bielefeld, Date: _______________________
Nauman Ali Chaudary
Table of Contents
List of Tables ........................................................................................................................... v
List of Figures ........................................................................................................................ vii
Abbreviations and Acronyms ................................................................................................. ix
Acknowledgement ................................................................................................................... x
ABSTRACT .............................................................................................................................. 1
CHAPTER 1: INTRODUCTION ........................................................................................... 6
CHAPTER 2: THEORETICAL FRAMEWORK, STATE OF THE ART IN MENTAL
HEALTH RESEARCH WITHIN A PUBLIC HEALTH PARADIGM ............................. 9
2.1 Theoretical Framework ................................................................................................ 9
2.1.1 Health and Mental Health: A Historical Perspective .............................................. 9
2.1.2 Approaches to Mental Health: An Interdisciplinary Theoretical Debate.............. 11
2.1.2.1 Sociological approach and theories ....................................................................... 15
2.1.2.2 Applicability of sociological approach ................................................................... 17
2.1.3 The Stress Theory ................................................................................................. 19
2.1.3.1 Conceptualization of stress, stressors and distress ................................................ 19
2.1.3.2 Background and developments in stress theory...................................................... 21
2.1.3.3 Stress theory: A theoretical framework for the present study ................................ 26
2.2 State of the Art in Mental Health Research within a Public Health Paradigm ..... 28
2.2.1 Mental health: A Truly Global Issue..................................................................... 28
2.2.1.1 Mental health issues among the university students ............................................... 31
2.2.1.2 General limitations of studies examining students’ mental health ......................... 32
2.2.1.3 Differential risk in terms of sex and demography .................................................. 33
2.2.2 Students‟ Mental Health Issues in Pakistan: Is it any different? ........................... 34
2.2.2.1 Burden of disease attributable to mental health in Pakistan ....................................... 35
2.2.2.2 Community perceptions of mental health in Pakistan.................................................. 36
2.2.2.3 University student and mental health services in Pakistan .......................................... 36
2.2.2.4 The health context of Pakistan ..................................................................................... 37
2.2.2.5 Budgetary allocations for health care ......................................................................... 38
2.2.2.6 Mental health care in Pakistan .................................................................................... 38
2.2.3 Two Dimensions of Mental Health ....................................................................... 39
2.2.3.1 Stress and depression ............................................................................................. 40
2.2.3.2 Stress, depression and university students ............................................................. 42
2.2.3.3 Mental health and physical health .......................................................................... 44
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2.2.4 Determinants of Student‟s Mental Health ............................................................. 45
2.2.4.1 Academic stressors ................................................................................................. 47
2.2.4.2 Non-academic stressors .......................................................................................... 48
2.2.4.3 Stressors of university students in the context of Pakistan ..................................... 52
2.2.4.4 Students’ response to stressors ............................................................................... 55
2.2.4.5 Variation among student segments ......................................................................... 56
2.2.4.7 Factors influencing the intensity of perceived stressors......................................... 57
2.2.5 Effects of Students‟ Mental Health Issues ............................................................ 58
2.2.5.1 Academic performance ........................................................................................... 59
2.2.5.2 Wellbeing ................................................................................................................ 62
2.2.5.3 Life satisfaction ...................................................................................................... 64
2.2.5.4 Coping .................................................................................................................... 65
2.3 Public Health Relevance ............................................................................................. 66
2.3.1 Health Promotion .................................................................................................. 67
2.3.2 Mental Health Promotion and Prevention ............................................................. 68
2.3.3 Public Health Relevance of Mental Health ........................................................... 69
2.3.3.1 Mental health as a human rights issue ................................................................... 70
2.3.3.2 Socioeconomic determinants of mental health ....................................................... 73
2.3.3.3 Impact of globalization on mental health ............................................................... 74
2.4 Significance of the Study ............................................................................................. 75
CHAPTER 3: MATERIAL AND METHODS ................................................................... 77
3.1 Objectives, Research Questions and Hypotheses of the Study ................................ 77
3.1.1 Specific Research Objectives ................................................................................ 77
3.1.2 Research Questions ............................................................................................... 78
3.1.3 Hypotheses of the Study ...................................................................................... 79
3.2 Ontological and Epistemological Considerations ..................................................... 79
3.3 Traditions in Mental Health Research ...................................................................... 81
3.4 Operationalization of the Concepts ........................................................................... 81
3.5 Research Design ........................................................................................................... 83
3.5.1 Study Settings ....................................................................................................... 84
3.5.2 Respondents of the Study ...................................................................................... 85
3.5.3 Selection Procedure of Universities ...................................................................... 86
3.5.4 Sampling Procedures and Sample Size ................................................................. 87
3.6 Tool for Data Collection .............................................................................................. 89
3.6.1 Pre-testing ............................................................................................................. 93
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3.6.2 Ethical Considerations .......................................................................................... 94
3.7 Field Experiences ......................................................................................................... 94
3.8 Data Analysis ............................................................................................................... 96
CHAPTER 4: RESULTS .................................................................................................... 103
4.1 Descriptive Results .................................................................................................... 103
4.1.1 Socio-demographic Characteristics..................................................................... 103
4.1.2 Self-rated Health Status and Health Related Behavior ....................................... 110
4.1.3 Psychosomatic Health Complaints...................................................................... 111
4.1.4 Perceived Stressors ............................................................................................. 113
4.1.5 Prevalence of Mental Health Issues .................................................................... 114
4.1.6 Academic Performance ....................................................................................... 115
4.1.7 Satisfaction with different areas of Life .............................................................. 117
4.1.8 Coping Strategies ................................................................................................ 118
4.2 Analytical Results ...................................................................................................... 121
4.2.1 Factors Associated with Perceived Mental Health Issues ................................... 121
4.2.2 Association between General Health and Mental Health Issues ......................... 125
4.2.3 Factors Influencing Students‟ Perceptions towards Stressors ............................. 127
4.2.4 Impact of Perceived Stressors on Student‟s Mental Health Issues ..................... 128
4.2.5 Impact of Mental health Issues on Academic Performance ................................ 129
4.2.6 Impact of Mental Health Issues on Subjective Well-being ................................. 131
4.3 Summary of Major Findings .................................................................................... 133
CHAPTER 5: DISCUSSION .............................................................................................. 137
5.1 Descriptive Results .................................................................................................... 137
5.1.1 Socio-demographic and Academic Characteristics ............................................. 137
5.1.2 General health and Health Related Behavior ...................................................... 139
5.1.3 Perceived Stressors of University Students ........................................................ 141
5.1.4 Prevalence of Mental Health Issues .................................................................... 142
5.1.5 Academic Performance and University Life ....................................................... 146
5.1.6 Satisfaction with Life at University .................................................................... 147
5.1.7 Coping Strategies ................................................................................................ 148
5.2 Determinants of University Students’ Mental Health ............................................ 149
5.2.1 Demographic and Academic Factors .................................................................. 149
5.2.2 General Health and Mental Health Issues ........................................................... 151
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5.2.3 Impact of Stressors on Mental Health Issues ...................................................... 152
5.3 Outcomes of Mental Health issues ........................................................................... 153
5.3.1 Academic Success: The Impact of Mental Health Issues ................................... 153
5.3.2 Mental Health Issues as a risk to Subjective Well-being .................................... 154
5.4 The Implications of Current Research in wider Context ...................................... 155
CHAPTER 6: CONCLUSION, STUDY LIMITATIONS AND RECOMMENDATIONS
................................................................................................................................................ 157
6.1 Conclusion .................................................................................................................. 157
6.2 Study Limitations ...................................................................................................... 160
6.3 Recommendations ..................................................................................................... 164
BIBLIOGRAPHY ................................................................................................................ 167
APPENDICES ...................................................................................................................... 212
Appendix I: Letter of approval from Institution Review Board (IRB), University of the
Punjab to carry out the study in selected universities ......................................................... 212
Appendix II: Tool for data collection (Questionnaire) ..................................................... 213
Appendix III: Time schedule and work plan..................................................................... 219

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List of Tables
Table 2.1: Health indicators for South Asia ............................................................................ 37
Table 2.2: Effect of stressors on physical, psychosocial and behavioral issues ..................... 56
Table 2.3: Well-being descriptors and constructs observed in the economics, sociology,
psychology and health professions literature ........................................................................... 63
Table 3.1: Sample size calculation .......................................................................................... 88
Table 4.1 Demography .......................................................................................................... 104
Table 4.2: Family background .............................................................................................. 107
Table 4.3: Academic details by sex ...................................................................................... 108
Table 4.4 : General health by sex distribution ...................................................................... 111
Table 4.5: Perceived stressors ............................................................................................... 113
Table 4.6: Frequencies and percentages of well-being, perceived stress and depression ..... 115
Table 4.7: Academic grades .................................................................................................. 116
Table 4.8: Performance at the university in comparison to others........................................ 117
Table 4.9: Frequency & percent coping strategies ................................................................ 119
Table 4.10: Factors associated with perceived prevalence of mental health issues .............. 122
Table 4.11: Impact of socio-demographic and academic characteristic on perceived stress 124
Table 4.12: Impact of socio-demographic and academic characteristic on depressive
symptoms ............................................................................................................................... 124
Table 4.13: Impact of socio-demographic and academic characteristic on psychological well-
being ....................................................................................................................................... 125
Table 4.14: Impact of self-rated health status (SRHS) & health related behaviors on
perceived mental health issues ............................................................................................... 126
Table 4.15: Impact of psychosomatic health complaints (PHCs) on mental health issues ... 127
Table 4.16: Bivariate association between respondent characteristics and mental issues with
stressors .................................................................................................................................. 128

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Table 4.17: Impact of perceived burdens on mental health issues of university students .... 129
Table 4.18: Association between respondent characteristics and mental issues with academic
performance ........................................................................................................................... 130
Table 4.19 Impact of mental health issues on academic performance .................................. 131
Table 4.20: Impact of mental health issues on well-being .................................................... 132

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List of Figures
Figure 2.1: Frame of theoretical orientations of current study ............................................... 18
Figure 2.2: Model of stressor, stress and distress ................................................................... 19
Figure 2.3: Selye‟s general adaptation syndrome model ........................................................ 22
Figure 2.4: The major contributions to stress theory .............................................................. 25
Figure 2.5: Conceptual framework of the study ..................................................................... 27
Figure 2.6: Percentages of DALYs constituting mental health, neurological & substance use
disorders ................................................................................................................................... 29
Figure 2.7: Proportion of global YLDs attributable to mental, neurological, and substance
use disorders, 2010................................................................................................................... 30
Figure 2.8: Absolute DALYs attributable to mental, neurological, and substance use
disorders, by Age, 2010 ........................................................................................................... 31
Figure 2.9: Age distribution of YLDs in Pakistan according to GBD 2010 ........................... 35
Figure 2.10: Health promotion framework ............................................................................. 67
Figure 3.1: Selection procedure of universities ...................................................................... 86
Figure 3.2: Geographical location of selected universities in Punjab ..................................... 87
Figure 3.3: Sample distribution among selected universities ................................................. 89
Figure 3.4: Analysis plan for association between socio-demographic, academic
characteristic and mental health issues .................................................................................... 99
Figure 3.5: Analysis plan for association between perceived stressors and mental health
issues ...................................................................................................................................... 100
Figure 3.6: Analysis plan for association between perceived mental health issues and
academic performance ........................................................................................................... 101
Figure 4.1: Age and sex distribution ..................................................................................... 103
Figure 4.2: Satisfaction level with BMI................................................................................ 105
Figure 4.3: Satisfaction with current weight by sex ............................................................. 105
Figure 4.4: Level of religiosity ............................................................................................. 106
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Figure 4.5: Perceived sufficiency of money ......................................................................... 110
Figure 4.6: Family income level of scholarship holders by income level. ........................... 110
Figure 4.7: Percentage distribution of psychosomatic health complaints (PHCs) ............... 112
Figure 4.9: Level of satisfaction with various spheres of their life ...................................... 118
Figure 4.10: Model representing summary of statistical findings ........................................ 132

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