An Evaluation of Students’ Perspective on Availability and Appropriateness of Mental Health Care Services in University of Juba, South Sudan

Abstract

This paper explores the quantitative and qualitative nature of services available in University of Juba (UOJ) to students with mental health issues. The study focused on identifying whether students in UOJ were aware of the meaning of mental illness, what caused it, what services were available for the university students with such conditions, where did they get alternative support, the relationship between mental health and academic performance, challenges faced by students with mental issues and how they could be handled. This was a case study that used only University of Juba (UOJ) out of the five public universities in the Republic of South Sudan. UOJ was identified on basis of its strategic position in the capital city of the country and also the largest with wider admission of students from all the ten states and the two administrative areas of South Sudan. The study considered students’ perspectives; therefore, data collected only confirms students living with disability views on the subject. The study used 20 respondents who were identified using purposive sampling and they were the ones identified through the help of the Deanship of Students’ Affairs (DSA). Data was collected using an open-ended questionnaire and data was largely analyzed and presented in qualitative form and presentation was done using a descriptive approach as well as a basic quantitative method; this included tables, graphs, percentages and graphic expressions. Findings suggest that UOJ students have knowledge of mental illness and can identify the affected students by symptoms. However, findings show that from the students’ perspective, they have limited services within the university and some prefer to seek help elsewhere other than the university. The study has found out thin university mental health responders are inadequately prepared to help students with mental health partly due to their low level of professional training on disabilities and also due to high level of stigmatization and negative attitude toward them. The main implications of the study are the need for a more elaborate referral system so that the UOJ can send students for further services from external agencies. This should come even after the university has identified, trained and recruited and placed qualified staff in the DSA to assist students with mental health issues. The study recommended that UOJ should set aside a budget to help in streamlining the DSA in order to be able to respond to mental health issues among students. Further, the university administration should work closely with external service providers to be able to help refer the students with mental health difficulties for specialized treatment. Finally, the study suggested areas that require further research like doing a similar study to other levels of education like high schools and also widening the study to include the opinion of service providers like students, university Students’ counsellors and other personnel under DSA in public universities.

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Rintaugu, L.N. (2022) An Evaluation of Students’ Perspective on Availability and Appropriateness of Mental Health Care Services in University of Juba, South Sudan. Open Access Library Journal, 9, 1-22. doi: 10.4236/oalib.1108967.

1. Introduction

According to Till (2013) [1], mental health implies that the individual has the ability to form and maintain affectionate relationships with others, perform social roles and recognize, acknowledge and communicate positive actions, thoughts and emotions. Similarly, Legg (2020) [2] says that mental health is cognitive, behavioral and emotional well-being, which determines how people think, feel and behave. Mental health is a general term that can be used to refer to psychological state of someone who is functioning at a satisfactory level of emotional and behavioral adjustment. The opposite of the same word can be mental illness, mental disorder, mental disturbance or maladjustment. This is a condition that can range from mild to severe if not well handled. Consequently, practitioners in the university setting need to be well equipped with knowledge and skills of identifying and responding to such conditions. This paper therefore seeks to explore the preparedness of the university responders to students’ mental issues in an attempt to provide the best care and support to students experiencing such conditions.

1.1. Background of the Study

In South Sudan in general and University of Juba in particular, a good percentage of students and in some cases the members of staff display behaviors that can be interpreted positively as symptoms of Stress, Anxiety and Depression (SAD). Some students enter the university with underlying mental conditions, which can become exacerbated as they transition into the independent life at university. Others may acquire SAD due to sharp contrast between their regular lives and the near-programmed university life. Challenges related to relationships, studies, environmental influence also contribute to mental health issues.

In South Sudan, most students have experienced one form of violence or another, which exposes them to possibility of experiencing Post-Traumatic Stress Disorder (PTSD). Majority have been exposed to violence in childhood either at the household or the community level which may remain repressed but exacerbates later in life and at University (Pedrelli, Nyer and Willens 2015) [3]. While all the above is true about most nations in the world, responders in institutions of higher learning may not be adequately prepared and/or the responder-student ratio may be so high to be handled effectively. At University of Juba, this role directly falls under the Deanship of Students’ Affairs where the office of the Students’ Counsellor is charged with the role of overseeing the general well-being of students. This office receives, evaluates, identifies and responds to social, moral, academic and mental issues of students. Some students come with a baggage of trauma after having previously been conscripted in armed conflict, having experienced violence, having been primary or secondary recipients of trauma or having perpetrated some form of violence. This coupled with decades of the country’s history of armed conflict both in pre- and post-independence periods has left a number of students with SAD or Post-Traumatic Stress Disorder (PTSD). This study therefore seeks to investigate the student’s perception of the kind of services offered to students with mental disabilities, their adequacy, availability, appropriateness, alternatives to the same and how they can be made more effective to serve UOJ students better.

1.2. Statement of the Problem

It is common knowledge that SAD or TSD can hamper normal functioning of a student and negatively affect their performance. A study carried out by Marangu et al. (2021) [4] found out that there is a “treatment gap”, which is defined as the number of people with a mental disorder that does not receive mental health care which they estimated at 85%. They cited Mutiso et al. (2020) [5] who cited the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS) and pointed to lack of administrative structures for mental health care provision such as policies and governance. This has resulted in low prioritization of mental health care in Kenyan universities which can be positively comparable to the situation in the University of Juba. Training of student-counsellors may not have reached its optimum and the counsellor-student ratio is also very high. Indeed, there is only one student counsellor against the entire university population, right from freshmen to post-graduate levels. The university has a total enrolment of over 15,000 students for both regular and post-graduate students. The paper seeks to examine the level of professional preparedness of responders to students’ mental health issues both in terms of training and quantitative adequacy.

From the foregoing discussion, the question is whether the personnel available in University of Juba recruited for the task of alleviating mental health issues are well equipped with knowledge, skills and the right attitudes through training, experience gathering, exposure and otherwise to respond to such issues.

1.3. Purpose of the Study

This study aimed at evaluating the level of preparedness of the responders to mental health issues of students in University of Juba. This would look into the nature and level of training in the area of psychological counselling in order to offer support through guidance, counselling and making referrals to students. The study would help in providing data on the adequacy of psychological responders in terms of training and their ratio to students. Moreover, the study would help to inform the university administration and other policy-makers in line with higher education on the gap in response to mental health issues among the university students, and suggest ways in which such gaps can be bridged. Findings from this study provide new insights into current gaps relating to mental health literacy levels of the mental health care in higher institutions of learning in the Republic of South Sudan with an aim of coming up with interventions to reverse the situation.

1.4. Objectives of the Study

1) To examine the prevalence of mental health illnesses, types and causes among students in University of Juba.

2) To evaluate the kind of interventions available for students in University of Juba to alleviate mental health issues.

3) To identify challenges facing mental health responders in University of Juba and suggest solutions to the challenges.

1.5. Questions

1) What are the commonest types of mental health issues among University of Juba students?

2) What kind of interventions is available for students with mental health difficulties in University of Juba?

3) What are the challenges facing mental health responders and caregivers in University of Juba and how can they be resolves?

2. Literature Review

2.1. Understanding Mental Health

Mental health is a state of well-being in which people realize their abilities, cope with the normal stresses of life work productively and are able to make contribution to their communities (Felman, 2020 [6]; WHO, 2022 [7]). Additionally, Centers for Disease Control (CDC)1 defines mental health as emotional, psychological and social well-being which affects how we think, feel and act. It also determines how we handle stress, relate to others and make healthy choices. This section explores literature on mental illness commonly found among university students, possible causes, interventions available and how such interventions can be made effective in handling mental illnesses.

2.2. Prevalence and Likely Causes of Mental Illnesses among University Students

Torrano et al. (2020) [8] citing Cleary et al. (2011) observes that the entrance to the university marks a period of transition for young people. Through this transition, students face new challenges, such as making independent decisions about their lives and studies, adjusting to the academic demands of an ill-structured learning environment, and interacting with a diverse range of new people. In addition, many students must, often for the first time, leave their homes and distance themselves from their support networks. The transition to independent living and study can be a huge trigger for mental health problems among university students. Rates of anxiety, depression, eating disorders, self-harm and suicide are high among the students.

Anwar (2021) [9] observes that common mental health conditions include depression, panic disorder, Post-Traumatic Stress Disorder (PTSD), obsessive compulsive disorder (OCD) and eating disorders.

Kamunyu, et al. (2016) [10] observes that studying at university is associated with experiencing significant stressors in including stress experienced by new students after transiting to a university life (Atwarter Julal, 2003 [11]). Triggers to these changes can be linked to increased academic demands, constrained finances, lack of employment and personal relationships (Julal, 2003) [11]. Jema (2021) quoting a study by University Student Mental Health Survey (2020) found out that almost half of the 21,000 students surveyed have experienced a serious psychological issue for which they needed professional help. Toto and Limane (2022) [12] states that most of the learning institutions have tight schedules and continuous sequences of study, which affects the students' performance and their mental well-being. Challenges and the predisposing factors that affect the students are bound to result from their school environment or their history; therefore, the growth environment and interaction play a significant role in determining one’s health.

Smith (2021) [13] maintains that students are particularly vulnerable to mental health struggles as they're often living away from home and dealing with the stresses of adult life for the first time. They continue to say that students can experience struggles with all aspects of emotional and mental health. These range from difficulties in managing stress, change and pressure, right through to more serious mental ill health such as psychosis and mood disorders According to Toto & Limone (2022) [12], university students are likely to experience challenges such as impaired functioning in cognition, substance abuse, poor performance in their school work, and learning disabilities. They are likely to abuse drugs such as tobacco, alcohol, cigarette smoking, and other hard drugs that impair normal body functioning. Most of these drugs are associated with various risk behaviors, depression, and anxiety. This suggests that emotional discomfort raises the likelihood of developing additional mental health issues. For this reason, the prevalence of mental illnesses among university students is higher compared to people in other environments.

According to AIMS Mental Health (2021), prevalence of stress, anxiety, and depression is high among university undergraduate students in developed and developing countries. Students entering university are from different socioeconomic background, which can bring a variety of mental health risk factors. Moffateh (2020) records that mental health is one of the most significant determinants of life quality and satisfaction. Poor mental health is a complex and common psychological problem among university undergraduate students in developed and developing countries. He adds that untreated poor mental health can cause distress among students and, hence, negatively influence their quality of lives and academic performance, including, but not limited to, lower academic integrity, alcohol and substance abuse as well as a reduced empathetic behavior, relationship instability, lack of self-confidence, and suicidal thoughts. Stress, anxiety and Depression (SAD) are a common phenomenon in university students and this is inferred from behaviors displayed by students at different levels in the university.

Alcohol is the leading cause of many disorders and deaths for campus students, while some abuse drugs to induce their studying habits. The recreational activities that undergraduates use alcohol and other drugs for result in addiction which causes many diseases (Toto & Limone 2022) [12]. Cruz et al. (2021) [14] notes that lack of trained mental health personnel is a significant barrier to increasing access to children’s mental health care in Low and Middle Income Countries (LMICs). Kamunyu et al. (2016) [10] cites Cheung and Liu (2005) [15] who argues that individual students are likely to seek professional help for different problems such as emotional, personal, interpersonal or academic/vocational problems, stress-related problems, relationship issues and mood problems. Students may experience feelings of worry, loneliness, substance misuse and thoughts of self-harm and almost half of students reported thoughts of self-harm, more than three quarters have concealed their symptoms due to fears of stigma.

In University of Juba just like most other universities in developing countries, students metal health issues range from drug and substance abuse arising from anxiety, compulsive-obsessive behavior, aggression that may have negative effect on others or leads to self-harm among such students, relational behaviors, impaired cognitive functioning, learning disabilities, poor academic performance, etc. This happens against a situation where there are inadequate human resource trained and recruited to handle mental health issues.

2.3. Impact of Mental Illness among University Students

According to Ngaru and Kagema (2017) [16], psychological problem tends to have a negative effect on the progress of learners in universities since it may inhibit their academic progress, it may increase the mortality rate of youth and may defeat the objective of improving the human capital of the youth through higher education. The occurrence of suicidal tendencies is a concern for the individual students, the parents, the university and the nation at large. They continue to say that teachers’ roles in child mental health care globally have been largely limited to mental health promotion or prevention centered on delivering classroom lesson plans to whole classes. Teachers’ roles in delivering care may currently be narrow because they feel under-trained to teach and work with students with mental health concerns; they also report being overburdened with their education duties and may lack the bandwidth to take on counselling tasks; and may not view students’ mental health as their responsibility.

Mboya et al. (2020) [17] in a study in Northern Tanzania states that university students with higher proportion of mental distress are likely to experience negative consequences such as significant impaired cognitive functioning, learning disabilities, poor academic performance, substance abuse (e.g. cigarette/tobacco smoking, alcohol use and khat chewing) which are associated with risk behaviors, higher risk of depression as well as anxiety disorders. This indicates that, mental distress increases the risk of other mental health problems

Kotera et al. (2021) [18] notes that good mental health is related to higher functioning and achievement, while poor mental health is related to lower productivity and poorer attainment (Royal College of Psychiatrists, 2011) [19].

2.4. Addressing Mental Health Issues in Universities

According to Anwar (2021) [9], there also tends to be a significant stigma attached to anything related to mental health, which is why it’s so essential that we acknowledge good mental health efforts and work to overcome the barriers that have been put up that keep us from addressing mental health in a positive, productive way. To effectively address mental health issues in the universities, there needs to be a strong counselling programme that can offer a wide range of services to students. This is because majority of students with mental health issues present with symptoms of psychological disturbances ranging from mild to severe levels. Sibandze et al. (2019) [20] citing Sahin (2016) [21] indicates that guidance and counselling would drastically improve if school counsellors could receive good training since detailed counselling is required for psychological counsellors and that supervisors of counsellors should not be school principals. Sahin (2016) [21] further alluded to the fact that the number of school counsellors should be sufficient and there should be adequate and appropriate facilities. They further cited Owino (2015) [22] who found that most guidance and counselling teachers said there were no guidelines that were followed in delivering guidance and counselling, heavy teaching loads which do not allow them to consult with others on matters concerning the programme, school counsellors sometimes have to do tasks that are not aligned with their professional responsibilities, prejudice of school administrators and teachers against guidance and counselling services while some counsellors are self-critical in practice and have troubling reaction to clients since they do not know what to do in a counselling session (Sibandze & mafumbate, 2019 [20], Pereira & Rekha, 2017). Mboya et al (2020) [17] suggested that there is a need to encourage university students to establish healthy relationships with both their families, friends and fellow students in order to reduce the burden of this problem. Student support services at the college should also be strengthened such as using peer counsellors who will play role in addressing and eventually reducing mental health issues among undergraduate students.

A study carried out by Ebert et al. (2019) [23] showed clearly that the majority of students reported at least some hesitation to seek treatment for emotional problem and that psychological barriers are paramount, thereby arguing that the treatment gap that exists among college students cannot be closed entirely by doing nothing more than increasing access to treatment.

Ngaru and Kagema (2017) [16] citing Calvete & Connor-Smith (2006) suggests support from family and friends have been found to reduce the impact of psychological problems among students. In addition, social support could help students to cope with everyday life stressor and lighten the burden of academic workload. Without enough support from family and friends, they would be in trouble and are vulnerable to depression, stress and anxiety. They add that the support received by the students could help to decrease their psychological problems since they feel that someone is there to help them, thus helping them to perform well in academic life. By having knowledge on how social support could help students to excel in study and cope with any psychological disturbances, much information could be derived to enhance the amount of support provided.

Mboya et al. (2020) [17] in a study carried out in Northern Tanzania highlights many challenges faced in dealing with universities mental health. These include inability to meet mental health needs because it is among one of the least prioritized areas. These include inadequate number of trained personnel in mental health, misplacement of human resource for mental health, lack of specific treatment, problematic insurance coverage for mental disorders, and stigma attached to mental health problems. Due to these challenges, mental health problems may be intensified especially in key populations such as university students.

In resolving the above challenges, Cruz et al. (2021) [14] says that teachers who receive appropriate training and supervision and acquire mental health experience in mental health promotion or prevention interventions in High Income Countries (HICs) have made gains in mental health knowledge, have had more positive attitudes towards mental health, and have improved self-efficacy in teaching students who need mental health support. Further, it is important for policy makers to design comprehensive guidance programmes that could clarify what school counsellors could do or should do and should see to it that school counsellors are employed and not appointed to merely fill up a position. In addition, the Ministry of Education and Training should ensure that each school has a full-time guidance and counselling teacher who will only specialize on providing guidance and counselling services and that there must be a timetabled guidance and counselling period for each and every grade in a school. Funds for carrying out the programme must be on the yearly school budget to ensure its continuity and success.

Pedrelli et al. (2021) notes that most college students do not have medical insurance and this may prevent them College providers may have to pay special attention to students whose needs cannot be addressed by the services provided on campus. Therefore, health centers or counselling centers should develop an extensive referral system easily accessible to their students with severe mental illness or in need of higher level of care. Lastly, some students may receive services from providers at their college as well as from outside their institution; therefore, it is critical that all providers coordinate care. Thus, a collaborative relationship between university health centers and behavioral health services may lead to an increase in identification and referrals for behavioral health treatments of students with mental health problems.

Kotera et al. (2021) [18] in a study of mental health of Malaysian students found out that mental problems may be exacerbated by negative attitudes towards mental health. According to their findings, negative mental health attitudes refer to beliefs that mental health sufferers are weak, incompetent, and unable to take care of themselves. Therefore, when internalized, they can cause feelings of shame.

3. Methodology, Research Tools and Sampling Techniques

3.1. Research Design

The study utilized a case study whereby out of 5 national universities in South Sudan, only University of Juba (UOJ) was selected. This was done because UOJ is centrally located in the capital city Juba, meaning it was easily accessible. It has a student base of about 20,000 Students across all Schools, Colleges and Institutes representing all communities of South Sudan. The university therefore was considered most appropriate for this study and the findings are considered generalizable to other similar situations.

3.2. Sampling Design and Sample Size

This study adopted purposive sampling where a sample of 20 students who identified through the help of the Deanship of Students Affairs. The students’ population at the university then that was about 1,200 students was treated as the entire population since the rest were on vacation while others are evening and weekend programme students and another group is made up of Distance Learning students. A lean sample was preferred due to the sensitive nature of the subjects and the researcher was targeting respondents who have had one or more types of mental health issue either in the past or at the time of the research. The respondents were identified through non-probability sampling because most of the schools and institutes of the university were on vacation and a few others were in examinations. This made the researcher to use the ones who were available in university then.

3.3. Data Analysis and Presentation

Raw data was coded by assigning exclusive acronyms for easy analysis. Data were transcribed and analyzed using qualitative approach, where their responses were recorded and discussion of their implications given in order to make the participants’ comments useful and understandable. Results were presented using word symbol and descriptive statistics like tables, percentages, frequencies, charts and graphs

3.4. Ethical Considerations

In this study the researcher maximized trustworthiness by ensuring adherence to ethical considerations, credibility, confidentiality, anonymity and strict conforming to research ethical guidelines. Participants were taken through the objectives of the research and explained to the reason for being considered in the study. They were given informed consent form and they had the option of joining the study or opting out. The researcher made sure that the rights of participants were not infringed.

4. Data Analysis and Discussion of Findings

4.1. Respondents Bio-Data

From the primary data gathered about respondents’ gender, 13 were males while 7 were females. This gave 65% and 35% respectively. From this data, more males took part in the study probably this being reflection of gender enrolment, where throughout all levels of education in South Sudan, males are more than females.

In terms of age (Table 1), none was below 18 years while majority fell between 19 - 25 years who were 11 making 55%, 26 - 30 years were 6 taking 30%, 31 - 35 years were only 2 making 10 % while only one was above 36 years taking 5%. This implies that in University of Juba, cases of underage students may be rare as indicated by this research.

Regarding the degree courses (Figure 1), Education 5 (25%), Engineering 2 (10%), Law 2 (10%), Peace & Development Studies 2 (10%), Medicine 1 (5%), Arts and Humanities 1 (5%), post-graduate/Masters 2 (10%) and Natural resources 4 (20%) and information Technology 1 (5%).

Table 1. Respondents age bracket.

Figure 1. Pie chart showing respondents year of study.

4.2. Information Regarding Mental Health in University of Juba

4.2.1. Do You Have Knowledge of Mental Illness? If Yes, What Do You Understand to Be the Cause?

In this item on whether respondents have any knowledge on mental illnesses, all said yes, they did. This means that 100% of the respondents were aware about the subject. The item further sought to know if they had an idea of what caused the condition.

Findings of a study carried out by Zivin, Eisenberg, Gollust and Golberste (2009) [24] [25] indicate that mental disorders are prevalent and persistent in a student population. While the majority of students with probable disorders are aware of the need for treatment, most of these students do not receive treatment.

Probed further to what they thought was the cause of this condition among the students in their university, the following responses were gathered:

Drug and substance abuse, economic hardships from family backgrounds, exposure to traumatizing situations like conflict, genetic factors or causes within the family, stress caused by studies, additional responsibilities, e.g., some are parent-students or family heads, relationships-related stress, prolonged or terminal sicknesses and spiritual/cultural causes, e.g., witchcraft.

According to Sasha and Alisa (2021) [26], there is a correlation between social media use and increased anxiety and depression. Sociologists have pointed to social media’s undermining of teenagers’ self-esteem, particularly among girls. Experts also contend that overprotective parents, so-called helicopter parents, who won’t let their kids fail, have also contributed to a more fragile generation.

Pierpaolo & Toto (2022) [12] enumerate factors that push university students into mental illness. Among them are sex, which they say has a significant contribution to the mental illnesses that people experience in learning institutions. They add that introvert students are also more likely to fall victims and students who face various social challenges such as poverty. Most of the learning institutions have tight schedules and continuous sequences of study, which affects the students’ performance and their mental well-being. They add that childhood trauma, abuse, and neglect are likely to be more disastrous when a person reaches the university or college level. Trauma greatly impacts a person’s thoughts and feelings about oneself and how they relate with other people in society. They summarize causes of mental illness as academic excellence pressure that put emotional feelings among students. The emotions and failure to meet their expectations land students into mental conditions that may perpetuate for a while. Change of environment and desire to adjust to a new form of livelihood in university also causes a resultant change in lifestyle. They purport that students commence drug and substances abuse which puts them at risk. A person’s history of the family's genetic composition, chronic illnesses, and injuries of the brain also causes brain challenges as well as other socio-economic factors.

4.2.2. What Are the Commonest Symptoms Exhibited by Students with Mental Health Illness in Your University?

Table 2 and Figure 2 show the common symptoms of mental illness among students.

Others: a mentally ill student wants to fight everyone, complaining always and trying to incite other students to strike, stealing, lying, overeating or having no appetite, having negative self-perception hence low self esteem. Pedrelli et al.

Table 2. Commonest symptoms exhibited by students with mental health illness.

Figure 2. Bar graph showing common symptoms of mental illness among students.

(2014) found out that mental health problems are prevalent in college students, with substance use, anxiety, and mood disorders being the most common. Students also face numerous stressors associated with having multiple roles, demands, and financial obligations.

In South Sudan, all the above mentioned reasons may be valid because of the shrinking economy which has made life for students very costly yet having very meagre resources. Many students are already practising parent roles with some as family heads while others are already into marriage owing to the low marriage age as defined by culture in various communities in South Sudan.

4.2.3. Are There Helpful Care Strategies for a Student with Mental Illness

7 respondents representing 35% said that there were helpful care strategies that are used to assist students with mental illnesses. The rest confirmed that they did not know of any strategies that are there for students with mental illnesses.

They were further told to explain the available services and strategies. 8 (40%) said that there is diagnosis and treatment of mental illness by the medical staff at the university health centre. 6 (30%) said that there is counselling services done by the university students counsellor while 4 (20%) said that there were no strategies for mentally ill students. (Figure 3)

Further, the item sought to know who in the university administers the availed mental health care strategies. The respondents said that they are done by:

- Deanship of Students’ Affairs 4 (20%)

- University administration 7 (35%)

- University students’ counsellor 12 (60%)

- University health centre 2 (10%)

Lynda and Anna (2019) [27] found out that Faculty can play a vital role in supporting students with mental health issues. Preventive measures and clinical services are important (Brownson et al., 2016). In the latter case, non-mental health individuals might observe a student’s need for help (Rosenbaum & Liebert, 2015) [28], as they “may be among the first to notice changes or problems

Figure 3. Clustered Column Line graph on who offers mental health services in UOJ.

students may be experiencing, be it acting up in class, slipping grades, or changes in social interactions”

4.2.4. How Would You Rate the Level of Appropriateness of Services Given to Students with Mental Illness in Your University?

This item used Likert’s’ 5-Pointer scale to measure the perception of the respondents on appropriateness of services given to students with mental illness in your university. Data collected indicates that none said that the services were very good while only four affirmed that the services were good. 6 (30%) did not know anything about the appropriateness of the services while 5 (25%) said the services were poor and very poor respectively.

According to a study done by Lynda and Anna (2019) [27], three reasons seem to top the list for why college students might avoid seeking mental health services. These include: stigma (self-stigma and perceived stigma from others); insufficient mental health support (in terms of resources and timely availability of services); and cost (Bezyak & Clark, 2016; Cheng et al., 2018).

4.2.5. Do You Believe That University Personnel Are Prepared Adequately to Handle Mental Health Issues among the Students?

Here, 85% agreed that the university personnel are not adequately prepared to handle mental issues among students. Only 2 (10%) said yes while 1 (5%) said they did not know.

Respondents who said that there was no adequate preparation by university staff were supposed to give reasons for their answer. They gave reasons for their response as indicated below:

­ No active office in the office that offers counselling to affected students.

­ Lack of awareness about mental health issues.

­ Lack of monitoring and identification of students’ behaviors.

­ Stigma associated with mental illness makes the affected students deny the condition.

Marangu et al. (2021) [4] from a study carried out in Kenya found that majority of students reported at least some hesitation to seek treatment for emotional problems. Part of this hesitation in UOJ could be due to student’s perception of the quality of available services for students with mental illness. Similar observation was made by a study by Zivin et al. (2009) [24] that while the majority of students with probable disorders are aware of the need for treatment, most of these students do not receive treatment, even over a two-year period.

4.2.6. Is There an Elaborate Referral System for Students with Mental Health Issues to Get Further Support from External Sources?

Most respondents 11 (55%) seemed to agree that there was no elaborate system of referring students with mental illnesses for further treatment from external agencies or facilities outside the university. Only 30 % agreed that there is a referral system while 15% said they did not know about referral system for mentally ill students in University of Juba. A successful referral has certain prerequisites: a fully completed, legible referral letter; a good therapeutic relationship between the physician and the patient; a meaningful discussion of the objectives of the referral with the patient; clarification of any questions raised by the patient; regular follow-ups; minimization of the reported attrition rate of 15% to 20%, and good compliance by the patient. In addition, the referring physician should at least contact the consultant referred to, who may seek further information about the patient. A coordination office might further improve the reception of the patient. (Qureshi, van der Molen, Schmidt, Al-Habeeb and Magzoub, 2009) [29]. They further point out some factors that destabilize a successful referral system and which need to be rectified constantly. Among them is inadequate documentation in the referral; unstructured referral letters; unwillingness to cooperate among health personnel; delay in or no consultant feedback; deficient or inefficient coordination offices; self-referred patients; patient non-compliance; and inadequate resources or logistic facilities at PHCCs and hospitals. A further probe need therefore to be done on whether the office that coordinates student affairs in University of Juba has overcome some or all of the above mentioned hurdles and managed to put in place an effective referral system for students with mental illnesses.

4.2.7. What Are the Alternative Sources of Support for Students with Mental Health Problems in Juba University?

Lynda and Anna (2019) [27] bring to light the fact that students tend to seek informal, non-professional help for their mental health needs, such as friends, romantic partners, family, school staff, coaches, and church personnel, professional treatment, especially that which takes place face to face?is important (Levin et al., 2018; Nobiling & Maykrantz, 2017).

A study by Marangu et al. (2021) [4] in Kenya found out that over half the participants (62%), viewed medical interventions and/or seeing a medical professional (doctor, psychiatrist, nurse and/or medical social worker) as helpful for a person with mental illness. Social interventions such as “talk with family and friends”, “listen and try to understand the problem”, “give love and affection” and “make happy and encourage him/her” were considered favourably by 32.7%. However, Barrable et al. (2018) [30] posits that there are rising levels of anxiety and depression amongst higher education students, compared to pre-university levels. Apart from severe mental health issues, mild to moderate psychological difficulties, which occur more frequently, can have a big negative impact on the life of students and often go undetected and unsupported. They add that many students who suffer distress often don’t reach out at all. Table 3 shows the alternative sources of support for students with mental health problems in University of Juba.

4.2.8. What Are the Attitudes towards Students with Mental Illness in Your University?

This item was about collecting data on what respondents knew about how students with mental illness are regarded. The following responses were gathered.

­ Negative attitude, embarrassing, seen as aggressive to other people without reason, unhappy and very hopeless, lonely, unstable emotions/swings of moods, talks alone (not in touch with reality), poor performing due to lack of concentration, lacking focus, pitied and also some are ignored.

Sasha and Alisa (2021) [26] say that there’s the decreasing stigma around mental illness. Similarly, Lynda and Anna (2019) [27] suggest that proactive measures can help prevent mental health concerns for college students. Efforts to raise awareness about mental health issues and available services and resources for addressing them, as well as to reduce stigma and promote better attitudes toward help-seeking, via open communications on campus at large and in individual classrooms provide one mechanism for supporting good mental health in college students. Further, Lynda and Anna (2019) [27] citing Condra et al. (2015) [31] posits that faculty members might feel uncomfortable interacting with students with mental health issues, lack knowledge of appropriate actions and resources, and even have negative attitudes toward these students.

Table 3. Alternative sources of support for students with mental health problems in Juba University.

The finding on this item sharply differs with findings of Marangu et al. (2021) [4] in a study carried out in Kenya, who found out that on attitudes towards people with mental illness highlighted positive attitudes, with the majority indicating that people with mental illness were capable of being good parents, maintain a successful marriage and have empathy towards other people.

4.2.9. Do You Believe That Mental Illness Affects Students’ Academic Performance among University Students? If Yes, How?

15 (75%) respondents said that they believe mental illness affects students’ academic performance while 5 (25%) said that they did not see any way in which mental illness affected students’ academic performance. Those who said yes, it did were required to support their response and they said that those with mental-illness perform poorly because of:

­ Skipping lectures.

­ Always being high on drugs.

­ Lack of motivation to perform well in education.

­ Mental illness blocks thinking capacity.

­ Poor performance due to poor relations with others.

­ Not focused on performing well but focused more on problems.

Yasuhiro Kotera, et al. (2021) [18] notes that poor mental health itself is a serious issue; and can lead to other diverse problems, for example it is associated with reduced academic achievement, inter-personal conflicts, sleep disturbance, low concentration, poor decision-making and resulting feelings of inadequacy. These can hinder students’ learning and research outputs which is a highly valued university priority.

Mental health problems can impair the quality and quantity of learning. They decrease students’ intellectual and emotional flexibility, weaken their creativity, and undermine their interest in new knowledge, ideas, and experiences. Mental and behavioral health problems are also learning problems (Lynda & Anna, 2019 [27], Douce and Keeling 2014 [32]).

4.2.10. Do Students of University of Juba Experience Challenges in Accessing Mental Health Services?

16 out of 20 respondents representing 80% affirmed that students experienced challenges in accessing mental health services while only 3 (15%) said there were no challenges and one respondent standing for 5% did not know about information this item sought to collect.

If yes, which ones

­ No mental facilities where university students can get services.

­ Inadequate staff that are specialized in mental health in the country.

­ Cost of treating mental health is high for students.

­ Ineffective counselling department in the university.

­ There are no qualified staff to handle mental issues among students.

­ Very high student-counsellor ratio

Sasha and Alisa (2021) [26] observe that the rising demand has put many schools in a difficult position, with limited budgets to address the growing student need. With demand for mental health care at all-time highs and continuing to increase, schools have been left scrambling for answers.

Pierpaolo and Toto (2022) [12] asserts that governments have put inadequate measures to ensure that citizens’ mental challenges are handled rightfully to achieve high levels of mentally healthy people. The perpetuated issue has also developed in various sectors of society.

4.2.11. Suggest Ways in Which Students with Mental Health Problems Can Be Assisted in University of Juba

The following were listed as ways in which mental health issues can be solved in UOJ.

・ Provision of medical care to students through the health unit in the university.

・ Provision of quality and adequate facilities to handle mental illnesses throughout the country.

・ University administration to set aside funds for supporting mental health activities.

・ The university to introduce a training course on mental health preferably under Psychology Department.

・ Working with other external service providers, e.g., military mental hospital in Juba.

・ Increase the number of counsellors and train them on mental health.

・ University administration to form medical team under the Deanship of Students affairs to help in identifying students with mental illness and refer them for assistance. This team will also do follow-up for students identified with mental illness.

Lynda and Anna (2019) [27] list key preventive measure to help students build healthy connections on and off campus, and thus a sense of inclusion, by encouraging collaborative work and support communities, membership in peer organizations, and other means of helping students interact with other students and faculty. They add that proactive measures can help prevent mental health concerns for college students. Efforts to raise awareness about mental health issues and available services and resources for addressing them, as well as to reduce stigma and promote better attitudes toward help-seeking, via open communications on campus. On the same vein, Alyson (2021) suggests that mapping concerns of students is also likely to make an impact on overall student mental health and well-being. These can include important issues such as finance, the future, support with their learning, and their own academic performance.

Faculty can play an important part in identifying student needs, encouraging help-seeking, and providing information on mental health services, and they might suggest or help institute useful campus resources, such as peer-support methods (Lynda & Anna 2019 [27], Giamos et al., 2017 [33]).

4.3. Summary and Implications of Findings

From data analysis in (4.1) above, it has come to light that in UOJ, students are aware about mental health issues and are able to identify students with such challenges by symptoms. However, they affirmed that there is limited access to services within the university for such needs and many prefer to look for alternative ways of handling their situation. Respondents attributed the cause of mental illness to use of illicit drugs, stress and anxiety related to their academic tasks, economic needs, exposure to traumatizing events, social roles and to some extent, genetic predisposition. The study also found out that there is no elaborate referral system which may limit students’ ability to access services from external agencies. This partly implies that students who seek for such services from outside the university are required to foot the medical bill and the university in this case would not be obliged to make follow-up to ascertain students’ welfare. That is why from the findings of this research, most students preferred ignoring the mental issue that speaking out about it. This comes as a way of protecting ones’ image because the study confirmed that there is generally negative attitude towards students with mental illness. The study further found out that mental health challenge affects students’ academic performance because some skips lectures, are always not focused, high on drugs or not interested in excelling. On the overall, the research findings imply that services are meagre and there is every need to step up and where not possible within the UOJ, referral can be made to enable students get further assistance.

Data from respondents suggested that this situation can be reversed by taking some measures among them being: provision of medical care to students through the health unit in the university; provision of quality and adequate facilities to handle mental illnesses throughout the country; university administration to set aside funds for supporting mental health activities; UOJ to introduce a training course on mental health preferably under Psychology Department; working with other external service providers, e.g., military mental hospital in Juba, etc. Most resounding is the suggestion that the university administration should recruit and train counsellors on mental health and place them to work with Deanship of Students affairs to help in identifying students with mental illness and refer them for assistance.

5. Conclusion, Recommendations and Suggested Areas for Further Research

5.1. Recommendations

From the foregoing discussion, the study makes the following recommendation to enable students to get access to services to help in coping with mental illness in University of Juba.

➢ This study strongly recommended University of Juba, other universities in South Sudan and all higher education institutions should ensure that there is awareness raising and training in the recognition of mental disorder to raise mental health literacy levels in order to reverse the attitude towards mentally sick students and staff. This will enable recognition of specific disorders among students and create willingness to speak up about the affected students and make them be willing to seek interventions.

➢ University administration should enforce regulations that prohibit students from consuming alcoholic beverages especially during lecture time or within the university boundaries.

➢ Students should be encouraged to seek help through individual or family therapy, support groups, community clinics, or by asking a friend or family member to assist. UOJ should develop a working relationship with external agencies that deal with mental health, either humanitarian agencies, community health facilities, private mental health care specialists to whom students with mental illnesses can be referred. This means that UOJ students may receive services from mental health providers inside and outside the campus.

5.2. Suggested Areas of Further Research

This research basically looked at issues related to mental health based on student’s perspective. Therefore, there is a need to do a more encompassing study that also seeks to include the opinion of the caregivers in the public universities. Further, there is a need to consider doing a study on service provision for mentally sick students in other levels of education for example senior secondary level.

6. Limitations

There was noted paucity of research in this area in South Sudan. There is data scarcity and especially previously done studies from which references would have been done. There was also the sensitive nature of the topic that made some respondents withhold some data. Finally, purposive sampling targeted mostly students with known cases of mental illness. This is feared to have invited some bias as the ideas expressed are those with mental health needs. However, it is believed that findings of this study can reliably be generalized to other public universities with similar characteristics in the Republic of South Sudan.

NOTES

1Centers for Disease Control (CDC). USA Department of Health and Human Services.

Conflicts of Interest

The author declares no conflicts of interest.

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