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Linking Engaged Learning, Student Mental Health and Well-Being, and Civic Development: A Review of the Literature

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Linking Engaged Learning, Student Mental Health and Well-Being, and Civic Development: A Review of the Literature

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Conducted for the Bringing Theory to Practice project, this literature review examines the theoretical and research bases for linking engaged learning, student mental health and well-being, and civic development. The findings of this review are discussed briefly in this article. Current prevention literature recommends a shift from targeted interventions toward community-level approaches in addressing students' mental health concerns. In this article, the author presents a definition of engagement learning and that the concept of engaged learning emerges from multiple theoretical frameworks and educational practices. She examines the two concepts of which it is comprised--"learning" and "engagement" in college.

Association of American Colleges and Universities. 1818 R Street NW, Washington, DC 20009. Tel: 800-297-3775; Tel: 202-387-3760; Fax: 202-265-9532; e-mail: pub_desk@aacu.org; Web site: http://www.aacu.org/publications/index.cfm

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ERIC - EJ762291 - Linking Engaged Learning, Student Mental Health and Well-Being, and Civic Development: A Review of the Literature, Liberal Education, 2007

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Conducted for the Bringing Theory to Practice project, this literature review examines the theoretical and research bases for linking engaged learning, student mental health and well-being, and civic development. The findings of this review are discussed briefly in this article. Current prevention literature recommends a shift from targeted interventions toward community-level approaches in addressing students' mental health concerns.

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Social and Emotional Learning Importance

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Social and Emotional Learning Importance

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Growing up can be tough. As young people's bodies and brains are changing rapidly, they're also grappling with new ideas and influences that will shape who they become.

Kids today might actually have it worse, thanks to technology. They're going through their awkward stages-the braces and bad haircuts and first crushes-on Instagram and Snapchat. And they're trying to make friends while everyone's noses are buried in their phones.

Research tells us these things are taking their toll. A 2018 Pew Research Center survey of kids aged 13 to 17 found that 7 in 10 teens think anxiety and depression are major problems for their peers. The same survey found that 6 in 10 kids feel pressure to get good grades while nearly 3 in 10 feel pressure to look good and fit in socially.

Dozens of recent studies tell a similar story. Students today are distracted, they're under a lot of pressure and they're suffering from mental health issues more than ever before.

The education community is increasingly getting involved in these issues, looping in social workers, licensed therapists and other mental-health services to help students who are struggling. They often talk about these things in the context of "caring for the whole child" or "teaching to the whole learner." The idea is that, in order for kids to be successful academically, their other needs must be met, too. That includes their social and emotional needs.

In the last few years, terms like "whole child" and "social-emotional learning" have become buzzwords. They're all over education conference agendas and making headlines in the news. But behind the buzzwords are programs, often led and managed by schools, that take into account all the different things a child needs to be able to learn and grow, even if those things reach outside the traditional roles of a school.

Earlier this year at the SXSW EDU conference in Austin, Texas, EdSurge sat down with Christina Cipriano, the director of research at the Yale Center for Emotional Intelligence and a research scientist at the Child Study Center at the Yale School of Medicine. Cipriano thinks about and researches social-emotional learning every day, so she broke down for us what SEL is, where it comes and how it works.

Listen to the discussion on this week's EdSurge On Air podcast. You can follow the podcast on the Apple Podcast app, Spotify, Stitcher, Google Play Music or wherever you listen. Or read a portion of the interview below, lightly edited for clarity.
EdSurge: Social-emotional learning (SEL) has become arguably one of the hottest topics in education in the last couple of years. For those who are still new to this topic, could you explain what SEL is and why it matters?
Christina Cipriano: Social-emotional learning is thinking about the competencies that underscore our ability to be available to learn and available to teach. There are a number of different frameworks that we use. One of the most dominant frameworks in the field is the CASEL five. It's the Collaborative for Academic, Social, and Emotional Learning. Those five competencies are self awareness, self management, social awareness, relationship skills and responsible decision making.

When we think about social-emotional learning, we talk about how social-emotional competencies underscore your ability to learn and your ability to teach. These are skills that all people and all learners across the lifespan need to continuously develop and invest their time and energy in to be able to be positive contributors to their life and those around them.
Is this a new concept? Why does it seem like all of a sudden we're hearing about SEL?
It is certainly not a new concept, and it's been around in literature for over two decades. However, it's recently gotten a lot of more air play as folks are realizing that whether you call it character education, peace building or conflict resolution, they all have foundations in the social-emotional learning frameworks and in that research base.

At our center we use the emotional intelligence science to underscore our framing of social-emotional learning. However, depending upon which research institution you talk to, you will see other ways of thinking about and framing the problem. At the end of the day, we're talking about teaching people how to be better citizens and more positive contributors to their society. We realize it's 2019, and that that is an important skill that everybody needs.
In what ways does SEL set up students for success that directly relates to academic learning-and also doesn't?
A good example of this would be thinking about a student or adult's ability to regulate your emotions or, as CASEL calls it, in managing yourself. We all have different triggers of stress throughout our life and different emotions that can hijack our body's ability to be able to process the world meaningfully. If we're not able to regulate or down-regulate in a given situation, we're not able to be available to process the information of what we're being taught.

This week's podcast sponsor is Emporia State University's Instructional Design and Technology program: designed for those interested in creating dynamic, interactive learning environments in both public and private sectors, the master's in IDT from ESU can be completed quickly and entirely online, preparing educators for the new age of the technology-driven learning environment. Learn more here.

So, regardless of how fantastic your teacher may be or how incredible that science curriculum is at engaging and motivating you, if you have a student who's dealing with stress or trauma or unable to kind of get over the interpersonal interaction they had right before they entered that classroom, or the trigger word that the teacher said, like "pop quiz," that set them off into a spiral, they're not going to be able to process the dynamic curriculum that's being presented to them.

And so social-emotional learning really teaches and targets those skill sets and competencies that underscore your availability to learn. In our case, and in our work at the center, we focus on also thinking about the social-emotional learning of the adults in the room and the educators as the co-constructors of knowledge in that environment.
So if this was the first time that anyone's ever mentioned this concept to me, maybe a question I would have is, "Well, that's great, but it doesn't sound like something you can teach." How do you teach things like emotional regulation and relationship skills?
My immediate answer is that if you don't think you can teach them, you have a fixed mindset and not a growth mindset. We need to be always open and available to learning through our interactions around us. The ways in which we teach these discrete skills depend upon the cognitive ability and development of the learner, and how they're going to most access them. For instance, when we focus on emotion regulation, we're thinking about students' cognitive reappraisal abilities and their self-talk strategies.

Now, there's a lot of different ways you can manage your emotions in a given situation. For some of us, like myself, you might want to go for a run to regulate, but not all schools are conducive to that. You can't just get up and do that. When we worked with teachers, we found that they want to know how to teach those skills that they can focus on how students will reappraise the situation to make a situation more positive, problem-focused, challenge-based-so that they think about it as something they can solve, and how they're talking to themselves. Really capture the essence of their self talk strategies in ways that are going to be most meaningful.

This doesn't mean that you're providing a pull-in lesson every week on Tuesdays at 3:00 p.m. to teach them how to reappraise their emotions, but rather that you are modeling those skills in the way that you interact with that student and with that learner before, during and after the situation, so that they're continuously seeing and learning [that].
So it's less about teaching it and more about naming it, addressing it and giving strategies to respond?
I would kind of reframe what you said there. I would say that that is teaching it. It's the ability for us to be able to recognize, understand, label, express and regulate our emotions. That's actually the acronym, RULER, that is our approach at the Yale Center for Emotional Intelligence for teaching these competencies. Going through that pattern of steps and having developmentally appropriate access points for all of our learners is the gateway in.
What did SEL look like before it kind of became this buzzword-before it was dominating SXSW EDU panels?
If you look back you'll see conversations about character education, moral education in the school, about being a good citizen, conflict resolution programming-all pockets that begin to target social-emotional learning competencies.

When we even talk about SEL as a larger field, there is discrepancy-depending upon what researcher, practitioner or policymaker you speak to-on how they will define what competencies fall within it and where the limits of the skill set lie. That's a bigger conversation in the field right now.

Alongside that discourse is also the conversation of how to adequately assess social-emotional learning. The most popular question that I get asked on a regular basis, weekly I will get an email from someone somewhere in the world who wants to know what the best SEL score is, what the best SEL score is. I set up a call and I have a nice conversation back about how well, you don't want to assess SEL. Having a SEL score is a completely inappropriate way of thinking about it. You want to be thinking about what social-emotional competency you're trying to assess, and what the most meaningful way to do that is.

That's important, because if we're not able to show that children and adults are learning using these programs and have outcomes that are meaningful, then this will unfortunately just become that thing that was and people will move their focus on in 10 to 20 years to the next big thing that comes into the space.

There's an urgency among the SEL community to begin to create those data points and to find that assessment landscape so that this doesn't turn into a conversation like we all unfortunately remember with No Child Left Behind policy, where standardized assessments came into the narrative and started to shift the focus of how programming was being offered in classrooms and created a culture of fear on test taking.
Who does SEL leave behind? What kind of students just aren't being taken into account in these kind of programs?
That's actually the purpose of the panel that I'm here at SXSW EDU giving with my colleagues today. We're looking at all of your traditionally underserved student populations and their inability to access current SEL programming. We're talking about children with specific learning disabilities and diverse learners, ethnic and racial minorities, children who are serviced in therapeutic settings, alternative environments, correctional facilities. So a real wide net of the "other" children in the story and thinking about how there may or may not be access points for them throughout the way our programs are currently structured.

An example I can give you is when we think about how we teach some of the well-known strategies for accessing and instructing social-emotional learning competencies like perspective taking and decision-making involve group discussion. If you have a child who has an auditory disability and you make sure that they have hearing aids, there is a translator, or there is sign language being used, that's only a step in the right direction, because we know that when a classroom of students is talking or when group work is occurring that children can talk over one another and it can be difficult to follow social overtures. Similarly, a student with Autism Spectrum Disorder or emotional behavioral disturbances may not be able to pick up on those social cues, which is the driving force of how the curriculum is originally written. Finding ways to create flexibility within the essence of the program so that it's not just the method of instruction but also how they can engage with the learning content is critical.

Unfortunately, there are few and far between examples of that level of full inclusivity across the kind of mainstream SEL programming to date.
For schools that don't have the resources to build an intentional, aspirational SEL program, what are some things that educators can do that require minimal time and money to improve a school's social-emotional supports?
First is becoming knowledgeable about what we're talking about when we're talking about SEL. I point people to the CASEL website and the wealth of resources that are available there through the national foundation to be able to access information and basic understandings of the frameworks and competencies, as well as how to implement a program in your school.

A second point is that it's important for the leadership to invest in social-emotional learning as something that is important from the top down, not just the bottom up. In order to have students who are increasing in their social-emotional competencies you need to have teachers who feel like they're available to teach, which means you need to focus on their psycho-social health and well being. Which means you need to focus on the leader, and their psycho-social health and well being.

When leaders are not bought in to the importance of it, this just becomes another thing to do that doesn't stick and does not sustain, and that is the complete antithesis of what folks in the SEL field want to happen with social-emotional learning.

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Why Social-Emotional Learning Is Suddenly in the Spotlight - EdSurge News

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Growing up can be tough. As young people's bodies and brains are changing rapidly, they're also grappling with new ideas and influences that will shape who they become. Kids today might actually have it worse, thanks to technology. They're going through their awkward stages-the braces and bad haircuts and first crushes-on Instagram and Snapchat.

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Calm
An app for sleep, meditation, and relaxation. Also provides music to help you focus, relax or sleep. Offers video lessons on mindful movement and gentle stretching. Includes nature scenes and sounds to enjoy while relaxing, sleeping, studying, or working.
Headspace
Guided exercises, videos and more to help you get healthier and happier. Offers options specific to meditation, sleep & wake up, stress & anxiety, movement & healthy living.
Insight Timer
App for sleep, anxiety, and stress. Includes over 30,000 guided meditations.
Liberate
The largest free & centralized library of dharma talks and guided meditations from Teachers of Color.
Shine
An app and community for individuals experiencing anxiety and depression. Motivating daily affirmation messages. Options to check in with yourself and reflect on your growth.

Down Dog
Select your time, level, focus, voice, and music, and Down Dog creates a unique, personalized yoga practice every time.
Campus Recreation
Students have free access to the campus gyms and group fitness classes, including yoga among others!

Remember that you have access to your RA, CD, advisor, teachers, and friends, too!
Feel Better Yoga
A locally owned yoga studio to offer some curated yoga.
Triangle Yoga
Offers a variety of yoga classes that can help you relax physically and mentally. They also have a student discount rate!
Franklin St. Yoga Center
Offers student discounts on a variety of class packages. They organize their classes by level so you can figure out the best class for you!

Note that there are lots of yoga studios in Carrboro as well!

Discover the Power of Self-Compassion
This three-session video webinar series to learn about the science of self-compassion from Dr. Neff and Dr. Germer. The power of self-compassion: A step-by-step training to bring kindness and inner strength to any moment of your life.
Self-Compassion
Defines self-compassion and provides access to research and personal practices to learn a lot about self-compassion with it's beneficial wellness attributes.

Counseling & Psychological Services
CAPS offers individual counseling and assessment services as well as campus events and small group programs on a variety of topics, including stress and mental health.
Wellbeing Coaching
Wellbeing Coaching, an evidence-based practice, is a partnership between a student and a staff facilitator, designed to help a student self-reflect on their wellbeing.
Emotional Wellness Toolkit
National Institutes of Health bring you an emotional wellness toolkit, that provides checklists and strategies to maintain your emotional wellness.
Mind Tools
The link above will take you to the Mind Tools Stress Diaries page, where you can use their template to track your stress and determine what's affecting you. The rest of the website offers other information on stress and tips and tools for how to manage it.
Virtual Pamphlet Collection
This website, through the University of Chicago, offers a plethora of information on a variety of health topics, including stress and anxiety. The website is a collection of materials used at various university counseling centers across the country.
You Really Need to Relax: Effective Methods
This document from the University of Michigan Health System guides you through progressive muscle relaxation and visualization exercises.
Go Ask Alice!
Go Ask Alice! is a fantastic health resource. The website is maintained by health educators at Columbia University, and it is set up in a Q&A format. If someone has a question, chances are that the folks at Go Ask Alice! have heard it before and have a great answer already on hand. You can submit questions, too! They answer questions about mental health, nutrition, alcohol/drugs, sexuality, relationships, and sexual health.

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Calm An app for sleep, meditation, and relaxation. Also provides music to help you focus, relax or sleep. Offers video lessons on mindful movement and gentle stretching. Includes nature scenes and sounds to enjoy while relaxing, sleeping, studying, or working. Headspace Guided exercises, videos and more to help you get healthier and happier.

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A few years ago, a student showed up in my class looking distraught. "I don't think I can be in class today," the student told me.

No explanation, no elaboration. Yet I knew from our previous conversations that this student suffered from anxiety and that the previous few weeks had been pretty overwhelming for her. I allowed the student to leave class. When I checked in with her later that day, she said she was feeling a lot better, but was just stressed because of everything on her plate.

That conversation took place in 2016. Rates of mental health problems had already been on the rise. From 2012 to 2018, for example, the number of self-reported suicide attempts more than doubled among college undergraduates.

Since then - in large part because of the pandemic - college leaders have expressed increased concern for the mental health of students. In September 2020, 61% of college presidents at four-year public institutions identified the mental health of students as a top concern. A year later, that figure jumped to 71%.

As a doctoral candidate studying the sociology of mental health, I have long been worried about the high rates of mental illness and general distress among college students. Based on my review of recent scholarship on these issues - along with guidance from mental health practitioners who work in a college setting - I developed a set of best practices for instructors and others who wish to see college students flourish.

Here are five practices that emerged from my research.

1. Signal support in the syllabus and in class

The syllabus is one of the first opportunities that instructors have to demonstrate their openness and commitment to students' mental health. Though many universities now require instructors to describe campus resources and accommodations available to students with disabilities, it may also be helpful to include additional language on mental health.

At the very least, instructors can provide information about the student counseling center, including the location, contact information and number of free appointments, if any. For students in online classes, be sure to specify which counseling services are available off-campus and how to access them.

Instructors can also signal their support in the classroom. During challenging periods, such as midterms and finals, consider saying something along these lines: "I know this is a stressful time. Please reach out if you feel like you're falling behind, or if you just want to talk. I also want to remind you about the free services available at the student counseling center." Such statements not only show empathy, but also guide students toward essential resources.

2. Identify at-risk students

A study by the Boston University School of Public Health found that 71% of faculty would appreciate some kind of checklist to help them identify students in emotional distress.

While warning signs may differ from one student to the next, a few key indicators to look for include: a sudden decline in academic performance; repeated absences from class; failure to respond to outreach; and changes in weight, grooming or personality.

3. Question, persuade, refer

If you encounter a student in psychological distress, consider using the well-established "QPR" protocol: question, persuade, refer. While not developed for a college population, QPR has been shown to be effective in a college setting, leading to " increases in suicide prevention knowledge, attitudes and skills." Even when students' mental health concerns do not present a suicide risk, instructors can draw on the QPR framework or a related approach, such as the validate-appreciate-refer approach by the nonprofit Active Minds.

First, question the student by gently raising your concerns after class, during office hours, or via email. Professor David Gooblar of the University of Iowa, sharing advice he learned from the school's director of counseling services, writes: "You can say, hey, you seem a little off these days. Is everything OK?" If things are not going well, persuade the student to seek treatment, and refer them to the college counseling center. If you fear your student may be suicidal, ask directly: "Are you thinking about killing yourself?" Many people believe that asking this question will exacerbate suicidal thoughts, but this is a myth; instead, it can help at-risk students get the help they need.

Ask your college counseling center if there are opportunities to receive formal training, such as the Applied Suicide Intervention Skills Training, known as ASIST.

4. Address real-world issues and events

Students don't live in a vacuum. Events such as the murder of George Floyd and the rise in hate crimes against Asian Americans have been linked to mental health challenges among Black and Asian American or Pacific Islander students, respectively. As Active Minds recommends, give students a chance to share their thoughts whenever "a major event has happened on campus, in the community, or nationally that you suspect may be on the students' minds."

5. Don't forget about your own mental health

More than 1 in 5 faculty members indicated in a 2021 survey that caring for students' mental health was taxing their own. Instructor burnout is a serious concern that requires an institutional response. In the meantime, self-care may require setting boundaries with students to protect one's own well-being. Instructors can also take advantage of existing campus resources, such as their employee assistance program.

While instructors and community members rally university leaders to devote more resources to mental health, college instructors would do well to prepare for times when a student reaches out with thoughts of suicide, the onset of major depression or the trauma of sexual assault. Instructors can also take proactive steps to address mental health more broadly, including by directing students to the resources they need before such challenges arise.

[ More than 150,000 readers get one of The Conversation's informative newsletters. Join the list today.]

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5 ways college instructors can help students take care of their mental health

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A few years ago, a student showed up in my class looking distraught. "I don't think I can be in class today," the student told me. No explanation, no elaboration. Yet I knew from our previous conversations that this student suffered from anxiety and that the previous few weeks had been pretty overwhelming for her.

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Chiefs for Change resource aims to strengthen states' student mental health responses

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The toolkit includes guidance for building state-level partnerships to maximize resources and avoiding duplication of efforts.

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Normal lamang na makaramdam ng takot at pagkabalisa sa panahon ng COVID-19, lalo na't tumatagal ang krisis na ito. Bukod sa pag-alaga ng ating kalusugan upang makaiwas sa coronavirus, mahalaga rin na alagaan natin ang ating mental health habang nananatili sa loob ng bahay.

Huwag hayaang malugmok sa mga negatibong naiisip at huwag mahihiyang humingi ng tulong kung kailangan mo ito.

1. Napag-iinitan ka ba ng mga magulang mo at palagi kang pinapagalitan? Imbis na mainis lang, kausapin sila ng masinsinan at gawing pagkakataon ang pagkakasama-sama sa bahay para makipag-bonding sa mga magulang. Makipagkwentuhan nang mas makilala at maunawaan ninyo ang isa't isa.

2. Miss mo na ba ang barkada? Gamitin ang social media, video call, chat o text para kumustahin at makausap ang mga kaibigan. Makinig sa mga mga kwento, naiisip at nararamdaman ng isa't isa. Let's survive this together!

3. Maghanap ng pagkakaabalahan o mapaglilibangan. Subukan mong matutunan ang isang hobby, skill, o talent. Nakakatulong ito sa pagbawas ng anxiety sa panahong ito. Kahit wala ka sa school, pwede ka pa ring matuto ng mga bagong bagay.

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Paano ko aalagaan ang aking mental health sa panahon ng COVID-19?

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Normal lamang na makaramdam ng takot at pagkabalisa sa panahon ng COVID-19, lalo na't tumatagal ang krisis na ito. Bukod sa pag-alaga ng ating kalusugan upang makaiwas sa coronavirus, mahalaga rin na alagaan natin ang ating mental health habang nananatili sa loob ng bahay.

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Mental health sa panahon ng COVID-19, paano maaalagaan? | NXT

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TedEd - Why students should have mental health days

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TedEd - Why students should have mental health days

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Why students should have mental health days | Hailey Hardcastle

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Improving well-being at school - Democratic Schools for All - www.coe.int

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Students’ well-being and their success in and outside school depend on their ability to use their competences for democratic culture.

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Highlights

*

Better teacher wellbeing is associated with better student wellbeing and with lower student psychological difficulties.

*

Lower teacher depressive symptoms are associated with better student wellbeing.

*

Teacher presenteeism and the teacher-student relationship may be mediating factors in these relationships.

*

There is an association between teacher-student relationship quality, teacher presenteeism and teacher absence with student wellbeing and psychological distress.

Abstract

Background

Factors within the school environment may impact young people's mental health and wellbeing. The aim of this study was to understand the association between teacher and student mental health and wellbeing. Further, it seeked to identify possible explanations by examining whether the strength of any association is weakened once quality of teacher-student relationships, teacher presenteeism and absence are considered.

Methods

Cross-sectional data were collected from 3216 year 8 (aged 12-13 years) students and from 1182 teachers in 25 secondary schools in England and Wales. The association between teacher wellbeing (measured by Warwick Edinburgh Mental Wellbeing Scale (WEMWBS)) with student wellbeing (WEMWBS) and with student psychological distress (Total Difficulties Score (TDS)) was assessed using Random Effects Mixed Models. Analyses were repeated using teacher depression (measured by Patient Health Questionnaire) as the explanatory variable.

Results

Better teacher wellbeing was associated with i) better student wellbeing (standardised effect = 0·07, 95% CI = 0·02 to 0·12) and ii) lower student psychological distress (standardised effect = −0·10, 95% CI = −0·16 to −0·04). Teacher presenteeism and the quality of the teacher-student relationship appeared to be on the pathway of these relationships. Higher levels of teacher depressive symptoms were associated with poorer student wellbeing and psychological distress (standardised effect = −0·06, 95% CI = −0·11 to −0·01 & 0·09, 95% CI = 0·03 to 0·15). This association did not withstand adjustment for teacher presenteeism.

Limitations

Cross sectional in design so unable to establish temporal associations.

Conclusions

Associations were found between teacher wellbeing and student wellbeing and psychological distress. There were also an association between teacher depression and student wellbeing. Both may be partially explained by teacher presenteeism and quality of teacher-student relationships.

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Is teachers' mental health and wellbeing associated with students' mental health and wellbeing?

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Better teacher wellbeing is associated with better student wellbeing and with lower student psychological difficulties. * Lower teacher depressive symptoms are associated with better student wellbeing. * Teacher presenteeism and the teacher-student relationship may be mediating factors in these relationships. * There is an association between teacher-student relationship quality, teacher presenteeism and teacher absence with student wellbeing and psychological distress.

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Department of Health Professions, Manchester Metropolitan University, Manchester, United Kingdom

Department of Psychology, Manchester Metropolitan University, Manchester, United Kingdom

Transitioning into the university environment can be both exciting and stressful for new and returning students alike. The pressure to perform well academically in an increasingly competitive environment, coupled with a vast array of lifestyle changes, can contribute to suboptimal wellbeing. Over recent years, uptake to wellbeing services within universities in the United Kingdom has grown given the concurrent rise in mental health difficulties reported. Higher education students now have to contend with a drastically altered learning landscape, owing to the discovery of novel coronavirus, Sars-Cov-2, otherwise referred to as COVID-19. In the United Kingdom, universities have moved to close their campuses to both students and non-essential staff in an effort to protect them from contracting the virus. The repercussions of these decisions have been monumental for the delivery of teaching, relationships and, importantly, the provision of student services. Ambiguity remains as to how teaching will be delivered for the forthcoming academic year. The uncertainty caused by the pandemic has yet to be considered in terms of student wellbeing and the new, mostly online, environments that students will be expected to navigate without their typical support networks. For the purpose of this paper, the concept of student wellbeing, a population-level term concerned with positive emotions rather than diagnosed mental health conditions, will be considered in relation to the COVID-19 outbreak. The current paper performs a conceptual analysis on student wellbeing in United Kingdom universities with a specific lens on the psychosocial impact of the global COVID-19 outbreak. Given the unprecedented world that students now learn in, considering the impact of the pandemic on psychosocial outcomes delineates the novel challenges that researchers and practitioners must consider when implementing student wellbeing initiatives moving forward.

Introduction

Transitioning into the university environment represents a significant venture in an individuals' life with feelings such as excitement and, conversely, trepidation. Multiple facets converge during this life event that impact almost all elements of an individuals' life. Beyond the obvious change in academic challenge where students are expected to become more autonomous in their studies, individuals may also relocate to another geographical location within the United Kingdom and, sometimes, internationally. This transition denotes a monumental shift in independence. For many new students, complete control over their behavioral choices becomes the norm for the first time with the potential for either positive or negative change ( Mulye et al., 2009). The student solely decides all elements of their life such as diet, exercise, alcohol consumption and drug use. Previous research has illustrated how behavioral choices tend to cluster together in a student population, whether that be maladaptive or optimal behavior ( El Ansari et al., 2018). For example, students who had a poor diet were found to be more likely to order takeaway food, smoke and engage in less physical activity ( Sprake et al., 2018). These suboptimal choices tend to be compounded by the financial restraints felt by students upon entry, imposed by rising tuition fees and limited disposable income. Money and debt worries are described by students as being the main risk factor for exiting their degree prior to completion ( Nevill and Rhodes, 2004), where financial concern can significantly impact upon social functioning ( Jessop et al., 2020). The social implications of becoming a university student can be disruptive to the students' previous support networks. Moving away from pre-existing support networks that include both family and friends can be especially daunting. Forging new social connections can be exceptionally difficult for prospective students and can lead to periods of loneliness or feelings of disconnectedness. Loneliness in university students has been significantly linked to increased stress, anxiety and depression ( Richardson et al., 2017). Synthesizing the above, the university experience presents multifaceted challenges to prospective students and has the potential to negatively impact upon student wellbeing. Despite this, entry levels to universities in the United Kingdom show no sign of waning. Record entry levels of 34.1% for 18 year olds into undergraduate study after year-on-year decreases ( UCAS, 2020) demonstrate that many young adults still strongly consider Higher Education (HE) as a next step in their life. Adding into this already complex intersection of factors impacting upon student wellbeing, the exponential transmission of novel coronavirus COVID-19 has altered the HE landscape monumentally, from teaching delivery to campus closures. This conceptual analysis will illustrate the intricacies of student wellbeing in Higher Education, why universities interest in this concept has increased over recent years, and how COVID-19 has impacted student wellbeing through its' prodigious impact on both physical life and psychological outcomes.

The mechanisms of daily life changed significantly upon the discovery and subsequent exponential transmission of COVID-19. COVID-19 (or Sars-Cov-2) is a novel coronavirus initially discovered in Wuhan, China in late December 2019. Initially reported as a case of "unknown pneumonia", the escalation of worldwide response has occurred rapidly. COVID-19 can cause the infected person to experience a range of respiratory symptoms but the most commonly reported symptoms include a new continuous cough, fever and a loss of taste and/or smell ( NHS, 2020). As COVID-19 has spread across the globe, the World Health Organization declared a Public Health Emergency of International Concern in January 2020 ( World Health Organisation [WHO], 2020). Community transmission has led to an exponential growth in cases both nationally and internationally, bringing with it stringent new measures to curb the virus' impact. Each nation has approached the COVID-19 problem with varying degrees of zeal and a range of targeted interventions normally centered around social distancing. The most utilized approach has been quarantine or, as colloquially described in the United Kingdom, "lockdown." Whilst this has looked different in each of the devolved nations, the core element of "lockdown" has been the reduction in social interaction of all forms, including typical working practices, shopping habits and education. Universities in the United Kingdom, and across the world, have closed their campuses to protect both their student and staff populations. Tertiary students have had to adapt to a completely novel learning experience as a result. COVID-19 poses both direct and indirect threats to student wellbeing; both as a direct contributor toward poor psychological outcomes and as the underpinning reason behind the stark reduction in social contact that students now cope with. Understanding how student wellbeing may operate during the global pandemic and post-COVID-19 is imperative to implementing new and adjusted measures to better support students in their academic journey. This paper will perform a conceptual analysis of 'student wellbeing' as it was first devised prior to COVID-19 and consider the impact of the 'new normal' on student wellbeing moving forward in the Discussion section. General research concerning wellbeing as a concept will first be considered before applying and synthesizing evidence in the tertiary student domain. One of the underlying principles of conceptual analysis is "the belief that to reach some agreement of that kind is a prerequisite for the development of useful (and/or interesting) knowledge..." ( Furner, 2004). The impact of COVID-19 will be considered in alignment with wellbeing and how student wellbeing may be affected by the global pandemic. Scopus and Web of Science were searched for relevant papers, using a range of search terms and relevant variations such as: wellbeing, student, university, tertiary and concept. Online software was also used to identify pertinent articles within the domain.

The Evolving Field of Wellbeing

The concept of wellbeing has been extensively studied with competing arguments to its' true definition. The foundation of wellbeing discussion is embedded in the World Health Organization's (WHO) early definition that health "...is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' ( World Health Organization [WHO], 1948). Despite early work discussing two separate approaches of the concept (hedonic ( Young, 1952) and eudaimonic wellbeing ( Rogers, 1961), it is now widely accepted that wellbeing is a multidimensional construct ( Wills-Herrera et al., 2009). Derived in part from the eudaimonic approach to wellbeing, early seminal work by Bradburn (1969) stimulated conversation about the construct. Bradburn proposed that wellbeing was ultimately composed of both positive and negative affect. Agreement has been reached that positive and negative affect are not strictly orthogonal but rather two separate constructs that are independent of one another ( Diener et al., 1995). Further research began to elucidate the underpinnings of wellbeing and 'ill-being' as two distinct constructs. 'Ill-being' was found to be driven by worry, somatic complaints and negative affect, coupled with a personal sense of low competence and external factors such as unfavorable socioeconomic factors. Wellbeing, on the other hand, was associated with personality factors such as extraversion, optimism and an overall sense of personal competence ( Headey et al., 1984). With inextricable links to the notion of wellbeing, happiness has also been explored as a core component. Resources, assessment of needs and comparison of life situation, the authors propose, all contribute toward human happiness ( Shin and Johnson, 1978). Additionally, the notion of 'quality of life' was discussed in relation to happiness, whereby it is argued that true quality of life should be defined by the individual. A review of subjective wellbeing (SWB) illustrated to the author key components of the concept:

"...the happy person is blessed with a positive temperament, tends to look on the bright side of things, and does not ruminate excessively about bad events, and is living in an economically developed society, has social confidants, and possesses adequate resources for making progress toward valued goals." ( Diener et al., 1999, p295).

Whilst subjective wellbeing and psychological wellbeing differentiate, a common thread throughout the progression of the wellbeing literature clearly emerges: wellbeing is a multifaceted concept consisting of both internal and external contributors. An individuals' affect, attitude toward life events and general outlook on life, coupled with environmental factors, contributes toward an improved sense of wellbeing. Happiness and positive affect, as a core tenet of wellbeing, has been found to correlate with a multitude of culturally desirable successes in many core aspects of life, such as love, work and health ( Lyubomirsky et al., 2005). The value of truly understanding, striving toward, and maintaining positive wellbeing is critically important to ensuring that individuals' within society thrive and flourish within their own right.

Attention in the United Kingdom has more recently focused upon the concept on a national level. Resulting from a 6-month National Debate, three domains of national wellbeing emerged: individual wellbeing (such as life satisfaction), factors that directly affect individual wellbeing (such as health, relationships, where we work and where we live) and contextual domains (such as the economy and natural environment) ( Beaumont, 2011). This framework concisely captures factors of wellbeing that have been previously discussed within the academic sphere. However, it has drawn criticism for its lack of conceptual depth. The illusion that the framework creates is that each 'domain' is viewed in silo and without interaction with the others. The academic evidence to date refutes this proposition, as research has consistently demonstrated how individuals possess distinct subjective reactions to each of the domains ( Cooper et al., 2011). Evidently, academic findings have yet to be effectively translated into real-world pieces that undoubtedly inform policy and practice within the United Kingdom.

Student Wellbeing: Before COVID-19

The term wellbeing generally alludes to a range of factors in ones' life that contributes toward fulfillment and good physical health. It has a complex role to play as both a predictor of outcomes for students, such as their academic attainment ( El Ansari and Stock, 2010) but also as an outcome in and of itself influenced by a variety of factors ( Kim and Kim, 2017). An updated definition for wellbeing was generated recently, where it was defined as: '...when individuals have the psychological, social and physical resources they need to meet a particular psychological, social and/or physical challenge' ( Dodge et al., 2012). As noted by GuildHE (2018), defining wellbeing within the Higher Education domain is a challenging prospect owing to the plethora of evidence available and the complexity of the concept. This echoes McNaught's (2011) proposition that wellbeing is a deeply personal, existential experience. The term student wellbeing can also be described as a population-level term encompassing positive emotion and the inner capacity for an individual to cope with the challenges of day-to-day life and their academic journey ( Barkham et al., 2019). In recent years, the student wellbeing sphere has started to embrace core tenets of the positive psychology approach.

Positive psychology, as coined by Seligman (2004), denotes a paradigm shift from the previous model of mental ill health that permeated the psychological domain. Rather than an explicit focus on a deficit-based model of mental illness, positive psychology transmutes the perception that we must fix what is deemed as being 'wrong' with an individual. Instead, it posits three central pillars of wellness and wellbeing: positive emotion, positive traits and positive institutions. Emerging from this early work is the PERMA model of wellbeing ( Seligman, 2011):

1. Positive emotion (P): refers to experiencing and retaining a positive outlook, focusing on life's events in a constructive manner.

2. Engagement (E): ensuring the opportunity for genuine engagement both professionally and personally with activities, adopting a state of flow and immersion in certain instances.

3. Relationships (R): possessing and nurturing a range of meaningful relationships with others and reducing the risk of isolation.

4. Meaning (M): feeling as if one is working toward something that transcends oneself, or believing in something that lends meaning to ones' life.

5. Accomplishment (A): whether in a personal or academic capacity, reaching a desired goal will lead to a sense of accomplishment and thus, contribute to a state of flourishment.

Oades et al. (2011) propose a conceptual framework for integrating PERMA concepts into the university environment, addressing areas such as curriculum, social aspects, faculty and residential domains to achieve a positive university. Similar to the early models rooted within the eudaimonic approach, the PERMA domains capture both internal and external components of ones' life reflecting the multifaceted nature of wellbeing. Recent research has demonstrated how each of the PERMA domains can be incorporated into teaching practices successfully, incorporating an innovative approach to supporting student wellbeing ( Matthewman et al., 2018). Moreover, introducing a positive psychology course to students can improve the PERMA domains in turn, as compared to regular psychology students ( Smith et al., 2020). The potential that the PERMA model holds in underpinning student wellbeing and subsequent services provided has yet to be fully realized given its' relative infancy within the student domain.

Pertinent within the student wellbeing literature is the role of resilience and how this contributes to elevated wellbeing. Resilience has been previously defined as:

"...the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and 'bouncing back' in the face of adversity" ( Windle, 2011, p163).

Being adaptable when faced with a range of challenges is largely determined by the assets and resources an individual holds, along with their life and environment. Conceptual models have been suggested specific to the role resilience has to play in the HE setting. One of note is the notion of a "coping reservoir" in medical students ( Dunn et al., 2008). The authors suggest that each student possesses their own "coping reservoir" that has an internal structure, made up of the individuals' temperament, personality characteristics and preferred coping style. The "coping reservoir" is subsequently impacted by negative and positive inputs that either deplete or replenish the reservoir. This can lead to either positive or negative outcomes reflective of the students' wellbeing, such as resilience or burnout. It is noted however, that wellbeing is a lot more complex than inputs and outputs. Despite this, evidence supporting the "coping reservoir" model has illustrated its' utility ( Heinen et al., 2017). Recognizing resilience as an outcome of optimal wellbeing is important to consider, as resilient individuals tend to cope with stressors more efficiently which is particularly useful in the university environment. Further to this, elements of the 'PERMA' model of wellbeing have been found to significantly predict higher resilience ( Abiola et al., 2017).

Resilience has also been discovered to be an antecedent of student wellbeing. It has been shown to have a positive relationship to subjective happiness as well as negative relationships with anxiety, depression and stress. Critical to developing resilience capability are the assets and resources that students access within the systems that they participate, such as university, home and work ( Turner et al., 2017). This mirrors the ONS' domains of wellbeing fairly well, placing the individual within a particular environment that contributes toward overall wellbeing ( Beaumont, 2011). The role of resilience as an antecedent and outcome of student wellbeing is important to consider and is captured loosely in Barkham et al.'s (2019) working definition, alluding to a students' inner capacity to cope. Interestingly, aside from the notion of a "coping reservoir," this has not been explicitly alluded to in more general models of wellbeing. Whilst individual wellbeing or personal characteristics frequently form the central pillar of wellbeing, it could be suggested that resilience contributes significantly to wellbeing and warrants greater acknowledgment.

Why Are Universities Interested?

Universities possess a unique organizational structure that incorporate a multitude of competing agendas concerning knowledge production, subsequent translation into real-world impact and financial stability. Ultimately, concentration must be placed on the university as a viable business and thus, means an increased pressure to run as a for-profit business ( Taylor, 2017). The notion of "student wellbeing" therefore, has competed for resources and funding alongside other organizational factors that are often prioritized highly.

The settings-based approach to health and wellbeing encapsulates how the university setting can be critical in promoting improved student wellbeing. For students, university represents a community where they can thrive and hopefully flourish both socially and academically ( Markoulakis and Kirsh, 2013). Embedding health and wellbeing promoting features within the university setting should be a priority given the unique opportunity that the environment offers to support better behavioral choices. The settings-based approach was initially derived from the World Health Organisation [WHO] (1986), where health was described as: "...created and lived by people within the settings of their everyday life; where they learn, work, play and love." Whilst the university environment in itself shares commonalities with other businesses in industry whereby it employs staff, it also possesses a range of unique roles within its' structure that generates a distinctive culture and mission ( Dooris, 1999). The university environment plays a role as a "future-shaper" of students and is a platform for cultural, social and economic change, rendering it as a perfect setting to integrate health promotion ( Cawood et al., 2010). The health-promoting university, otherwise known as the Healthy Universities initiative, draws upon the settings-based approach to embed health into the organizational structure of the institution and instill health into the daily operation. The Healthy Universities initiative aims to achieve key outcomes by:

* Creating healthy and sustainable learning, working and living environments for students, staff and visitors.

* Integrating health and sustainable development as multi-disciplinary cross-cutting themes in curricula, research and knowledge exchange.

* Contributing to the health, well-being and sustainability of local, regional, national and global communities ( Dooris and Powell, 2012).

The Okanagan Charter (2015) has built upon the idea of health promotion infused within the university setting. By embedding health within campuses, universities serve to enhance the success of their institutions whilst promoting equity, wellbeing and social justice. Ultimately, this will strengthen communities economically, socially and ecologically. Through a recent reconceptualization, it was found that developing a supportive ethos and culture, embedding health, targeting the entire university population, embracing challenges and building a broad understanding of health contributes to the status of being a Healthy University ( Dooris et al., 2019). Similarly, students identified that a whole university ethos, coupled with access to health services, is imperative to the initiative ( Holt et al., 2015). Becoming a Healthy University is intrinsically appealing owing to the clear relationship between wellbeing and academic attainment. Previous research suggests that health, health behaviors and health awareness hold relationships with key determinants of academic attainment, such as perceived importance of achieving good grades ( El Ansari and Stock, 2010). The importance of promoting health within the university environment is therefore high, owing to the subsequent gains achieved resulting from improved wellbeing.

Discussion

The global pandemic has shifted the student wellbeing domain considerably due in part to the extensive pragmatic changes that have been introduced to curb the spread of COVID-19. Education, across the board, has experienced drastic changes to teaching delivery. Transition into online learning has occurred rapidly and has presented a range of novel challenges both to staff and students. As noted by Burki (2020), the utilization of virtual learning may well persist until a suitable vaccine for COVID-19 has been developed. Navigating the vast array of technological platforms now being relied upon for telecommunication (such as Zoom, Skype for Business and Microsoft Teams), as well as becoming fully competent using platforms such as Moodle, also stimulates questions surrounding the pragmatic barriers that students may face when attempting to study, collaborate with peers and submit pieces of work. Computer literacy, for example, is understood to be fairly high with the student demographic ( Link and Marz, 2006). Given that teaching has not been a strictly face-to-face endeavor for some time, it is assumed that students will engage with technology seamlessly and with little difficulty. However, it must be considered that a proportion of the student population will now encounter difficulties with the technology-heavy approach to learning. An individuals' sense of personal competence can contribute to suboptimal wellbeing and a perceived sense of decreased wellbeing should a student feel a loss of capability when it comes to their studies. Universities should strive to provide comprehensive support to their students in terms of navigating their new learning experience and extensive resources to underpin the transition to online learning.

Preliminary work has demonstrated that, even in simulation-based scenarios, it is possible to deliver functionally similar sessions that allow students to attain their educational objectives ( Torres et al., 2020). Fully scoping the requirements for each individual session should be paramount to retaining similarity between an on-campus and online scenario, ensuring that functionality is truly aligned with the objective of each session. However, the authors do note that barriers do occur, with practical elements such as internet speed providing challenges to the learning experience. Conversely, Da Silva (2020) suggests that virtual learning could contribute to greater attendance and participation with sessions, removing the anxiety associated with asking questions in front of course peers. This claim is corroborated by recent student surveys indicating that students value online learning for its flexibility and the ability to study at a time convenient to them ( Lall and Singh, 2020). Interestingly, 10% of students surveyed described the lack of face-to-face contact as one of the main strengths of online learning. This could be linked to the idea of reduced anxiety surrounding learning in general but also highlights the importance of others in conceptual frameworks of wellbeing. The concept of others may not always refer to positive relationships held with others but the presence of social judgment, especially concerning perceived stigma relating to mental health. This is, however, counteracted by 26% of the sample disliking online learning as they are unable to meet with friends. Clearly, the transition to virtual learning and assessment comes with both advantages and disadvantages. The technological move could potentially compromise the notion of Accomplishment, one of the five tenets of Seligman's (2011) PERMA model. Each university has approached assessment differently as a result of the pandemic, deploying novel methods that many students have not experienced before such as open-book examinations. The uncertainty surrounding assessment will inevitably provoke anxiety within the student population. Coupled with this uncertainty is the anxiety of completing assessments in a completely novel fashion, where students may worry that the new forms of assessment used will not truly capture their ability, especially when compared to traditional methods. Graduation ceremonies were not exempt from cancelation, negating a significant life event that celebrates the student's achievements after years of hard work. This also calls into question the notion of Meaning stipulated in the PERMA model. Seligman (2011) posits that a state of flourishment can be attained by working for something that transcends oneself. Research has demonstrated that education and career are one of the main sources of meaning for undergraduate students ( Hill et al., 2013). If students feel as if their work is not meaningful, especially given that their studies will occur in a predominantly isolated fashion, detrimental wellbeing could ensue. Ensuring that students are fully informed of new assessment protocols, as well as moving to celebrate their successes in an engaged way, could potentially mitigate the risk of suboptimal wellbeing in this instance. Institutions and, more importantly, researchers should consider the transition in a balanced fashion to truly understand the role virtual learning has on student wellbeing over the course of the COVID-19 pandemic and beyond.

The environment in which the student now resides and studies will provide unique barriers to a streamlined learning experience. Considering the drastic shift in environment that students have experienced, perhaps the biggest potential contributor to poor student wellbeing is the change in physical location. Currently, all academic content is delivered through technological means whilst campuses remain closed. The impact of this change is significant and far-reaching, deviating from the typical university experience that students have become accustomed to. A lack of physical contact with academic staff, coupled with their reduced capacity associated with the technological shift, has put students under increased pressure to meet deadlines without the typical access to support that they would normally experience. Prior to COVID-19, students may have sought advice by physically meeting with a supervisor or module lead. Staff should, in the wake of the pandemic, consider offering virtual office hours to sustain and promote frequent engagement with students to mitigate the disruption they are experiencing to their studies ( Zhai and Du, 2020). The absence of physical contact is not limited to teaching staff. Students are now faced with a prolonged period of time without their friends and course companions. Where group work and collaborative projects are now a mainstay of many university courses, the opportunity for students to work with fellow students has been reduced and become more challenging. The likelihood that students will experience more frequent and intense feelings of loneliness, anxiety and isolation is high, owing to the disconnectedness many will feel as a result of leaving the university campus ( Zhai and Du, 2020). As previously stated, loneliness has been found to be significantly associated with stress, anxiety and depression in students ( Richardson et al., 2017). In addition to education and career, undergraduate students consider relationships as a main contributor to meaning ( Hill et al., 2013), considered integral to wellbeing according to the PERMA model. The importance of combatting feelings of loneliness should be considered owing to the highly detrimental effect this has on student wellbeing. For many, the university campus is home and moving away due to the COVID-19 pandemic represents a significant upheaval for the individual.

Wellbeing described more generally often stresses the importance of the individuals' lived environment and how this impacts upon individual wellbeing, such as the places that we work and live ( Beaumont, 2011). In this instance, the place where students study, as opposed to work, has evolved considerably. The way in which the lived environment has interacted with how we experience relationships during the pandemic is important to note as access to friends and family has practically ceased due to nationwide restrictions to curb the spread of COVID-19. For some students, the ability to return to the familial home to self-isolate together has been near impossible, especially for international students. There are instances of students remaining in university halls or accommodation throughout the pandemic, living independently but without the social support networks they previously possessed as their cohabiting peers have returned home. The impact that this isolation has on student wellbeing is monumental, as the lived environment and accessibility to social support across the globe has ultimately nullified the possibility of physical contact with loved ones. Thankfully, the digital era that we now live in offers online methods of sustaining regular contact with those within our social networks. Paradoxically, early research suggested that increased engagement with the internet was to the detriment of social relationships, exacerbating feelings of loneliness and depression ( Kraut et al., 1998). The use of social media specifically has been found to have both positive and negative effects on psychosocial wellbeing, identity and belonging in adolescents ( Allen et al., 2014). In current circumstances where physical loneliness may be impossible to avoid, the positive elements of internet use and social media engagement should be considered. As long as social media usage is engaged with as a means to sustain existing relationships and forge new connections, it can be a powerful tool in reducing an individuals' feelings of loneliness ( Nowland et al., 2018). Whilst the lockdown measures continue to persist within the context of the pandemic, the use of social media will be key in maintaining appropriate support networks for students. In the absence of offline social activities, social media could play a crucial role in alleviating feelings of loneliness within the student population. Given the importance that social connectedness and relationships play relative to a students' wellbeing, digital solutions provide a good substitution for face-to-face interaction.

Whilst the COVID-19 pandemic has had pragmatic implications relating to campus closures and a transition to virtual learning, the virus itself creates a degree of uncertainty that is unprecedented. COVID-19, as a novel coronavirus, is being studied at a phenomenal pace with more scientific information becoming readily available with each passing day. Understanding the transmission, prevalence and symptoms of the virus is critical to keeping the virus under control but until that information becomes clearer, ambiguity surrounding the virus is high. Misinformation has been spread exponentially throughout the duration of the pandemic through a variety of mediums. Social media platforms such as WhatsApp have experienced an overwhelming level of viral messages, with one particular message purporting to contain the cure for the virus, which involved mixing garlic and boiling water ( Clarke, 2020). A headline published in the BMJ in late April 2020 ( Wise, 2020) is a prime example of how information can be taken out of context and contribute to elevated public anxiety and fear. The article headline stated: "A third of COVID-19 patients admitted to United Kingdom hospitals die," with a remark added when shared by the BMJ on Twitter that the fatality rate was "on par with Ebola." This information was disseminated widely in the United Kingdom press despite the Ebola claim being factually incorrect when case fatality rates (CFRs) are directly compared - Ebola's CFR is approximately 50%, whereas COVID-19's CFR is around 6.5% with significant underreporting of milder cases ( Winters et al., 2020). Further to this, over 25% of COVID-19 related videos on YouTube were found to contain nonfactual information totaling over 62,000,000 cumulative views ( Li et al., 2020). The infodemic that has ensued has been overwhelming for the general population and for students especially. Amongst the false information being circulated is legitimate scientific knowledge. Many news outlets are providing around the clock coverage of the pandemic and how it is affecting countries and communities across the globe. Accessing and assimilating information relating to COVID-19, whether factual or not, is incredibly easy. For students, relating this to their personal circumstances and how it impacts upon their studies can be detrimental to their wellbeing. Contextual domains are compromised where the economic and educational landscape are now unrecognizable. The unpredictability of the pandemic will undoubtedly contribute to suboptimal mental health outcomes for the general population ( Zandifar and Badrfam, 2020). Tertiary students worldwide are facing unmitigated uncertainty in regard to their studies, ranging from fear of contracting the virus once campuses eventually open to the unknown quantity surrounding the completion of their studies. A range of interventions have been posited thus far to combat the onset of poor mental health outcomes including the provision of online mental health resources, online provision of self-help and counseling services, and the deployment of online surveys to understand the prevalence of poor mental health outcomes ( Rajkumar, 2020). Universities should consider their resources and provision throughout the pandemic and beyond. Not only in terms of content, but in their accessibility to students' from a variety of demographic backgrounds. The negative affect associated with the pandemic has the potential to impact on student wellbeing for the foreseeable future, therefore further research is required to understand what provision would be most suitable for the HE context. The use of newly produced psychometric measures with university students could facilitate greater understanding of the mental health impact of COVID-19, such as the Coronavirus Anxiety Scale ( Lee, 2020) or the Fear of COVID-19 Scale ( Ahorsu et al., 2020).

There are limitations to this piece of work and the evidence synthesized. Mainly, research produced during the COVID-19 pandemic is sparse, varied and conducted within a plethora of different scenarios. Studies have originated primarily from Asia where the epicenter of the COVID-19 pandemic can be traced. Little research has been completed thus far within the United Kingdom specifically as Europe's peak of the pandemic arrived later than in Asia. The vast cultural differences observed, alongside the diverse set of methods deployed to explore the impact of COVID-19, means that it is difficult to extrapolate findings directly into the HE setting within the United Kingdom. Only as time passes and more research is conducted in relation to COVID-19 will more concrete conclusions be available. The long-term impact of the virus on student wellbeing, and wellbeing of the general population, is unknown.

Synthesizing the evidence to date in relation to pre-existing models of wellbeing suggests that the psychological impact of the virus will be far-reaching. Whilst students face an unknown length of time living with uncertainty regarding their studies, research teams should move quickly to understand student wellbeing in these unprecedented times and beyond. Considering the negative implications of COVID-19 is intuitive, however, small victories may emerge. The shift to virtual learning and student services could encourage greater participation now that stigma and peer judgment has been significantly reduced. The collective trauma experienced by the university community during the pandemic must not be underestimated, but the potential to rebuild stronger is now more likely than ever ( Wilton, 2020). The lessons learnt during this period will undoubtedly contribute toward more online services, greater awareness of the impact of loneliness on the student experience and an increased need to diversify services to suit a variety of student demographics.

Author Contributions

DB conducted the analysis and drafted the manuscript. ND and MH reviewed the manuscript and provided feedback prior to submission and formed the Ph.D. supervisory team. All authors contributed to the article and approved the submitted version.

Funding

The lead authors' Ph.D. program is fully funded by a strategic partnership held between Nuffield Health and Manchester Metropolitan University.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

References

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Assessing the Impact of the COVID-19 Pandemic on Student Wellbeing at Universities in the United Kingdom: A Conceptual Analysis

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Transitioning into the university environment can be both exciting and stressful for new and returning students alike. The pressure to perform well academically in an increasingly competitive environment, coupled with a vast array of lifestyle changes, can contribute to suboptimal wellbeing.

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Medical Student Mental Health 3.0: Improving Student Wellness Through Curricular Changes

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Medical education can have significant negative effects on the well-being of medical students. To date, efforts to improve student mental health have focused largely on improving access to mental health providers, reducing the stigma and other barriers ...

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Educators are often the first to notice mental health problems in children and young adults. Here are some ways you can help your students and their families.

What Educators Should Know

You should know:

What Educators Should Look for in Student Behavior

Consult with a school counselor, nurse, or administrator and the student's parents if you observe one or more of the following behaviors:

Feeling very sad or withdrawn for more than two weeks

Seriously trying to harm oneself, or making plans to do so

Sudden overwhelming fear for no reason, sometimes with a racing heart or fast breathing

Involvement in many fights or desire to badly hurt others

Severe out-of-control behavior that can hurt oneself or others

Not eating, throwing up, or using laxatives to make oneself lose weight

Intense worries or fears that get in the way of daily activities

Extreme difficulty concentrating or staying still that puts the student in physical danger or causes problems in the classroom

Repeated use of drugs or alcohol

Severe mood swings that cause problems in relationships

Drastic changes in the student's behavior or personality

What Educators Can Do in Classrooms and Schools

You can support the mental health of all students in your classroom and school, not just individual students who may exhibit behavioral issues. Consider the following actions:

Learn more about mental health by taking a mental health awareness training

Promote social and emotional competency and build resilience

Help ensure a positive, safe school environment

Teach and reinforce positive behaviors and decision-making

Encourage helping others

Encourage good physical health

Help ensure access to school-based mental health supports

Developing Effective School Mental Health Programs

Efforts to care for the emotional well-being of children and youth can extend beyond the classroom and into the entire school. School-based mental health programs can focus on promoting mental wellness, preventing mental health problems, and providing treatment.

Effective programs:

Promote the healthy social and emotional development of all children and youth

Recognize when young people are at risk for, or are experiencing, mental health problems

Identify how to intervene early and appropriately when there are problems

Learn More about Ways to Support Your Students and Their Families

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Educators are often the first to notice mental health problems in children and young adults. Here are some ways you can help your students and their families.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8501475/

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Grace Zurielle C. Malolos, 1 ,* Maria Beatriz C. Baron, 1 Faith Ann J. Apat, 2 Hannah Andrea A. Sagsagat, 3 Pamela Bianca M. Pasco, 1 Emma Teresa Carmela L. Aportadera, 4 Roland Joseph D. Tan, 1 , 5 Angelica Joyce Gacutno-Evardone, 6 and Don Eliseo Lucero-Prisno III 7 , 8

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has subjected the mental health and well-being of Filipino children under drastic conditions. While children are more vulnerable to these detriments, there remains the absence of unified and comprehensive strategies in mitigating the deterioration of the mental health of Filipino children. Existing interventions focus on more general solutions that fail to acknowledge the circumstances that a Filipino child is subjected under. Moreover, these strategies also fail to address the multilayered issues faced by a lower-middle-income country, such as the Philippines. As the mental well-being of Filipino children continues to be neglected, a subsequent and enduring mental health epidemic can only be expected for years to come.

Keywords: Mental Health, Philippines, COVID-19, Psychology, Child, Child care, Health services, Social problems

Introduction

The Philippine Development Plan for 2017-2023 highlights that children are among the most vulnerable population groups in society, including them in strategies for risk reduction and adaptive capacity strengthening.1 Approximately 40% of the total Philippine population is comprised of Filipinos below 18 years of age.2 Despite having a large portion of the Philippine population declared as vulnerable, concerning issues involving them still persist and remain unaddressed.

Among Filipino children aged 5 to 15, 10% to 15% are affected by mental health problems.3 According to the World Health Organization (WHO), 16.8% of Filipino students aged 13 to 17 have attempted suicide at least once within a year before the 2015 Global School-based Student Health survey.4 This is just one of the many indicators showing the state of mental health of these children. These statistics involving children's mental health are concerning as childhood is a crucial period where most mental health disorders begin. Efforts should be made to identify these issues early for proper treatment in prevention of negative health and social outcomes.4 Childhood mental and developmental disorders also frequently persist into adulthood, making it more likely for them to have compromised growth with greater need for medical and disability services and higher risk of getting involved with law enforcement agencies.5 In this context, the COVID-19 pandemic threatens to worsen these numbers, affecting the delivery of the Philippines' health care services, including those for children's mental health.

Since the beginning of the pandemic, children have been subjected to multiple threats to their mental health. Adding insult to injury, several concurrent factors in the Philippine society exacerbate this. While these are experiences shared by all people regardless of age, impediments to emotional and social development are greater in children than in adults.6 They may also be more vulnerable to developing mental health issues such as depression and anxiety.7 Together with these circumstances and the weakened health care system, children's vulnerability towards mental health problems may be worsened by the pandemic, leading to more new cases and exacerbating existing ones.2

Status of mental health system for children in the Philippines

According to the National Statistics Office (NSO), mental health illnesses rank as the third most common form of morbidity among Filipinos.8 In the assessment conducted on the Philippine mental health system, a prevalence of 16% of mental disorders among children was reported.9 With this alarming number of cases, it is surprising to see how the Philippines is currently responding to this problem. To date, there are only five government hospitals with psychiatric facilities for children, 84 general hospitals with psychiatric units, and 46 outpatient facilities from which there are only 11 that are designated for children and adolescents. Additionally, there are only 60 child psychiatrists practicing in the Philippines, with the majority of them practicing in urban areas such as the National Capital Region. Hence, children with mental health problems who are in rural areas have less access to such services.10

As the pandemic continues, combined with the menace of the typhoon season, thousands of children are placed in a situation where the future is uncertain. A local study showed that youth age and students are among those with significant association to a greater psychological impact due to the pandemic.11 In addition, UNICEF also reports that children nowadays face a trifecta of threats which include direct consequences of the disease itself, interruption in essential services, and increasing poverty and inequality. All of these can lead to higher incidences of stress, anxiety, and depression.12

General mental health implications of COVID-19 on Filipino children

The fear and anxiety of contracting the virus, the suspension of physical classes, the disruption of regular daily routine, and the decrease of social support from school peers collectively add burden to the mental well-being of children.7,13 The shift to online classes increases the burden on the mental well-being of children. Excessive use of these technologies has been associated with developmental delays and has resulted in sleep schedule disruptions.14 This situation is aggravated by the strict implementation of the confinement of children at home. Children living with preexisting mental health concerns,13 and living in cramped households and communities face worse circumstances.

Militarization of the Philippine COVID-19 response

Aside from being regarded as one of the countries with the longest lockdown, the Philippines has also been called out by the United Nations for employing a highly militaristic approach in response to the COVID-19 pandemic.15Militarization may come across as threatening, because it implies a potential for violence.16 Furthermore, few studies abroad have reported that children and adolescents may tend to view police forces as punitive figures whom they fear.17,18 While these qualitative studies were conducted long before the current health crisis began, it may be possible for increased military presence in communities to exacerbate the fears already emanating from the pandemic itself; this can negatively impact a child's psychological development.4 Still, local evidence to confirm these associations, especially in the context of the pandemic, is lacking. Many studies have already documented the impact of lockdown on children, but none of them have looked into how the strategies for implementation may also be contributory to their mental health or well-being.

Typhoons and the mental health of Filipino children

The Philippines has been hit by 22 tropical typhoons during the COVID-19 pandemic, leaving thousands of families homeless.19 Children who are already frightened of COVID-19 and previous tropical storms have had to relive their experience with each new typhoon that came. In addition, children in crowded evacuation centers are at increased risk of contracting diseases and experiencing gender-based violence.20 Given how past typhoons of similar strength and destruction have caused lasting adverse mental health effects on children,21 the same or even worse, may be expected as a result of the more recent calamities. Super typhoons Goni and Vamco have caused further disruptions in schooling and livelihood, therefore leaving more children vulnerable to the effects of the pandemic. Those who have been forced to seek refuge in evacuation centers are at an increased risk of acquiring COVID-19, among other diseases.20

Child Labor and Abuse in the Time of COVID-19

The COVID-19 crisis caused an unprecedented reduction in economic activity and working time, thus increasing poverty. Fewer employment opportunities and lower wages drive exploitative work. Further suppression of wages induces child labor. There may be deliberate recruitment of children to cut costs and boost earnings.22

In addition to the threats of child labor, a study entitled The Hidden Impact of COVID-19 on Children reported that violence occurred in nearly one-third (32%) of households. Lesser household incomes were associated with more reports of violence towards children.23 According to UNICEF, the Philippine government saw a 260% increase in online child abuse reports from March-May. Many victims are first abused by their parents, who livestream sexual violence for predators in wealthy Western nations. This occurrence resulted from job and income loss and more time spent at home due to strict quarantine measures. The abuse in children occurs at an average of 2 years before being rescued.24

Strategies Addressing the mental health implications of COVID-19 on Filipino children

Numerous strategies have been utilized to address the mental health impacts of COVID-19 on Filipinos. With the mental health implications predicted at the beginning of the pandemic, the Psychological Association of the Philippines has compiled a list of free telemedicine consultations. As of August 24, the Philippine Red Cross has also established a COVID-19 hotline with 9790 helpline volunteers to address mental health and other similar concerns. The Department of Health has also conducted nationwide campaigns in observance of the National Mental Health Week.25

Albeit present, these interventions are limited to the general population, and strategies specific to addressing the mental health situation of children remain scarce and staggered. Compounding factors of classifying among the lower- to middle-income countries of militarization, natural disasters, and child labor and abuse have yet to be considered. In addition, it is also important to consider that happiness, with its multifactorial nature, is a vital component of an individual's overall wellbeing.26

Conclusion

The already-challenged state of mental well-being of Filipino children has been worsened by the pandemic and the lack of good mental health policies by the government. While there is increasing awareness for mental health, children-centered interventions remain deficient. Approaches must integrate commonly-known mental health effects on children with existing and anticipated Philippine societal issues. Without doing so, it may be expected that as the COVID-19 pandemic is mitigated, a mental health epidemic will replace it.

Competing interests

The authors have no conflicts of interest.

Ethical approval

Not applicable.

Authors' contributions

GZCM and DELP were involved in the conception of the paper. GZCM led the writing of the manuscript and acted as corresponding author. GZCM, MBCB, FAJA, HAAS, PBMB, ETCA and RJDT wrote sections of the manuscript. AJGE and DELP reviewed and edited the initial draft of the manuscript prior to submission. All authors have reviewed and agreed to the final version of the paper.

References

4. Golberstein E, Wen H, Miller BF. Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents. JAMA Pediatr. 2020;174(9):819-20. doi: 10.1001/jamapediatrics.2020.1456. [[ PubMed] [ CrossRef] Google Scholar]

5. Scott JG, Mihalopoulos C, Erskine HE, Roberts J, Rahman A. Childhood mental and developmental disorders. In: Patel V, Chisholm D, Dua T, Laxminarayan R, Medina-Mora ME, eds. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities. 3rd ed. Vol 4. Washington, DC: The International Bank for Reconstruction and Development, The World Bank; 2016. 10.1596/978-1-4648-0426-7_ch8 [ PubMed] [ CrossRef]

14. Hageman JR. Children's and families' behavioral and mental health during COVID-19. Pediatr Ann. 2020;49(10):e405-e6. doi: 10.3928/19382359-20200922-05. [[ PubMed] [ CrossRef] Google Scholar]

16. Lieblich E, Shinar A. The case against police militarization. Mich J Race Law. 2018;23(1-2):105-3. [ Google Scholar]

17. Powell MB, Skouteris H, Murfett R. Children's perceptions of the role of police: a qualitative study. Int J Police Sci Manag. 2008;10(4):464-73. doi: 10.1350/ijps.2008.10.4.099. [[ CrossRef] Google Scholar]

18. Beckett H, Warrington C, Ackerley E, Allnock D. Children and Young People's Perspectives on the Police's Role in Safeguarding: A Report for Her Majesty's Inspectorate of Constabularies. England: University of Bedfordshire; 2015.

19. Rocha ICN, Dos Santos Costa AC, Islam Z, Jain S, Goyal S, Mohanan P, et al. Typhoons during the COVID-19 pandemic in the Philippines: impact of a double crises on mental health. Disaster Med Public Health Prep. 2021:1-4. 10.1017/dmp.2021.140 [ PMC free article] [ PubMed] [ CrossRef]

21. Horiguchi H, Nakazawa M. Long-Lasting Effects of the 2013 Yolanda Typhoon on Overall Health of Mothers and Children. Disaster Med Public Health Prep. 2020:1-8. 10.1017/dmp.2020.40 [ PubMed] [ CrossRef]

26. Heizomi H, Allahverdipour H, Asghari Jafarabadi M, Safaian A. Happiness and its relation to psychological well-being of adolescents. Asian J Psychiatr. 2015;16:55-60. doi: 10.1016/j.ajp.2015.05.037. [[ PubMed] [ CrossRef] Google Scholar]

Articles from Health Promotion Perspectives are provided here courtesy of Tabriz University of Medical Sciences

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Mental health and well-being of children in the Philippine setting during the COVID-19 pandemic

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The coronavirus disease 2019 (COVID-19) pandemic has subjected the mental health and well-being of Filipino children under drastic conditions. While children are more vulnerable to these detriments, there remains the absence of unified and comprehensive ...

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Well-Being and Mental Health of Students during the COVID-19 Pandemic

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Background: During the COVID-19 pandemic, a decrease in well-being and an increase in mental health problems were registered in medical and psychotherapeutic practices, counseling centers, and clinics. According to previous studies, younger people and women seemed to be particularly affected. The ai…

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Why good mental health is important for study | Charles Darwin University

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It’s an expression we use every day, so it might surprise you that the term ‘mental health’ is frequently misunderstood. Meagan Miskin is the Health, Wellbeing & Injury Management Consultant at CDU and she shares the importance that good mental health plays when it comes to work, study and life.

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https://youtu.be/4XROOeMr0nE

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International students – Mental Health and Wellbeing during COVID-19

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Focusing on Student Well-Being in Times of Crisis

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One teacher recommends supporting student safety through three Cs: communication, consistency, and control.

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Schools can now visit the Policy and Advisory Library (PAL) for this information. This page will remain in this location but will be for corporate staff only. School staff should use PAL for all policy, procedures and other operational information.

Principals and school staff must follow the Mental Health and Wellbeing - Employees Policy , Mental Health and Wellbeing - Employees Procedure and section which are available in the Policy and Advisory Library (PAL).

Corporate and regional staff should follow the information below.

Mental health and wellbeing is defined by the World Health Organisation as ' a state in which every individual realises his/her potential, can cope with normal stressors of life, can work productively and fruitfully and is able to make a contribution to his/her community.'

Raising awareness of workplace mental health and wellbeing matters. A mentally health and safe workplace is defined as one that promotes employee mental health and wellbeing, protects mental health by reducing work-related risk factors, actively prevents, and addresses mental injury and illness from occurring.

Issues impacting on mental health have been identified by the Department as hazards requiring management in all Department workplaces. These hazards must be included in the workplace OHS Risk Register.
Procedures Guides
Managing psychological/mental health of employees

Managing psychological/mental health of employees in the workplace follows the same risk management principles as in physical hazard and risk management. This includes:

Commitment and leadership

The Department's Health, Safety and Wellbeing (HSW) Policy reflects the Department's commitment to providing employees, contractors, volunteers and visitors with a healthy and safe working and learning environment and mitigating physical and psychosocial hazards and risks.

Procedure that outlines consistent approach in planning Occupational Health and Safety (OHS) activities in Department workplaces to manage psychological health and safety.

Implementation

Provide and sustain the infrastructure and resources needed to achieve conformity with Department procedures in managing workplace psychological health and safety.

Evaluation and corrective action

Establish and maintain procedures to monitor, measure, and record psychological health and safety and the effectiveness of the procedure in managing psychological health.

Management review

Establish and maintain a process to conduct scheduled management review of the procedure in managing psychological health including the review and analysis of key outcome data and a review process to which the goals of a psychologically healthy and safe workplace are being achieved.

Strategies that can be implemented to mitigate psychosocial risks include:

encouraging employees to participate in decision-making

demonstrating fairness in management style and application of policies

training and evaluating supervisors on communication and people skills

providing flexible work arrangements

providing work-life balance policies and practices and a supportive culture

showing appreciation for employees' efforts

ensuring the workplace environment is respectful to all workers

measuring employee satisfaction regularly and acting on findings

providing employees with the information and resources they need to do their jobs well

addressing work overload issues

The following need to be actioned in order to manage psychological hazards:

Identify psychological hazards and record them in the workplace's OHS Risk Register

Identify the cause / workplace factors using the Mental Health and Wellbeing Guide

Undertake risk assessments of the hazards and workplace factors using the Risk Assessment Template

Implement and record risk controls in the workplace's OHS Risk Register

Monitor and review controls

Provide information, instruction and training on psychological health and wellbeing

Document and carry out corrective actions on reported incidents

The workplace manager and/or management OHS nominee are to record additional controls in the Corporate/Regional Offices OHS Risk Register and Risk Assessment Template or equivalent.

The Department is committed to the positive MHW of our employees, and currently offer a range of mental health and wellbeing supports and resources.

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Schools can now visit the Policy and Advisory Library (PAL) for this information. This page will remain in this location but will be for corporate staff only. School staff should use PAL for all policy, procedures and other operational information.

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"I recommend it for those who are entering the field of student conduct practice as well as for those who are seeking more depth in their understanding of the student conduct process." --The Review of Higher Education"Includes the thinking of notable experts in the profession and offe…

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Mental health problems can affect many areas of students' lives, reducing their quality of life, academic achievement, physical health, and satisfaction with the college experience, and negatively impacting relationships with friends and family members. These issues can also have long-term consequences for students, affecting their future employment, earning potential, and overall health. ¹

Consequences for the Student

Mental health problems can affect a student's energy level, concentration, dependability, mental ability, and optimism, hindering performance. 2 Research suggests that depression is associated with lower grade point averages, and that co-occurring depression and anxiety can increase this association. ² Depression has also been linked to dropping out of school. ²

Many college students report that mental health difficulties interfere with their studies. On the American College Health Association 2015 survey, college students identified the following mental health issues as negatively impacting their academic performance within the last 12 months: ³

Stress (30% of students)

Anxiety (22%)

Sleep difficulties (20%)

Depression (14%)

Consequences for Others

Peers, family members, faculty, and staff may be personally affected out of concern for these students.

Depression and anxiety can have harmful effects on relationships and work productivity.

Suicide and suicidal thoughts can affect the larger campus community.

Roommates, peers, faculty, and staff also experience profound grief over student suicides and suicidal behavior.

Consequences for Campuses

Campuses feel the burden when students with mental health difficulties do poorly on course work and drop out of school.

Colleges and universities must be prepared to address the psychological impact of suicides on other students, as well as on teachers and staff.⁴

Poor student retention can mean losses in tuition, fees, and alumni donations.

Consequences for Communities and the Larger Society

The community is negatively affected when students are unable to finish their degrees and contribute valuable skills in a competitive job market.

One study found that five percent of students do not finish their education due to psychiatric disorders and estimated that 4.29 million people would have graduated from college had they not been experiencing such disorders.⁵

References

1. Eisenberg, D., Gollust, S. E., Golberstein, E., & Hefner, J. L. (2007). Prevalence and correlates of depression, anxiety, and suicidality among university students. American Journal of Orthopsychiatry, 77(4), 534-542.

2. Eisenberg, D., Downs, M., & Golberstein, S. (2009). Stigma and help-seeking for mental health among college students. Medical Care Research and Review, 66(5), 522-541.

3. American College Health Association. (2015). National College Health Assessment II: Spring 2015 reference group executive summary. Hanover, MD: Author. Retrieved from http://www.acha-ncha.org/reports_ACHA-NCHAII.html.

4. Meilman, P. W., & Hall, T. M. (2006). Aftermath of tragic events: The development and use of community support meetings on a university campus. Journal of American College Health, 54(6), 382-384.

5. Kessler, R. C., Foster, C. L., Saunders, W. B., & Stang, P. E. (1995). Social consequences of psychiatric disorders, I: Educational attainment. American Journal of Psychiatry, 152(7), 1026-1032.

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Consequences of Student Mental Health Issues

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Mental health problems can affect many areas of students' lives, reducing their quality of life, academic achievement, physical health, and satisfaction with the college experience, and negatively impacting relationships with friends and family members. These issues can also have long-term consequences for students, affecting their future employment, earning potential, and overall health.

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School During the Pandemic: Mental Health Impacts on Students

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School During the Pandemic: Mental Health Impacts on Students

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https://youtu.be/1qq7lDL-bzY

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Why students should have mental health days | Hailey Hardcastle

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Student Wellbeing and Mental Health - EdSystems NIU

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Student Wellbeing and Mental Health A Framework and Resources for Measuring Student Needs and Development During Remote and Blended Learning​ Download the PDF Data on student wellbeing and mental health can help us to understand the magnitude of the effects of the crisis and the disparate impacts it is having on diverse populations.

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JMIR Form Res. 2020 Mar; 4(3): e15962.

Guest Editor (s): Gunther Eysenbach

Reviewed by Christo El Morr and Qi Yuan

Sun Young Park, BA, MS, PhD, #¹ Nazanin Andalibi, BS, PhD, ¹ Yikai Zou, BS, MS, ¹ Siddhant Ambulkar, BS, ² and Jina Huh-Yoo, BA, MS, PhD ³

Abstract

Background

Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges associated with this transitional period. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help.

Objective

This study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during this period of emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice.

Methods

Semistructured interviews with 19 students, including graduate and undergraduate students, were conducted at a large university in the Midwest in the United States.

Results

This study's findings identified three key needs: students (1) need to receive help that aligns with the perceived severity of the problem caused by a life event, (2) have to continuously rebuild relationships with support givers because of frequent life events, and (3) negotiate tensions between the need to disclose and the stigma associated with disclosure. The study also identified three key factors related to maintaining mental well-being: time, audience, and disclosure.

Conclusions

On the basis of this study's empirical findings, we discuss how and when help should be delivered through technology to better address university students' needs for maintaining their mental well-being, and we argue for reconceptualizing seeking and receiving help as a colearning process.

Keywords: emerging adults, university students, life events, mental wellbeing, mental wellness, mental health, social support

Introduction

Background

During this transitional phase of emerging adulthood, university students experience various life events at different scales, ranging from entering college, leaving home and moving to a new city, and making new networks, to taking finals and looking for a job [ 4]. These life events become potential stressors as students are expected to increase their personal responsibility and independence and make constant adjustments, including personal, emotional, and social adjustments [ 5]. Research shows that support from peers, family, and health care resources aids their life satisfaction, self-esteem, perceived social acceptance, and well-being [ 6, 7].

We build upon recent work in human-computer interaction (HCI) and Health Informatics [ 13- 17], which approaches university students' struggles and challenges as a mental well-being problem rather than as a clinical, mental illness problem. This approach helps address the problems that students need to engage but often ignore because they consider those problems not to be mental health concerns but "normal" problems that occur during emerging adulthood [ 12]. Focusing on mental well-being helps us understand students' everyday lived experiences of muddling through major life events during their emerging adulthood.

With this perspective, this study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during their emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice. In this paper, we report findings from semistructured interviews with 19 students on a university campus. We identified three key needs: (1) the need to receive help that matches the perceived severity of a problem caused by life events, (2) the need to constantly draw on new support givers because of frequent life events, and (3) the need to negotiate the tension between the benefits of self-disclosure and the stigma associated with such disclosure. On the basis of this study's findings and analysis, we make the following contributions:

We extend our knowledge about university students' understandings and perceptions of mental health and coping strategies.

We discuss how students strive to maintain their mental well-being and perceive the boundary between what counts as mental "illness" vs "wellness" in assessing whether to get help.

We present design implications for sociotechnical systems to support the needs of students to better maneuver through this important transitional life phase.

Related Work

The American Psychological Association defines emerging adulthood as the "in-between age," referring to the phase of development between adolescence and adulthood [ 18]. Regardless of socioeconomic prospects, those between the ages of 18 and 29 years commonly struggle with "feeling in between" [ 19]. Emerging adults, particularly those who attend universities, go through a great amount of stress. According to the US Department of Education (2011), student enrollment in college increased to 38% since 1999, reaching its peak. However, the majority of those who drop out of college do so in their first year [ 20], indicating that the transition process is crucial to students' success. In addition to dealing with academic pressure, they are expected to make a series of adjustments, ranging from academic assimilation to personal (eg, changed interests), emotional (eg, home sickness), and social (eg, finding new friends) adjustments [ 5].

What makes emerging adulthood more uniquely challenging than other periods is the intensity of multiple life events mounting up together in a short period. The danger of multiple life events occurring in a short period has been noted in life events research-critical life events (eg, moving, starting a new job, leaving family, and paying new rent or mortgage) and their accumulation can predict long-term medical and psychiatric illness problems [ 21, 22]. The major life events of emerging adults often begin with entering college and leaving home and their old, existing networks. To help such students with the struggles brought by the transitional phase of emerging adulthood, the American College Health Association has identified coping with stress as a high priority issue in the Healthy Campus initiative [ 23]. This initiative takes a multifaceted approach to mental well-being, which includes environmental (eg, managing air quality), physical (eg, eating well), and social (eg, student clubs) health. Universities offer Counseling and Psychological Services (CAPS) with mental health professionals. CAPS further provide campus-wide programs for first-generation college students and underserved students to reduce attrition (eg, drop out) [ 24- 26]. Despite the benefit of these initiatives, the literature still notes the problems of students not utilizing CAPS until emergency situations occur, if they ever do [ 27]. Nearly 80% of the students who die by suicide never participate in counseling services [ 28- 30]. The reasons for this underutilization include lack of awareness [ 31], stigma [ 32], long waiting list times [ 33], and preference for self-management [ 34].

Besides the institutional and national effort to support students, many studies showed that students mostly seek and receive social support from their existing networks in dealing with their struggles. Peer and family support plays a critical role in offering students a sense of belonging [ 7], affirmation of their concerns [ 35], encouragement and empathy [ 36], and facilitation of mental health maintenance as a compensatory measure when other support is unavailable [ 37, 38]. Social support enabled by technology, such as social network sites and Web-based and virtual social communities, has shown the potential benefits to supporting students, such as facilitating students' identity transitions [ 39], offering access to help when lacking in-person support [ 40], addressing unpleasant experiences with negative content on the Web [ 41], and resolving stigmatized concerns [ 42, 43]. However, research indicates that barriers related to seeking and getting social support, including stigma of mental illness [ 44, 45], a sense of autonomy (eg, "I don't need a doctor to solve this problem"), a fear of losing one's positive image (ie, "face") [ 46], and secrecy and negative cultural attitudes toward mental illness [ 47], often suppress help-seeking behaviors [ 48], which hampers students from getting timely and proactive support. These previous studies on emerging adulthood highlight both the critical need for proper support for university students during their stressful life transitional period and the associated barriers that hinder students from seeking and receiving such support.

Researchers developed and evaluated technological interventions for mental health issues such as anxiety and depression. Some examples include Harmony (a mobile health app that assists patients, caregivers, and clinicians in managing serious illnesses) [ 49], DStress (a mobile app that coaches users in balancing compliance and achievement toward daily goals of stress reduction) [ 9], the UPRIGHT project (in which researchers designed and validated resilience-based interventions for promoting early adolescents' mental health) [ 6], and Intellicare (a suite of skill-focused apps that successfully provide users with more flexibility in choosing a suitable treatment) [ 15]. Furthermore, technology-mediated therapies have been implemented (a conversational mobile app, Pocket Skills, that provides Dialectical Behavioral Therapy [ 8] and Web-based cognitive behavioral therapy) [ 50]. Although these interventions have shown their effectiveness and usefulness for treating mental illness, they mainly focus on those who are clinically diagnosed and actively seeking treatment, not those who do not consider their problems as serious mental health conditions but approach them by attempting to maintain their mental well-being.

Upon reviewing the literature on emerging adults' mental health on college campuses, we find examining how students engage everyday life challenges and the everyday maintenance aspect of their mental well-being to be a critical, emerging, and underinvestigated research topic in HCI and Health Informatics communities. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help. Building on the previous work summarized here, this study includes the following research questions (RQs):

RQ1: How do university students perceive their problems and maintain their mental well-being while going through various, frequent life events?

RQ2: What are the implications for designing sociotechnical systems that are tailored to meeting university students' unique needs around life events?

Methods

We conducted interviews with 19 university students (6 undergraduate and 13 graduate) from a large US Midwest university for a semistructured interview study. The inclusion criteria were as follows: (1) English speaking, (2) interested in speaking about their mental health or well-being, and (3) enrolled either as an undergraduate or a graduate student of the university. We recruited the participants through school-wide departmental email lists and word of mouth, and we stopped data collection when saturation was reached.

The study was approved by the Institutional Review Board (IRB) of the first author's university, and all coauthors who had access to the transcripts were registered as study team members. Our interview sessions were conducted in private rooms on the university campus. A member of the research team began the interview by informing the participants about the study's goals and interview procedures and assuring them that they could skip any questions they did not feel comfortable answering or stop the interview at any point. The participants were told that confidentiality would be maintained and that they could withdraw their participation at any time without any consequence. This study followed IRB guidelines, which state that if any crisis situation was observed (eg, threats and suicidal posts), the participant would be immediately referred to the staff at the University CAPS. Each participant received US $15 for study participation.

The duration of each interview session ranged from approximately 1 to 1.5 hours. The questions were designed to help us gain further insights that might not be uncovered in public reports on overall campus climate, where we see increases in student struggles with stress, anxiety, depression, and requests for on-campus counseling services. The interview questions probed the students' process of identifying their stressors, their experiences of seeking and receiving support or help, their development and adaptation of coping strategies to maintain mental health or well-being, and the tools and technologies they used in this process. At the end of the interview, the researchers offered information about college counseling services and other mental health support resources available on campus to those who were in need or had no previous experience of them.

All of the interviews were audio recorded and transcribed for the analysis. This study followed all of our institution's confidentiality, privacy, and security policies for handling and storing all the participants' data. Three researchers analyzed the data using the open coding method [ 51], using the Atlas.ti 7 (ATLAS.ti Scientific Software Development GmbH) qualitative coding software program. We conducted axial coding to explore and develop the key attributes and dimensions of each theme particular to the RQs. Working collaboratively, we explored, compared, and revised the themes as the analysis progressed. We revised the themes through a series of discussions and iterations until consensus was reached. We also conducted affinity diagramming [ 52] to generate common themes and identified any breakdowns and design implications during the analysis process. We followed the Contextual Inquiry Design process [ 52] to identify common themes from the affinity diagram to generate design requirements.

Results

Overview

In this section, we first provide demographic information on this study's participants and then present the three needs that were identified in this study. These three needs are critical to understanding how students maneuver through various life events, seek help, and maintain their mental health and well-being.

Study Participants

Table 1 shows the overall participant demographics. The students ranged in age between 20 and 29 years (mean 25 years, SD 4 years), and 13 students were female, and 6 students were male. In all, 7 students were international students. Reported ethnicities were as follows: East Asian (6), non-Hispanic white (6), Indian (5), and African American (2). A total of 14 out of the 19 students had had experiences with professional counseling services. Two (P7 and P19) students were clinically diagnosed with a psychological disorder.

The Need to Receive Help That Aligns With the Severity of the Problem

The participants emphasized the importance of how and when they receive help for their problems based on how they perceived the severity and duration of the problem they were struggling with. We found that knowing or not knowing when a problem would end and having multiple stressful events accumulate at once mainly affected students' perception about the severity of their problems. This perceived severity then affected the students' expectations about help seeking. Below, we describe how life events affected perceived problem severity and what students considered "good help" to be as a result.

The Severity of the Problem Is Perceived Differently Based on Life Events

The problems students struggled with in maintaining their mental well-being included adjusting to new cities and life on new campuses, meeting new people, paying for tuition, examinations, and job searches. Some of these problems involved more certainty in terms of how long they would last, such as final exams; others, on the other hand, seemed to last forever, such as job search-related stress. Accordingly, uncertainty regarding how long their problem would last affected how students perceived the severity of the problem and how they approached it. For instance, until receiving her recent job offer, P3, who was an international graduate student, had been "really, really stressed." She explained the following:

The past year, when I was first year [of the graduate school], I was really stressed... I would never go back to my home [in China] during the time because I can only come back with a job offer.

Here, P3 described the stressful event as having lasted for a year, which significantly affected her mental well-being during that year. She did not previously know, nor could she have predicted, how long the job search would take while it was happening. The job search was stressful, and the fact that it occurred over an indefinite period of time added a considerably increased amount stress. P3 was expressing the severity of the problem in relation to the event duration because she was unable to start or plan other things until her job status was secured, directly affecting her legal status to live in the United States after graduation.

In perceiving the severity of their problem, we found that a few students even put a predefined time boundary on the problem (how long it would last) and remarked that their current problems would pass and there would eventually be closure. This perception helped them get through the problem. For instance, when P3 was having a problem with her boyfriend during her job search period, she mentioned that she had given herself 3 months (a limited amount of time) to deal with the stress and move on when she would start a new job:

I told myself just three months to get over it. I was eating snacks, watching TV shows, and doing exercises.

Starting college as an independent young adult brought multiple problems in school, work, and relationships at the same time. These multiple problems occurring in the same period exacerbated the perceived severity of each individual problem. For instance, P5 experienced a high level of stress when she had a serious problem with her boyfriend while also applying for summer internships and working on her final exams. P8, similarly, shared an extreme, distressing moment because of the stress brought on by multiple, urgent work responsibilities:

There was this one time when I had a very large amount of work to do. I had a part-time job, had one big [class] assignment, and had one [class] project due, all within the next 48 hours. Even if I stayed up the entire 48 hours, there was no way I was going to finish everything. I knew that because of the amount of work involved, and that was really causing me stress because either the assignment, the project or the part-time job had to suffer, and I wasn't sure which. I was being paid for the part-time job, the project was a group project and if I don't do the work then nobody gets a grade, and the assignment was an individual assignment for me, but it was a large part of the grade, so I had to leave at least one.

P8 further explained that he had to seek emotional support from family members and friends and go to his academic advisor for useful advice. As in the case of P8, multiple problems could occur during the same transitional period, thus requiring the student to navigate the different types of support resources available to receive the proper help. This indicates that merely having one therapist may not work well for students.

Seeking Help That Is Accessible and Available at an Appropriate Time

The urgency and timing of seeking help varied together with whether the students framed the problem as having ended or as ongoing. All students in the study commented on the importance of receiving support during the particular period when the struggles were still happening to effectively deal with their struggles. However, ensuring timely support was challenging because seeking support required a great amount of effort in their hectic daily lives. For instance, students mentioned that they often found resource constraints in their existing support environments on campus. Several participants mentioned that existing support resources such as CAPS and other professional services sometimes failed to address their need to receive help at the right time, especially for time-pressured and serious concerns. This was because of tedious nature of scheduling phone calls, long wait times for in-person appointments, inflexible working hours, and an inefficient screening process, all of which made it difficult to access care in a timely manner:

There was a pretty long waiting time. The initial session was I think after a week and a half, and then the next appointment was after a couple of weeks. Time is the only problem [with CAPS], and I realize that the timing is not in their control because of the number of people here.

Another student described his experience:

I decided to go to CAPS, and was kind of disappointed because at first I filled out that whole questionnaire and the first meeting wasn't even an actual meeting it was just going over the questionnaire with a counseling student.

These factors that delayed the timing of receiving help frequently made the students uninterested in reaching out to CAPS for help.

As their perception of the problem severity was time bound, when students were unable to find proper help in a timely fashion, they tried to manage it on their own or consider that the problem might go away some time after they endured that particular stressful event. We found that after a certain amount of time passed, the students did not necessarily want to be reminded of an issue, nor did they feel the need for professional help anymore. Rather, they wanted to put their problems behind them, letting them resolve on their own over time or trying to ignore them. Ensuring help at the appropriate time was particularly tricky for students who were required to change their locations periodically:

I came back home for the summer so I couldn't see them [therapists at CAPS] again. I could have come in the fall but it wouldn't have been the same. It would a long break and I would have thought through some things on my own and stuff like that. I didn't go to them afterwards.

As the participants, including P9, left the campus for summer and winter breaks for various reasons such as internships, vacations, or other duties, many had to leave in the middle of getting help without fulfilling their needs, and they felt that the help that came later was meaningless.

In addition, we found that when seeking and receiving help, some students experienced a discrepancy between what they expected and how the help was actually delivered. Types of problems they had might be similar to those of their peers, as emerging adults on campus were going through similar life events. Although the perceived severity might differ, students felt that their struggles might not look as serious to others as they perceived them to be. In fact, they experienced difficulty in getting proper recognition or serious consideration from others. Consequently, students quickly lost interest or motivation to actively seek help when they did not feel they were getting enough recognition or empathy from others upon initial sharing. P3 mentioned how her problem was not appropriately acknowledged or addressed by the therapists' consultation:

The therapist said, 'Ok it's been one hour, I think we are going to wrap up.' Then I was so surprised, what!? Are we finished? I thought you were going to give me some suggestions. At least some homework for what I am going to do... Then, she [therapist] said, 'no, no you have so many stress to relieve, so this time you just relieve all your tension, you just let your sore come out. And next time we will talk about others.'

In this quote, P3 showed her frustration about how her severe problem was mostly treated as one of the many other stresses without the proper understanding she expected. In this study, this kind of experience, not getting sufficient recognition of the severity of their problems, made even those students who initially sought help consider that their problems might not be serious enough for professional treatment and that they might need to be manage the problem themselves.

Many of the students in the study wanted to receive help in a more casual way through frequent and informal conversations, instead of fixed (regular but limited) and formal conversations. As most students saw their problems as issues that could come and go and get better or worse, and as similar to what their peers were all dealing with, rather than as mental health issues requiring formal diagnoses, they preferred casual and frequent interactions, which allowed them easy access when needed. P15 expressed the need to see mental health practitioners more frequently and informally as a preventative approach, rather than seeing them only when "something was going wrong," such as "when feeling depressed, when feeling anxious, when having maniac episodes whatever it might be."

Similarly, a couple of students proactively managed their stress through frequent hangouts with friends. P14 shared her experience of using her regular get together as an outlet for her distress:

It makes me feel good about how things are. I get to offload my emotional stress. I do that [talk about things in mind/head] once a week when we all get together. But on a daily basis we don't talk as much about anything emotional or anything about our job, just like, have you had food, where are you going, things like that.

P14 designated a weekly time to "talk about things" with a small group of friends who she hung out with on a daily basis as a way to focus on sharing stressful issues, as they might go through similar stressful life events and share similar struggles. Having weekly gatherings with close friends made sharing problems comfortable instead of awkward or uncomfortable.

In sum, students struggled with various problems brought by life events, especially multiple problems concurrently happening during a transitional period, and they tried to look for help that could effectively address the problems. Despite the seriousness of a problem and the critical need for help, the problems students struggled with were mostly considered to be part of normal emerging adulthood-related issues, not "serious" ones, by the students themselves and even by others whom they tried to ask for help. Students thus preferred casual help, or they took a preventative approach so that those "normal" problems would not develop into "serious" ones.

The Need to Build, Rebuild, and Maintain Support Givers for Frequent Life Events

All students participating in the study had recently gone through major life events and changes: they had left their hometowns or relocated, sought or made new friends in college or at work, or made changes in their career-for example, switching majors, changing schools, delaying their degree, and coming back to school from industry. These transitions caused changes in social support structures, exacerbating stress and problems in maintaining their mental well-being. The following quote from P8 illustrates the highly stressful period of transitions and the loss and regaining of social support:

The transition time was very rough because I was used to a place with a lot of people and a lot of activities. When I first came here... I don't know, I found a lot of simple things to be very difficult. I didn't have my own mode of transportation, so had to rely on the bus services. Small experiences like that really added to my stress levels and I found the fact I lived away from the main campus, [which] meant that I had to spend a lot of time on my own, which I didn't like because I like hanging around people. When I was staying alone it was quite difficult for me.

Relationship Building Is Constantly Needed to Have Access to Potential Support Givers

The various life events the participants experienced not only forced them to quickly adjust to new life contexts and rebuild their social connections but also made it difficult to maintain their existing social connections. For this reason, students often felt that the support they wanted was not readily available or workable, but inconsistent; supportive social groups or support givers were likely to come and go. For instance, P18 described her premed group members with whom she initially developed deep relationships, and she described how these relationships were enhanced by their common struggles and active support for each other. Later, she felt helpless and discouraged when all the members of the group transferred to other universities or decided to pursue something else:

I think with pre-med courses, it's nice to have a community where you can be stressed out together and fall on each other for advice and study together and help each other. But then when everybody dropped, and it was just me, I think that's when it got to be very stressful because I was doing everything on my own.

The short-term and inconsistent social support received from their existing support givers was somewhat detrimental to the students' mental health, often resulting in sudden feelings of being lost or alone. Although some relationships were strong and long lasting, the students needed to be prepared to lose connections and relationships they often put a large amount of time and effort into building and rebuilding.

Most of the students in this study experienced the diminishment, disappearance, or replacement of intimate friends they previously relied on to receive support, such as the replacement of high school friends with a small group of close friends from the freshman cohort, or they experienced the quality of relationships with old friends changing over time. P9 explained how the friendships he had with close friends growing up and their support for each other became rather unstable and shifted after 3 years of college as they experienced conflict and disagreement:

These were probably the two people I would go to if I had trouble with school and things, but after I had a disagreement with them, I felt very alone and isolated. Now, I'm a better friend to them but I think because we had that break we're not as close as we used to be. It's always in the back of my mind that we had this fight so I'm not that close to them as much anymore.

This shows that even with existing support givers (eg, intimate friends), effort was still needed to maintain relationships as all parties went through different stages and events of their own lives during emerging adulthood, affecting their current or future situations, viewpoints, and needs.

While going through different life events and needing to seek appropriate help, the students encountered situations where they needed to determine how to disclose and share their problems with the new social connections they had just built or developed. The new social connections were usually people they had recently met in classes, at work, at various events, or where they lived. For instance, P10 shared her experience of sharing her concerns with a new friend she had started to get close with recently:

I talk a lot this semester with Olivia [her classmate], but like until the end of the semester, not really earlier. I feel like this semester, the early part of this semester I'm always alone because I am mostly in Fishbowl to finish 520 assignment or something. (...) She also shares her concern as well. I think for the academic part, we are very similar. In the same situation, I guess. And we haven't got internship yet and we're also worried about finding a project, final exams, so it's hard. Our schedules are more similar. We sometimes work together on weekends.

Having similar situations, interests, or struggles as other individuals helped students quickly build new relationships and potentially share their problems, although the sharing might initially be limited to their common interests.

While sharing problems with newly developed social connections, students did not share their real, deep problems upfront, unless those were the commonly shared issues they already knew about each other (eg, met at a counseling session). They wanted to share problems in a friendship after building a relationship and worried that sharing such issues in the beginning of the relationship could lead to making some "unattractive" or "undesirable" impressions:

I wouldn't necessarily want people to know that to be the first thing they know about me. I want them to know me as a person. I feel like, yes, that's an important thing to know about me in a friendship and stuff, but I don't want that to be the first thing.

Seeking Alternatives to Support Givers on the Web

Owing to the challenges of having a constant change of support givers while going through frequent life events, the students often sought alternative forms of support, such as making new Web-based social connections and asking for help (eg, Facebook groups, mental health-related web forums, and anonymous others on Reddit or Instagram). As Web-based support is always accessible, students found that this served as a support baseline that they could contact regularly or whenever they wanted to check in as a casual (not as structured and serious as a CAPS or professional service) but also steady (with minimum effort to set up) way of maintaining their mental well-being. However, despite the benefits of having Web-based help, students reported issues with the sustainability and the consistency of support based on their experiences. They believed that the size of the group, the qualities of the anonymous members, and whether there was guidance and a moderator within the Web-based communities often affected the quality of the support they received. Many, including P19, mentioned the double-edged sword aspect of anonymity in Web-based groups and communities regarding the anonymous members and expected behaviors:

I don't like Reddit, not at all! 'Cause Reddit is totally about anonymity. And I don't enjoy that. I think anonymity is to some degree dehumanizing. It's really unaccountable. And people allow their worst selves out because they don't understand impact when they're anonymous.

According to the participants, the size of the group mattered for the perceived quality of group dynamics and conversation. When the Web-based support group was too large, the conversation among the group members would become disorganized and derailed by new information, which often made participants feel less valued. In contrast, with small groups, the students often felt they did not get enough diverse opinions, which could lead to a lack of effective solutions or ideas to address their problems. Nearly all of the participants advocated 7 to 10 members as an ideal group size for sharing their concerns and having effective group discussions:

Less than 10 participants [would be good] in order to have sufficient dialogue and participation among everyone.

The personal qualities of the web members were also seen as an important consideration to ensure that the support was sustainable. Students considered being faithful, committed, and respectful of others' privacy the most needed qualities of support members as potential support givers, especially given the relative anonymity of many support spaces. The students also commented on their desire to engage both intimate friends and strangers in their envisioned Web-based support group to receive the most useful help, as each provided different types of support on different subjects. In addition, moderated interactions within support groups were seen as critical for students to better receive quality social support. They remarked that careful moderating and monitoring helped maintain the support environment as a healthy and useful place for everyone to get consistent support for the long term. A few students (P8, P12, P14, and P16) who had never used any Web-based support group expressed their interest in joining a small group conversation moderated by professionals who could understand the members, properly react to what was said in the group, and maintain group positivity:

You have a different mental state when you're talking to a therapist compared to talking to just anonymous people. I might not be able to respond if one [a person] was sad or depressed. In a sense, a therapist response would be much nicer and much more understanding compared to what I can provide.

Similarly, some who already had experience with moderated Web-based support groups also preferred to have a more structured support environment where a moderator provided group therapy or assigned particular goal-oriented tasks to help members achieve their goals. Several advocated for having more than one moderator or professional monitor to track the conversations to ensure that the members would interact appropriately, particularly in anonymous environments.

The Need to Negotiate Tensions Between the Benefit of Disclosure and the Stigma Associated With Disclosure

The last challenge that students mentioned was balancing self-disclosure to seek help and the stigma that prevents such disclosure. To express a need for help, the students attempted to find ways that allowed them to avoid the stigma associated with the disclosure while also maintaining their mental well-being.

Students Hold Tension in Maintaining Desirable Presentations of Self

One common concern related to transitions across frequent life events, particular to emerging adulthood, was maintaining and developing a desirable presentation of self in social interactions. Although wanting to maintain a "positive" image or reputation is a well-known phenomenon in social science research [ 53], it becomes particularly challenging when one's network keeps changing, as was the case for the students participating in this study. Students commented that the stigma associated with sharing personal problems could hinder the development of positive social relationships, often discouraging them from openly sharing their concerns with their social connections, such as friends, family, and the people with whom they had recently developed relationships. Particularly, as many students considered their problems might be trivial and common, they considered that what they were going through should not be overestimated as a serious problem. This thinking process aggravated their stressful situations.

The transitions during emerging adulthood made it difficult to keep up with their original support givers (ie, old and intimate friends), and it forced them to build new connections (ie, new friends). The new social connections students built were the ones with whom they wanted to further develop intimacy. These new connections were critical to their emerging adulthood in that they were the students' most preferred source of support. Thus, to further develop these new relationships in the ways they desired, students did not want to disclose their problems too much, but they preferred to maintain a positive self-presentation toward their new connections. For example, some students wanted to maintain an image of being fun and outgoing. They worried that if they disclosed too much about their depression, sadness, or struggles, their new friends would view them differently and categorize them as "not a fun friend to be around" or "problematic." P2 described hiding his concerns from friends in an effort to maintain the character of being fun and happy:

You have five friends and they expect you to be very fun and outgoing, you can't help but stay in that character. It's very difficult or you feel uncertain that if you were to reveal a little bit [of your] personal self, would they still be the same towards you know, [the] friendship or not.

As in the case of P2 above, many students worried that the negative, long-term impact of sharing their concerns with their social connections, particularly with newer ones, would outweigh the potential benefits, which ultimately prevented them from getting effective help.

Owing to the tension between their need to share with friends and the associated stigma, many students put a lot of effort into sharing their problems in ways they perceived to be less risky. They would slowly and carefully bring their concerns into the conversation or look for the right time to bring up an issue. For example, we saw that some students waited to share their concerns until a friend approached them first, instead of asking for help directly; others tended to hide their true feelings, pretending to live and act in a way that conformed to how their friends viewed them, until they felt more comfortable talking about their problems. P6 explained how long it took him to feel comfortable sharing his struggles with others, explaining that there was a certain time at which such disclosure would be allowed normatively:

At the end of April when everyone is getting ready to [graduate] and started to pull out their hearts and essentially had a very close talk. That was with everyone else, and I was just sitting there and said I'm not graduating, they are, so I should at least tell them something that has been on my mind for the past few years. There was that instance where I felt should tell them.

Here, the fact that his friends were all graduating and would not be around anymore made it easier for P6 to disclose the issues that he was holding onto. His friends' transitions also made it less burdensome to deal with their reactions, which was why he chose to disclose at that time.

Disclosure was difficult when students experienced pressure to follow and meet societal expectations or standards, such as being independent financially, accomplished educationally or professionally, or settled at a culturally expected age. This finding was more apparent among the Asian students, who felt pressured to be "good" or "mature" for their families in their particular culture. For instance, P10 who started her graduate study in her late 20s explained her struggle with feeling stigmatized by her age and financial situation:

I actually borrowed money from my parents. At my age I shouldn't do that, and especially, my parents used their retire money to support me. That's a big issue. After graduation I will definitely have to find a good job and pay back. My family invested [in] me to go abroad, so that means I will have the responsibility to support my family back as well. I think that's a concern I have. (...) The other thing is my age, I would say. I think relationship and marriage is also very...not super stressful, but when I think about it, I will kind of worried about that. Because I've never had a relationship before and right now I'm almost 30. Especially my parents worry about that. I feel everything is related to my family. If my family worry about this then I will worry about that too. I know they want me to have a family in close future, but so far in my situation I don't think I have enough time to do that, seeking one and building a relationship..."

Like P10, even though students talked to their parents every day to share their thoughts, we found that many of them tried not to reveal struggles related to their schoolwork because they wanted to present themselves as a smart, hardworking daughter or son.

Exploring a Casual, Nuanced Way of Sharing Problems

As a way to deal with the stigma associated with sharing problems, students favored communicating with their social connections (potential support givers) through images. Image-based communication included any images, such as the students' own drawings, famous paintings, landscapes, body parts, any artifacts from their daily lives, funny or abstract pictures, and funny memes, shared through mobile or Web-based messages or social network sites. This was popular among the participants, especially for when they just wanted a small amount of casual support that could cheer them up in their daily lives or for when they wanted to provide support for someone else, without anyone explicitly seeking help:

I use Facebook and Instagram basically just to see what people are up to and for funny videos and photos of dogs and videos of dogs. I like memes a lot, so if I see a funny meme I just like it. (...) so like funny pictures and funny comments, internet memes. If I see one, I'll just click like so that my friends will see it, and my friends will start laughing about it. I use that as a stress buster really.

Similarly, sharing dog and cat photos on the Web was also a popular form of support during less energized moods.

Image-based communication allowed the students to indirectly express their nuanced feelings, as they could use some of the affordance images offer to express and share their feelings in a very subtle and subjective way, without directly revealing their true feelings or intentions. It also enabled students to adjust their own moods while sharing or posting images as a way to overcome negative feelings or curate their own feelings. Students (P11 and P16) used their social media as a digital diary, using images to share and record their moods:

I think this semester I post a lot less, but usually I post a lot. Facebook is almost like one kind of my diary. I post everything, [including] not good [ones]. Especially not good things on that. (...) I don't know [the motivation], but I think it's just like, letting it go, away for me to like expressing my anger or depression. Because I feel, if I cannot find a person to talk, because on Facebook it's also a way for me to let it go and let the others know that I'm not good.

Like P11, other participants expected image sharing and posting to enable them to feel more comfortable and embedded during their everyday lives, while reducing the stress and stigma related to their support-seeking behaviors. By using a platform that people use to communicate about everyday situations, the shared problems are portrayed as mundane and normal problems of daily life rather than as serious mental health problems.

Discussion

Overview

University students go through a critical transitional life phase of emerging adulthood between adolescence and young adulthood. This life phase requires increased responsibility, maturity, and independence, causing more stress and problems with maintaining mental well-being. For this reason, there have been increased mental health incidents on college campuses [ 13, 54], and more researchers have been exploring technological interventions for emerging adults on university campuses [ 50]. Below, we describe the maintenance work required for students' mental well-being using the literature on self-disclosure [ 55]. We also discuss the boundary students perceive between mental well-being and illness, which played a critical role in students seeking help. We then discuss implications for potential sociotechnical systems that can support the needs of students in better maneuvering through this important transitional phase of life.

Negotiating Time, Audience, and Disclosure for Mental Well-Being Maintenance Work Across Life Events

This study revealed that students' mental well-being needs constantly shift and evolve as they go through the life events associated with emerging adulthood. These transitions, shaped by life events, critically impact their mental well-being. This study's findings draw attention to how students negotiate the three needs in their lived experiences related to time, audience, and disclosure. The severity and duration of the life events ( time) defined the expectations of how help should be delivered. Students encountered new social relationships, which they had to constantly rebuild and maintain as sources of support. These relationships at the same time served as the audience for whom the students had to balance the tension between the stigma and disclosure of problems and seeking help. As such, these three needs are closely interconnected and constantly negotiated to maintain their mental well-being. This interconnected relationship has been identified in the studies about disclosure in HCI and Communication fields.

For instance, "time" has been found to be a critical component in when, how, and whether disclosures occur, exploring the facilitation and hindrance of disclosures [ 55, 56]. Reasons for delayed disclosure [ 56, 57], a delay between a significant, stressful event and the time of disclosure, include fear that the disclosure will be poorly received and not supported by others as well as moving on from the event and not feeling the need to share or reopen wounds [ 56]. Although delayed disclosures have primarily been studied in the context of abusive and traumatic situations (eg, sexual abuse) [ 58], this study shows that delayed disclosure also happens when students wait for the right "timing" to disclose their problems and seek help. An example from this study's findings showed that one student (P5) waited until his friends' graduation to reveal his issue to reduce the burden of having to manage friends' reactions to his disclosure. Moreover, this was during a moment when the friends had mutually agreed to share intimate experiences as a way to reflect on their college years. The reciprocity norm of mutual self-disclosure in dyadic relationships [ 59] explains this observation of mutual sharing at the right time.

"Audience" is another important factor in explaining why people disclose or do not disclose stigmatizing experiences (eg, depression) in the Disclosure Decision-Making Frameworks [ 55, 56]. The concept of audience connects with our findings on rebuilding relationships, such as the new social connections students need to build. According to Goffman, "audience" refers to the individuals for whom one performs and who might be the recipients of one's direct or indirect disclosures as part of a help request [ 53]. The disclosing person assesses how these individuals, that is, the audience, might react and respond to the disclosure or lack thereof and makes a (non)disclosure decision accordingly. In this study, such an assessment includes balancing the potential benefits of disclosure with the risk of losing the status of being a fun friend to be around, especially when the goal is to rebuild and maintain new relationships with the audience. This negotiation is fraught as these new relationships entail potential disclosure to audiences who can be a source of support.

Furthermore, this study also showed that as a result of the risk of stigma associated with disclosing problems, students used fun and positively valued social media sharing to release stress for themselves and others. Previous work has argued that social media design should facilitate the disclosure of stressful situations directly or indirectly [ 56]. This study added to this conversation by arguing that sharing positive content is not necessarily shallow or "just for fun"; it can, in fact, be part of an activity that releases tension and stress among individuals.

Understanding the Perceived Boundary Between Mental Wellness and Illness as a Collective Effort

In this study's findings, students perceived most of their problems to be either normal or on a continuum between normal and serious. The latter would imply the need for seeking immediate help from a professional source, compared with the former, where the problem may resolve on its own as time passes. Students view the problem as fluctuating day to day, or even hour by hour, and as being influenced by many things in their daily lives, just like physical health. They think normal problems can progress to become serious and serious problems can revert to being normal as time passes (after a certain stressful life event is over). Coupled with stigma and barriers to self-disclosure [ 55], students attempted to avoid as much as possible the need to label their problems as illness problems.

The students in this study tended to consider their problems within the realm of wellness-a state where they think they have abilities to cope with the normal stresses of life and manage on their own. However, students also worried that their wellness problems could potentially develop into more serious ones and become illness problems. To prevent this progression, students actively and proactively tried to seek effective, workable resolutions. This study's findings showed that students set a maximum time (eg, three months and two weeks) in which to resolve problems (eg, relationship breakup and being stressed about grades or job search) to prevent the problems from overwhelming their overall well-being. Having a social network to share their problems with, whereby students could set up regular weekly hangouts with close friends to prevent the problems from progressing into more serious ones helped.

In this study, we reported different perspectives between the mental health literature and findings in terms of when a problem is considered as part of "wellness" vs "illness." This difference makes it difficult to determine when and how we should intervene to support students' help-seeking behaviors effectively. The traditional mental health literature on emerging adulthood problematizes the students' perceived, self-endorsed boundaries between wellness and illness, defining it as a barrier to mental health care and support [ 60]. The literature legitimizes self-management activities for mental health but only to a certain extent. Self-management activities, referring to seeking help from family and friends and going to meditation groups, are largely described as barriers to mental health care access. Rickwood et al [ 61, 62] found that participants preferred to talk to friends and family rather than health care professionals, which might prevent access to health care when added to participants' lack of emotional competence and negative attitudes toward seeking professional help. Biddle et al [ 63] showed that participants continuously self-assessed whether they could accommodate high levels of distress and avoid seeking help.

Where the boundary between wellness (ie, whether a problem is a normal part of emerging adulthood) and illness (ie, a symptom of a serious mental health disorder) lies or whether the boundary should even exist remains an open question. This might be an applicable question for the general population, such as those with mental health issues in the workplace [ 69], but it is the salient case for students as they are especially close to their peers who go through similar types of problems and life events during their emerging adulthood, which can make the students more ignorant or blunt about their problems. The question about the boundary has often been unclear even for health professionals because of individualized, situational factors [ 70]. Health care workers need to individually assess how much the unstable, uncertain experiences of a student should be treated as a healthy part of self-development and how much should be treated as a symptom of a serious mental health disorder [ 70]. This nuanced boundary as well as the differing viewpoints between health care professionals and students can add to maintaining student mental well-being negatively. This problem forces students on college campuses to be tolerant of severe problems and to ignore the need to get help.

We argue that this boundary between wellness and illness needs to be carefully negotiated, evaluated, and coordinated for each individual student through collective efforts among the social systems made up of responsible stakeholders: university students themselves, health care professionals, family, friends, educators, designers, institutions, and the public health sector.

Reconceptualizing a Support Group as a Place for Colearning

In examining the ways in which students received support, including from their groups of intimate friends, Web-based groups, and social media, we noticed that being part of a "support group" had a negative connotation for our students. Many students avoided labeling the wanted help as a "support group," as the term problematizes what should be a normal process of being supportive of each other in a seamless way throughout everyday contexts. The negative connotation associated with support groups served as a barrier to students accessing helpful resources, such as CAPS or related peer groups, on campus. It is worth investigating how to engage and assist students with various stressors in their emerging adulthood more effectively.

Accordingly, this study calls for an urgent need to reconceptualize the existing notion of support as a colearning space where individuals learn to maintain their own mental wellness: how to be aware of it, how to keep it healthy, and how to prevent potential risks. This knowledge is not something normally gained from formal education, although it should be. Importantly, in this reconceptualization, each individual can be a help giver as well as a receiver. This sort of mutual exchange has been discussed in the literature as the helper therapy principle [ 71], which is the central concept for building support groups. In this study, a few of those who wrote blogs or made images related to mental wellness awareness expressed their interest in working with counseling services to help their peers, based on their own experiences. At any given time, one can be a helper for multiple people on different issues, while seeking help for one's own mental well-being maintenance work. This multiparticipatory nature of a support exchange can facilitate accountability among the helpers and the individuals receiving help.

Design Implications

We discussed university students' challenges and efforts to maintain their mental well-being around time, disclosure related to stigma, and the right audience. This study indicated that it is important to facilitate the negotiation of students' own perceived boundaries of where illness begins through self-reflection and evaluation so that they can receive appropriate help. To that end, ideal sociotechnical systems should be designed in more inclusive ways that allow self-reflection to support students in managing their mental health in a casual, informal, and positive manner, rather than approaching the challenge from a mental illness perspective.

This study's findings show value in integrating functionality from such systems to support students' mental well-being maintenance work. They call for investigating how existing systems and applications for the general population can be extended and designed to offer self-reflective and self-evaluative mechanisms for students' mental well-being. For instance, existing practices, such as Expressive Art Therapy (EAT), which offers individuals the opportunity to use any expressive and creative art form (eg, singing, poetry, art, dance, or performance) to reflect on and identify what the root of a problem is, increase self-awareness, enhance social relationships, and foster emotional growth and development [ 73- 75]. EAT can then be integrated into existing everyday systems and applications to provide nonclinical solutions. Specifically, existing media applications for self-expression, such as video blogs, amateur music sharing, sharing creative artwork or images, drawing, or poetry sharing forums, can be used to support these varieties of forms of expression as a form of EAT. Similarly, doodling can be used to benefit the process of mindfulness training with some guidance (eg, "Choose whether to document a current happy moment or think back to a happy time and doodle your memory") [ 76]. Integrating such expressive capabilities into existing applications could enable students to be mindful and aware of their mental health status. In addition, integrating such an approach with Positive Psychology [ 6, 77, 78] can help students release their stress and discover positive moments and strengths, instead of focusing on the problems and the negativities. Examples include enabling the platform to suggest recording a thankful moment from the day through a photo, writing, or drawing and sharing it with friends on Instagram or in a group chat or cocreating humorous internet memes with friends on Sketch as a positive mood booster. These activities can foster emotional growth, enhance social relationships, and improve self-awareness [ 22, 35]. These outcomes will eventually help young adults define their own perceived boundary of mental health and receive proper help when needed.

Upon developing the platform, we argue that it should be designed to facilitate the involvement of a community of all relevant stakeholders in supporting the mental well-being maintenance work of an emerging adult on campus (eg, students, health care providers, practitioners, institutions, designers, and app developers). This platform will not only help students to self-reflect and evaluate their mental well-being maintenance activities but also help stakeholders to easily analyze functionalities, use cases, and user populations of existing applications. It will also help them analyze new applications as they are developed and suggest potential connections to existing therapeutic practices of mental well-being. The platform could show usage trends of user populations, along with new features that these applications might be able to provide. It could also offer a database of EAT curated by health care professionals. The stakeholders could then exchange feedback regarding how these existing and newer applications could work together to support therapeutic mechanisms according to the life events of an individual.

The findings also indicate that it is critical to support the process of navigating and renegotiating time, audience, and disclosure. The aforementioned platform could provide a variety of approaches to requesting as well as receiving situated help, ranging from the immediate and direct to the more casual and abstract. On the basis of the mood or level of activity of a user or a particular life event, a platform could directly intervene by matching or suggesting appropriate helpers or by nudging and casually connecting with family and friends to encourage students to share their struggle with others. This could help with providing support within the appropriate time window when the impact of that event is still active. For instance, the findings showed students did not want to be reminded of their problem after a certain amount of time had passed after the issue occurred. Such a platform could also pick up on and identify potential emotional breakdowns or challenges that might come up, based on their behavioral and emotional patterns. In addition, in terms of suggesting an audience, selecting helpers from social group contacts or outsourcing highly customized help based on the topic or similar interests and needs (eg, nearby peer groups, mentors, and professional consultants) could be done for the user. Matching with others based on similar needs or interests was found to be helpful in previous work using others' life transition trajectories as a form of social support among peer patients [ 79]. The incentive for anyone to become a helper could be established by keeping them informed of both the short-term and long-term positive outcomes of addressing a problem through feedback, thus alleviating tension related to stigma and facilitating the rebuilding and maintenance of relationships between users and new and potential helpers.

Conclusions

We investigated the mental well-being maintenance practices of emerging adults on a university campus: how students perceive problems, set expectations for help, and go through the work of from whom, when, and how to seek help. We identified three needs that are required for students to maintain their mental well-being: (1) getting help at an appropriate time and in an appropriate form that aligns with the severity of the problem, (2) building relationships with potential support givers, and (3) negotiating tension between disclosure and the associated stigma. This formative study informed how sociotechnical system support for this population should be sensitive to how help is framed and offered to make it easier to embrace. We also discussed how and when help should be delivered through technology and argued for reconceptualizing help as a colearning process. This research was conducted with a subsample of emerging adults, focusing on those at a large university in the Midwest. Although the participants do not represent the broader population of emerging adults nor all university students, this study's findings demonstrate a unique set of needs and challenges that should be acknowledged and supported in the population to which these findings theoretically generalize. This study contributes to helping mental health practitioners, researchers, and system designers understand and support students' mental well-being maintenance practices as part of the normal course of life beyond the clinical context.

Abbreviations

CAPS

Counseling and Psychological Services

EAT

Expressive Art Therapy

HCI

human-computer interaction

IRB

Institutional Review Board

RQ

research question

Footnotes

Conflicts of Interest: None declared.

References

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Articles from JMIR Formative Research are provided here courtesy of JMIR Publications Inc.

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Understanding Students' Mental Well-Being Challenges on a University Campus: Interview Study

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Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges ...

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Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan

Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan

Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

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 ( Cleary et al., 2011). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013; Mey and Yin, 2015), it does not return to pre-university levels ( Cooke et al., 2006; Bewick et al., 2010). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006; Hunt and Eisenberg, 2010; Verger et al., 2010; Auerbach et al., 2018; Lipson et al., 2019). Some researchers refer to these trends as an emerging "mental health crisis" in higher education ( Kadison and DiGeronimo, 2004; Evans et al., 2018). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006; Antaramian, 2015), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009; Hunt and Eisenberg, 2010). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008; Eisenberg et al., 2011; Lipson et al., 2019) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007; Gulliver et al., 2010; Hunt and Eisenberg, 2010; Sharp and Theiler, 2018). This study aims to extend the understanding of mental health in university students by providing a bird's eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000; Bailey, 2012; Wittchen et al., 2014a). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview"). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of "the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry." (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012). In this regard, Eshun and Gurung (2009) pointed out that "culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment." (4). Fernando (2019) argued that issues related to the 'mind' developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010; Summerfield, 2013). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge "counterflow") (see White et al., 2014).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013; Galderisi et al., 2015). An example is the definition by the World Health Organization which refers to 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, 2004). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents "people's beliefs and feelings that they are living a desirable and rewarding life" ( Diener, 2012). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one's life ( Deci and Ryan, 2008). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one's true potential ( Ryff and Singer, 2008). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005, 2007; Keyes and Michalec, 2010). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975-2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview." All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: ["mental health"]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: ["mental illness," "mental disorder ∗," "mental distress," "psychological distress," "psychopathology," "depression," "anxiety," "stress," "suicide," "eating disorder ∗," "substance use"]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: ["well-being," "wellbeing," "wellness," "life satisfaction," "happiness," "positive affect," "purpose in life," "personal growth," "self-determination"].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: ["university," "college," "higher education," "tertiary education," "post-secondary education," "postsecondary education," "undergrad ∗ student," "grad ∗ student," "master's student," "doctoral student," "Ph.D. student"]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors' name, organization, and country. Also, the title, the abstract, the author's keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps. In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors' keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth Trajectory: Evolution of Publications and Citations in the Field

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975-2000); a fermentation stage, with a notable increase in publications in the field (2000-2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010-2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004; Evans et al., 2018), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013).

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2. Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry, which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health, substance abuse, general internal medicine, neurosciences neurology, health care sciences services, and nursing. Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences, family studies, and social work research.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the "psy disciplines"' (i.e., psychology and psychiatry) ( McAvoy, 2014), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011), who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018; Mitchell et al., 2019).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4. The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students' mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010; Summerfield, 2013).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006; Abramo et al., 2009). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012; Wagner et al., 2015), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4. Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009; Vaillant, 2012; Fernando, 2019). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005; Freshwater et al., 2006). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004; Freshwater et al., 2006).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate "new insights into theory, practice, and research in mental health and development." (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology, the Journal of Counseling Psychology, and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014; Wittchen et al., 2014b). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology. To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy.

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students' mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011). Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students' mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975-January 2020 period are presented in Figure 6. The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

The most frequent keywords in the dataset, excluding students' descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health, as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse, most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health, including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

Conclusion

This study provides a comprehensive overview of the research on university students' mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

Funding

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

References

LeViness, P., Bershad, C., Gorman, K., Braun, L., and Murray, T. (2018). The Association for University and College Counseling Center Directors Annual Survey. Available online at: https://www.aucccd.org/assets/documents/Survey/2018%20AUCCCD%20Survey-Public-June%2012-FINAL.pdf (accessed February 24, 2020).
Google Scholar

# data[].attributes.attachment_link.title
Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

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The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020.

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https://youtu.be/_gJ5V525SCk

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The Five Ways to Wellbeing - boosting mental wellbeing

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A whole school approach to supporting students' wellbeing and mental health

Schools play a critical role in supporting the mental health and wellbeing of all Queensland state school students. The department's Student learning and wellbeing framework assists schools to implement a whole school approach to supporting students' wellbeing and mental health across the continuum-from universal promotion and prevention approaches to targeted responses to students' mental health concerns.

Educators, parents, and children and young people themselves all have a role to play as part of a whole school approach to supporting the wellbeing and mental health of all Queensland state school students.

Find out specific information about how to support students' wellbeing and mental health.

Information for parents, including:

strategies for supporting your child's wellbeing and mental health

getting support for your child's wellbeing and mental health

responding to traumatic events.

Information for students, including:

supporting your wellbeing and staying safe

looking out for your mental health

where to get support for your wellbeing and mental health.

Information for school staff, including:

departmental resources

providing support

external support agencies.

Coronavirus (COVID-19) and supporting students-advice for parents

The department has developed:

The importance of supporting students' wellbeing for enhancing learning and social and emotional development is well established. Nurturing students' wellbeing in safe, supportive and inclusive school and home environments assists children and young people to be resilient, confident and lifelong learners.

Resilient and confident students not only perform better academically but are more likely to develop and maintain healthy, positive relationships and make responsible lifestyle choices.

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Supporting students' wellbeing and mental health

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The importance of wellbeing for learning is well evidenced - students learn best in environments where their social, emotional and physical wellbeing is nurtured.

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Mathematics Phobia Still Haunts School Students In Assam - Sentinelassam

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. 2021 Jun;36(2):166-185.

doi: 10.1177/08295735211001653.

Affiliation

¹ University of Calgary, AB, Canada.

Free PMC article

Kelly Dean Schwartz et al. Can J Sch Psychol.

Free PMC article

. 2021 Jun;36(2):166-185.

doi: 10.1177/08295735211001653.

Affiliation

¹ University of Calgary, AB, Canada.

Abstract

Students have been multiply impacted by the COVID-19 pandemic: threats to their own and their family's health, the closure of schools, and pivoting to online learning in March 2020, a long summer of physical distancing, and then the challenge of returning to school in fall 2020. As damaging as the physical health effects of a global pandemic are, much has been speculated about the "second wave" of mental health crises, particularly for school-aged children and adolescents. Yet, few studies have asked students about their experiences during the pandemic. The present study engaged with over two thousand ( N = 2,310; 1,288 female; M age = 14.5) 12- to 18-year-old Alberta students during their first few weeks of return-to-school in fall 2020. Students completed an online survey that asked about their perceptions of COVID-19, their fall return-to-school experiences (84.9% returned in-person), their self-reported pandemic-related stress, and their behavior, affect, and cognitive functioning in the first few weeks of September. The majority of students (84.9%) returned to school in person. Students reported moderate and equal concern for their health, family confinement, and maintaining social contact. Student stress levels were also above critical thresholds for 25% of the sample, and females and older adolescents (age 15-18 years) generally reported higher stress indicators as compared to males and younger (age 12-14 years) adolescents. Multivariate analysis showed that stress indicators were positively and significantly correlated with self-reported behavioral concerns (i.e., conduct problems, negative affect, and cognitive/inattention), and that stress arousal (e.g., sleep problems, hypervigilance) accounted for significant variance in behavioral concerns. Results are discussed in the context of how schools can provide both universal responses to students during COVID-19 knowing that most students are coping well, while some may require more targeted strategies to address stress arousal and heightened negative affect.

Keywords: COVID-19; coping; health and wellbeing; high school; junior high school; mental health; participants; secondary education/adolescence; social and educational environment; stress.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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COVID-19 and Student Well-Being: Stress and Mental Health during Return-to-School - PubMed

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Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan

Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan

Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

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 ( Cleary et al., 2011). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013; Mey and Yin, 2015), it does not return to pre-university levels ( Cooke et al., 2006; Bewick et al., 2010). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006; Hunt and Eisenberg, 2010; Verger et al., 2010; Auerbach et al., 2018; Lipson et al., 2019). Some researchers refer to these trends as an emerging "mental health crisis" in higher education ( Kadison and DiGeronimo, 2004; Evans et al., 2018). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006; Antaramian, 2015), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009; Hunt and Eisenberg, 2010). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008; Eisenberg et al., 2011; Lipson et al., 2019) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007; Gulliver et al., 2010; Hunt and Eisenberg, 2010; Sharp and Theiler, 2018). This study aims to extend the understanding of mental health in university students by providing a bird's eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000; Bailey, 2012; Wittchen et al., 2014a). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview"). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of "the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry." (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012). In this regard, Eshun and Gurung (2009) pointed out that "culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment." (4). Fernando (2019) argued that issues related to the 'mind' developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010; Summerfield, 2013). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge "counterflow") (see White et al., 2014).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013; Galderisi et al., 2015). An example is the definition by the World Health Organization which refers to 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, 2004). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents "people's beliefs and feelings that they are living a desirable and rewarding life" ( Diener, 2012). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one's life ( Deci and Ryan, 2008). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one's true potential ( Ryff and Singer, 2008). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005, 2007; Keyes and Michalec, 2010). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975-2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview." All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: ["mental health"]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: ["mental illness," "mental disorder ∗," "mental distress," "psychological distress," "psychopathology," "depression," "anxiety," "stress," "suicide," "eating disorder ∗," "substance use"]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: ["well-being," "wellbeing," "wellness," "life satisfaction," "happiness," "positive affect," "purpose in life," "personal growth," "self-determination"].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: ["university," "college," "higher education," "tertiary education," "post-secondary education," "postsecondary education," "undergrad ∗ student," "grad ∗ student," "master's student," "doctoral student," "Ph.D. student"]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors' name, organization, and country. Also, the title, the abstract, the author's keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps. In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors' keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth Trajectory: Evolution of Publications and Citations in the Field

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975-2000); a fermentation stage, with a notable increase in publications in the field (2000-2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010-2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004; Evans et al., 2018), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013).

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2. Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry, which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health, substance abuse, general internal medicine, neurosciences neurology, health care sciences services, and nursing. Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences, family studies, and social work research.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the "psy disciplines"' (i.e., psychology and psychiatry) ( McAvoy, 2014), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011), who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018; Mitchell et al., 2019).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4. The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students' mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010; Summerfield, 2013).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006; Abramo et al., 2009). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012; Wagner et al., 2015), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4. Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009; Vaillant, 2012; Fernando, 2019). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005; Freshwater et al., 2006). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004; Freshwater et al., 2006).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate "new insights into theory, practice, and research in mental health and development." (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology, the Journal of Counseling Psychology, and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014; Wittchen et al., 2014b). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology. To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy.

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students' mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011). Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students' mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975-January 2020 period are presented in Figure 6. The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

The most frequent keywords in the dataset, excluding students' descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health, as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse, most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health, including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

Conclusion

This study provides a comprehensive overview of the research on university students' mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

Funding

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

References

LeViness, P., Bershad, C., Gorman, K., Braun, L., and Murray, T. (2018). The Association for University and College Counseling Center Directors Annual Survey. Available online at: https://www.aucccd.org/assets/documents/Survey/2018%20AUCCCD%20Survey-Public-June%2012-FINAL.pdf (accessed February 24, 2020).
Google Scholar

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Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

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The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020.

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student well-being and mental health - Bing

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https://www.edweek.org/leadership/students-train-to-spot-peers-with-mental-health-struggles-and-guide-them-to-help/2022/03

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Students Train to Spot Peers With Mental Health Struggles and Guide Them to Help

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As schools respond to COVID’s toll on student mental health, peers can play a valuable role.

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https://books.google.com/books?hl=en&lr=&id=PplF1P6RVm0C&oi=fnd&pg=PA216&dq=student+well+being+and+mental+health&ots=BuCZkKJhMu&sig=TOab17F3RpqCb7Mq-TemQCpuz7c

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student well-being and mental health - Bing

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Looking after our mental health

As countries introduce measures to restrict movement as part of efforts to reduce the number of people infected with COVID-19, more and more of us are making huge changes to our daily routines.

The new realities of working from home, temporary unemployment, home-schooling of children, and lack of physical contact with other family members, friends and colleagues take time to get used to. Adapting to lifestyle changes such as these, and managing the fear of contracting the virus and worry about people close to us who are particularly vulnerable, are challenging for all of us. They can be particularly difficult for people with mental health conditions.

Fortunately, there are lots of things that we can do to look after our own mental health and to help others who may need some extra support and care.

Here are tips and advice that we hope you will find useful.

Keep informed. Listen to advice and recommendations from your national and local authorities. Follow trusted news channels, such as local and national TV and radio, and keep up-to-date with the latest news from @WHO on social media.

Have a routine. Keep up with daily routines as far as possible, or make new ones.

Get up and go to bed at similar times every day.

Keep up with personal hygiene.

Eat healthy meals at regular times.

Exercise regularly.

Allocate time for working and time for resting.

Make time for doing things you enjoy.

Minimize newsfeeds. Try to reduce how much you watch, read or listen to news that makes you feel anxious or distressed. Seek the latest information at specific times of the day, once or twice a day if needed.

Social contact is important. If your movements are restricted, keep in regular contact with people close to you by telephone and online channels.

Alcohol and drug use. Limit the amount of alcohol you drink or don't drink alcohol at all. Don't start drinking alcohol if you have not drunk alcohol before. Avoid using alcohol and drugs as a way of dealing with fear, anxiety, boredom and social isolation.
There is no evidence of any protective effect of drinking alcohol for viral or other infections. In fact, the opposite is true as the harmful use of alcohol is associated with increased risk of infections and worse treatment outcomes.

And be aware that alcohol anddrug use may prevent you from taking sufficient precautions to protect yourself again infection, such as compliance with hand hygiene.

Screen time. Be aware of how much time you spend in front of a screen every day. Make sure that you take regular breaks from on-screen activities.

Video games. While video games can be a way to relax, it can be tempting to spend much more time on them than usual when at home for long periods. Be sure to keep the right balance with off-line activities in your daily routine.

Social media. Use your social media accounts to promote positive and hopeful stories. Correct misinformation wherever you see it.

Help others. If you are able to, offer support to people in your community who may need it, such as helping them with food shopping.

Support health workers. Take opportunities online or through your community to thank your country's health-care workers and all those working to respond to COVID-19.

Don't discriminate
Fear is a normal reaction in situations of uncertainty. But sometimes fear is expressed in ways which are hurtful to other people. Remember:

Be kind. Don't discriminate against people because of your fears of the spread of COVID-19.

Don't discriminate against people who you think may have coronavirus.

Don't discriminate against health workers. Health workers deserve our respect and gratitude.

COVID-19 has affected people from many countries. Don't attribute it to any specific group.

If you are a parent

In times of stress, it is common for children to seek more of your attention.

What you can do:

Maintain familiar routines as much as possible, or create new ones, especially if you must stay at home.

Discuss the new coronavirus with your children in an honest way, using age-appropriate language.

Support your children with at-home learning and make sure time is set aside for play.

Help children find positive ways to express feelings such as fear and sadness. Sometimes engaging in a creative activity, such as playing or drawing, can help you with this process.

Help children stay in contact with friends and family members through telephone and online channels.

Make sure that your children have time away from screens every day and spend time doing off-line activities together. Do something creative: draw a picture, write a poem, build something. Bake a cake. Sing or dance, or play in your garden, if you have one.

Try and ensure that your children do not spend significantly more time than usual on video games.

If you are an older adult

Keep in regular contact with loved ones, for example by telephone, e-mail, social media or video conference.

Keep regular routines and schedules as much as possible for eating, sleeping, and activities you enjoy.

Learn simple daily physical exercises to do at home when in quarantine so you can maintain mobility.

Find out how to get practical help if needed, like calling a taxi, having food delivered or asking for medical care. Make sure you have a one-month supply or longer of your regular medicines. Ask family members, friends or neighbours for support, if needed.

If you have a mental health condition

If you are being treated for a mental health condition, make sure that you continue to take medication as prescribed, and that you have a way of re-stocking your medication. If you are see a mental health specialist, find out how to continue with that support during the outbreak.

Keep in touch with people who care for you and know who you can contact for support if your mental health declines.

If you are being treated for an alcohol or drug use disorder, be aware that the COVID-19 outbreak may lead to increased feelings of fear, anxiety and isolation that can increase the risk of relapse, substance use, disengagement from treatment or non-compliance with treatment regimens. Make sure that you continue to take medication as prescribed, particularly if you receive treatment with opioid medicines such as methadone or buprenorphine, and that you have a way of obtaining a regular supply of your medication. If you are receiving support through a psychologist or support group, find out how to continue that support during the outbreak.

If you are being treated for gaming or gambling disorder, continue with your treatment if possible. Check with your therapist or health-care provider about the best way of continuing with therapy during confinement at home.

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Looking after our mental health As countries introduce measures to restrict movement as part of efforts to reduce the number of people infected with COVID-19, more and more of us are making huge changes to our daily routines.

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https://www.who.int/news-room/feature-stories/mental-well-being-resources-for-the-public

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Mental health is essential to our overall well-being and as important as physical health. When we feel mentally well, we can work productively, enjoy our free time, and contribute actively to our communities.

This page provides resources to help you keep mentally healthy and to reduce stress. We hope you will find them useful. In cases of mental distress, the first step is to talk to someone you trust. If you feel you need it, seek help from a professional.

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Mental well-being: resources for the public

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Mental health is essential to our overall well-being and as important as physical health. When we feel mentally well, we can work productively, enjoy our free time, and contribute actively to our communities.

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Promoting the healthy development of all students, as well as enabling all students to reach their full potential, is a priority for educators across Ontario. Students' health and well-being contribute to their ability to learn in all disciplines, and that learning in turn contributes to their overall well-being.

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https://www.education.vic.gov.au/school/teachers/health/mentalhealth/Pages/promoting-mental-health.aspx

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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A typical day for a high schooler may involve balancing chemistry equations, analyzing classic novels and memorizing key facts and figures from American history. Beyond their normal school work, students also learn how to maintain positive relationships with their friends and families, prepare for the increased responsibilities of adulthood, and balance their academic work with part-time jobs and extra-curricular activities. This is a lot for anyone, but may be particularly challenging for those experiencing multiple stressors - such as poverty, poor access to health care, and exposure to community violence - and students with unidentified mental health problems.

Mental Health and Academic Achievement

Recent estimates show that approximately 20 percent of adolescents ages 12-20 have a seriously debilitating mental health disorder, such as anxiety or depression. The same study found that an even larger percentage of adolescents experience mental health symptoms that may impair their daily activities and which place these youths at risk for more significant mental health problems. A wealth of research shows that youth who develop a mental health disorder as a teenager are at increased risk for continued mental health difficulties as adults. These concerning facts speak to the need to find innovative ways to expand mental health services at every possible touchpoint, from the doctor's office to the classroom.

Though many students suffer with these conditions in silence, we can see the implications of an untreated mental health condition on a high schooler's transcript. For example:

One study found that students who report having some type of emotional difficulty are three times as likely to be tardy or absent from school compared to those without these disorders.

Another showed that 83 percent of students with emotional and behavioral disorders scored below the average student in reading, writing and math compared to the general population.

Finally, a report from the Centers for Disease Control and Prevention shows that mental illness and emotional disturbance accounts for 31 percent of high school dropouts.

Despite the well-known facts that mental health conditions are both highly prevalent and have a great impact on student well-being and performance, between 60 to 90 percent of adolescents with mental health conditions don't receive treatment. A number of barriers lead to these unmet mental health needs, including stigma, lack of identification, inadequate insurance coverage and a shortage of mental health care providers.

Integrating Mental Health into a School Day

Considering that adolescents spend the majority of their waking hours in school, people across the country, including myself, have explored opportunities to integrate mental health services into a student's school day. For example, many have developed school-based health clinics that provide health and mental health services to students. My specific interests lie in school-based mental health prevention programs, so we can intervene before students' emotional problems become more significant and concerns about stigma influence their willingness to receive treatment.

My past research has demonstrated the efficacy of a group depression prevention program that I developed called Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST). IPT-AST is an adaptation of interpersonal psychotherapy, an evidence-based treatment for depression, and is built on the idea that things that happen in our relationships affect how we feel, which in turn impacts how we act in our relationships. For instance, getting into a fight with a friend makes us feel sad or angry, and when we are in bad mood, we may lash out at others or become withdrawn from our relationships.

IPT-AST teaches students skills to promote positive relationships and address problematic relationships with friends and family to prevent these youth from developing more significant depression. We have conducted three different studies of IPT-AST in schools and have found that the program positively impacts depression and anxiety symptoms. We also saw a decrease in the number of depression diagnoses that students experienced. Our preliminary findings also suggest that IPT-AST and other mental health prevention programs have a positive impact on students' academic functioning. Researchers will need to further examine this finding to justify a continued focus on mental health prevention in schools.

We recently submitted a grant application to the Institute of Education Sciences to train school counselors in the Philadelphia School District in delivering IPT-AST. If funded, this study will examine the effects of counselor-delivered IPT-AST on a variety of outcomes including social, emotional, and academic functioning.

The education system is in a unique position to ensure that students' minds are both sharp and healthy, but this requires a continued, and increasing, commitment to providing these types of services in schools. Addressing mental health conditions may be just as important for student success as any essay or geography lesson.

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Math, English and Depression Prevention: The Importance of Addressing

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A typical day for a high schooler may involve balancing chemistry equations, analyzing classic novels and memorizing key facts and figures from American history. Beyond their normal school work, students also learn how to maintain positive relationships with their friends and families, prepare for the increased responsibilities of adulthood, and balance their academic work with part-time jobs and extra-curricular activities.

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Highlights

*

We examined relations among teachers' depressive symptoms and students' experiences.

*

Eight experiences were investigated reflecting varying levels of teacher effort.

*

More symptoms related to less instruction applied by the teacher to the whole class.

*

More symptoms related to less time in planning/organizing instruction.

Abstract

Recent studies have established connections among teachers' mental health and student outcomes, however there is limited understanding of how these teacher characteristics manifest in the classroom to affect students. The present study informed this gap by examining the associations among third grade teachers' ( N = 32) self-reported symptoms of clinical depression and their students' ( N  = 326) classroom instructional experiences. Eight student experiences described by the Individualizing Student Instruction framework were investigated, including academic instruction facilitated by the teacher in various student groupings, students' independent and group work, teachers' planning/organizing instruction, and students' time off-task and in transitions. Multilevel modeling revealed negative associations between teachers' depressive symptoms and (a) teacher-facilitated academic instruction provided to the whole class and (b) teachers' planning/organizing instruction. Results suggest that teachers experiencing more symptoms may under-utilize instructional approaches that require more effort on their part. We discussed the implications of our findings for students' academic and social-emotional learning, and the potential benefits of incorporating mental health support components into teacher training and professional development aimed at improving instructional practices.

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Being mentally healthy and living well is important to every single one of us - whether we are living with a mental illness or not.

Defining mental health

Mental health is a positive concept related to the social and emotional wellbeing of individuals and communities.

Having good mental health, or being mentally healthy, is more than just the absence of illness, rather it's a state of overall wellbeing.

The concept is influenced by culture, but it generally relates to:

Enjoyment of life

Having the ability to cope with and 'bounce back' from stress and sadness

Being able to set and fulfil goals

Having the capability to build and maintain relationships with others.

The term 'social and emotional wellbeing' is preferred by Aboriginal and Torres Strait Islander peoples as it reflects a more holistic view of health. It is also used by some people from culturally and linguistically diverse backgrounds, who may have differing concepts of mental health and mental illness.

Everymind uses the term 'mental health and wellbeing' to be inclusive of both concepts.

Influences on mental health and wellbeing

Mental health is influenced by several biological, psychological, social and environmental factors which interact in complex ways. These include:

Structural factors such as safe living environments, employment, education, freedom from discrimination and violence, and access to economic resources

Community factors such as a positive sense of belonging, community connectedness, activities to highlight and embrace diversity, social support, and participation in society

Individual factors such as the ability to manage thoughts and cope with stressors and having communication and social skills to support connection with others.

Tips for mental health and wellbeing

We all know that to keep a car going, we have to fill it with petrol, check the oil and water regularly and give the tires some air. To see a bank balance grow, we need to make steady deposits. But how often do we take the time to reflect on whether we are giving ourselves what we need to flourish and live well?

It can be so easy for us to take our mental health for granted; to prioritise other things; to put it off until next week. It can also seem too big and too hard. But it's not. There are some things everyone can do. The following are some tips to get you started

1. Get enough sleep and rest. Sleep affects our physical and mental health, but can be the first thing we trade in when we get busy or stressed

2. Take time out for things you enjoy. Balance in life is important, so taking time out for things you enjoy can make a difference to how you think and feel

3. Be active and eat well. Our physical and mental health is closely linked, so adding exercise and nutritious food every day can make us feel better

4. Nurture relationships and connect with others. Our connection to others is what builds us up and keeps us strong

5. Learn to manage stress. If you have trouble winding down or managing thoughts you may find relaxation, yoga or writing your feelings down helpful

6. Get involved and join in. Being part of a group with common interests provides a sense of belonging so find out about sporting, music, volunteer or community groups locally

7. Build your confidence. Learning improves your mental fitness and taking on a new challenge can build confidence and give you a sense of achievement

8. Be comfortable in your own skin. Everyone is unique and should be celebrated. Know who you are and what makes you happy.

9. Set realistic goals and deal with tasks one at a time. It is good to be specific when you set a goal to help keep you on track

10. Reach out for help when you need it. Everyone needs support from time to time. Talking to a family member, a friend, your doctor or one of the many services available can make all the difference.

Mental health and wellbeing is important to individuals, families, schools, workplaces and communities. There is a role for all of us to play.

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Could Mental Math Boost Emotional Health? | Duke Today

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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https://www.unicef.org/coronavirus/8-teacher-tips-student-mental-health

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As adults, we all have diverse needs and different ways of coping with stressful situations. For children, it is the same. Some children will have dealt well with restrictions and school closures caused by the COVID-19 pandemic. For others, it is challenging to cope with all the changes and uncertainty. Some children will return to school having experienced some level of stress, anxiety, isolation and grief. Some may have experienced increased violence at home.

School teachers and personnel are critical in supporting children's transition back to in-person classroom learning, particularly after extended periods of school closure. In addition to continuing to use the different skills teachers have been using to ensure their students' learning and emotional well-being while schools were closed, the following suggestions might be helpful when schools reopen:

1. Listen to children's concerns

COVID-19 and school closures impacted many children and adolescents' mental health and well-being. As teachers, it is essential to listen to students' concerns and demonstrate understanding as well as empathy. Offer your students the opportunity to have a one-to-one conversation with you to reconnect and discuss any concerns that might have arisen when their school was closed. If a child shares anything that is particularly concerning, please follow the protection or child safeguarding systems in place.

2. Check how children are doing

Before teaching new academic content to students, teachers and school personnel should take time to check how children are doing. Remember that children may have difficulty concentrating at first or may need more time to get back into the routine of learning. Provide opportunities for children to take breaks, move around, and re-connect with their friends and peers.

3. Provide children with accurate information around COVID-19

As children return to school, they may have different thoughts and questions about COVID-19. Children want and need factual information. Use child-friendly and age-appropriate resources available in your country/region that is based on scientific evidence to respond to children's questions about COVID-19 accurately.

While it is important to acknowledge the scale of what is happening globally, make sure to emphasize all the efforts made and precautions taken to reduce risks in the school reopening plans. Do not forget to remind children of school safety protocols, including what to do in case there is a COVID-19 case detected in the classroom.

4. Seek suggestions from children on how to create a welcoming, safe and comfortable classroom

Engage children in making the classroom a welcoming, safe and comfortable space. When doing so, make sure to respect school safety procedures and use available material resources.

Children can provide suggestions; help decorate the walls of the classroom with colourful and welcoming messages and work in small groups so they can support each other to catch up on learning. Let them know that being supportive of each other will help them get through this together. Remember to praise children for their contributions and efforts. Teachers can foster feelings of safety and security by interacting and developing positive relationships with each student and using routines during the day to help children feel safe and secure.

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8 ways teachers can support students' mental health during COVID-19 school returns

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Transitioning back to in-person classroom learning during COVID-19

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

# data[].attributes.attachment_link.title
School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

# data[].attributes.attachment_link.description
Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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Mental Health, Substance Use, and Wellbeing in Higher Education

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Student wellbeing is foundational to academic success. One recent survey of postsecondary educators found that nearly 80 percent believed emotional wellbeing is a "very" or "extremely" important factor in student success. Studies have found the dropout rates for students with a diagnosed mental health problem range from 43 percent to as high as 86 percent.

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Student Wellbeing and Mental Health - EdSystems NIU

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Student Wellbeing and Mental Health A Framework and Resources for Measuring Student Needs and Development During Remote and Blended Learning​ Download the PDF Data on student wellbeing and mental health can help us to understand the magnitude of the effects of the crisis and the disparate impacts it is having on diverse populations.

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Focusing on Student Well-Being in Times of Crisis

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One teacher recommends supporting student safety through three Cs: communication, consistency, and control.

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JMIR Form Res. 2020 Mar; 4(3): e15962.

Guest Editor (s): Gunther Eysenbach

Reviewed by Christo El Morr and Qi Yuan

Sun Young Park, BA, MS, PhD, #¹ Nazanin Andalibi, BS, PhD, ¹ Yikai Zou, BS, MS, ¹ Siddhant Ambulkar, BS, ² and Jina Huh-Yoo, BA, MS, PhD ³

Abstract

Background

Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges associated with this transitional period. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help.

Objective

This study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during this period of emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice.

Methods

Semistructured interviews with 19 students, including graduate and undergraduate students, were conducted at a large university in the Midwest in the United States.

Results

This study's findings identified three key needs: students (1) need to receive help that aligns with the perceived severity of the problem caused by a life event, (2) have to continuously rebuild relationships with support givers because of frequent life events, and (3) negotiate tensions between the need to disclose and the stigma associated with disclosure. The study also identified three key factors related to maintaining mental well-being: time, audience, and disclosure.

Conclusions

On the basis of this study's empirical findings, we discuss how and when help should be delivered through technology to better address university students' needs for maintaining their mental well-being, and we argue for reconceptualizing seeking and receiving help as a colearning process.

Keywords: emerging adults, university students, life events, mental wellbeing, mental wellness, mental health, social support

Introduction

Background

During this transitional phase of emerging adulthood, university students experience various life events at different scales, ranging from entering college, leaving home and moving to a new city, and making new networks, to taking finals and looking for a job [ 4]. These life events become potential stressors as students are expected to increase their personal responsibility and independence and make constant adjustments, including personal, emotional, and social adjustments [ 5]. Research shows that support from peers, family, and health care resources aids their life satisfaction, self-esteem, perceived social acceptance, and well-being [ 6, 7].

We build upon recent work in human-computer interaction (HCI) and Health Informatics [ 13- 17], which approaches university students' struggles and challenges as a mental well-being problem rather than as a clinical, mental illness problem. This approach helps address the problems that students need to engage but often ignore because they consider those problems not to be mental health concerns but "normal" problems that occur during emerging adulthood [ 12]. Focusing on mental well-being helps us understand students' everyday lived experiences of muddling through major life events during their emerging adulthood.

With this perspective, this study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during their emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice. In this paper, we report findings from semistructured interviews with 19 students on a university campus. We identified three key needs: (1) the need to receive help that matches the perceived severity of a problem caused by life events, (2) the need to constantly draw on new support givers because of frequent life events, and (3) the need to negotiate the tension between the benefits of self-disclosure and the stigma associated with such disclosure. On the basis of this study's findings and analysis, we make the following contributions:

We extend our knowledge about university students' understandings and perceptions of mental health and coping strategies.

We discuss how students strive to maintain their mental well-being and perceive the boundary between what counts as mental "illness" vs "wellness" in assessing whether to get help.

We present design implications for sociotechnical systems to support the needs of students to better maneuver through this important transitional life phase.

Related Work

The American Psychological Association defines emerging adulthood as the "in-between age," referring to the phase of development between adolescence and adulthood [ 18]. Regardless of socioeconomic prospects, those between the ages of 18 and 29 years commonly struggle with "feeling in between" [ 19]. Emerging adults, particularly those who attend universities, go through a great amount of stress. According to the US Department of Education (2011), student enrollment in college increased to 38% since 1999, reaching its peak. However, the majority of those who drop out of college do so in their first year [ 20], indicating that the transition process is crucial to students' success. In addition to dealing with academic pressure, they are expected to make a series of adjustments, ranging from academic assimilation to personal (eg, changed interests), emotional (eg, home sickness), and social (eg, finding new friends) adjustments [ 5].

What makes emerging adulthood more uniquely challenging than other periods is the intensity of multiple life events mounting up together in a short period. The danger of multiple life events occurring in a short period has been noted in life events research-critical life events (eg, moving, starting a new job, leaving family, and paying new rent or mortgage) and their accumulation can predict long-term medical and psychiatric illness problems [ 21, 22]. The major life events of emerging adults often begin with entering college and leaving home and their old, existing networks. To help such students with the struggles brought by the transitional phase of emerging adulthood, the American College Health Association has identified coping with stress as a high priority issue in the Healthy Campus initiative [ 23]. This initiative takes a multifaceted approach to mental well-being, which includes environmental (eg, managing air quality), physical (eg, eating well), and social (eg, student clubs) health. Universities offer Counseling and Psychological Services (CAPS) with mental health professionals. CAPS further provide campus-wide programs for first-generation college students and underserved students to reduce attrition (eg, drop out) [ 24- 26]. Despite the benefit of these initiatives, the literature still notes the problems of students not utilizing CAPS until emergency situations occur, if they ever do [ 27]. Nearly 80% of the students who die by suicide never participate in counseling services [ 28- 30]. The reasons for this underutilization include lack of awareness [ 31], stigma [ 32], long waiting list times [ 33], and preference for self-management [ 34].

Besides the institutional and national effort to support students, many studies showed that students mostly seek and receive social support from their existing networks in dealing with their struggles. Peer and family support plays a critical role in offering students a sense of belonging [ 7], affirmation of their concerns [ 35], encouragement and empathy [ 36], and facilitation of mental health maintenance as a compensatory measure when other support is unavailable [ 37, 38]. Social support enabled by technology, such as social network sites and Web-based and virtual social communities, has shown the potential benefits to supporting students, such as facilitating students' identity transitions [ 39], offering access to help when lacking in-person support [ 40], addressing unpleasant experiences with negative content on the Web [ 41], and resolving stigmatized concerns [ 42, 43]. However, research indicates that barriers related to seeking and getting social support, including stigma of mental illness [ 44, 45], a sense of autonomy (eg, "I don't need a doctor to solve this problem"), a fear of losing one's positive image (ie, "face") [ 46], and secrecy and negative cultural attitudes toward mental illness [ 47], often suppress help-seeking behaviors [ 48], which hampers students from getting timely and proactive support. These previous studies on emerging adulthood highlight both the critical need for proper support for university students during their stressful life transitional period and the associated barriers that hinder students from seeking and receiving such support.

Researchers developed and evaluated technological interventions for mental health issues such as anxiety and depression. Some examples include Harmony (a mobile health app that assists patients, caregivers, and clinicians in managing serious illnesses) [ 49], DStress (a mobile app that coaches users in balancing compliance and achievement toward daily goals of stress reduction) [ 9], the UPRIGHT project (in which researchers designed and validated resilience-based interventions for promoting early adolescents' mental health) [ 6], and Intellicare (a suite of skill-focused apps that successfully provide users with more flexibility in choosing a suitable treatment) [ 15]. Furthermore, technology-mediated therapies have been implemented (a conversational mobile app, Pocket Skills, that provides Dialectical Behavioral Therapy [ 8] and Web-based cognitive behavioral therapy) [ 50]. Although these interventions have shown their effectiveness and usefulness for treating mental illness, they mainly focus on those who are clinically diagnosed and actively seeking treatment, not those who do not consider their problems as serious mental health conditions but approach them by attempting to maintain their mental well-being.

Upon reviewing the literature on emerging adults' mental health on college campuses, we find examining how students engage everyday life challenges and the everyday maintenance aspect of their mental well-being to be a critical, emerging, and underinvestigated research topic in HCI and Health Informatics communities. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help. Building on the previous work summarized here, this study includes the following research questions (RQs):

RQ1: How do university students perceive their problems and maintain their mental well-being while going through various, frequent life events?

RQ2: What are the implications for designing sociotechnical systems that are tailored to meeting university students' unique needs around life events?

Methods

We conducted interviews with 19 university students (6 undergraduate and 13 graduate) from a large US Midwest university for a semistructured interview study. The inclusion criteria were as follows: (1) English speaking, (2) interested in speaking about their mental health or well-being, and (3) enrolled either as an undergraduate or a graduate student of the university. We recruited the participants through school-wide departmental email lists and word of mouth, and we stopped data collection when saturation was reached.

The study was approved by the Institutional Review Board (IRB) of the first author's university, and all coauthors who had access to the transcripts were registered as study team members. Our interview sessions were conducted in private rooms on the university campus. A member of the research team began the interview by informing the participants about the study's goals and interview procedures and assuring them that they could skip any questions they did not feel comfortable answering or stop the interview at any point. The participants were told that confidentiality would be maintained and that they could withdraw their participation at any time without any consequence. This study followed IRB guidelines, which state that if any crisis situation was observed (eg, threats and suicidal posts), the participant would be immediately referred to the staff at the University CAPS. Each participant received US $15 for study participation.

The duration of each interview session ranged from approximately 1 to 1.5 hours. The questions were designed to help us gain further insights that might not be uncovered in public reports on overall campus climate, where we see increases in student struggles with stress, anxiety, depression, and requests for on-campus counseling services. The interview questions probed the students' process of identifying their stressors, their experiences of seeking and receiving support or help, their development and adaptation of coping strategies to maintain mental health or well-being, and the tools and technologies they used in this process. At the end of the interview, the researchers offered information about college counseling services and other mental health support resources available on campus to those who were in need or had no previous experience of them.

All of the interviews were audio recorded and transcribed for the analysis. This study followed all of our institution's confidentiality, privacy, and security policies for handling and storing all the participants' data. Three researchers analyzed the data using the open coding method [ 51], using the Atlas.ti 7 (ATLAS.ti Scientific Software Development GmbH) qualitative coding software program. We conducted axial coding to explore and develop the key attributes and dimensions of each theme particular to the RQs. Working collaboratively, we explored, compared, and revised the themes as the analysis progressed. We revised the themes through a series of discussions and iterations until consensus was reached. We also conducted affinity diagramming [ 52] to generate common themes and identified any breakdowns and design implications during the analysis process. We followed the Contextual Inquiry Design process [ 52] to identify common themes from the affinity diagram to generate design requirements.

Results

Overview

In this section, we first provide demographic information on this study's participants and then present the three needs that were identified in this study. These three needs are critical to understanding how students maneuver through various life events, seek help, and maintain their mental health and well-being.

Study Participants

Table 1 shows the overall participant demographics. The students ranged in age between 20 and 29 years (mean 25 years, SD 4 years), and 13 students were female, and 6 students were male. In all, 7 students were international students. Reported ethnicities were as follows: East Asian (6), non-Hispanic white (6), Indian (5), and African American (2). A total of 14 out of the 19 students had had experiences with professional counseling services. Two (P7 and P19) students were clinically diagnosed with a psychological disorder.

The Need to Receive Help That Aligns With the Severity of the Problem

The participants emphasized the importance of how and when they receive help for their problems based on how they perceived the severity and duration of the problem they were struggling with. We found that knowing or not knowing when a problem would end and having multiple stressful events accumulate at once mainly affected students' perception about the severity of their problems. This perceived severity then affected the students' expectations about help seeking. Below, we describe how life events affected perceived problem severity and what students considered "good help" to be as a result.

The Severity of the Problem Is Perceived Differently Based on Life Events

The problems students struggled with in maintaining their mental well-being included adjusting to new cities and life on new campuses, meeting new people, paying for tuition, examinations, and job searches. Some of these problems involved more certainty in terms of how long they would last, such as final exams; others, on the other hand, seemed to last forever, such as job search-related stress. Accordingly, uncertainty regarding how long their problem would last affected how students perceived the severity of the problem and how they approached it. For instance, until receiving her recent job offer, P3, who was an international graduate student, had been "really, really stressed." She explained the following:

The past year, when I was first year [of the graduate school], I was really stressed... I would never go back to my home [in China] during the time because I can only come back with a job offer.

Here, P3 described the stressful event as having lasted for a year, which significantly affected her mental well-being during that year. She did not previously know, nor could she have predicted, how long the job search would take while it was happening. The job search was stressful, and the fact that it occurred over an indefinite period of time added a considerably increased amount stress. P3 was expressing the severity of the problem in relation to the event duration because she was unable to start or plan other things until her job status was secured, directly affecting her legal status to live in the United States after graduation.

In perceiving the severity of their problem, we found that a few students even put a predefined time boundary on the problem (how long it would last) and remarked that their current problems would pass and there would eventually be closure. This perception helped them get through the problem. For instance, when P3 was having a problem with her boyfriend during her job search period, she mentioned that she had given herself 3 months (a limited amount of time) to deal with the stress and move on when she would start a new job:

I told myself just three months to get over it. I was eating snacks, watching TV shows, and doing exercises.

Starting college as an independent young adult brought multiple problems in school, work, and relationships at the same time. These multiple problems occurring in the same period exacerbated the perceived severity of each individual problem. For instance, P5 experienced a high level of stress when she had a serious problem with her boyfriend while also applying for summer internships and working on her final exams. P8, similarly, shared an extreme, distressing moment because of the stress brought on by multiple, urgent work responsibilities:

There was this one time when I had a very large amount of work to do. I had a part-time job, had one big [class] assignment, and had one [class] project due, all within the next 48 hours. Even if I stayed up the entire 48 hours, there was no way I was going to finish everything. I knew that because of the amount of work involved, and that was really causing me stress because either the assignment, the project or the part-time job had to suffer, and I wasn't sure which. I was being paid for the part-time job, the project was a group project and if I don't do the work then nobody gets a grade, and the assignment was an individual assignment for me, but it was a large part of the grade, so I had to leave at least one.

P8 further explained that he had to seek emotional support from family members and friends and go to his academic advisor for useful advice. As in the case of P8, multiple problems could occur during the same transitional period, thus requiring the student to navigate the different types of support resources available to receive the proper help. This indicates that merely having one therapist may not work well for students.

Seeking Help That Is Accessible and Available at an Appropriate Time

The urgency and timing of seeking help varied together with whether the students framed the problem as having ended or as ongoing. All students in the study commented on the importance of receiving support during the particular period when the struggles were still happening to effectively deal with their struggles. However, ensuring timely support was challenging because seeking support required a great amount of effort in their hectic daily lives. For instance, students mentioned that they often found resource constraints in their existing support environments on campus. Several participants mentioned that existing support resources such as CAPS and other professional services sometimes failed to address their need to receive help at the right time, especially for time-pressured and serious concerns. This was because of tedious nature of scheduling phone calls, long wait times for in-person appointments, inflexible working hours, and an inefficient screening process, all of which made it difficult to access care in a timely manner:

There was a pretty long waiting time. The initial session was I think after a week and a half, and then the next appointment was after a couple of weeks. Time is the only problem [with CAPS], and I realize that the timing is not in their control because of the number of people here.

Another student described his experience:

I decided to go to CAPS, and was kind of disappointed because at first I filled out that whole questionnaire and the first meeting wasn't even an actual meeting it was just going over the questionnaire with a counseling student.

These factors that delayed the timing of receiving help frequently made the students uninterested in reaching out to CAPS for help.

As their perception of the problem severity was time bound, when students were unable to find proper help in a timely fashion, they tried to manage it on their own or consider that the problem might go away some time after they endured that particular stressful event. We found that after a certain amount of time passed, the students did not necessarily want to be reminded of an issue, nor did they feel the need for professional help anymore. Rather, they wanted to put their problems behind them, letting them resolve on their own over time or trying to ignore them. Ensuring help at the appropriate time was particularly tricky for students who were required to change their locations periodically:

I came back home for the summer so I couldn't see them [therapists at CAPS] again. I could have come in the fall but it wouldn't have been the same. It would a long break and I would have thought through some things on my own and stuff like that. I didn't go to them afterwards.

As the participants, including P9, left the campus for summer and winter breaks for various reasons such as internships, vacations, or other duties, many had to leave in the middle of getting help without fulfilling their needs, and they felt that the help that came later was meaningless.

In addition, we found that when seeking and receiving help, some students experienced a discrepancy between what they expected and how the help was actually delivered. Types of problems they had might be similar to those of their peers, as emerging adults on campus were going through similar life events. Although the perceived severity might differ, students felt that their struggles might not look as serious to others as they perceived them to be. In fact, they experienced difficulty in getting proper recognition or serious consideration from others. Consequently, students quickly lost interest or motivation to actively seek help when they did not feel they were getting enough recognition or empathy from others upon initial sharing. P3 mentioned how her problem was not appropriately acknowledged or addressed by the therapists' consultation:

The therapist said, 'Ok it's been one hour, I think we are going to wrap up.' Then I was so surprised, what!? Are we finished? I thought you were going to give me some suggestions. At least some homework for what I am going to do... Then, she [therapist] said, 'no, no you have so many stress to relieve, so this time you just relieve all your tension, you just let your sore come out. And next time we will talk about others.'

In this quote, P3 showed her frustration about how her severe problem was mostly treated as one of the many other stresses without the proper understanding she expected. In this study, this kind of experience, not getting sufficient recognition of the severity of their problems, made even those students who initially sought help consider that their problems might not be serious enough for professional treatment and that they might need to be manage the problem themselves.

Many of the students in the study wanted to receive help in a more casual way through frequent and informal conversations, instead of fixed (regular but limited) and formal conversations. As most students saw their problems as issues that could come and go and get better or worse, and as similar to what their peers were all dealing with, rather than as mental health issues requiring formal diagnoses, they preferred casual and frequent interactions, which allowed them easy access when needed. P15 expressed the need to see mental health practitioners more frequently and informally as a preventative approach, rather than seeing them only when "something was going wrong," such as "when feeling depressed, when feeling anxious, when having maniac episodes whatever it might be."

Similarly, a couple of students proactively managed their stress through frequent hangouts with friends. P14 shared her experience of using her regular get together as an outlet for her distress:

It makes me feel good about how things are. I get to offload my emotional stress. I do that [talk about things in mind/head] once a week when we all get together. But on a daily basis we don't talk as much about anything emotional or anything about our job, just like, have you had food, where are you going, things like that.

P14 designated a weekly time to "talk about things" with a small group of friends who she hung out with on a daily basis as a way to focus on sharing stressful issues, as they might go through similar stressful life events and share similar struggles. Having weekly gatherings with close friends made sharing problems comfortable instead of awkward or uncomfortable.

In sum, students struggled with various problems brought by life events, especially multiple problems concurrently happening during a transitional period, and they tried to look for help that could effectively address the problems. Despite the seriousness of a problem and the critical need for help, the problems students struggled with were mostly considered to be part of normal emerging adulthood-related issues, not "serious" ones, by the students themselves and even by others whom they tried to ask for help. Students thus preferred casual help, or they took a preventative approach so that those "normal" problems would not develop into "serious" ones.

The Need to Build, Rebuild, and Maintain Support Givers for Frequent Life Events

All students participating in the study had recently gone through major life events and changes: they had left their hometowns or relocated, sought or made new friends in college or at work, or made changes in their career-for example, switching majors, changing schools, delaying their degree, and coming back to school from industry. These transitions caused changes in social support structures, exacerbating stress and problems in maintaining their mental well-being. The following quote from P8 illustrates the highly stressful period of transitions and the loss and regaining of social support:

The transition time was very rough because I was used to a place with a lot of people and a lot of activities. When I first came here... I don't know, I found a lot of simple things to be very difficult. I didn't have my own mode of transportation, so had to rely on the bus services. Small experiences like that really added to my stress levels and I found the fact I lived away from the main campus, [which] meant that I had to spend a lot of time on my own, which I didn't like because I like hanging around people. When I was staying alone it was quite difficult for me.

Relationship Building Is Constantly Needed to Have Access to Potential Support Givers

The various life events the participants experienced not only forced them to quickly adjust to new life contexts and rebuild their social connections but also made it difficult to maintain their existing social connections. For this reason, students often felt that the support they wanted was not readily available or workable, but inconsistent; supportive social groups or support givers were likely to come and go. For instance, P18 described her premed group members with whom she initially developed deep relationships, and she described how these relationships were enhanced by their common struggles and active support for each other. Later, she felt helpless and discouraged when all the members of the group transferred to other universities or decided to pursue something else:

I think with pre-med courses, it's nice to have a community where you can be stressed out together and fall on each other for advice and study together and help each other. But then when everybody dropped, and it was just me, I think that's when it got to be very stressful because I was doing everything on my own.

The short-term and inconsistent social support received from their existing support givers was somewhat detrimental to the students' mental health, often resulting in sudden feelings of being lost or alone. Although some relationships were strong and long lasting, the students needed to be prepared to lose connections and relationships they often put a large amount of time and effort into building and rebuilding.

Most of the students in this study experienced the diminishment, disappearance, or replacement of intimate friends they previously relied on to receive support, such as the replacement of high school friends with a small group of close friends from the freshman cohort, or they experienced the quality of relationships with old friends changing over time. P9 explained how the friendships he had with close friends growing up and their support for each other became rather unstable and shifted after 3 years of college as they experienced conflict and disagreement:

These were probably the two people I would go to if I had trouble with school and things, but after I had a disagreement with them, I felt very alone and isolated. Now, I'm a better friend to them but I think because we had that break we're not as close as we used to be. It's always in the back of my mind that we had this fight so I'm not that close to them as much anymore.

This shows that even with existing support givers (eg, intimate friends), effort was still needed to maintain relationships as all parties went through different stages and events of their own lives during emerging adulthood, affecting their current or future situations, viewpoints, and needs.

While going through different life events and needing to seek appropriate help, the students encountered situations where they needed to determine how to disclose and share their problems with the new social connections they had just built or developed. The new social connections were usually people they had recently met in classes, at work, at various events, or where they lived. For instance, P10 shared her experience of sharing her concerns with a new friend she had started to get close with recently:

I talk a lot this semester with Olivia [her classmate], but like until the end of the semester, not really earlier. I feel like this semester, the early part of this semester I'm always alone because I am mostly in Fishbowl to finish 520 assignment or something. (...) She also shares her concern as well. I think for the academic part, we are very similar. In the same situation, I guess. And we haven't got internship yet and we're also worried about finding a project, final exams, so it's hard. Our schedules are more similar. We sometimes work together on weekends.

Having similar situations, interests, or struggles as other individuals helped students quickly build new relationships and potentially share their problems, although the sharing might initially be limited to their common interests.

While sharing problems with newly developed social connections, students did not share their real, deep problems upfront, unless those were the commonly shared issues they already knew about each other (eg, met at a counseling session). They wanted to share problems in a friendship after building a relationship and worried that sharing such issues in the beginning of the relationship could lead to making some "unattractive" or "undesirable" impressions:

I wouldn't necessarily want people to know that to be the first thing they know about me. I want them to know me as a person. I feel like, yes, that's an important thing to know about me in a friendship and stuff, but I don't want that to be the first thing.

Seeking Alternatives to Support Givers on the Web

Owing to the challenges of having a constant change of support givers while going through frequent life events, the students often sought alternative forms of support, such as making new Web-based social connections and asking for help (eg, Facebook groups, mental health-related web forums, and anonymous others on Reddit or Instagram). As Web-based support is always accessible, students found that this served as a support baseline that they could contact regularly or whenever they wanted to check in as a casual (not as structured and serious as a CAPS or professional service) but also steady (with minimum effort to set up) way of maintaining their mental well-being. However, despite the benefits of having Web-based help, students reported issues with the sustainability and the consistency of support based on their experiences. They believed that the size of the group, the qualities of the anonymous members, and whether there was guidance and a moderator within the Web-based communities often affected the quality of the support they received. Many, including P19, mentioned the double-edged sword aspect of anonymity in Web-based groups and communities regarding the anonymous members and expected behaviors:

I don't like Reddit, not at all! 'Cause Reddit is totally about anonymity. And I don't enjoy that. I think anonymity is to some degree dehumanizing. It's really unaccountable. And people allow their worst selves out because they don't understand impact when they're anonymous.

According to the participants, the size of the group mattered for the perceived quality of group dynamics and conversation. When the Web-based support group was too large, the conversation among the group members would become disorganized and derailed by new information, which often made participants feel less valued. In contrast, with small groups, the students often felt they did not get enough diverse opinions, which could lead to a lack of effective solutions or ideas to address their problems. Nearly all of the participants advocated 7 to 10 members as an ideal group size for sharing their concerns and having effective group discussions:

Less than 10 participants [would be good] in order to have sufficient dialogue and participation among everyone.

The personal qualities of the web members were also seen as an important consideration to ensure that the support was sustainable. Students considered being faithful, committed, and respectful of others' privacy the most needed qualities of support members as potential support givers, especially given the relative anonymity of many support spaces. The students also commented on their desire to engage both intimate friends and strangers in their envisioned Web-based support group to receive the most useful help, as each provided different types of support on different subjects. In addition, moderated interactions within support groups were seen as critical for students to better receive quality social support. They remarked that careful moderating and monitoring helped maintain the support environment as a healthy and useful place for everyone to get consistent support for the long term. A few students (P8, P12, P14, and P16) who had never used any Web-based support group expressed their interest in joining a small group conversation moderated by professionals who could understand the members, properly react to what was said in the group, and maintain group positivity:

You have a different mental state when you're talking to a therapist compared to talking to just anonymous people. I might not be able to respond if one [a person] was sad or depressed. In a sense, a therapist response would be much nicer and much more understanding compared to what I can provide.

Similarly, some who already had experience with moderated Web-based support groups also preferred to have a more structured support environment where a moderator provided group therapy or assigned particular goal-oriented tasks to help members achieve their goals. Several advocated for having more than one moderator or professional monitor to track the conversations to ensure that the members would interact appropriately, particularly in anonymous environments.

The Need to Negotiate Tensions Between the Benefit of Disclosure and the Stigma Associated With Disclosure

The last challenge that students mentioned was balancing self-disclosure to seek help and the stigma that prevents such disclosure. To express a need for help, the students attempted to find ways that allowed them to avoid the stigma associated with the disclosure while also maintaining their mental well-being.

Students Hold Tension in Maintaining Desirable Presentations of Self

One common concern related to transitions across frequent life events, particular to emerging adulthood, was maintaining and developing a desirable presentation of self in social interactions. Although wanting to maintain a "positive" image or reputation is a well-known phenomenon in social science research [ 53], it becomes particularly challenging when one's network keeps changing, as was the case for the students participating in this study. Students commented that the stigma associated with sharing personal problems could hinder the development of positive social relationships, often discouraging them from openly sharing their concerns with their social connections, such as friends, family, and the people with whom they had recently developed relationships. Particularly, as many students considered their problems might be trivial and common, they considered that what they were going through should not be overestimated as a serious problem. This thinking process aggravated their stressful situations.

The transitions during emerging adulthood made it difficult to keep up with their original support givers (ie, old and intimate friends), and it forced them to build new connections (ie, new friends). The new social connections students built were the ones with whom they wanted to further develop intimacy. These new connections were critical to their emerging adulthood in that they were the students' most preferred source of support. Thus, to further develop these new relationships in the ways they desired, students did not want to disclose their problems too much, but they preferred to maintain a positive self-presentation toward their new connections. For example, some students wanted to maintain an image of being fun and outgoing. They worried that if they disclosed too much about their depression, sadness, or struggles, their new friends would view them differently and categorize them as "not a fun friend to be around" or "problematic." P2 described hiding his concerns from friends in an effort to maintain the character of being fun and happy:

You have five friends and they expect you to be very fun and outgoing, you can't help but stay in that character. It's very difficult or you feel uncertain that if you were to reveal a little bit [of your] personal self, would they still be the same towards you know, [the] friendship or not.

As in the case of P2 above, many students worried that the negative, long-term impact of sharing their concerns with their social connections, particularly with newer ones, would outweigh the potential benefits, which ultimately prevented them from getting effective help.

Owing to the tension between their need to share with friends and the associated stigma, many students put a lot of effort into sharing their problems in ways they perceived to be less risky. They would slowly and carefully bring their concerns into the conversation or look for the right time to bring up an issue. For example, we saw that some students waited to share their concerns until a friend approached them first, instead of asking for help directly; others tended to hide their true feelings, pretending to live and act in a way that conformed to how their friends viewed them, until they felt more comfortable talking about their problems. P6 explained how long it took him to feel comfortable sharing his struggles with others, explaining that there was a certain time at which such disclosure would be allowed normatively:

At the end of April when everyone is getting ready to [graduate] and started to pull out their hearts and essentially had a very close talk. That was with everyone else, and I was just sitting there and said I'm not graduating, they are, so I should at least tell them something that has been on my mind for the past few years. There was that instance where I felt should tell them.

Here, the fact that his friends were all graduating and would not be around anymore made it easier for P6 to disclose the issues that he was holding onto. His friends' transitions also made it less burdensome to deal with their reactions, which was why he chose to disclose at that time.

Disclosure was difficult when students experienced pressure to follow and meet societal expectations or standards, such as being independent financially, accomplished educationally or professionally, or settled at a culturally expected age. This finding was more apparent among the Asian students, who felt pressured to be "good" or "mature" for their families in their particular culture. For instance, P10 who started her graduate study in her late 20s explained her struggle with feeling stigmatized by her age and financial situation:

I actually borrowed money from my parents. At my age I shouldn't do that, and especially, my parents used their retire money to support me. That's a big issue. After graduation I will definitely have to find a good job and pay back. My family invested [in] me to go abroad, so that means I will have the responsibility to support my family back as well. I think that's a concern I have. (...) The other thing is my age, I would say. I think relationship and marriage is also very...not super stressful, but when I think about it, I will kind of worried about that. Because I've never had a relationship before and right now I'm almost 30. Especially my parents worry about that. I feel everything is related to my family. If my family worry about this then I will worry about that too. I know they want me to have a family in close future, but so far in my situation I don't think I have enough time to do that, seeking one and building a relationship..."

Like P10, even though students talked to their parents every day to share their thoughts, we found that many of them tried not to reveal struggles related to their schoolwork because they wanted to present themselves as a smart, hardworking daughter or son.

Exploring a Casual, Nuanced Way of Sharing Problems

As a way to deal with the stigma associated with sharing problems, students favored communicating with their social connections (potential support givers) through images. Image-based communication included any images, such as the students' own drawings, famous paintings, landscapes, body parts, any artifacts from their daily lives, funny or abstract pictures, and funny memes, shared through mobile or Web-based messages or social network sites. This was popular among the participants, especially for when they just wanted a small amount of casual support that could cheer them up in their daily lives or for when they wanted to provide support for someone else, without anyone explicitly seeking help:

I use Facebook and Instagram basically just to see what people are up to and for funny videos and photos of dogs and videos of dogs. I like memes a lot, so if I see a funny meme I just like it. (...) so like funny pictures and funny comments, internet memes. If I see one, I'll just click like so that my friends will see it, and my friends will start laughing about it. I use that as a stress buster really.

Similarly, sharing dog and cat photos on the Web was also a popular form of support during less energized moods.

Image-based communication allowed the students to indirectly express their nuanced feelings, as they could use some of the affordance images offer to express and share their feelings in a very subtle and subjective way, without directly revealing their true feelings or intentions. It also enabled students to adjust their own moods while sharing or posting images as a way to overcome negative feelings or curate their own feelings. Students (P11 and P16) used their social media as a digital diary, using images to share and record their moods:

I think this semester I post a lot less, but usually I post a lot. Facebook is almost like one kind of my diary. I post everything, [including] not good [ones]. Especially not good things on that. (...) I don't know [the motivation], but I think it's just like, letting it go, away for me to like expressing my anger or depression. Because I feel, if I cannot find a person to talk, because on Facebook it's also a way for me to let it go and let the others know that I'm not good.

Like P11, other participants expected image sharing and posting to enable them to feel more comfortable and embedded during their everyday lives, while reducing the stress and stigma related to their support-seeking behaviors. By using a platform that people use to communicate about everyday situations, the shared problems are portrayed as mundane and normal problems of daily life rather than as serious mental health problems.

Discussion

Overview

University students go through a critical transitional life phase of emerging adulthood between adolescence and young adulthood. This life phase requires increased responsibility, maturity, and independence, causing more stress and problems with maintaining mental well-being. For this reason, there have been increased mental health incidents on college campuses [ 13, 54], and more researchers have been exploring technological interventions for emerging adults on university campuses [ 50]. Below, we describe the maintenance work required for students' mental well-being using the literature on self-disclosure [ 55]. We also discuss the boundary students perceive between mental well-being and illness, which played a critical role in students seeking help. We then discuss implications for potential sociotechnical systems that can support the needs of students in better maneuvering through this important transitional phase of life.

Negotiating Time, Audience, and Disclosure for Mental Well-Being Maintenance Work Across Life Events

This study revealed that students' mental well-being needs constantly shift and evolve as they go through the life events associated with emerging adulthood. These transitions, shaped by life events, critically impact their mental well-being. This study's findings draw attention to how students negotiate the three needs in their lived experiences related to time, audience, and disclosure. The severity and duration of the life events ( time) defined the expectations of how help should be delivered. Students encountered new social relationships, which they had to constantly rebuild and maintain as sources of support. These relationships at the same time served as the audience for whom the students had to balance the tension between the stigma and disclosure of problems and seeking help. As such, these three needs are closely interconnected and constantly negotiated to maintain their mental well-being. This interconnected relationship has been identified in the studies about disclosure in HCI and Communication fields.

For instance, "time" has been found to be a critical component in when, how, and whether disclosures occur, exploring the facilitation and hindrance of disclosures [ 55, 56]. Reasons for delayed disclosure [ 56, 57], a delay between a significant, stressful event and the time of disclosure, include fear that the disclosure will be poorly received and not supported by others as well as moving on from the event and not feeling the need to share or reopen wounds [ 56]. Although delayed disclosures have primarily been studied in the context of abusive and traumatic situations (eg, sexual abuse) [ 58], this study shows that delayed disclosure also happens when students wait for the right "timing" to disclose their problems and seek help. An example from this study's findings showed that one student (P5) waited until his friends' graduation to reveal his issue to reduce the burden of having to manage friends' reactions to his disclosure. Moreover, this was during a moment when the friends had mutually agreed to share intimate experiences as a way to reflect on their college years. The reciprocity norm of mutual self-disclosure in dyadic relationships [ 59] explains this observation of mutual sharing at the right time.

"Audience" is another important factor in explaining why people disclose or do not disclose stigmatizing experiences (eg, depression) in the Disclosure Decision-Making Frameworks [ 55, 56]. The concept of audience connects with our findings on rebuilding relationships, such as the new social connections students need to build. According to Goffman, "audience" refers to the individuals for whom one performs and who might be the recipients of one's direct or indirect disclosures as part of a help request [ 53]. The disclosing person assesses how these individuals, that is, the audience, might react and respond to the disclosure or lack thereof and makes a (non)disclosure decision accordingly. In this study, such an assessment includes balancing the potential benefits of disclosure with the risk of losing the status of being a fun friend to be around, especially when the goal is to rebuild and maintain new relationships with the audience. This negotiation is fraught as these new relationships entail potential disclosure to audiences who can be a source of support.

Furthermore, this study also showed that as a result of the risk of stigma associated with disclosing problems, students used fun and positively valued social media sharing to release stress for themselves and others. Previous work has argued that social media design should facilitate the disclosure of stressful situations directly or indirectly [ 56]. This study added to this conversation by arguing that sharing positive content is not necessarily shallow or "just for fun"; it can, in fact, be part of an activity that releases tension and stress among individuals.

Understanding the Perceived Boundary Between Mental Wellness and Illness as a Collective Effort

In this study's findings, students perceived most of their problems to be either normal or on a continuum between normal and serious. The latter would imply the need for seeking immediate help from a professional source, compared with the former, where the problem may resolve on its own as time passes. Students view the problem as fluctuating day to day, or even hour by hour, and as being influenced by many things in their daily lives, just like physical health. They think normal problems can progress to become serious and serious problems can revert to being normal as time passes (after a certain stressful life event is over). Coupled with stigma and barriers to self-disclosure [ 55], students attempted to avoid as much as possible the need to label their problems as illness problems.

The students in this study tended to consider their problems within the realm of wellness-a state where they think they have abilities to cope with the normal stresses of life and manage on their own. However, students also worried that their wellness problems could potentially develop into more serious ones and become illness problems. To prevent this progression, students actively and proactively tried to seek effective, workable resolutions. This study's findings showed that students set a maximum time (eg, three months and two weeks) in which to resolve problems (eg, relationship breakup and being stressed about grades or job search) to prevent the problems from overwhelming their overall well-being. Having a social network to share their problems with, whereby students could set up regular weekly hangouts with close friends to prevent the problems from progressing into more serious ones helped.

In this study, we reported different perspectives between the mental health literature and findings in terms of when a problem is considered as part of "wellness" vs "illness." This difference makes it difficult to determine when and how we should intervene to support students' help-seeking behaviors effectively. The traditional mental health literature on emerging adulthood problematizes the students' perceived, self-endorsed boundaries between wellness and illness, defining it as a barrier to mental health care and support [ 60]. The literature legitimizes self-management activities for mental health but only to a certain extent. Self-management activities, referring to seeking help from family and friends and going to meditation groups, are largely described as barriers to mental health care access. Rickwood et al [ 61, 62] found that participants preferred to talk to friends and family rather than health care professionals, which might prevent access to health care when added to participants' lack of emotional competence and negative attitudes toward seeking professional help. Biddle et al [ 63] showed that participants continuously self-assessed whether they could accommodate high levels of distress and avoid seeking help.

Where the boundary between wellness (ie, whether a problem is a normal part of emerging adulthood) and illness (ie, a symptom of a serious mental health disorder) lies or whether the boundary should even exist remains an open question. This might be an applicable question for the general population, such as those with mental health issues in the workplace [ 69], but it is the salient case for students as they are especially close to their peers who go through similar types of problems and life events during their emerging adulthood, which can make the students more ignorant or blunt about their problems. The question about the boundary has often been unclear even for health professionals because of individualized, situational factors [ 70]. Health care workers need to individually assess how much the unstable, uncertain experiences of a student should be treated as a healthy part of self-development and how much should be treated as a symptom of a serious mental health disorder [ 70]. This nuanced boundary as well as the differing viewpoints between health care professionals and students can add to maintaining student mental well-being negatively. This problem forces students on college campuses to be tolerant of severe problems and to ignore the need to get help.

We argue that this boundary between wellness and illness needs to be carefully negotiated, evaluated, and coordinated for each individual student through collective efforts among the social systems made up of responsible stakeholders: university students themselves, health care professionals, family, friends, educators, designers, institutions, and the public health sector.

Reconceptualizing a Support Group as a Place for Colearning

In examining the ways in which students received support, including from their groups of intimate friends, Web-based groups, and social media, we noticed that being part of a "support group" had a negative connotation for our students. Many students avoided labeling the wanted help as a "support group," as the term problematizes what should be a normal process of being supportive of each other in a seamless way throughout everyday contexts. The negative connotation associated with support groups served as a barrier to students accessing helpful resources, such as CAPS or related peer groups, on campus. It is worth investigating how to engage and assist students with various stressors in their emerging adulthood more effectively.

Accordingly, this study calls for an urgent need to reconceptualize the existing notion of support as a colearning space where individuals learn to maintain their own mental wellness: how to be aware of it, how to keep it healthy, and how to prevent potential risks. This knowledge is not something normally gained from formal education, although it should be. Importantly, in this reconceptualization, each individual can be a help giver as well as a receiver. This sort of mutual exchange has been discussed in the literature as the helper therapy principle [ 71], which is the central concept for building support groups. In this study, a few of those who wrote blogs or made images related to mental wellness awareness expressed their interest in working with counseling services to help their peers, based on their own experiences. At any given time, one can be a helper for multiple people on different issues, while seeking help for one's own mental well-being maintenance work. This multiparticipatory nature of a support exchange can facilitate accountability among the helpers and the individuals receiving help.

Design Implications

We discussed university students' challenges and efforts to maintain their mental well-being around time, disclosure related to stigma, and the right audience. This study indicated that it is important to facilitate the negotiation of students' own perceived boundaries of where illness begins through self-reflection and evaluation so that they can receive appropriate help. To that end, ideal sociotechnical systems should be designed in more inclusive ways that allow self-reflection to support students in managing their mental health in a casual, informal, and positive manner, rather than approaching the challenge from a mental illness perspective.

This study's findings show value in integrating functionality from such systems to support students' mental well-being maintenance work. They call for investigating how existing systems and applications for the general population can be extended and designed to offer self-reflective and self-evaluative mechanisms for students' mental well-being. For instance, existing practices, such as Expressive Art Therapy (EAT), which offers individuals the opportunity to use any expressive and creative art form (eg, singing, poetry, art, dance, or performance) to reflect on and identify what the root of a problem is, increase self-awareness, enhance social relationships, and foster emotional growth and development [ 73- 75]. EAT can then be integrated into existing everyday systems and applications to provide nonclinical solutions. Specifically, existing media applications for self-expression, such as video blogs, amateur music sharing, sharing creative artwork or images, drawing, or poetry sharing forums, can be used to support these varieties of forms of expression as a form of EAT. Similarly, doodling can be used to benefit the process of mindfulness training with some guidance (eg, "Choose whether to document a current happy moment or think back to a happy time and doodle your memory") [ 76]. Integrating such expressive capabilities into existing applications could enable students to be mindful and aware of their mental health status. In addition, integrating such an approach with Positive Psychology [ 6, 77, 78] can help students release their stress and discover positive moments and strengths, instead of focusing on the problems and the negativities. Examples include enabling the platform to suggest recording a thankful moment from the day through a photo, writing, or drawing and sharing it with friends on Instagram or in a group chat or cocreating humorous internet memes with friends on Sketch as a positive mood booster. These activities can foster emotional growth, enhance social relationships, and improve self-awareness [ 22, 35]. These outcomes will eventually help young adults define their own perceived boundary of mental health and receive proper help when needed.

Upon developing the platform, we argue that it should be designed to facilitate the involvement of a community of all relevant stakeholders in supporting the mental well-being maintenance work of an emerging adult on campus (eg, students, health care providers, practitioners, institutions, designers, and app developers). This platform will not only help students to self-reflect and evaluate their mental well-being maintenance activities but also help stakeholders to easily analyze functionalities, use cases, and user populations of existing applications. It will also help them analyze new applications as they are developed and suggest potential connections to existing therapeutic practices of mental well-being. The platform could show usage trends of user populations, along with new features that these applications might be able to provide. It could also offer a database of EAT curated by health care professionals. The stakeholders could then exchange feedback regarding how these existing and newer applications could work together to support therapeutic mechanisms according to the life events of an individual.

The findings also indicate that it is critical to support the process of navigating and renegotiating time, audience, and disclosure. The aforementioned platform could provide a variety of approaches to requesting as well as receiving situated help, ranging from the immediate and direct to the more casual and abstract. On the basis of the mood or level of activity of a user or a particular life event, a platform could directly intervene by matching or suggesting appropriate helpers or by nudging and casually connecting with family and friends to encourage students to share their struggle with others. This could help with providing support within the appropriate time window when the impact of that event is still active. For instance, the findings showed students did not want to be reminded of their problem after a certain amount of time had passed after the issue occurred. Such a platform could also pick up on and identify potential emotional breakdowns or challenges that might come up, based on their behavioral and emotional patterns. In addition, in terms of suggesting an audience, selecting helpers from social group contacts or outsourcing highly customized help based on the topic or similar interests and needs (eg, nearby peer groups, mentors, and professional consultants) could be done for the user. Matching with others based on similar needs or interests was found to be helpful in previous work using others' life transition trajectories as a form of social support among peer patients [ 79]. The incentive for anyone to become a helper could be established by keeping them informed of both the short-term and long-term positive outcomes of addressing a problem through feedback, thus alleviating tension related to stigma and facilitating the rebuilding and maintenance of relationships between users and new and potential helpers.

Conclusions

We investigated the mental well-being maintenance practices of emerging adults on a university campus: how students perceive problems, set expectations for help, and go through the work of from whom, when, and how to seek help. We identified three needs that are required for students to maintain their mental well-being: (1) getting help at an appropriate time and in an appropriate form that aligns with the severity of the problem, (2) building relationships with potential support givers, and (3) negotiating tension between disclosure and the associated stigma. This formative study informed how sociotechnical system support for this population should be sensitive to how help is framed and offered to make it easier to embrace. We also discussed how and when help should be delivered through technology and argued for reconceptualizing help as a colearning process. This research was conducted with a subsample of emerging adults, focusing on those at a large university in the Midwest. Although the participants do not represent the broader population of emerging adults nor all university students, this study's findings demonstrate a unique set of needs and challenges that should be acknowledged and supported in the population to which these findings theoretically generalize. This study contributes to helping mental health practitioners, researchers, and system designers understand and support students' mental well-being maintenance practices as part of the normal course of life beyond the clinical context.

Abbreviations

CAPS

Counseling and Psychological Services

EAT

Expressive Art Therapy

HCI

human-computer interaction

IRB

Institutional Review Board

RQ

research question

Footnotes

Conflicts of Interest: None declared.

References

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Understanding Students' Mental Well-Being Challenges on a University Campus: Interview Study

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Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges ...

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https://www.education.vic.gov.au/school/teachers/health/mentalhealth/Pages/promoting-mental-health.aspx

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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https://youtu.be/Q5nCXZkcvOo

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https://beyou.edu.au › resources › w...Wellbeing Tools for Students - Be You

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https://beyou.edu.au › resources › w...Wellbeing Tools for Students - Be You

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Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan

Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan

Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

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 ( Cleary et al., 2011). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013; Mey and Yin, 2015), it does not return to pre-university levels ( Cooke et al., 2006; Bewick et al., 2010). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006; Hunt and Eisenberg, 2010; Verger et al., 2010; Auerbach et al., 2018; Lipson et al., 2019). Some researchers refer to these trends as an emerging "mental health crisis" in higher education ( Kadison and DiGeronimo, 2004; Evans et al., 2018). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006; Antaramian, 2015), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009; Hunt and Eisenberg, 2010). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008; Eisenberg et al., 2011; Lipson et al., 2019) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007; Gulliver et al., 2010; Hunt and Eisenberg, 2010; Sharp and Theiler, 2018). This study aims to extend the understanding of mental health in university students by providing a bird's eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000; Bailey, 2012; Wittchen et al., 2014a). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview"). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of "the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry." (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012). In this regard, Eshun and Gurung (2009) pointed out that "culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment." (4). Fernando (2019) argued that issues related to the 'mind' developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010; Summerfield, 2013). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge "counterflow") (see White et al., 2014).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013; Galderisi et al., 2015). An example is the definition by the World Health Organization which refers to 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, 2004). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents "people's beliefs and feelings that they are living a desirable and rewarding life" ( Diener, 2012). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one's life ( Deci and Ryan, 2008). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one's true potential ( Ryff and Singer, 2008). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005, 2007; Keyes and Michalec, 2010). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975-2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview." All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: ["mental health"]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: ["mental illness," "mental disorder ∗," "mental distress," "psychological distress," "psychopathology," "depression," "anxiety," "stress," "suicide," "eating disorder ∗," "substance use"]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: ["well-being," "wellbeing," "wellness," "life satisfaction," "happiness," "positive affect," "purpose in life," "personal growth," "self-determination"].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: ["university," "college," "higher education," "tertiary education," "post-secondary education," "postsecondary education," "undergrad ∗ student," "grad ∗ student," "master's student," "doctoral student," "Ph.D. student"]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors' name, organization, and country. Also, the title, the abstract, the author's keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps. In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors' keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth Trajectory: Evolution of Publications and Citations in the Field

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975-2000); a fermentation stage, with a notable increase in publications in the field (2000-2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010-2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004; Evans et al., 2018), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013).

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2. Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry, which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health, substance abuse, general internal medicine, neurosciences neurology, health care sciences services, and nursing. Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences, family studies, and social work research.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the "psy disciplines"' (i.e., psychology and psychiatry) ( McAvoy, 2014), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011), who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018; Mitchell et al., 2019).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4. The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students' mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010; Summerfield, 2013).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006; Abramo et al., 2009). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012; Wagner et al., 2015), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4. Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009; Vaillant, 2012; Fernando, 2019). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005; Freshwater et al., 2006). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004; Freshwater et al., 2006).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate "new insights into theory, practice, and research in mental health and development." (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology, the Journal of Counseling Psychology, and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014; Wittchen et al., 2014b). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology. To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy.

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students' mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011). Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students' mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975-January 2020 period are presented in Figure 6. The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

The most frequent keywords in the dataset, excluding students' descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health, as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse, most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health, including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

Conclusion

This study provides a comprehensive overview of the research on university students' mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

Funding

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

References

LeViness, P., Bershad, C., Gorman, K., Braun, L., and Murray, T. (2018). The Association for University and College Counseling Center Directors Annual Survey. Available online at: https://www.aucccd.org/assets/documents/Survey/2018%20AUCCCD%20Survey-Public-June%2012-FINAL.pdf (accessed February 24, 2020).
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# data[].attributes.attachment_link.title
Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

# data[].attributes.attachment_link.description
The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020.

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Promoting mental health and wellbeing in your school

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Promoting mental health and wellbeing in your school

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https://www.education.vic.gov.au/school/teachers/health/mentalhealth/Pages/promoting-mental-health.aspx

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https://www.education.vic.gov.au › ...PDFQuick Guide to Student Mental Health and Wellbeing Resources

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https://www.education.vic.gov.au › ...PDFQuick Guide to Student Mental Health and Wellbeing Resources

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