Conclusion

This study was probably the first attempt to examine the prevalence of mental health issues among students across different universities of Pakistan. The health context of Pakistan, which is marked by a high burden of mental health issues and scant provision of mental health services, was especially relevant to this study. This study focused on students from each faculty of the universities and this approach distinguished it from other studies which focused on students from a particular discipline. This study was based on the argument that student‟s perception about their mental health is an important indicator to clinical diagnosis and as such, it can guide public health practitioners to informed policy decisions. In this study, three of the most important mental health issues i.e. perceived stress, depression and psychological well-being were measured. The findings of this study were generally consistent with studies conducted in other part of the world, however, with some substantial variations.

The prevalence of perceived stress and depression was high whereas that of psychological well-being was low.

The study sample represented students from diverse demographic and academic backgrounds.

The reason for diversity in demographic background was that the selected universities were among the largest public sector universities in the country. Additionally, the participation of students from all the sections of the universities was ensured by accounting for them in the sampling plan. Consequently, the sample of this study was mostly representative of the population even in minute details.

This study examined the impact of demographic and academic factors on the mental health issues discussed in this study. Demographic characteristics, barring sex and financial sufficiency, were not found to have an impact on the mental health issues. Females and students with insufficient finances were more likely to experience mental health issues. In terms of academic characteristics, students enrolled in Bachelors program, living in hostels or private accommodation were more affected by the mental health issues. The place of living may have affected the extent of social support available to a student which in turn could affect mental health.

158 This study sought to understand the relationship of general health and health related behaviors with mental health. It was found that there were variations among students with regard to health related behaviors. For instance, female students did not look after their health as much as males and they visited doctors more often. As compared with other studies in the world, proportions of students engaged in physical activity and those consulting doctors were very low. This may be because self-medication is very common in Pakistan and people consult doctors only in situations of emergency or when the self-medication proves futile.

Chronic illnesses and psychosomatic health complaints were higher among students in our study than most other studies across the world. Within the study sample, female students reported these issues more than their male counterparts. Among the psychosomatic health complaints, headache, low back pain and tiredness were most common. It was observed that many students could not understand the meaning of different psychosomatic complaints. This may be because psychosomatic complaints are not considered serious issues in Pakistani society and are rarely discussed. Overall, poor general health and lack of positive health related behaviors were found to have a negative impact on mental health issues.

The study showed that students feel more burdened by academic stressors, however, it was non-academic stressors which contributed to mental health issues. Interestingly, perceived stress was most prevalent but it was depressive symptoms which were most sensitive to stressors. The reasons for this variation could lie in the nature of mental health issue or coping resources but this can well be an interesting research question for future studies. In this study, some stressors were introduced which were thought to be specifically relevant in Pakistani context. These stressors namely family expectations, interaction with opposite gender and English language as medium of instruction were all found to stress students.

Financial situation was not considered by many students as a substantial stressor unlike most previous studies. This again could be explained in terms of Pakistani culture in which parents usually assume complete responsibility of their children‟s education related expenses. While an attempt was made to single out different stressors which affect mental health but in real life situations, these stressors generally complement each other. They are frequently interwoven in a way that it becomes a futile exercise to examine them independent of each other.

The educational grading system in Pakistan is far from uniform and it is difficult to construct a valid measure of academic performance which could be applied to all or most of the

159 universities in Pakistan. It is often argued that the most successful students in Pakistan are those who tend to be better in memorizing the text rather than those who critically interpret and evaluate it. In this study, academic performance was conceptualized as objective and subjective academic performance. It was found that regardless of the subjects they study, rural students and male students have lower grades in this study than their counterparts.

Mental health issues adversely affect the physical and cognitive abilities of individuals. This study examined the effect of mental health issues on academic performance of university students. It was found that both subjective and objective academic performances were negatively affected by the prevalence of mental health issues. Even students with better objective academic performance did not rate their performance well subjectively if they were suffering from mental health issues. This may be due to high expectations of students and intense competition between them which contribute to decline in subjective academic performance and could also be detrimental to mental health.

Pakistan is going through a turbulent phase of its history which is marred by slow economic growth, militancy, political instability and low expenditure on social services. This situation is further exacerbated by declining employment opportunities and chronic energy shortfall which could worsen in wake of increasing population and rising energy needs (Afzal

& Yusuf, 2013; Ahmad et al., 2014; Chaudhry & Rahman, 2009). In this context, this study asked students about their level of satisfaction with different spheres of life. When this study was conducted, anti-government protests were also going on in major cities of Pakistan.

Consequently, most students expressed their dissatisfaction with the political, economic and security situation of the country. Within the university, students were dissatisfied with the facilities such as drinking water, hygiene situation, health and sports. This was understandable as the public universities in Pakistan have budgetary constraints and are substantially under-funded as compared with universities in developed countries.

Additionally, students are not part of decision making processes in universities and there is disconnect between university administration and students.

Similar to the academic performance, both stress and depression adversely affected subjective well-being of the students. Low subjective well-being can be an intermediary factor which could impede a student‟s performance in almost every sphere of life. Even with high grades, students with low subjective well-being or mental health issues could struggle in their early careers as they would lack self-esteem, locus of control and efficacy.

160 The propensity of stressors to translate into distress and mental disorders is mediated by coping resources of individuals. This study included questions related to a number of coping strategies which students use to counter stress. It was found that spending time with friends and family, internet usage and prayers were often used coping strategies. Some negative coping strategies included smoking, substance use and self-injury. As compared with other studies, the proportion of students using religion as a coping strategy was much higher. Very few students sought professional services to address their mental health issues. This could be due to unavailability of mental health services and even if it was available in some cases, students might not have the required level of awareness to utilize them.

The theoretical framework of this study was based on the stress theory. Stress theory postulates that stressors create stress and their relationship is mediated by contextual factors.

This stress could be transformed into distress and other mental health issues if not managed by the use of coping strategies. The present study has analyzed each of these segments of the stress theory and found them to be linked in the same order as hypothesized. While the study was generally successfully in achieving its stated objectives, limitations were identified throughout the research process which could have restricted the extent to which these results could be generalized. Additionally, the limitations of this study could guide future research not only on mental health but also studies on other subjects conducted in Pakistan. These limitations are discussed in detail in the next section.