Health inequalities among university students: the association between social capital, sense of belonging and psychological health

Background A mental health crisis has hit university campuses across the world. According to a survey conducted by the World Health Organization approximately one-third of first-year students suffer for a common DSM–IV mood (e.g., major depressive disorder), anxiety, or substance disorder. The study also showed significant country variations, with the highest rates of mental health problems found among students from Australia. Furthermore, in recent years, there has been growing concern about the poor mental health of young people of gay, lesbian, bisexual, or questioning/queer (LGBQ) sexual orientation. Apart from individual characteristics (e.g., genetic predisposition for depression), studies have documented the role of social determinants (e.g., socioeconomic status) on the etiology and evolution of mental disorders. A number of studies suggest that social capital, often referred to as features of social structures including interpersonal trust and mutual support, is an important determinant of health. Although there is evidence of an association between social capital and many indicators of health most research to date has been conducted among adult and adolescent samples and has primarily focused on one geographical area. Evidence on the effect of social capital on young adults’ and students’ health, specifically, remains limited. However, to tackle the ongoing student mental health crisis it is important to look beyond the common social determinants of health. The here presented thesis comprises three parts: • Part I: The SPLASH study • Part II: The HMS study • Part III: Overall conclusion Key aims Part I: To facilitate a cross-national comparison of the prevalence of mental health problems and to investigate whether social capital is associated with such problems in university students in 12 countries. Part II: To explore differences in mental health problems between LGBQ and heterosexual students, with a specific focus on the moderating effects of sexual assault and sense of belonging. The specific objective of the secondary data analysis is to test for a potential three-way interaction effect (i.e., moderated moderation) between sexual assault, sense of belonging, and sexual orientation. Specifically, the study aims to examine a) whether there is a difference in mental health between LGBQ and heterosexual students, b) whether exposure to sexual assault may affect students’ psychological states, such as depressive symptoms and suicidality, c) whether a high sense of belonging can buffer the effects of sexual assault exposure on psychological states, and d) whether this differs according to sexual orientation. Data used Several methodological approaches were applied due to the diverse range of aspects studied. Part I: To assess whether there is an association between social capital and students’ health, the Social Capital and Students’ Health study (SPLASH) was developed. This is a two-wave panel study conducted among students from different faculties during their first year at university in Europe, Asia, the Western Pacific, and Latin and North America. Data was obtained through a self-administered questionnaire, including questions on sociodemographic characteristics, depressive symptoms, suicidal ideation, health behaviors and social capital. Part II: Because not enough data for LGBQ students was available (sample size = 7 students), a secondary data analysis was performed using variables from the 2017-2018 Healthy Minds Study (HMS) dataset. HMS is an annual cross-sectional web-based survey that examines mental health, service utilization, and related factors among undergraduate and graduate students in the United States. Statistical analyses Part I: Multilevel logistic regression modelling was used to analyze hierarchical data with individuals (1st level) nested in universities/countries (2nd level). The analyses were adjusted for sociodemographic characteristics, covariates (e.g., perceived stress), and country-level characteristics (e.g., country income). Part II: To test for a possible three-way interaction effect, Hayes PROCESS macro models were used in SPSS. Results Part I: A total of 4,228 students participated in the SPLASH study. Forty-eight percent presented clinically relevant depressive symptoms. The likelihood of having clinically depressive symptoms was greater among those with low individual levels of cognitive social capital (OR: 1.82, 95% CI: 1.44 – 2.29) and those living in regions with low levels of social capital and political instability (OR: 3.22, 95% CI: 1.21 – 8.58). Part II: In the HMS, 60,200 students from 60 campuses in the United States participated. Around 20% (circa 12,000 students) identified as LGBQ. A significantly higher proportion of LGBQ students reported depression, suicidal ideation, and sexual assault compared to heterosexual students. A significant three-way interaction effect was found for sexual orientation, sexual assault, and sense of belonging, predicting depressive symptoms (b= -0.06, p=0.042) and suicidality (b= -0.10, p=0.004). The effect of sexual assault on mental health differed depending on sexual orientation and sense of belonging. In particular, among LGBQ students, a high sense of belonging was protective in the presence of sexual assault, while its absence had a deleterious effect on mental health. Discussion: Part I and Part II: Both the SPLASH study and the HMS study offered a new data on possible risk and protective factors for depressive symptomology among university students. However, both studies followed a cross-sectional design, and therefore, inferences about causality and the directionality of the variables cannot be made. It is possible that social capital and sense of belonging influence students’ mental health or vice versa. Conclusions Part I: The SPLASH study shows that social capital has a positive effect on the self-rated and psychological health of university students. To understand the decrease in students’ psychological health, one must also consider social aspects of their environment, such as social capital. Strengthening social capital should be considered an important health promotion strategy. Tackling mental health issues among university students requires joint action from universities, mental health professionals, policymakers, and political leaders. Part II: The secondary data analysis of the HMS study illuminates an important step in understanding mental health disparities in LGBQ students. The findings highlight the need to reduce mental health problems and sexual assault on college campuses, and to foster a sense of belonging to the college. Further longitudinal studies may continue to examine stressors and protective factors that account for mental health disparities among LGBQ and heterosexual students. A modified version of the second part of this thesis has been published in the Journal of American College health (Backhaus et al. 2019).