Mental Health Help-Seeking Behaviours in University Students: Are First-Generation Students Different?

Abstract


Introduction
Mental health problems are highly prevalent among higher education students and are a significant predictor of academic dissatisfaction and drop out intentions (Brown, 2018;Lipson & Eisenberg, 2018).Of particular concern are students whose parents or siblings have not obtained a university degree, referred to as first-in-family (FiF) or first-generation students.Typically consisting of minorities and second-generation immigrants, they are more likely to come from low socioeconomic backgrounds, be older, work full-time and live off-campus compared with their non-FiF peers (McFadden, 2016;O'Shea, 2020;O'Shea et al., 2018) and are at greater risk of dropout (Henderson et al., 2020).While they show increased psychological stress upon entering university (Jenkins et al., 2013), they may be less likely to acknowledge such problems and seek help (Talebi et al., 2013), especially if they are from racial and ethnic minorities (Olaniyan, 2021).
Stigma, which has been shown to be a major barrier for students to seek mental health support (Eisenberg et al., 2009;Lally et al., 2013), has been reported to affect FiF students more than their non-FiF peers (Garriott et al., 2017).FiF students may be especially unwilling to seek help due to the pressures of succeeding they face, their concerns about negatively affecting close relationships (Chang et al., 2020) and the lack of support and guidance they receive from family for university-related First-in-family (FiF) students experience significant barriers to university participation and are less likely to seek mental health help.This can contribute to increased dropouts when compared to non-FiF students.Using a mixed methods approach, we aimed to ascertain sources of mental health support and underlying factors for the preferences favoured by students from UK universities.Answers to the General Help Seeking Questionnaire (GHSQ) and to two open-ended questions were collected online.We found that FiF (n=194) students were more likely to seek help from friends relative to their non-FiF (n=134) peers.Trust was particularly important for FiF students, while for non-FiF students, the perceived benefit of talking to anyone about mental health was more relevant.Attitudes towards mental health discussion were influenced by background.Stigma and perceived burdensomeness negatively affected helpseeking among all students.
Our findings suggest FiF students derive more benefits for their mental health concerns from friendship circles, implicating the importance of social integration programmes at university.Future work would benefit from evaluating mental health help-seeking intentions of students with more specific characteristics (e.g., race, gender), to better understand determinants influencing preferences and help institutions plan more fitting provisions to support students.
challenges (Talebi et al., 2013).Social support, including parental validation, is particularly important, and has been associated with positive student experiences (Roksa et al., 2021).While FIF students value self-efficacy, they have been reported as seeking help if potential empathetic and non-judgmental support is accessible (Hagler et al., 2023).Having a sense of belonging is also of relevance, as studies have reported a lower sense of belonging perceived by FIF students (Kreniske et al., 2022).Participation in enrichment programmes developed to promote students' success have positively affected the mental wellbeing of FIF students (Becker et al., 2017).In addition to predicting mental health, a sense of belonging is important for academic success (Gopalan & Brady, 2020;Museus & Chang, 2021).Likewise, higher levels of social integration, including acculturation to higher education settings which commonly embody middle-class norms, have been associated with better academic outcomes and satisfaction with life (Herrmann & Varnum, 2018).
Using a mixed-methods study design, we here describe the attitudes and intentions of UK university students towards mental health help-seeking.Increasing our understanding of their preferences and behaviours could help the design of better institutional support.

Study Design and Measures
Participants who were completing or had completed a bachelor's degree at any UK university were recruited through social media and convenience sampling via a fortnightly recruitment circular from King's College London (KCL), between June and July 2020.The study was approved by KCL Research Ethics Committee (LRU-19/20-17347) and students were asked to give consent to participate.Answers to two open-ended questions: How would you go about getting help for mental health concerns?and How comfortable do you feel talking to others about your own mental health or other struggles?and to the General Help Seeking Questionnaire (GHSQ) (Rickwood et al., 2005;Wilson et al., 2005) were collected online using Qualtrics.The GHSQ measures attitudes towards help seeking for psychological distress from a variety of sources: a) intimate partner, b) friend, c) parent, d) other relative/family member, e) mental health professional, f) phone helpline, g) doctor/GP, or h) minister or religious leader; participants are asked to rate on a 7-item Likert scale how likely they are to seek help from sources for: 1) personal and emotional health concerns, and 2) suicidal thoughts.A total of 328 answers were analysed (194 FiF,.FiF students were operationalised as those first in their immediate family (parents and siblings included) to attend tertiary education.

Data Analyses
Quantitative data analyses were conducted using SPSS Statistics 26 (IBM).Simple univariate analyses and non-parametric Mann-Whitney U tests were applied.Qualitative data analyses were conducted using NVivo 12.0.Thematic analysis was performed as described (Braun & Clarke, 2006).This was conducted by identifying the themes that came up for both FiF and non-FiF groups.Responses were coded into themes.Percentages were obtained to quantifiably measure differences in the themes identified by both groups.

Quantitative Outcomes: General Help-Seeking
The most referenced source of help for personal/emotional problems, mentioned by 42% of all students irrespective of whether they were FiF, was intimate partners.Conversely, the least referenced source was religious leaders for FiF and phone helplines for non-FIF participants (Table 1).Similarly, for suicidal ideation, intimate partners were the preferred option for both groups (Table 2).Overall, FiF students reported significantly higher intentions to seek help from friends for both personal/emotional concerns and suicidal ideation relative to non-FiF students.No significant difference in intent to seek help from any other source was observed between groups. (a) Analysis = Mann-Whitney U test; (b) Respondents that reported the highest score of 7 on the GHSQan indication of an extremely high likelihood of help seeking.Abbreviations: FiF, First-in-Family; GHSQ; General Help Seeking Questionnaire. (a) Analysis = Mann-Whitney U test; (b) Respondents that reported the highest score of 7 on the GHSQan indication of an extremely high likelihood of help seeking.Abbreviations: FiF, First-in-Family; GHSQ; General Help Seeking Questionnaire.

Qualitative Outcomes: Exploring Help-Seeking Actions, Attitudes, and Motivations
In response to How would you go about getting help for mental health concerns?, four main approaches were identified: Seeking Medical Help From a Professional Contrary to the GHSQ responses, directly seeking professional medical help was the most cited action referenced in 23% of qualitative responses.Most saw the GP as a practical gateway to pharmacotherapy or a referral to mental health services.For example, one non-FiF student shared: I would initially visit my GP and explain what is going on.Based on the recommendations of my GP, I would consider engaging in professional treatment where I am more likely to learn about and manage my symptoms on a more personal level.
Another FiF student stated "[I'd] contact my local GP so they can refer me to the appropriate service."Other students felt that pharmacotherapy was the most practical solution, with the clearest route to this being actioned through GP services.A FiF student shared "if my mental concerns got really bad and was having an impact on my ability to function, I would make an appointment with my GP for the intention of getting pills to help me."Unlike the other help-seeking sources, students felt that directly seeking medical help would lead to a more immediate solution and was more practical and meaningful, as reflected by this FiF respondent: [I'd] talk to a doctor or therapist, someone who would be able to give real, useable advice."

Seeking Advice From Friends and Family
The second most referenced source of action was to first seek advice and guidance, and there was a strong emphasis on specifically approaching friends and family for all students.For example, one FiF respondent shared "I would try to discuss the issue with my friends and ask them if they have dealt with similar issues, what they felt, and how they reacted to the problem", while another FiF student reflected "I feel most comfortable talking to my family about my mental health because they are the closest to me."However, for FiF students the preference was to seek help from their friends first, with 15% citing this in their qualitative responsean outcome that aligns well with our quantitative data.Family was only referenced in 10% of FiF respondents.Interestingly, this was the reverse for non-FiF students, where family was reported as the primary source of advice in 14% of participants, followed by friends (in 10%).As such, parents and siblings were referred to more by non-FiF students than by their FiF peers (siblings: FiF: 1%, non-FiF: 3%; parents: FiF: 3%, non-FiF: 6%).However, it is noteworthy that while some respondents mentioned that they would approach their parents, this was usually in reference to small matters or after having sought help elsewhere first, such as from the GP, friends or siblings, as highlighted by this FiF respondent: "Initially I would talk with my partner and childhood friend.I would likely start to think about seeing a GP before talking to my parents and tell them only after I have organised help through the GP."

Relying on Self-Help and Online Services
For some students there was a preference for self-help.This option was marginally preferred by non-FiF students (15%, FiF: 12%).Online resources were used to find appropriate services, to "first see [ing] what help is available" and to more fully understand own mental health concerns as illustrated by this FiF response: "Most likely I would first have a look online and maybe do a mental health quiz to try to figure out what could be wrong and to understand my own feelings."Some students, irrespective of FiF status, explicitly expressed they would not seek help, preferring to deal with problems on their own.Some referred to past negative experiences whereas some were unsure of how to initiate asking for help.One FiF respondent shared "I experience pretty bad mental health issues but haven't found anyone I feel comfortable speaking to.I don't like the GPs at my doctor's surgery and have found them unhelpful.I don't know what else to do."

Contacting/Accessing University Mental Health Team Services
Something not captured by the GHSQ was that 10% of FiF and non-FiF students reported that their first point of action dealing with mental health concerns would be to contact their personal tutor (who are academic members of staff assigned to each undergraduate student to support their overall university experience) or access the university mental health support services.One FiF student explained how this was their preferred and only action, "When I was struggling with mental health, I used the counselling service provided by university.I did not ask anyone else, because the counselling service felt secure and safe enough."Some students expressed how accessible and "easy to apply for" these counselling services were.However, more FiF students (6%) reported feeling uncomfortable seeking help from university staff/services relative to their non-FiF peers (3%).The most common reason for this stemmed from negative past experiences, which "put [students] off talking to university staff."FIF students felt uncomfortable around the idea that in doing so they may be adversely affected: "I do not feel as comfortable talking to university staff because I feel it might affect my reputation as a student and I do not want to receive any special treatment."Others felt that university staff simply "could not help [me] and may not understand" or had limited resources to do so effectively.For non-FiF students, the reasons were less clear, although one student stated that "it's not really their [university staff] job to look out for student mental health."

Mental Health Help-Seeking Attitudes and Motivations
In response to: 'How comfortable do you feel talking to others about your own mental health or other struggles?',we identified negative and positive themes, including three and four subthemes, respectively.For both groups, more responses were related to feeling uncomfortable talking about mental health (FiF: 59%; non-FiF: 55%).

Negative Attitudes and Motivations
(1) Stigma Mental health stigma had an important influence over help seeking behaviours in both FiF (10%) and non-FiF (9%) students.For example, one FiF respondent said: I feel and have felt very uncomfortable in sharing my mental health issues with friends, family, and professionals.Though mental health is a prominent theme in universities and wider society, I feel that there is still an underlying stigma towards those who experience mental health crises.I do not want to be defined by my mental health problems.
This was a sentiment shared by a non-FiF respondent whereby the "fear of being labelled in some way" and given a diagnosis was an important motivating factor for specifically avoiding professional help.Some respondents reported finding it more difficult to approach older family members than youngers ones as "the importance of mental health is more ingrained in the younger generation, and is, therefore, less taboo to discuss" (shared by a non-FiF respondent), while one FiF student expressed how the course they were taking played an important part in how they feel: "I think in medical degree(s) it's still very stigmatised and there are a lot of fears about fitness to practice and also the, 'professionalism' element of talking about your own experiencese.g., it being seen as inappropriate." The fear of being judged or being perceived differently was reoccurring among both groups.For one non-FiF student, it was the idea of being perceived differently or not the meeting expectations of those closest to them that was troublesome, sharing "I find it difficult to talk to [friends and family] because I feel I may harm perceptions about me that they already have or feel like that I have let them down", while for several other students the notion of being "perceived as weak" when discussing mental health was a major contributing factor when it came to seeking help more generally; many felt "there is a culture of being strong and coping alone."Additionally, for many respondents the fear of judgement influenced how or where they would seek help.For example, one FiF respondent stated: I would first go to a professional service such as a counsellor at university before going to my family and friends simply because this person does not know me or my history and can give me advice without any bias and judgement.
For another student, being anonymous was very important because they did not "want to cause worry to others." Finally, for some students, admitting they had mental health concerns was associated with shame and embarrassment that then ultimately influenced their help-seeking behaviours.For example, one FiF student stated: I don't feel very comfortable at all because I feel like I was being judged and I would feel embarrassed to speak out about my feelings.So, I would find this very awkward, and it would make me nervous to do so.It certainly would be very hard for me to talk to others about my struggles.
A non-FiF student explained "I don't feel comfortable with talking about mental health problems as it makes me feel vulnerable and embarrassed.I'd have to be very close with someone to talk about how I really feel."For one FiF student this was even more complicated because in addition to the shame associated with talking about mental health, there was also a level of defeatism, as they shared: I've always imagined that I'd need the therapists chair and a sleeping mask to talk properly as it would help me feel disconnected while talking about it.The main cause is probably feeling ashamed and feeling like there's little [that] anyone can realistically do to help.
(2) Perceived burdensomeness For many respondents, and marginally more so for non-FiF students (FiF: 10%; non-FiF: 14%), the most frequent reasoning for feeling uncomfortable or avoiding seeking help for mental health was "to avoid being a burden to, or worrying, others" especially in relation to talking to family or friends about such concerns.One FiF respondent shared: I hate talking about my mental health.At university, every time I did, I felt like I was being a burden, so I stopped.Now, when I'm asked about how I am, I just say "I'm good, thanks" when I'm not!Not by a country mile.
Furthermore, some respondents belittled their mental health concerns believing, "I'm making a problem out of something that maybe isn't actually a big deal", while some felt that others should be more of a priority.For example, one non-FiF respondent mentioned "It's silly but someone once told me that other people have it worse than me and that I should just get on with it.It's stuck with me", while another non-FiF student stated "I try to avoid the NHS 1 because I feel others will need it more than me." (3) Culture and upbringing While not as influential as stigma or perceived burdensomeness, one's family view of mental health, one's upbringing, and ethnic/religious background were referenced by both student groups (FiF: 5%; non-FiF: 4%).For example, one non-FiF respondent shared: 1 The NHS stands for the National Health Service.It refers to the UK government-funded medical and health care services.I feel somewhat comfortable, but it is still hard sometimes.This is because in my family, growing up, we didn't really talk about mental health problems with each other, and so it is not something that I learnt how to do in my formative years.
For a FiF respondent, they found talking about mental health "very uncomfortable", because "[their] upbringing was very 'British' stiff upper lip", and several others admitted it was difficult to talk about their mental health "because [their families] do not 'believe' in mental health" (FiF), "do not often speak of such emotion" (FiF), or they "grew up with the mindset of if you aren't having a good time then don't tell anyone" (non-FiF).For FiF respondents only (1%), the stigma associated with mental health from their wider cultural background played an important role in their help-seeking behaviours.For example, one FiF student stated "I find it difficult to talk to my family about it and barely do so as I am from a family whose culture stigmatises mental health and they are not very aware about mental health issues", while another FiF student explained "Due to my cultural background, within which mental health is not taken seriously and often downplayed, I wasn't and wouldn't be comfortable talking about it with family.However, I would feel slightly more comfortable with friends and professionals."

Positive Attitudes and Motivations Towards Help-Seeking for Mental Health Concerns
(1) Trust FiF respondents expressed only feeling comfortable talking about mental health to those they were close to and could trust, and "closeness" was referenced more by them (15%) than by non-FiF students (5%).One FiF respondent shared: "I feel most comfortable talking to my family about my mental health because they are the closest to me and since I live with them, they would be able to help me the most."Some respondents felt more comfortable being anonymous or talking to someone unknown to them believing it to be "easier to be open and honest with a professional you do not know."The reasons for this stemmed largely around stigma, fear of judgement or perceived burdensomeness as previously discussed.
(2) Talking about mental health is important and beneficial The most reoccurring reason mentioned by non-FiF respondents (12%) was that they felt it was beneficial: I believe that it's important to share your feelings as this relieves intense feelings and allows you to process your emotions in a safe space.Also talking to others helps you to view your current situation differently which can be helpful when you feel that your situation is beyond repair … and … it's good to resolve this as soon as possible to avoid further damage.
While some explicitly expressed not feeling comfortable, they felt it was necessary to do so: "I don't know if I would be comfortable, but I would do it because I know that it would be the only way to get help."This sentiment was echoed by 9% of FiF students.
(3) Mental health awareness and education Increased awareness of mental health in universities was a common reason for both groups: "I feel extremely comfortable.I believe this is because I study psychology, so I have greater understanding of mental illness and do not think it is something to be ashamed of."From another student: There is a stigma surrounding men discussing their mental health and emotions.I do not want to be part of or perpetuate this stigma.As such, I am often open about what I'm thinking and feeling.Hopefully, others will feel the same.
Unlike FiF respondents, non-FiF respondents referred to "the ease of opening up" more frequently when talking about their mental health: "I am a very open person and like to talk about my feelings so I would be comfortable discussing my mental health" and "I've never really had a problem being open with these things." (4) Previous mental health experiences Lastly, within both groups (4%), there was mention of 'previous experience' of talking about one's mental health.In all cases, positive previous experiences encouraged confidence in discussing mental health.For example, one FiF respondent shared "I feel very comfortable talking to professionals.I went to rehab 15 years ago for alcohol dependency and learned the value of sharing with a professional", while a non-FiF respondent stated how comfortable they now felt "after suffering from severe anxiety and depression and seeing the benefits of talking about it."

Discussion
Here, we examined differences in help-seeking intentions between FiF and non-FiF UK students using the GHSQ and openended questions.Results from the GHSQ indicated that all students preferred discussing emotional, personal concerns and suicide ideation with their intimate partners, but that FiF students were significantly more likely to seek help from friends, relative to their non-FiF peers.This latter finding was corroborated by the qualitative responses in which more FiF students referenced "turning to friends for help" with their mental health concerns.We also found that stigma, perceived burdensomeness and cultural background influenced help-seeking intentions among all students, negatively impacting helpseeking behaviours, preventing students from openly discussing their own experiences with mental health.When exploring positive attitudes towards help-seeking, trust and closeness were particularly important for FiF students, while for non-FiF students the perceived benefit of talking to anyone about mental health was more commonly referenced.More FiF students specifically mentioned the importance of reducing mental health stigma by consciously engaging in open discussions about psychological struggles.Finally, we found that for all students, the experience of university culture and the increased effort of institutions to dismantle mental health encouraged openness, and that previous positive help-seeking experiences were important in shaping help-seeking attitudes.However, more FiF students reported feeling uncomfortable approaching university staff with their mental health concerns than their non-FiF peers.
Our results emphasise the importance of friendship as a vital support system for FiF students.This aligns with previous research showing that higher levels of mental health help-seeking were associated with higher levels of social support (Lian et al. 2020), as well as research that implicates friendship(s) as one of the main sources of success for FiF students, primarily because it operates as a bridge to access economic and social resources that these groups may otherwise have limited access to (Stuart, 2006).Indeed, research shows how access to these resources facilitates a better transition into university life both socially and academically (Stuber et al., 2018).Likewise, a lack of social integration or sense of belonging at university has been reported as hindering students' help-seeking behaviours (Sithaldeen et al. 2022).Researchers have highlighted the importance of universities fostering a sense of belonging among students as having increased social contact with friends has been found to positively predict mental health of students (Rubin et al., 2016).Social integration has been shown to improve transition and participation (Henderson et al., 2020), and significantly improve mental health (Stebleton et al., 2014).Considering that attitudes towards formal support services for mental health are partially transmitted through one's social network and thus can be an important factor for determining whether professional help is pursued (Kearns et al., 2015;Vogel et al., 2007), encouraging social engagement amongst FiF students could be particularly beneficial.
Unlike their non-FiF peers, FiF students may simply be unable to seek mental health support from their wider family.FiF students are more likely to come from lower socioeconomic backgrounds and from families with other pressing priorities, e.g., the basic financial demands of living (McFadden, 2016).Seeking help from within the family can place an additional burden a sentiment expressed by many of our respondents -and hence could explain why they may approach friends, the Internet, or the university first.Approaching these sources diverts the attention away from issues associated with the home -a factor that may not influence non-FiF students whose families may have the financial resources available to access care privately and speedily.Therefore, it is crucial to be aware of the additional constraints faced by FiF students and their families.
Contrary to previous research (Garriott et al., 2017;Ricks & Warren, 2021), we did not find many differences between the help-seeking attitudes of FiF and non-FiF students, and particularly in relation to factors having a negative impact.Students from both groups disclosed discomfort in talking about their mental health due to three main factors: (1) concern over distressing those close to them, (2) being perceived as a burden, and (3) due to a culture or upbringing that stigmatises and discourages discussion about mental illness.Many students were affected by self-stigma and feared judgement, being labelled, or being perceived differently by others simply because of their mental health.While these issues have previously been thought to more deeply affect FiF students (Garriott et al., 2017), finding that these factors are important barriers for all students, irrespective of FiF status, is in line with preceding research (Gulliver et al., 2010;Lally et al., 2013).It is important to consider the impact of the COVID pandemic, which forced students at the time of the study to complete their studies off campus and maintain social distancing.These circumstances may have caused university experiences for both groups to be more similar, with all experiencing reduced access to social and academic support.Interestingly, while all students referenced stigma as a barrier to openly discussing their mental health, FiF students referred to wanting to reduce it more than their non-FiF peers.It seems intuitive that FiF students may wish to actively contribute to breaking the barriers that stigma creates and for which many may have been deeply affected by.
While we found that the preferred help source for students was medical professionals as the fastest and most reliable way of obtaining solutions to their concerns (i.e., via therapy or pharmacology), this was contrary to our GHSQ findings, where talking with one's intimate partner was the most cited help-seeking action.This outcome could be the result of the differing terminology and language used between the quantitative and qualitative tools.For example, the qualitative questions refer to mental health specifically, which is a more medicalised term, and the definition itself can often place more emphasis on the negative aspects of mental wellbeing, i.e., illness (Galderisi et al., 2015).Therefore, participants may attribute a greater importance to mental health than, for example, personal or emotional concerns, which evoke a more intimate meaning.
Terminology is vitally important within the context of mental health and one's culture, and social background and language can greatly impact conceptualisations of mental health (Vaillant, 2012), which may have impacted the outcomes of this study.Finally, our work highlighted how students rely on the Internet as their primary source of help and guidance, in line with previous research (Kauer et al., 2014).However, it is unclear whether this outcome is associated with the pandemic and social distancing restrictions at the time of the study, or whether this reflects a subgroup of students, for whom self-reliance and independence are preferrable to being reliant on others.It is also noteworthy that some students found their university mental health support services as invaluable help-seeking sources, and more research is now needed to further explore the role that universities can play as viable routes to better mental health care.Importantly, we also found that more FiF students reported feeling uncomfortable in approaching university staff and services due to negative past experiences and the fear of being judged or adversely affected -an area of concern that future work could focus on.
This study has several strengths, starting with the mixed methods design that enabled an in-depth exploration of help-seeking preferences and attitudes, and the factors influencing these outcomes, in a large mixed student sample.The anonymous, online nature of our data collection may have alleviated any discomfort that participants might have otherwise experienced during in-person interviews, and the lack of any word or time restrictions provided participants with the opportunity to truly reflect upon their responsesall of which we believe added to the richness and quality of our qualitative data.We also acknowledge limitations.We only captured a snapshot of behaviours during a particularly challenging time given the global pandemic and did not measure the participants' current or pre-existing mental health, which could have influenced motivations for participation and responses.Our sample included both current and former students from any UK university and we did not measure the graduating year, which would affect access to mental health resources as after leaving university students lose access to on-campus counselling.As research has shown university counselling to be effective in improving student mental health (Broglia et al., 2023), it is important to understand how individuals continue to seek help for their mental health when this source of help is taken away.Finally, the definition of FiF is broad, encompassing many factors (e.g., race, socioeconomic status, gender, age, disabilities) that can affect mental health help-seeking behaviours (House et al., 2020).These factors were not controlled for in our study, so we could not establish if they influenced respondents' help-seeking preferences and behaviours.Similarly, we did not measure student status (current students vs. graduates), reducing our ability to apply our findings to just current university students instead of a more general population of graduates from higher education.As the study was conducted as part of a dissertation paper, the time to collect data was limited.Having a larger sample and measuring student status would allow for more representative and generalisable insight around the help-seeking behaviours of FiF students in the UK.Future studies may benefit from recruiting students from more homogenous populations (e.g., specific universities, on specific courses) and investigate the effect of personal characteristics (e.g., gender, race) on mental health help-seeking behaviours, towards a better understanding of determinants influencing preferences and attitudes to provide better organised support.

Table 1
Breakdown and Results of the Respondents' (N=328) Scores on the GHSQ for Help-Seeking Intentions for Personal and Emotional

Table 2
Breakdown and Results of the Respondents' (n=328) Scores on the GHSQ for Help-Seeking Intentions for Suicidal Ideation