A SOUTH AFRICAN UNIVERSITY STUDENT MENTAL HEALTH DIAGNOSTIC

Insights from the Motsepe Foundation Graduate and Undergraduate Mental

Health Survey
DECEMBER 2022

Research Note 5, compiled by the Motsepe Foundation Research Unit

Contents

1. Mental Health Context............................................................................................................ 3

2. Motsepe Foundation Survey: Results ..................................................................................... 4
3. Mental Health and South African Universities...................................................................... 13
4. Interventions: How can we make the system more responsive and effective? ................... 15

pg. 2
 1. Mental Health Context
The World Health Organisation (WHO) notes that
declining mental wellbeing is a global phenomenon.
According to the South African Department of Higher
Education, more than 14,000 students reached out for
psychosocial support in 2021. Challenges they faced
included academic stress and anxiety, dealing with
substance abuse as well as experiencing depression or
suicidal thoughts.1
Several studies find a greater prevalence of suicidal
ideation among university students in South Africa
than the general population of the country: the
prevalence of suicidal ideation - defined by the
frequency of thinking about, considering or planning
for suicide - amongst first-year students
approximately 46.4%2 compared to 9.1%3 amongst the
general population. To compare, in the United States
where suicide is the leading cause of death amongst
university and college students, first-year suicidal
ideation is estimated at 32.7%.4
Mental health challenges are inter-related and can
easily generate a vicious cycle: disappointing academic
performance can cause stress which can exacerbate
depression, anxiety and substance abuse, potentially
leading to further reductions in academic
performance.
1
https://www.iol.co.za/capetimes/news/thousands-of-tertiary-students-seek-psychosocial-support-
0ddae46b-847c-468d-901d-8d29be6629f8
2
https://www.tandfonline.com/doi/abs/10.1080/07481187.2019.1701143?journalCode=udst20
3
https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/prevalence-and-
correlates-of-nonfatal-suicidal-behaviour-among-south-africans/43DD08778E164C221D42B14DEAF47D22
4
https://pubmed.ncbi.nlm.nih.gov/29588052/
NOTE
The 2022 World Happiness Report
considers self-reported happiness
among 146 countries. Nordic
countries are consistently ranked as
the happiest places in the world,
whilst Zimbabwe, Lebanon and
Afghanistan ranked lowest. South
Africa ranked 91.
The 2021 Mental State of the World
report studied 34 countries. South
Africa, together with the United
Kingdom, placed last in terms of
mental wellbeing. South Africa was
reported as having the highest share
of respondents who are distressed /
struggling, implying a difficulty to
function and a clinical risk in mental
wellbeing.
The latter report identifies a global
‘generational decline’, with youthful
is
populations becoming unhappier from
around 2010. Possible explanations
provided include changes in
inequality, environmental causes, and
the impact of the internet.
Another trend, one that may run
contrary to common perception, is of
declining mental health as country
GDP-per-capita grows. The report
suggests that economic prosperity
may have a negative effect on mental
wellbeing when the gains result in
socioeconomic disadvantage among
some groups. Another suggestion
given is that countries with cultures
that emphasise high standards,
excellence and individualism report
the poorest mental wellbeing.
pg. 3
 2. Motsepe Foundation Survey: Results

2.1 Aim and Approach

The Motsepe Foundation, in an effort to enhance support for its bursary students and higher
education students generally, conducted a survey in 2022 to assess the pandemic and post-
pandemic mental wellbeing amongst its network of current undergraduate students and
alumni.

The sample consisted of an almost equal distribution of current students and university
graduates affiliated to the bursary programme. We contacted 947 students and alumni,
receiving 259 responses; respondents were all between the ages of 18 and 35, with the
gender distribution skewed towards women, who make up the majority of bursary recipients
given the programme focus on promoting gender equality in STEM (science, technology,
engineering and mathematics) fields. 5

Students’ fields of study are amongst those considered particularly stressful, with a majority
pursuing the sciences and medicine. This is of particular note given that medical students are
reported as experiencing disproportionately
high levels of mental ill-health and burnout.6
Since bursary recipients are selected based on
their financial need, the survey had an indirect
focus on students from low socioeconomic
backgrounds. It is also worth noting attempts
made by the Motsepe Foundation to reduce
financial stress amongst bursary recipients by
covering all tuition, accommodation,
textbooks, laptops, and meals, as well as
additional provisions of cash allowances for
personal student needs. 7
NOTE
Factors such as social / familial isolation and
sweeping changes in lifestyle are more
specific to undergraduate experiences and
correlate with student incidence of mental
ill-health.
It needs to be recognized that the university
environment is experienced differently by
different people. For some students,
navigating the social aspect of campus life
can limit their wellbeing if their lack of
adequate resources prevents their
participation. For others, an essential need
to achieve academic excellence, due to
extreme external or individual pressures,
can result in poor lifestyle choices such as
losing sleep and limited physical exercise.

5186 women, 73 of men; None of the respondents identified as gender non-conforming; 131 alumni, 128 current
undergraduates.
6 http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742020000100015
7 The questionnaire given to respondents is included in the appendix.
pg. 4
2.2 Drivers of Mental Health Challenges

Of the total respondents, 42% reported feelings of DISCUSSION

anxiety, depression, or suicidal thoughts at least
once a month, and 17% reported mental distress
that is prolonged for weeks at a time.
Shown in Figure 1, more than half of respondents
(62%) ranked academic performance as the main
Whilst different surveys are used to
gauge the prevalence of mental
distress in other parts of the world,
the results of the Motsepe Foundation
survey correlates to results found in a
more comprehensive studies of
medical students.

contributor to their mental ill-health. Despite efforts For example, a Brazilian study found a
41% prevalence of anxiety and 8%
to reduce financial stress, almost a quarter (24%) of prevalence of depression amongst
the students and graduates reported financial stress medical students and interns.

as the main contributor to anxiety, depression, or
suicidal thoughts.
Pressures associated to academic performance can
explain the relatively high reports of mental ill-health
among university students. These pressures can be
individual or externally related.
In the Brazilian study, ‘Loneliness’ and
‘having a history of psychiatric/
psychological treatment before
entering college’ were cited as the
main factors associated with
depression and anxiety amongst
students.

In this survey, all students awarded the bursary are selected based on their superior high
school academic performance. Maintaining this performance at a tertiary level can heighten
stress, and this may be unintentionally compounded by additional pressures imposed by
bursary sponsors. Students enrolled in university on scholarships may face increased pressure
to perform well academically due to sponsors opting to end bursary support if students
perform poorly during the year.

Another explanation could be related to the quality of basic education. The Department of
Basic Education reports improved outcomes in mathematics and science, while noting that
more needs to be done to improve pedagogy, train teachers and enable school access to
relevant tools.

pg. 5
For the respondents, their fields of study are primarily STEM-focused, and their basic
education was completed at schools considered underserved in resources and infrastructure.
While many universities offer bridging courses to prepare high school learners for tertiary
curriculums, the survey suggests more could be done to prepare learners and alleviate
academic stress.

Figure 1: Main contributing factors to student anxiety, depression, or suicidal thoughts

180 70,0%
160 60,0%
140
50,0%
120
100 40,0%
80 30,0%
60
20,0%
40
20 10,0%

0 0,0%
Academic/ Financial stress Interpersonal Living conditions Other
performance stress relations

2.3 Differences between Males and Females

In a gendered analysis of the results, double the proportion of female students compared to
male students reported feelings of anxiety, depression, or suicidal ideations. However, male
and female students were equally likely to seek out help from the university and other
networks.

Figure 2 shows this lower reporting of mental ill-health amongst male students compared to
female students – a distribution that remains when comparing current students and
graduates. Almost half (48%) of female respondents admitted mental-ill health symptoms at
least once a month compared to a quarter of male respondents (25%). This might result from
a cultural or social reluctance amongst men to admit vulnerability; further analysis is required
to understand these large, gendered differences.

pg. 6
 Figure 2: Gendered comparison of mental ill-health amongst students and alumni

I feel anxious, depressed or suicidal at least once a month

200
150
100
50
0
Female Male

Experience Mental Ill-Health Do Not Experience Mental Ill-Health or Don't Know

Figure 3 compares the mental ill-health amongst graduates to undergraduates, finding only a
slight increase in mental ill-health amongst current students. Though more female students
report mental ill-health, 45% of male and female students reported monthly symptoms of
mental ill-health, compared to 39% of male and female graduates. The difference is small but
it confirms the results of other studies that find that mental ill-health is greater amongst
undergraduates.

Figure 3: Graduate and undergraduate comparison of mental ill-health experiences

I feel anxious, depressed or suicidal at least once a month

150

100

50

0
male female total respondents

Undergraduate Alumni

Figure 4 presents a gendered assessment of student experiences of mental health support at

their institutions: more than half of male students reported positive experiences of university
provided interventions, compared to less than a third of female students who had requested
university support.

pg. 7
The survey did not assess reasons for the different experiences, but it might be that the short-
term and resilience-focused interventions offered do not provide adequate support to female
students. Further exploration into this, understanding the different support mechanisms
involved and why female students do not report its effectiveness positively is required.

Figure 4: Gendered comparison of experiences with available mental health support services
at university

100
80
60
40
20
0
Female Male

Negative Experience of Mental Health Support or Not Sure

Positive Experience of Mental Health Support at University

2.4 Financial Stress and Hopefulness

By assessing students’ hope for the future, the survey aimed to discover how different stress
factors could affect mental wellbeing and outlooks. As Figure 5 shows, among the current
student minority who report financial stress as the main contributor to their mental ill-health,
hope for the future is disproportionately less than those who report academic stress as the
main contributor to mental ill-health.

Among those who report academic stress as the main reason for mental ill-health, 85% are
positive for the future and 44% report feeling seen and heard in their time of stress. This is
higher than those who report financial stress as the main reason for mental ill-heath, with
72% reporting positive hope for the future and 40% feeling seen and heard in their time of
stress.

The overall scoring of their mental state of wellbeing is also slightly lower in comparison. On
a scale from 1-5, those with primary academic stress averaged at 3 compared to those with
primary financial stress averaging at 2.7. This suggests that financial stress is more detrimental
to current wellbeing than academic stress.

pg. 8
 Figure 5: Undergraduate students’ optimism based on their main source of mental ill-health

Total

I feel seen and heard

Hopeful for the future

0 20 40 60 80 100

Academic Stress Financial Stress

2.5 Alumni and Current Students

Universities may have made further progress in the last two-years to improve their student
mental health services. Figure 6 shows that more current students report positive experiences
with mental health services at university (47%), compared to the alumni and post-graduates
(37%) responding with their retrospective university experiences.

Figure 6: Graduate and undergraduate comparison of experiences with mental health

services at university (%)

35

30

25

20

15

10

0
Alumni Current
I had a positive experience of support systems at university
I had a negative experience of support systems at university

pg. 9
2.6 Seeking Help

More than half of students and graduates surveyed seek help DISCUSSION
for mental wellbeing from friends and family in the first A study of tertiary students in
Nigeria found that only 32.6%
instance. Thereafter, the youth surveyed found support
of respondents think the
through their faith and beliefs. Only 1-out-of-five offered mental health services
are effective. While 90%
respondents would consider seeking help from mental health
agreed that they would advise
professionals and a very small proportion would not seek someone who is mentally ill to
seek care, a majority of
help at all.
respondents did not know
where the most effective care
It is hard to explain the reasoning behind the overall low would be found.
interest in mental health professionals: it may be that
These findings correlate to
accessing mental health services is difficult, or the quality of countries where information
about mental health is lacking.
services received may be perceived as inadequate, or stigma
may remain, or there may be other reasons entirely that we
have not been able to capture. Some research suggests that
family and friends may stigmatise professional help or offer unhelpful guidance, which may
act against students seeking help in the future.8 In cases where it is imperative that
professional help be provided, this would be a cause for concern.

Figure 7: Where students and graduates seek help for their mental wellbeing

8
https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-11-196
pg. 10
2.7 High-Risk Students

Defining high risk students as those who rate their current mental wellbeing as one out of
five, our results show, worryingly, that they are least likely to reach out for help and that a
majority are current undergraduate students.

Their responses, shown in Figure 8, indicate an already negative perception of mental health
services available at university and a general fear of reaching out. In addition, their emotional
intelligence fares poorer, with low self-esteem indicated, as well as expressed difficulty
regulating emotions and socialising with others.

Figure 8: Responses from undergraduate students who rated their current state of wellbeing 1-out-
of-five

I feel seen and heard when I share my challenges

I am comfortable around people

I easily express my emotions with words

At University, I had a positive experience of mental

health support

I have sought help

High-Risk Students

0 5 10 15 20 25

pg. 11
pg. 12
 3. Mental Health and South African Universities

In 2020, Universities South Africa (USAf) initiated one of the largest student mental health
surveys undertaken to date in order to assess the state of mental health at South African
universities. The results from the comprehensive anonymous survey indicated that black
African students, those who identified as Asian or coloured, and those who attended
historically white institutions, were at higher risk of mental illness. At historically white
institutions, a prevalence of anxiety disorders and greater levels of stress was reported. While
the survey notes that further investigation is required to understand this correlation,
inadequate measures to support diversity and inclusion could be a factor.

Interestingly, the survey suggested that the University of South Africa (UNISA), the largest
open distance learning institution in Africa, had the lowest proportion of individuals who
meet the criteria for a psychiatric disorder.

Researchers found that UNISA students are predominantly over the age of 35-years, while
many students at historically white institutions are under the age of 20. Part of the
explanation is that students experiencing mental ill-health are more likely to drop out during
their undergraduate years, which results in declining rates of psychological distress among
students over 20-years across all higher education institutions.9

In an effort to better and support students’ mental health, universities have implemented a
range of counselling offerings. We give some examples.

In 2016, the University of Cape Town (UCT) sought to develop an institutional policy aimed at
student mental health. Their research into best practices found that student mental health
policies, while available in high-income countries, are not available for South African
institutions. 10

9
https://www.usaf.ac.za/towards-improving-the-mental-health-of-students-at-south-african-universities/
10
https://www.journals.ac.za/index.php/sajhe/article/view/3597
pg. 13
Universities are showing willingness to bridge the gaps in mental health services to the more
than 1-million students who are enrolled in South African universities and colleges.11
However, this comes with significant additional short-term costs, at a time when universities
are under financial pressure and the fiscal framework in support of universities appears
unsustainable.

Universities providing and expanding their mental health services are compelled to re-
allocate budgets away from other necessary priorities, including transformation initiatives,
which are considered beneficial to reducing student distress.

In 2018, the University of Cape Town approved a Student Mental Health Policy to widen
access to support services for students and increase the psychological services footprint on
campus. Students seeking mental health services are required to undergo a risk assessment
to ensure high-risk students are identified and referred to specialist support without delay.

In line with most university offerings, UCT has a focus on short-term, solution-focused
individual sessions that progress towards group therapy. The shorter cycles, and emphasis on
resilience, are targeted at low-risk students and try to ensure institutions offer effective and
affordable services to all students in need.

The onset of the COVID-19 pandemic shifted universities and colleges towards emergency
remote and online education. The isolation during lockdown, fear of contracting the virus,
changed work and study environments, and other compounding stressors, increased anxiety
amongst students and lecturers.

In response to increased mental health needs, Mangosuthu University of Technology (MUT),

similar to most tertiary institutions, introduced a hybrid approach, offering face-to-face
counselling, online counselling, psychotherapy sessions, and a 24-hour emergency helpline.
In addition, their student counselling unit, through trained peer helpers, conducts mental
health psychoeducation and awareness programmes to remove stigma and provide
information on available support offerings.

The University of Pretoria (UP) has taken their student awareness on mental health further,
to include easily available self-help materials such as podcasts and downloadable documents
that provide tips on topics such as managing stress and increasing psychological resilience.

11
https://www.careersportal.co.za/news/over-a-million-students-enrolled-in-university-for-2022
pg. 14
Since the large-scale introduction of hybrid support services in 2020, universities have begun
considering incorporating tech-centred approaches into their mix of offerings. UP has already
implemented a mental health chatbot, which provides real-time answers to questions relating
to depression, anxiety, life-style management, substance abuse and gender-based violence.

In a new study of various digital solutions, students from Stellenbosch University, the
University of the Western Cape, and the University of the Free State are testing interventions
such as cognitive behavioural therapy apps. Organised by the South African Medical Research
Council, this pilot study is the first collaboration between South African universities of this
kind and is aimed at testing scalable digital solutions for anxiety and depression. Part of the
aim of the pilot is to test the effectiveness of virtual group therapy sessions, which are already
showing positive outcomes.

Digital alternatives are potentially affordable interventions for common diagnoses, and with
further research and data, may be proposed as a viable offering to expand uptake of mental
health services. Other universities have been invited and are considering joining the trail.12

4. Interventions: How can we make the system more responsive and effective?

To understand why introducing mental health care at scale is difficult, we need to recognise
that varying factors define and shape mental health: genetics, childhood and adult
experiences, physical illnesses, as well as complex social issues such as discrimination and
poverty.

Universities, accommodating a significant number of young people during a transitional phase

from adolescence to adulthood, often function as a sphere of the mental health ecosystem
where challenges arise.

Youth in South Africa appear to be particularly vulnerable. It has been reported that up to
20% of high school pupils in South Africa have tried to take their own lives. 13

12
https://mg.co.za/opinion/2022-08-13-can-technology-help-to-promote-students-mental-health/
13
https://www.dailymaverick.co.za/opinionista/2022-05-30-teen-mental-health-stigma-our-education-and-
health-systems-fail-to-tackle-stigma/
pg. 15
Findings from the Motsepe Foundation survey suggest the most at-risk students are least
likely to seek help and an assessment approach to target students as they enrol can allow
interventions, such as digital support services, to become more effective.

In South Africa, without co-ordinated plans or policies to guide university interventions, the
role universities play in ensuring academic success through mental health support remains
varied. While online, virtual and short-term counselling interventions are proven to be cost-
effective, they may not be adequate to reduce drop-out rates. Some students may require
long-term care, extending into semester breaks, and others may prefer the privacy of in-
person counselling due to group living conditions in residence or at home. While limited
information around the diversity of counsellors is available in South Africa, it is also important
that mental health professionals reflect the diversity of students on campus. 14

4.1 Screening

Professor Jason Bantjes, the Chief Specialist Scientist at the South African Medical Research
Council, points to Belgium as a guide where mental health screenings upon enrolment into
tertiary education destigmatises mental ill-health. Subsequent student acceptance into
institutions is unaffected by their assessments and allows the institution to provide necessary
support through a targeted approach – upon the student’s willingness.

4.2 More First-Year Support

An additional suggestion by researchers and professionals is the introduction of, and

increased resources allocated towards, psychological and stress management services for
first-year university students in South Africa. The specific mention of stress management
services relates to the unavoidable stresses that trigger mental illness at university – namely
academic performance and the necessary social, emotional and self-control dimensions
required for navigating the transition from basic education into tertiary adulthood.

14
https://www.insidehighered.com/views/2022/09/28/colleges-must-invest-more-mental-health-opinion
pg. 16
By introducing self-care, mindfulness techniques and group therapy from a basic education
level and into tertiary institutions, a foundation is laid that prepares the youth for the
transition into adulthood in an uncertain global environment.15 Interventions, prior university
enrolment, enables an ecosystem of support, involving the individuals, communities, and the
public sector.

4.3 Mobilise Communities to Support

Whilst mental ill-health is due to varying factors, the current ecosystem of support for
students excludes other spheres such as family, community, and the public sector.

The survey results find the primary contact amongst students for mental health care and
support are their family and friends. When feeling depressed, anxious or suicidal they are
more likely to go their family, faith, and exercise before considering treatment from
psychological professionals.

Mobilising communities and faith leaders to intervene, through education and training, can
reduce pressures on public and institutional systems – specifically for minor cases of mental
illness when specialist treatment is not required.

Particularly in the South African context, traditional healers and faith leaders are part of the
community front-line in supporting sufferers with mental illness.16 Through training, the
professional support services become embedded into community structures and allow
family and faith leaders an opportunity to guide youth with more severe illnesses towards
adequate treatment.

4.4 Enhance Public Sector Support

To use the WHO as a guide, “health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity”. This introduces mental health as a
component of healthcare, not separated from physical wellbeing.

15
https://www.nytimes.com/2022/10/06/education/learning/students-mental-health.html
16
https://www.youtube.com/watch?v=ypZ9YH_wIQY
pg. 17
The public sector responsibility for youth mental health can be witnessed through their
investments into youth success. Public sector allocations made towards education, skills
development and physical health, are lost when individuals become crippled by mental ill-
health during their prime working age. 17

The public sector has a responsibility to retain mental health professionals within the sector
and to train professionals to respond to the diverse and multi-ethnic setting.18 SADAG
suggests that over 85% of sufferers from mental ill-health rely on free public health services.
While universities offer free individual counselling options, more specialised and long-term
treatments aren’t available free of charge.

4.5 Understand Nuanced Differences Better

The survey suggests that there are differences between men and women students that are
important for mental health services.

In particular, the fact that men are less likely to indicate mental health challenges raises
questions, as does the fact that women are less likely to be satisfied with mental health
services received.

Another area that warrants further deliberation is how to ensure that high risk students are
integrated into the system and provided with appropriate support.

Finally, more work needs to be done in assessing whether and to what extent bots, on-line
sessions and the like can improve health service offerings: whilst they hold potential for
expanding the scope of services, it may be that important therapeutic elements are lost in the
shift away from in-person support.

17
https://www.mja.com.au/system/files/issues/187_07_011007/mcg10312_fm.pdf
18
https://www.sacap.edu.za/blog/management-leadership/mental-health-south-africa/

pg. 18
pg. 19
Appendix: Questionnaire for Motsepe Foundation Survey

1.Age 3.Field of Study

2.Gender 4.Year of Study

5.I feel I have a decent number of good qualities

6.I easily express my emotions with words

7.I am comfortable around people

8.I am thriving across all aspects of my life

9.I believe that lacking areas of my life will be better in a few years

10.I find it difficult to regulate my emotions

11.I feel anxious, depressed or suicidal at least once a month

12.I feel anxious, depressed or suicidal for weeks at a time

13.I find it easy to seek help when I feel anxious, depressed or suicidal

14.I have sought help at least once

15.At University, I had/ have a positive experience of mental health support

16.As a student, the main reason for my anxiety, depression or suicidal thoughts were:

Financial stress Interpersonal relations

Academic/ performance stress Living circumstances

Other

17.When I seek help, I go to:

Professionals in mental health My faith

Friends and family Exercise / meditation

The internet I don't seek help

18.I have felt more anxious, depressed or suicidal since the pandemic

pg. 20
19.I am hopeful for the future

20.I get positive affirmations from:

my own inner dialogue from friends and family

from my spiritual beliefs from my achievements

21.I feel seen and heard when I share my challenges

22.Right now, I rate my state of mind to be

pg. 21