The Mental Maze: A Mixed-Methods Approach to Understanding Undergraduate Student Mental Health at a South African University

2.1. Study Design and Philosophical Assumptions

This research adopted a pragmatic philosophical perspective [24], which advocates for the use of diverse methodologies to achieve a richer comprehension of the research problem [25]. Grounded in practicality, pragmatism promotes the examination of research questions through an interconnected, meaningful lens rather than in isolation [24, 25]. This approach was especially pertinent to the present study, as relying exclusively on questionnaires could constrain participants' ability to articulate their experiences, emotions, and viewpoints in depth. By supplementing quantitative surveys with qualitative interviews, the study sought to capture a more holistic portrayal of students' attitudes, behaviours, and perspectives. The interplay of methods facilitated a layered investigation of mental health [26]. Consequently, a mixed-methods design was implemented, merging quantitative and qualitative approaches to address the research questions, aims, and objectives [23]. More specifically, an explanatory sequential design was followed, wherein the qualitative phase (phase 2) expanded upon insights derived from the quantitative phase (phase 1). Data integration occurred across both phases, with quantitative findings shaping the focus and direction of the qualitative exploration. Additionally, this study followed the Sex and Gender Equity in Research (SAGER) guidelines [27]. A summary of the methods employed in this study is presented in Table 1.

2.2. Ethical Considerations

All participants provided written consent to take part in this study. Ethics approval was obtained from the Humanities and Social Sciences research ethics committee at a university in the Western Cape province of Cape Town, South Africa (reference number HS21/10/24) prior to the commencement of the research.

3.1. Demographic Information

Table 2 presents the demographic details of the study participants. In the quantitative stage, the study included 534 undergraduate students, with 53.6% identifying as female. Participants’ ages ranged from 18 to 42 years, with a mean age of 21.11 years (SD = 2.71). The majority of students were first-year undergraduates (n = 206, 38.6%) and were enrolled in the Faculty of Community and Health Sciences (n = 143, 26.8%). Most participants were single (n = 298, 5.8%) and lived off campus (n = 495, 89.9%). In the qualitative stage, 18 students participated, including 12 females (66.7%) and 6 males (33.3%). Their ages ranged from 19 to 24 years, with a mean age of 21 years (SD = 1.37). Many of these students were enrolled in the Faculty of Community and Health Sciences (n = 8, 44.4%) and were in their second (n = 6, 33.3%) or third (n = 6, 33.3%) year of study. A large proportion of the participants were single (n =14, 77.8%) and lived off campus (n =15, 83.3%).

3.2. Quantitative Results

4.1. Sex Of Participants In Relation To Mental Health

In terms of sex, both male and female students reported high levels of anxiety, with males slightly more affected by extremely severe anxiety (41.5%) compared to females (39.9%). While this gap was not substantial, it suggested that male students may be particularly vulnerable to intense psychological distress. The qualitative data reinforced this, with students speaking of emotional distress and internal struggles, such as overthinking, self-doubt, and a lack of motivation. These emotional patterns reflected broader concerns regarding mental health stigma and the internalisation of stress, which may differ subtly by gender. These results aligned with a previous South African study where it was reported that, compared to males, females had a significantly higher risk of depressive symptoms [38]. This suggests that female students may be generally more affected by these mental health challenges. These statistics have been found to differ from those of the WHO, where it has been indicated that anxiety disorders are about 50% more common among women than men throughout the life course [1]. Results of this current research study have suggested males to be influenced by a range of psychological, social, and cultural factors [26]. In many contexts, including South Africa, societal expectations of masculinity often place pressure on males to appear strong, self-reliant, and less emotionally expressive. This can lead to difficulties in acknowledging or seeking help for mental health issues, resulting in heightened anxiety that may go unaddressed [38, 39]. Furthermore, across the entire student population within this research study, almost half (40.6%) reported experiencing extremely severe anxiety. These results have been found to be similar to those reported by the WHO, where it has been indicated that among both males and females, anxiety is one of the most common mental disorders [1]. It is thus necessary for universities to explore alternative methods to enhance mental well-being and provide coping mechanisms that are suitable for contemporary students [40].

4.2. The Role Of Campus Residence In Students’ Mental Health

Results derived from this study have indicated campus residence to influence mental health outcomes. Students residing on campus had a marginally higher prevalence of extremely severe anxiety (42.6%) compared to those living off campus (40.4%). Furthermore, a greater proportion of on-campus students reported normal levels of stress (55.5%), suggesting a mixed mental health profile. The qualitative findings shed light on these complexities, with students describing academic pressure and a lack of balance in their daily routines. Living on campus may amplify exposure to academic demands and reduce opportunities for rest, leading to a more intense university experience that can strain mental well-being. A plausible reason for this may be potential environmental factors contributing to differential experiences of mental health challenges among students living in distinct settings. In light of the South African context, previous research has indicated higher levels of depression and stress among off-campus students, which may be attributed to environmental and logistical factors [39, 40]. Students living off campus often face longer commute times, which can lead to fatigue, time constraints, and increased stress [41]. Additionally, the lack of immediate access to campus resources, such as counseling services and academic support, may exacerbate feelings of loneliness and hinder the ability to cope with academic pressures [42, 43]. Additionally, studies have reported that financial burdens associated with off-campus accommodation, coupled with potential safety concerns, may further contribute to heightened stress levels [44, 45]. In contrast, on-campus students typically benefit from closer proximity to university resources, a more structured living environment, and increased social interaction, which could mitigate some of the stressors associated with university life [46].

4.3. Relationship Status As A Factor Of Mental Health

When considering relationship status, students who reported being in a relationship experienced higher levels of extremely severe anxiety (44.5%), whereas students not in a relationship were more likely to report normal stress levels (47%). These findings suggest that while relationships can offer social support, they may also contribute to additional emotional burden. This has been consistent with the theme of coping mechanisms and support systems in the qualitative data, where the role of relationships, whether familial, romantic, or peer-based, was discussed as both a source of encouragement and emotional strain. In the South African context, higher rates of depression and stress among undergraduate university students not in relationships could be influenced by several factors [37, 39]. Students not in relationships might experience feelings of isolation or loneliness, especially in a university environment where social connections play a significant role in emotional well-being [47, 48]. The pressure to fit in or meet societal expectations concerning relationships could also contribute to feelings of inadequacy or stress [30]. Additionally, mental health stigma in South Africa is still prominent, and that may deter students from seeking support, thus exacerbating their anxiety regardless of their relationship status [38]. To address the high levels of mental health challenges observed among students, a tailored approach is needed. Given that students not in relationships experience higher rates of depression and stress, while both groups face extremely high levels of anxiety, a possible solution may include targeted support for emotional well-being [49]. For students not in relationships, student emotional programs to combat isolation, such as social events and peer mentoring, could help reduce feelings of loneliness and stress [14]. For students in relationships, relationship counseling and workshops focused on healthy communication could alleviate relationship-related pressures. Reducing stigma around mental health and integrating support into academic advising could ensure that students receive comprehensive care, addressing both academic and emotional challenges [50-52].

4.4. Variation In Mental Health Across Years Of Study

Regarding the year of study, mental health outcomes varied by year of study. First- and second-year students showed the highest levels of normal stress (46.6% and 52%, respectively), whereas third- and fourth-year students experienced the highest levels of extremely severe anxiety (60% and 65.5%, respectively). These results reflected the cumulative nature of academic pressure. Students in the later years of their studies reported feeling overwhelmed by expectations and deadlines, describing a loss of balance and routine. This intensification of pressure was captured in qualitative themes relating to motivation and the drive to succeed, where students expressed concerns about meeting academic goals and navigating future uncertainties. These results have been found to be twice as high as those of a previous study, where it was indicated that 10% of first-year students displayed symptoms of severe depression [51]. A plausible reason for this may be the transitional period a student encounters once they enter the university environment for the first time [53, 54]. First-year students are different from the other undergraduate levels because, during their transition into the university environment, they require support systems to help them adjust academically and mentally to cope with this new tertiary phase of their studies [52]. These lower statistical scores among first-year students and higher scores among upper-level students highlight the toll of academic demands and transitional stressors over time [53, 54]. Although this study did not directly examine the specific sources of anxiety, it is plausible that a combination of academic workload, financial stress, uncertainty about future employment, and transition-related pressures may exacerbate these elevated levels across the year of study [50-53]. The academic expectations placed on students in the final years, such as completing dissertations, preparing for professional practice, or meeting graduation requirements, may intensify psychological strain. This indicates the need for increased support and targeted interventions for students in the later stages of their university journey, as they navigate heightened academic demands, mental health challenges, and the transition to professional careers [55-57]. This may, however, particularly be the case in South Africa, where job security is scarce, and good academic performance may serve as an asset for employability [19, 26].

4.5. Faculty Affiliation And Mental Health Experiences

At the faculty level, students from Dentistry (60.4%), Law (59.6%), and Education (46.4%) faculties recorded the highest prevalence of extremely severe anxiety. By contrast, students in Natural Sciences (53.7%), Community and Health Sciences (52.4%), Economic and Management Sciences (47.0%), and Arts and Humanities (40.3%) more frequently reported normal stress levels. Nevertheless, anxiety remained a concern across all faculties, including within Community and Health Sciences, where 32.2% of students still experienced extremely severe anxiety. Qualitative data illuminated these findings through discussions of identity, peer judgment, and external expectations, particularly within academically intense faculties. Students shared how faculty-specific cultures could influence perceptions of belonging, workload, and pressure, contributing to variations in mental health experiences. These results have been found to be approximately twice as high when compared to a previous study by Van Der Walt and colleagues [38]. Their study reported that students studying within the medical field reported experiencing symptoms of depression (36.4%) above the threshold for anxiety [38]. A plausible explanation for this is that the Dentistry faculty falls within the medical field and, as a result, students may experience more academic pressure and workload [58-60]. In the context of Law and Dentistry, this may be attributed to the demanding and high-stakes nature of their curricula, which often involve intense workloads, frequent assessments, and limited flexibility. Furthermore, both programs are known for their competitive atmospheres and early exposure to professional expectations, which may compound stress and anxiety levels. These results show the need for faculty-specific mental health interventions that consider the unique pedagogical and structural pressures experienced by students in these disciplines [57-61]. Particularly within some South African universities, students within the medical fields experience heightened academic pressures, rigorous clinical training, and increased mental health challenges, which may impact their overall well-being and academic performance [54, 58, 61]. This is largely due to the demanding curriculum, long hours of practical training, high expectations for clinical competency, and the emotional toll of patient care, all of which contribute to increased stress and mental health challenges among medical students [54, 60]. Moreover, this suggests that, in the South African context, students within the faculties of Economic and Management Sciences, Education, Law, and Natural Sciences may experience heightened anxiety due to the unique academic and social pressures they face. These faculties often come with intense competition, rigorous academic requirements, and the pressure to secure stable careers post-graduation [19, 41]. Students within the Education faculty, for example, may struggle with the emotional demands of their future roles in shaping young minds, while Law students often face stress from the demanding nature of their studies and the pressure to succeed in a highly competitive field [61]. Similarly, students in the Natural Sciences faculty deal with complex subjects and practical laboratory assessments, which may increase their anxiety [62]. Therefore, it is important to develop mental health initiatives that are relevant to students within their respective faculties to ensure that tailored and context-specific support is provided [63-65].

4.6. Strengths and Limitations of the Current Study

This study aimed to determine and explore the prevalence of mental health challenges among undergraduate students at a South African university. This study did not aim to replace existing South African research on mental health. Instead, it is transferable to similar contexts as it enriches the literature by offering contextual insights into the mental health challenges experienced by undergraduate university students, with particular emphasis on the unique environment of HDIs. Therefore, the strength of this study lies in its ability to provide a context-specific understanding of mental health challenges within the domain of HDIs, highlighting factors that may not be captured in broader research and offering targeted insights for more effective interventions. However, this study has not been without limitations. This study employed convenience sampling for both the quantitative and qualitative phases, which may limit the generalizability of findings. The use of this method was influenced by practical constraints, including limited access to institutional databases for randomised selection and the voluntary nature of student participation. As a result, some faculties or student subgroups may be over- or underrepresented. Future research should aim to utilize more representative sampling strategies, such as stratified or random sampling across faculties and academic years, to ensure the broader applicability of results across diverse student populations. Additionally, the cross-sectional design of the study may prevent the establishment of causal relationships. To address these issues, future research should consider employing random sampling methods and adopting longitudinal designs that could allow for the identification of causal links. While efforts have been made to minimise bias, the inclusion of both online and hard-copy versions of the questionnaire may have introduced potential biases related to differences in user behaviour between the two formats. Although we took rigorous steps to validate and analyse the data, we encourage readers to interpret the findings with caution, considering the possible biases. The use of the DASS-21 to screen mental health challenges comprised another limitation, as the tool has been designed to identify students at risk but has not been intended for diagnostic purposes. As such, future studies should consider using instruments specifically designed for clinical diagnoses. Additionally, since the DASS-21 questionnaire was self-administered, participants' responses may have been influenced by subjectivity. Future research could benefit from employing diagnostic tools that reduce the potential for bias inherent in self-reported data. Lastly, although the study has provided valuable insights into students’ mental health, it did not specifically investigate the roles of race, socioeconomic status, or language background. Given South Africa’s complex sociopolitical history, these intersecting identities may likely influence mental health experiences and outcomes. The omission of these factors has been a limitation of the current study, pointing to an important direction for future research that can more fully explore how such social determinants shape mental health among diverse student populations.

4.7. Recommendations

Based on the results of this study, the following recommendations are provided to improve the mental health of undergraduate students, with a specific focus on female students, on-campus support, first-year students, and faculty-specific initiatives. Firstly, given that female students exhibited higher levels of mental health symptoms, student support services should consider developing gender-specific, tailored interventions. This may involve female wellness days, coordinated by Gender Equity Units, tailored to address the unique challenges faced by this population. Secondly, results have shown a higher prevalence of mental health challenges among students living off campus; therefore, universities could provide online therapeutic services, chatbots, and resources that are easily accessible and readily available. Emerging artificial intelligence tools, such as chatbots, could potentially assist in providing preliminary mental health support or counselling, particularly by offering accessible, immediate responses to students experiencing psychological distress. This could provide students with effective and efficient support services. Moreover, universities may use the information obtained via the chatbot to gain insights into student patterns, engagement levels, and outcomes. This would ensure that a tailored intervention could be employed. Thirdly, the higher levels of mental health disorders among first-year students indicated that the transition to the university environment may be daunting and challenging for some. Therefore, first-year transition programs should be initiated where first-year peer-mentors could assist first-year students with coping and support strategies. This could assist first-year students with adjusting to the university environment and academic expectations. First-year workshops could focus on mental and emotional well-being before the examination period. Lastly, the variation in mental health disorders across different faculties suggested academic pressures and environments to play a role in student well-being. Mental health services should collaborate with faculty members to develop tailored interventions that address the specific needs of students in each faculty, for example, implementing stress management workshops for students in high-pressure faculties, such as Community and Health Sciences.

4.8. Practical Policy Recommendation for Implementation

To translate findings into actionable policy, several context-sensitive interventions are recommended. Faculties with high mental health challenges, such as Law and Dentistry, could benefit from embedding dedicated mental health professionals to provide timely and discipline-specific support [65]. Additionally, peer-support models should be expanded across student residences to foster community-based coping mechanisms and early identification of distress. Universities are also encouraged to strengthen collaborations with public health systems to bridge service gaps, particularly for students living off-campus who may face barriers to accessing campus-based resources. Such partnerships could include referral pathways, joint awareness campaigns, and integrated mental health services that extend beyond university settings. Together, these strategies aim to create a holistic support network tailored to the diverse needs of the student population. A fundamental challenge for universities is transitioning from reactive mental health responses to preventive strategies that are inclusive, sustainable, and culturally resonant. This requires implementing early screening and awareness programs, integrating mental health education into curricula, and fostering campus cultures that reduce stigma and promote well-being. Importantly, interventions must be tailored to reflect the diverse cultural backgrounds of the student body, ensuring relevance and accessibility. Sustainable mental health support also depends on institutional commitment, cross-sector collaboration, and continuous evaluation to adapt to evolving student needs. By embedding mental health into the core of institutional planning and student development, universities can meaningfully contribute to Sustainable Development Goal 3 (SDG3), ensuring healthy lives and promoting well-being among undergraduate university students.

4.9. Future Research

Future studies may build on the sample size by investigating various universities across South Africa. This could enable a more comprehensive understanding of mental health among undergraduate university students, ultimately increasing the diversity of perspectives and experiences. This study has highlighted coping strategies and support systems as vital components of student resilience, reflecting student agency in managing mental health challenges. However, the differential effectiveness of these mechanisms across demographic groups warrants further exploration. For example, male students, who reported higher rates of severe anxiety, may face unique barriers, such as stigma, that reduce their likelihood of accessing peer or professional support. Additionally, informal support networks, including family, friends, and student communities, play a critical role in mediating mental health outcomes, yet their influence may vary by cultural and social contexts. Future research should investigate these dynamics in-depth to inform tailored interventions that address gendered and cultural nuances in help-seeking and coping. Furthermore, researchers could examine the effectiveness of student support services in mental health outcomes. This could offer a more comprehensive analysis of their impact on student well-being. As a result, targeted interventions could be developed and implemented among the university student population aimed at enhancing their holistic health. While this study has emphasised student experiences and aligned with Sustainable Development Goal 3 by advocating for institutional accountability, the roles of academic staff, curricula, and institutional culture remain underexplored. Future research should aim to include faculty members and administrators to capture their perspectives on how academic demands, teaching practices, and institutional norms contribute to student mental health outcomes. Integrating these systemic and interpersonal levels of analysis can prove to be crucial for developing comprehensive, sustainable solutions that address the root causes of distress within higher education settings.