1.1 Integration
Integration at university can be described as having two components: social and academic (Tinto, 2012). Social integration is the interactions between students and the degree of congruency between each student and his or her social environment. Tinto notes though, that friendships are more important than ''social fit'', suggesting that students who do not fit the social norm of the university may still feel socially integrated, as long as they are able to form a friendship circle of similar individuals. Academic integration is measured by grade performance (an external factor) and intellectual development (an internal factor). Grade performance indicates that the student is able to produce work that is satisfactory to the requirements of the university, while intellectual development indicates that the student is engaged with, and is being challenged by, the academic content. Taken together, they are indicators of a good ''academic fit'' between student and institution. Withdrawal from
university is ''a longitudinal process of interactions between the individual and the academic and social systems of the college'' (Tinto 1975, p. 94). The interactions that students
experience in both social and academic realms lead to modification of their study goals and commitment to university - ultimately impacting on their decision to stay or leave.
Decisions to stay or leave university are influenced by factors inside and outside the university. Competing demands constitute the push and pull factors that either keep an individual at university or contribute to dropout. Forming friendships at university (social integration) and receiving positive feedback for academic work (academic integration) is likely to ''pull'' the student towards the university, while feeling socially isolated (lack of social integration) or struggling academically (lack of academic integration) may ''push'' the student away. Likewise, factors outside the university will affect students' decisions to stay or leave:
financial difficulties will pull the individual to paid employment instead of university study, whereas the incentive of receiving a degree will push back to the university. These decisions are made early: dropout rates are highest in first year, therefore the focus is to ensure students are integrated as quickly as possible.(DeBerard, Spielmans & Julka 2004). As a result, social and academic integration are generally presented as issues of transition to university.
One crucial factor that is likely to impact on students' decisions about continuing their education is the presence of mental health problems. Such problems also directly impact on
their studies (and therefore their academic integration) and their social interactions.
Heiligenstein, Guenther, Hsu, and Herman (1996) found a significant correlation between depression and academic impairment amongst students who attended the university counselling service with symptoms of depression. Of their sample, 92% reported academic impairment, with more severe depression being related to greater impairment. The high rates of impairment in this study may be explained by the sample - students are more likely to present for mental health treatment only after they recognise a functional impact in their lives. The authors also noted the bidirectional relationship between depression and
academic impairment, where a vicious cycle may exist (e.g. absenteeism from class leads to worse mood, which results in further withdrawal).
Precursors of mental health problems such as high stress levels also play an important role.
Stewart, Lam, Betson, Wong, and Wong (1999) investigated the stress-academic
performance relationship amongst medical students and found that academic performance affected stress, regardless of pre-existing levels of anxiety and depression. They noted that academic performance before and during medical school was negatively correlated with stress - that is, those performing the best academically were also the least stressed. The authors of this study also noted that the relationship between stress and academic performance is likely to be bidirectional, noting a number of confounding as well as pre- existing factors (e.g. high school academic experiences). Despite some mixed results regarding the exact nature of the relationship, mental health and academic performance appear to be related.
Mental health difficulties are also likely to impact, and be impacted by, a student's ability to integrate socially into the university. For example, social withdrawal is a feature of
depression, and a diagnosis of depression includes ''clinically significant distress or impairment in social, occupation, or other important areas of functioning'' (American Psychiatric Association, 2000, p. 349). The relationship between social withdrawal and mental illness is also likely to be bidirectional. In an epidemiological study of over 10,000 Irish adults, Lente et al. (2012) found that positive mental health was predicted by lower levels of loneliness and better social supports. Conversely, lower levels of social wellbeing was the strongest predictor of poor mental health.
Tinto's (1975) model of university dropout suggests that poor social and academic
integration is likely to lower students' commitment to their institution, which in turn increases the likelihood of voluntary withdrawal. In the short term, withdrawing from study may be beneficial to students' mental health (e.g. decreased stress), however over the long term, these individuals are not achieving their goals or fulfilling their potential - the long term impact of withdrawal from university due to mental health difficulties is unknown. If poor mental health leads to withdrawal because of low integration (both social and academic), intervening via integration initiatives may assist individuals at risk of withdrawing due to mental health difficulties to stay at university.
Other student attributes can also be used to predict student success. For example,
McKavanagh and Purnell (2007) described three traits of ''at risk'' students as being difficulty in maintaining motivation, unrealistic expectations about managing studies, and reluctance to seek help. Using data from 1100 interviews with students who were not academically progressing to a satisfactory degree, they found that negative interactions with the university impacted on motivation. Furthermore, over half of those students interviewed were working more than 30 hours per week, indicating lack of awareness as to what is required to
complete a university degree. Most relevant to the current research, the interviews found that only 12% of students had sought help once they identified that a problem existed.
1.2 Help Seeking
When faced with a mental health difficulty, perceiving and understanding that there is a need for help relies on mental health literacy. Mental health literacy is ''the ability to gain access to, understand and use information in ways that promote and maintain good mental health'' (Lauber et al. 2005, Background section, para. 1). In a review of the mental health literacy and help seeking literature, Hunt and Eisenberg (2010) reported that awareness of the need for help is one of the most significant barriers to help-seeking; therefore understanding and promoting mental health literacy is essential.
Yorgason et al. (2008) argued that it is insufficient for information to merely be posted somewhere on the university's website: universities should engage in improving awareness through commercial marketing techniques. Furthermore, access to counselling services should consider students' time constraints during what is likely to be a time of heightened anxiety and stress (if they are experiencing difficulties). Given the likelihood that as symptoms of mental illness progress it is less likely that individuals will actively seek treatment themselves, it is important for universities to proactively promote mental health literacy and help seeking. As well as promoting mental health and counselling, ensuring students remain engaged with the university is also important; students not attending campus or classes due to mental health concerns are even less likely to actively seek services.
The literature indicates a general lack of awareness of on-campus counselling services and minimal uptake of these services by university students. Lack of awareness of services is another major barrier to seeking help (Hunt & Eisenberg 2010). Yorgason et al. (2008) surveyed 266 undergraduate students on the connection between their mental health and knowledge and use of university mental health services. Those most in need of assistance cited lack of time (9% of overall sample) as the reason for not seeking help, followed by lack of knowledge (6% of overall sample). When asked about future help seeking behaviour, the same responses were most prevalent: 33% of the sample cited not enough time as a major barrier, followed by lack of knowledge (25%). Given these results, the authors highlight the importance of easy access to counselling services.
Eisenberg, Golberstein, and Gollust (2007), in a survey of over 2500 undergraduate and postgraduate university students, noted that while 30% of students had perceived a need for professional help for a mental health or emotional problem, in the last 12 months, only 15%
of students had actually sought help. Of those not seeking help, the most common reasons were believing that stress is normal at university, that they did not perceive a need for help, believing the problem would get better by itself, not having time, thinking "no one can understand my problems", and worrying about what others will think. The authors note that while the financial barriers to help seeking is generally not present in university student populations as on-campus counselling is generally free, there is still a significant gap between the perceived need for help and actual help seeking behaviour. Furthermore, the authors argue that improvements in access to counselling must be matched with efforts to improve mental health literacy, reduce stigma, and ensure adequate service provision once the student makes contact with the service.
1.3 Aims and Hypotheses
The aim of the study described in this paper was to investigate the role of integration as a predictor of attitudes towards help seeking over the course of the first year of study.
University integration is a convenient predictor variable to examine, as it is a construct that can be targeted for change through interventions conducted across students and within the classroom. As discussed, students come to university with a variety of pre-existing
attributes, some of which are not under the control of the university. Students develop mental health problems because of both university and non-university related issues. The institution is best placed to intervene in an area that is under its control, such as integration.
Based on a review of integration and help seeking research, it was hypothesized that expectations of integration at the start of semester would predict help seeking scores at the end of first semester and end of the year and that actual integration at the end of first semester would predict help seeking scores at the same time and at the end of the year.