Abstract
Background
University students are increasingly vulnerable to psychological distress, yet many do not seek professional mental health care. This study aimed to examine the prevalence of psychological distress, patterns of help-seeking behavior, and the barriers to accessing mental health services among Yemeni undergraduate students.
Methods
A cross-sectional online survey was conducted among 2,872 undergraduate students from 16 universities across Yemen. Psychological distress was screened using the General Health Questionnaire-28 (GHQ-28), and perceived barriers to care were assessed using the Barriers to Access to Care Evaluation (BACE-III) scale. Descriptive statistics, chi-square tests, logistic regression, and correlation analyses were performed to examine associations between demographic factors, psychological distress, and perceived barriers to care.
Results
Nearly half of the participants (49.7%) screened positive for psychological distress. Among those with psychological distress, 92.2% had not sought professional mental health care. The most commonly reported barriers included wanting to solve problems independently (69.2%), preference for traditional or religious healing methods (54.2%), and uncertainty about where to obtain professional care (52.2%). Additional barriers included discomfort discussing personal emotions (50.9%), lack of someone to facilitate access to care (50.2%), and concern about family perceptions (47.6%). Attitudinal and instrumental barriers were more frequently reported than stigma-related barriers. Logistic regression analysis identified female sex and a history of mental disorders as significant predictors of psychological distress.
Conclusion
Psychological distress appears to be common among Yemeni undergraduate students, while professional mental health care utilization remains very low. Attitudinal and practical barriers, particularly self-reliance and limited awareness of available services, may play an important role in discouraging help-seeking. Efforts to improve mental health literacy, expand accessible counseling services, and develop culturally appropriate support systems may help address unmet mental health needs among university students in Yemen.
Keywords: Psychological distress, Mental health care, Help-seeking behavior, Barriers, Undergraduate students
Background
Mental health is a fundamental component of overall well-being and influences an individual’s ability to cope with daily stressors, maintain productive activities, and participate meaningfully in society [1]. Mental disorders represent a major public health concern and are among the leading causes of disability worldwide [2]. Young adulthood is a particularly sensitive period for the onset of mental health problems, and the transition from high school to university often coincides with substantial academic, social, and personal changes [3]. During this period, students may encounter increased academic pressure, financial difficulties, social adjustments, and uncertainty regarding their future careers, all of which may contribute to psychological distress [4].
Studies conducted in different regions of the world indicate that university students experience considerable levels of mental health problems. Estimates suggest that between 12% and 50% of university students meet criteria for at least one mental health condition, with symptoms of anxiety, depression, and stress frequently reported within this population [5, 6]. Despite the availability of various mental health interventions, help-seeking behavior among young adults remains relatively low. Previous research has identified several factors that may discourage students from seeking professional support, including stigma surrounding mental illness, limited mental health literacy, cultural beliefs, and structural barriers such as financial costs and limited service availability [7]. These challenges may be particularly pronounced in low- and middle-income countries (LMICs), where mental health resources are often scarce and access to care remains limited [4].
In Yemen, the context of mental health is further complicated by years of armed conflict, economic instability, and ongoing humanitarian crises. These conditions have exposed large segments of the population to prolonged stress, trauma, and displacement, which may increase the risk of psychological problems [8]. At the same time, the country’s mental health care system remains severely under-resourced. Yemen currently has fewer than 0.5 psychiatrists per 100,000 people, and most available services are concentrated in major urban areas [9]. As a result, many individuals, including university students, may face considerable difficulties in accessing appropriate mental health care.
Although some studies have explored the prevalence of mental health problems in Yemen, there is still limited evidence regarding the factors that influence help-seeking behavior among young adults, particularly university students [10, 11]. In addition to structural barriers such as limited service availability and financial constraints, cultural attitudes, stigma, and uncertainty about where to obtain professional support may also play important roles in shaping help-seeking behavior.
Understanding these barriers is important for developing effective interventions and improving access to mental health services in resource-limited and conflict-affected settings. Therefore, this study aimed to assess the prevalence of psychological distress, describe patterns of help-seeking behavior, and identify perceived barriers to accessing professional mental health care among Yemeni undergraduate students.
Methods
Study design and study period
A cross-sectional study was conducted from December 2024 to February 2025 among undergraduate students from 16 universities in Yemen. The study aimed to assess the prevalence of psychological distress, examine patterns of help-seeking behavior, and identify perceived barriers to professional mental health care. Universities were selected to ensure geographic diversity and included both public and private institutions.
Sample size
The sample size was calculated using the OpenEpi sample size calculator [12]. The primary outcome of interest was the prevalence of psychological distress among undergraduate students. Based on a previous study conducted among university students in Egypt, the prevalence of psychological distress was estimated at 64.7% [13]. Assuming a 95% confidence level, 5% margin of error, and 80% statistical power, the minimum required sample size was calculated to be 340 participants.
Given that this study aimed to include students from multiple universities across Yemen and to improve the precision of subgroup analyses, we aimed to recruit a substantially larger sample. Therefore, the survey was distributed widely across participating universities, and data collection continued until a large multi-university sample was obtained. In total, 2,872 undergraduate students completed the questionnaire and were included in the final analysis.
Sampling and data collection approach
A convenience sampling approach was used. To encourage broad participation, the survey link, hosted on Google Forms, was distributed to students across all academic years through the participating universities’ official communication channels and student social media groups. Data collection commenced on December 1, 2024, and continued until the target sample size was reached. Participants were able to complete the anonymous questionnaire at their convenience. Because the survey was circulated through open networks, the total number of students reached could not be determined, precluding the calculation of a response rate. Electronic informed consent was obtained on the first page of the survey, and participants were required to confirm their consent before proceeding.
Study tools
The survey was divided into four sections to assess the study objectives comprehensively. The first section focused on demographic data such as participants’ sex, age, marital status, residence, living arrangements (e.g., living alone or with family), family history of mental illness, and parents’ educational levels. This information provided essential context for understanding the sociodemographic profile of the participants and their potential influence on mental health care utilization.
The second section utilized the General Health Questionnaire-28 (GHQ-28), an Arabic version of a validated self-reported screening instrument used under permission obtained from Mapi Research Trust (Special Terms No. 143019) to screen for symptoms of psychological distress. The GHQ-28 consists of 28 items grouped into four subscales: somatic symptoms (items 1–7), anxiety/insomnia (items 8–14), social dysfunction (items 15–21), and severe depression (items 22–28). A binary scoring method was applied, with a cut-off score of 9 used to classify participants as screening positive or negative for psychological distress. The Arabic GHQ-28 has demonstrated good validity and reliability, with a sensitivity and specificity of 0.83 in Arab populations, supporting its suitability for use in this study [14].
The third section assessed the utilization of mental health services for participants over the cut-off point on the GHQ-28.
Participants who screened positive for psychological distress were asked to indicate whether they had sought help for psychological or emotional problems and the primary source of help. Response options included: none, professional mental health care, religious or spiritual support, or other sources. This question aimed to identify the types of mental health care services accessed by students and the extent to which professional care was sought.
The fourth section evaluated barriers to mental health care using the Barriers to Access to Care Evaluation (BACE-III) Arabic Version. The Arabic version of the BACE-III scale consists of 28 items after removing two items, with both Cronbach’s alpha and McDonald’s Omega coefficients exceeding 0.9, indicating excellent reliability [15]. This scale measures stigma-related, attitudinal, and instrumental barriers to seeking professional mental health care. Each item is rated on a 4-point Likert scale: 0 (Not at all), 1 (Somewhat), 2 (Quite a lot), and 3 (A lot). Higher scores indicate greater perceived barriers. Barriers were summarized using both mean scores and response distribution, minor barrier (response = 1), or major barrier (responses of 2 “quite a lot” and 3 “a lot”, combined), as per the BACE-III manual for researchers. This scale provided detailed insights into the obstacles preventing students from accessing professional mental health care.
Statistical analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS version 27). Descriptive statistics (e.g., percentages, frequencies, means, and standard deviations) were used to summarize participants’ demographic characteristics and identify barriers to mental health care utilization. The Pearson chi-square test was used to examine associations between demographic variables, screening positive for psychological distress, and the need for professional mental health care. Binary logistic regression was employed to model the relationship between demographic variables and psychological distress, with adjusted odds ratios (AORs) and 95% confidence intervals were reported. All selected variables were entered simultaneously into the multivariable logistic regression model. Correlation analyses were conducted using Pearson correlation for continuous variables and point-biserial correlation for relationships involving dichotomous variables. Additionally, Python (with libraries such as Matplotlib and Seaborn) was used to create visualizations, including the stacked bar chart for the top barriers to accessing mental health care and the correlation heatmap exploring relationships between psychological distress, barriers to care, and family history of mental health conditions. Statistical significance was set at a p-value of less than 0.05.
Results
Demographic characteristics and psychological distress
The questionnaire was completed by 2872 undergraduate students, with females comprising 43.1% of the sample. Nearly half of the participants (49.7%) screened positive for psychological distress using the GHQ-28, with 59.7% of female students (740 out of 1239) screening positive. The participants’ ages ranged from 17 to 26 years, with a mean age of 23 (SD = 2.4). Most participants were single (72.1%), and 81.8% lived with their families. Additionally, 90.6% of the participants resided in urban areas (Table 1). Significant differences in psychological distress were observed according to sex, marital status, residence, family history of mental disorders, and treatment methods used.
Table 1.
Demographic characteristics of the study participants and those with psychological distress
| Variables | Total sample (n) % (N = 2872) |
Screened positive for psychological distress (n) % N = 1428 (49.7%) |
P value |
|---|---|---|---|
| Sex | < 0.001* | ||
| Female | 1239 (43.1) | 740 (59.7) | |
| Male | 1633 (56.9) | 688 (42.1) | |
| Age | |||
| Mean | 23 | 22 | |
| SD | 2.4 | 2.4 | |
| Minimum | 17 | 17 | |
| Maximum | 26 | 26 | |
| Residence | 0.03* | ||
| Urban | 2601 (90.6) | 1310 (50.4) | |
| Rural | 271 (9.4) | 118 (43.5) | |
| Faculty | 0.3 | ||
| Medial | 1476 (51.4) | 747 (50.6) | |
| Non-medical | 1396 (48.6) | 681 (48.8) | |
| Do you live alone | 0.6 | ||
| Yes | 2350 (81.8) | 1164 (49.5) | |
| No | 522 (18.2) | 264 (50.6) | |
| Marital status | 0.01* | ||
| Single | 2071 (72.1) | 1060 (51.2) | |
| Ever married | 801 (27.9) | 368 (45.9) | |
| Father education level | 0.1 | ||
| Secondary or below | 1151 (40.1) | 552 (48) | |
| Above secondary | 1721 (59.9) | 876 (50.9) | |
| Mother education level | 0.8 | ||
| Secondary or below | 1354 (47.1) | 676 (49.9) | |
| Above secondary | 1518 (52.9) | 752 (49.5) | |
| Means of treatment used | < 0.001* | ||
| No | 2052 (74.7) | 963 (46.9) | |
| Professional | 201 (7.3) | 111 (55.2) | |
| Religious | 380 (13.8) | 221 (58.2) | |
| Others | 114 (4.1) | 66 (57.9) | |
| History of mental disorder | < 0.001* | ||
| No | 2295 (79.9) | 1074 (46.8) | |
| Yes | 577 (20.1) | 354 (61.4) | |
Values in bold and marked with an asterisk (*) represent statistically significant results (p < 0.05)
Utilization of mental health care services
Of the 1428 participants who screened positive for psychological distress, 92.2% did not seek professional mental health care. Only 7.8% of students with psychological distress reported seeking professional mental health care (Table 2). In the overall sample, 7.3% reported seeking professional mental health care, 13.8% reported using religious forms of support, and 4.1% reported other sources of help (Table 1). Statistically significant differences were observed between those who did not seek professional mental health care based on the history of mental disorders only (Table 2).
Table 2.
The associathion between demographic variables and need for professional mental health care
| Variables | Seeking professional mental health care | P value | ||
|---|---|---|---|---|
| Total (N = 1428) |
Yes (n) % 111 (7.8%) |
No (n) % 1317 (92.2%) |
||
| Sex | 0.2 | |||
| Female | 740 | 64 (8.6) | 676 (91.4) | |
| Male | 688 | 47 (6.8) | 641 (93.2) | |
| Residence | 0.7 | |||
| Urban | 1310 | 101 (7.7) | 1209 (92.3) | |
| Rural | 118 | 10 (8.5) | 108 (91.5) | |
| Faculty | 0.5 | |||
| Medial | 747 | 55 (7.4) | 692 (92.6) | |
| Non-medical | 681 | 56 (8.2) | 625 (91.8) | |
| Do you live alone | 0.5 | |||
| Yes | 18 (6.8) | 246 (93.2) | ||
| No | 93 (8) | 1071 (92) | ||
| Marital status | 0.09 | |||
| Single | 1060 | 75 (7.1) | 985 (92.9) | |
| Ever married | 368 | 36 (9.8) | 332 (90.2) | |
| Father education level | 0.1 | |||
| Secondary or below | 552 | 50 (9.1) | 502 (90.9) | |
| Above secondary | 876 | 61 (7) | 815 (93) | |
| Mother education level | 0.3 | |||
| Secondary or below | 676 | 48 (7.1) | 628 (92.9) | |
| Above secondary | 752 | 63 (8.4) | 689 (91.6) | |
| History of mental disorder | < 0.001* | |||
| Yes | 354 | 39 (11) | 315 (89) | |
| No | 1074 | 72 (6.7) | 1002 (93.3) | |
Values in bold and marked with an asterisk (*) represent statistically significant results (p < 0.05)
Barriers to receiving professional mental health care
Barriers to accessing professional mental health care are summarized in Table 3. The barriers were ranked based on the percentage of responses indicating the extent of the barrier (i.e., not at all, a little, quite a lot, and a lot). The top six barriers were identified based on the highest percentage of participants reporting them as major barriers.
Table 3.
Barriers to receiving professional mental health care among students with psychological distress
| Questions | Not a barrier (Not at all stopped me) (n) row % |
Minor barrier (Stopped me a little) (n) row % |
Major barrier (“quite a lot” or “a lot”) (n) row % |
Mean (SD) |
|---|---|---|---|---|
| Stigma-related barriers | ||||
| Concern that I might be seen as weak for having a mental health problem | 549 (41.7%) | 345 (26.2%) | 423 (32.1%) | 0.90 (0.85) |
| Concern that it might harm my chances when applying for jobs | 455 (34.5%) | 349 (26.5%) | 513 (39.0%) | 1.04 (0.86) |
| Concern about what my family might think | 319 (24.2%) | 371 (28.2%) | 627 (47.6%) | 1.23 (0.82) |
| Concern that I might be seen as ‘crazy’ | 668 (50.7%) | 259 (19.7%) | 390 (29.6%) | 0.79 (0.87) |
| Concern that I might be seen as a bad parent | 686 (52.1%) | 256 (19.4%) | 375 (28.5%) | 0.76 (0.86) |
| Concern that people I know might find out | 537 (40.8%) | 314 (23.8%) | 466 (35.4%) | 0.95 (0.87) |
| Concern that people might not take me seriously if they found out I was having professional care | 555 (42.1%) | 302 (22.9%) | 460 (34.9%) | 0.93 (0.87) |
| Not Wanting a mental health problem to be on my medical records | 543 (41.2%) | 267 (20.3%) | 507 (38.5%) | 0.97 (0.89) |
| Concern that my children may be taken into care or that I may lose access or custody without my agreement | 716 (54.4%) | 216 (16.4%) | 385 (29.2%) | 0.75 (0.88) |
| Concern about what my friends might think, say, or do | 531 (40.3%) | 348 (26.4%) | 438 (33.3%) | 0.93 (0.85) |
| Concern about what people at work might think, say or do | 519 (39.4%) | 358 (27.2%) | 440 (33.4%) | 0.94 (0.85) |
| Feeling embarrassed or ashamed | 609 (46.2%) | 319 (24.2%) | 389 (29.5%) | 0.83 (0.85) |
| Total stigma score | 11 (7.3) | |||
| Attitudinal-related barriers | ||||
| Dislike talking about my feelings, emotions, or thoughts | 286 (21.7%) | 360 (27.3%) | 671 (50.9%) | 1.29 (0.8) |
| Wanting to solve the problem on my own | 140 (10.6%) | 266 (20.2%) | 911 (69.2%) | 1.59 (0.67) |
| Concern about the treatments available (e.g., medication side effects) | 338 (25.7%) | 303 (23.0%) | 676 (51.3%) | 1.26 (0.84) |
| Afraid of being put in hospital against my will | 481 (36.5%) | 209 (15.9%) | 627 (47.6%) | 1.11 (0.91) |
| Thinking that professional care probably would not help | 447 (33.9%) | 298 (22.6%) | 572 (43.4%) | 1.09 (0.87) |
| Thinking I did not have a problem | 393 (29.8%) | 370 (28.1%) | 554 (42.1%) | 1.12 (0.84) |
| Preferring to get help from family or friends | 367 (27.9%) | 306 (23.2%) | 644 (48.9%) | 1.21 (0.85) |
| Preferring to get alternative forms of care (e.g., traditional / religious healing or alternative /complementary therapies) | 321 (24.4%) | 282 (21.4%) | 714 (54.2%) | 1.30 (0.84) |
| Having had previous bad experiences with professional care for mental health | 932 (70.8%) | 176 (13.4%) | 209 (15.9%) | 0.45 (0.75) |
| Total attitude score | 10 (3.7) | |||
| Instrumental-related barriers | ||||
| Being too unwell to ask for help | 868 (65.9%) | 221 (16.8%) | 228 (17.3%) | 0.51 (0.77) |
| Not being able to afford the financial costs involved | 468 (35.5%) | 266 (20.2%) | 583 (44.3%) | 1.09 (0.88) |
| Difficulty taking time off education | 377 (28.6%) | 289 (21.9%) | 651 (49.4%) | 1.21 (0.86) |
| Problems with transport or travelling to appointments | 535 (40.6%) | 280 (21.3%) | 502 (38.1%) | 0.97 (0.88) |
| Being unsure where to go to get professional care | 374 (28.4%) | 255 (19.4%) | 688 (52.2%) | 1.24 (0.86) |
| Having no one who could help me get professional care | 403 (30.6%) | 253 (19.2%) | 661 (50.2%) | 1.20 (0.87) |
| Professionals from my own ethnic or cultural group not being available | 418 (31.7%) | 291 (22.1%) | 608 (46.2%) | 1.14 (0.87) |
| Total instrument score | 7 (4.0) | |||
| Total BACE score | 29 (11.9) | |||
The most commonly cited barrier was “Wanting to solve the problem on my own”, which 69.2% of participants identified as a major barrier. The second most common barrier was “Preferring alternative forms of care (e.g., traditional/religious healing)”, reported as a major barrier by 54.2% of participants. The third barrier was “Being unsure where to go to get professional care”, identified as a major barrier by 52.2% of participants. The fourth barrier was “Dislike talking about my feelings, emotions, or thoughts”, reported as a major barrier by 50.9% of participants. The fifth barrier was “Having no one who could help me get professional care”, identified as a major barrier by 50.2% of participants. The sixth barrier was “Concern about what my family might think”, reported as a major barrier by 47.6% of participants. These barriers are visualized in Fig. 1, which presents a stacked bar chart of the top six barriers to accessing mental health care among those who did not seek professional care.
Fig. 1.
Stacked bar chart for top 6 barriers to accessing mental health care among those who didn’t seek professional care
Regarding stigma-related barriers, the most cited one was “Concern about what my family might think”, which 47.6% of participants identified as a significant barrier. Instrumental-related barriers, such as “Not being able to afford the financial costs involved” and “Difficulty taking time off education”, were also significant, with 44.3% and 49.4% of participants, respectively, reporting them as major barriers (Table 3).
Predictors of psychological distress
In the multivariable logistic regression model, female sex and a history of mental disorders were significant predictors of psychological distress. Female students had higher odds of screening positive for psychological distress (AOR = 1.66), and students with a history of mental disorders were also more likely to experience psychological distress (AOR = 1.80) (Table 4).
Table 4.
Logistic regression analysis of factors associated with psychological distress
| Variables | Univariate Regression | Multivariate Regression | ||
|---|---|---|---|---|
| OR (95% C.I) | P-Value | OR (95% C.I) | P-Value | |
| Sex | ||||
| Female (reference) | 1 (r) | < 0.001* | 1 (r) | < 0.001* |
| Male | 0.49 (0.42–0.57) | 0.51 (0.44–0.6) | ||
| Residence | ||||
| Rural | 1 (r) | 0.03* | 1 (r) | 0.1 |
| Urban | 1.32 (1.02–1.69) | 1.21 (0.93–1.58) | ||
| Marital Status | ||||
| Single (reference) | 1 (r) | 0.01* | 1 (r) | 0.003* |
| Ever married | 0.81 (0.68–0.95) | 0.77 (0.65–0.91) | ||
| Means of treatment used | ||||
| No | 1 (r) | 1 (r) | ||
| Professional | 1.39 (1.04–1.86) | 0.02* | 1.3 (0.96–1.76) | 0.08 |
| Religious | 1.57 (1.26–1.96) | < 0.001* | 1.45 (1.15–1.82) | < 0.001* |
| Others | 1.55 (1.06–2.27) | 0.02* | 1.4 (0.95–2.07) | 0.08 |
| History of mental disorder | ||||
| No | 1 (r) | < 0.001* | 1 (r) | < 0.001* |
| Yes | 1.8 (1.49–2.17) | 1.69 (1.39–2.06) | ||
Values in bold and marked with an asterisk (*) represent statistically significant results (p < 0.05)
Correlation analysis
A correlation heatmap was created to explore the relationships between psychological distress, barriers to mental health care, and family history of mental health conditions (Fig. 2). Correlation analysis showed a moderate positive association between psychological distress and total BACE score (r = 0.483, p < 0.01), as well as a strong positive correlation between total stigma score and total BACE score (r = 0.883, p < 0.01). A moderate positive correlation was observed between psychological distress and total stigma (r = 0.427, p < 0.01). Family history of mental disorders showed weak but statistically significant correlations with psychological distress (r = 0.126, p < 0.01) and total BACE score (r = 0.101, p < 0.01).
Fig. 2.
Correlation Heatmap: Psychological distress, Barriers to mental health care, and family history of mental health conditions
Discussion
This study found a high prevalence of psychological distress among Yemeni undergraduate students, with nearly half (49.7%) of participants screening positive on the GHQ-28. Female students were disproportionately affected, with approximately 60% reporting significant distress. These findings suggest considerable mental health vulnerability among university students in Yemen, particularly among women who may face additional stress related to gender-specific social expectations and limited support systems. The results may also reflect the broader context of Yemen’s prolonged conflict, economic instability, and limited access to mental health services [8]. Significant associations between psychological distress and factors such as sex, marital status, urban residence, and a family history of mental illness are consistent with findings from similar populations in low- and middle-income countries [13]. Together, these findings emphasize the importance of addressing student mental health through culturally and contextually appropriate strategies.
When compared to findings from other countries, the prevalence of psychological distress among Yemeni university students in our study (49.7%) is notably high but falls between reported rates from Egypt and Ethiopia. A study conducted among Egyptian undergraduates found a higher prevalence of psychological distress at 64.7%, with 90.3% of those affected recognizing the need for professional mental health care [13]. In contrast, a study in Ethiopia reported a lower prevalence of psychological distress symptoms at 34.6%, and 70.5% of distressed individuals expressed a perceived need for care [16]. In Saudi Arabia, 33.6% of participants showed signs of depression, and although 42.5% acknowledged a need for mental health services, only 16.2% actually accessed them in the past year [17]. In our study, despite nearly half of participants screening positive for distress, an alarming 92.2% did not seek professional mental health care. This suggests that Yemeni students may face even greater barriers to accessing support compared to their peers in other low- and middle-income countries, likely associated with a combination of stigma, lack of awareness, limited-service availability, and the broader consequences of prolonged conflict [18].
The present study also showed that female students were significantly more likely than males to experience psychological distress, with 59.7% screening positive. This finding highlights the need for targeted mental health support for female students. Similar gender differences have been reported in studies conducted in Saudi Arabia and Egypt, where female students were more likely to report psychological symptoms than their male counterparts [13, 17]. One possible explanation for this difference is the social and cultural challenges that women may face in Yemen. In some contexts, customary or tribal norms may restrict women’s autonomy and limit their participation in social and economic activities, potentially correlating with higher levels of psychological stress [19, 20]. Reports of gender-based violence and early marriage in Yemen may also be linked to psychological vulnerability among young women [21]. These social stressors may compound academic and personal pressures experienced during university life.
A positive correlation was observed between psychological distress and total BACE scores, suggesting that students experiencing higher levels of distress also perceived greater barriers to accessing professional care. This relationship may reflect a reinforcing cycle in which psychological symptoms coexist with perceived obstacles to help-seeking [7].
In the logistic regression model, female sex and a history of mental disorders were significant predictors of psychological distress. Students with a family history of mental disorders may have increased exposure to mental health challenges within their families, which could be associated with greater psychological vulnerability. At the same time, previous research suggests that individuals with such experiences may also have greater awareness of mental health issues and available services [22, 23].
Interestingly, our study found no significant difference in psychological distress between medical and non-medical students. This finding aligns with results from a similar study conducted in Egypt, where both groups reported comparable levels of distress [13]. However, this result contradicts other studies, including those conducted in various regions, which reported significantly higher distress levels among medical students associated with academic pressure, long hours of study, and emotional strain related to clinical exposure [24, 25]. The absence of such a difference in our context may be attributed to broader social and environmental stressors affecting students in Yemen, such as political instability, economic hardship, and the psychological impact of prolonged conflict. These factors may overshadow program-specific academic stress [8, 11]. Furthermore, we observed no significant difference between medical and non-medical students in their likelihood of seeking professional mental health care. This is notable, as medical students might be expected to have greater awareness of mental health conditions and available services. Their reluctance to seek help may reflect persistent stigma, lack of trust in the mental health system, or professional expectations to appear resilient [7].
Regarding barriers to help-seeking, the most frequently reported obstacle was the desire to solve problems independently, cited by 69.2% of participants. This finding suggests that many students prefer to manage psychological difficulties on their own rather than seek formal care. Such attitudes may be related to beliefs in personal resilience, concerns about stigma, or uncertainty about the effectiveness of professional mental health treatment [26]. In contexts where mental health services are limited or poorly understood, self-reliance may become a common coping strategy [18].
The second most frequently reported barrier was a preference for alternative forms of care, including traditional or religious healing methods (54.2%). This finding likely reflects the cultural importance of religious and community-based coping strategies in Yemeni society, where spiritual practices may play a central role in addressing emotional distress [11, 27]. While such practices can provide important sources of support, reliance on them alone may delay or prevent individuals from seeking professional care when needed.
Other commonly reported barriers included uncertainty about where to obtain professional care (52.2%) and discomfort discussing personal emotions or problems (50.9%). These findings suggest gaps in mental health literacy and awareness of available services among students. Addressing these gaps through targeted educational initiatives and campus-based support services may help improve help-seeking behavior.
The lack of someone to assist in accessing care (50.2%) was another commonly reported barrier and may reflect both limited social support and insufficient institutional guidance within universities [28]. Concern about family perceptions was also frequently reported (47.6%) and emerged as the most prominent stigma-related barrier. This highlights the important role that family attitudes may play in shaping help-seeking behavior in collectivist cultural contexts [29, 30].
Overall, our findings suggest that attitudinal and instrumental barriers may play a greater role than stigma alone in discouraging students from accessing mental health care. Similar patterns have been reported in other studies conducted in settings where mental health services are limited or poorly integrated into existing health systems [13, 31, 32]. Nevertheless, stigma remains an important consideration, particularly in conservative social contexts where mental illness may be misunderstood or associated with shame.
Based on these findings, several strategies may help improve access to mental health care among university students in Yemen. Universities could implement mental health awareness initiatives aimed at improving mental health literacy and reducing stigma. Expanding access to campus-based counseling services and strengthening peer support systems may also encourage students to seek help. In addition, involving religious and community leaders in mental health advocacy may help bridge the gap between traditional coping practices and professional mental health care. At the national level, strengthening mental health infrastructure and expanding the mental health workforce will be essential for addressing the growing mental health needs of young people in conflict-affected and resource-limited settings such as Yemen.
Limitations
This study has several limitations that should be acknowledged. First, the use of a self-administered online questionnaire may have introduced response bias, as students experiencing greater psychological distress or stronger interest in mental health topics may have been more likely to participate. Second, the reliance on a convenience online sampling strategy is an important methodological limitation, as it may have introduced selection bias and reduces the overall representativeness of the sample. Furthermore, because the survey link was disseminated through open university communication channels, we were unable to calculate a response rate. Consequently, these findings cannot be assumed to represent all Yemeni undergraduate students, and any generalizations should be made with caution. Third, the cross-sectional design of the study prevents establishing causal relationships between psychological distress and the associated factors identified in this study. Additionally, information on help-seeking behavior and perceived barriers was based on self-reported responses, which may be influenced by recall bias or social desirability. Moreover, help-seeking behavior was evaluated using a single self-reported item, which limits the depth and precision with which service utilization can be assessed. Finally, although the study included students from multiple universities across Yemen, the online recruitment strategy may have resulted in the underrepresentation of students from rural areas or those with limited internet access, potentially affecting the overall distribution of participants.
Conclusion
This study found a high prevalence of psychological distress among Yemeni university students, with nearly half of participants screening positive for distress and the majority not seeking professional mental health care. Attitudinal and instrumental barriers, particularly the preference to manage problems independently and uncertainty about where to obtain professional help, emerged as the most commonly reported obstacles to care. Stigma-related concerns, especially those related to family perceptions, were also frequently reported, although they appeared to play a less dominant role compared with other barriers.
These findings highlight the importance of improving mental health awareness, expanding access to student counseling services, and addressing practical barriers that limit help-seeking among university students. Strengthening mental health support systems within universities and integrating culturally appropriate mental health initiatives may help reduce unmet mental health needs among students, particularly in conflict-affected and resource-limited settings such as Yemen.
Acknowledgements
We would like to express our deepest gratitude to the Yemeni medical student community for their invaluable support and active participation in this research. Their collaboration, commitment, and enthusiasm toward advancing medical knowledge were fundamental to the success of this study. Our heartfelt thanks go to Professor Abdulwahab Al-Mutahhar for his exceptional mentorship and unwavering support throughout this project. His insightful guidance, constructive feedback, and continuous encouragement greatly enriched the quality and direction of our work. We are also sincerely grateful to Dr. Shahd AlQato for her kind support and motivation throughout this journey; her presence was a source of inspiration during the entire research process. Special thanks are extended to the following individuals who contributed to the data collection phase in a supporting capacity: Asmaa Moazeb, Hadeel Al-Ashwal, Hind Al-Sabry, Maryam Algwmari, and Sarah Mohammed Alsabry. Their assistance, though in minor roles, played a meaningful part in the completion of this study.
Clinical trial number
Not applicable.
Authors' contributions
MB, MT, and NA contributed equally to this work. The conception and design of the study were carried out by MB, MT, NA, AME and MMA. Data acquisition was performed by MB, MT, NA, MRA, and ES. Analysis and interpretation of data were conducted by MB, MT, AME and ZMO. Drafting of the manuscript was undertaken by MB, MT, and SA. Critical revision of the manuscript for important intellectual content was done by AA, HZM, AME and MA. All authors reviewed and approved the final version of the manuscript to be published.
Funding
None.
Data availability
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.
Declarations
Ethical approval and consent to participate
The methods employed in this study adhered to the principles outlined in the Declaration of Helsinki and its subsequent amendments. Ethical approval was obtained from the Institutional Review Board at Sana’a University (Approval No. 2396). Participation in the study was entirely voluntary, anonymous, and without any form of compensation. The objectives of the study were clearly explained on the first page of the online questionnaire. Participants provided electronic informed consent before beginning the survey and were free to withdraw at any point without any consequences.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Mohamed Baklola, Mohamed Terra and Naji Al-bawah contributed equally to this work.
Contributor Information
Mohamed Baklola, Email: Mohamedbaklola2000@gmail.com.
Mohamed Terra, Email: Mohamedtera75@gmail.com.
Naji Al-bawah, Email: Najialbawah@gmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.