Exploring mental health literacy and barriers to seeking counselling among university students in Lebanon: a cross-sectional study

Abstract

Objectives

This study aims to assess the level of mental health literacy (MHL) and identify its associated factors among undergraduate university students in Lebanon. A secondary objective is to evaluate the Global Barriers to Counselling scores, their associated factors, and to examine their relationship with MHL.

Design

Cross-sectional study using an online self-administered questionnaire.

Setting

University-level educational settings in Lebanon, including students from both public and private institutions across multiple regions.

Participants

This study enrolled undergraduate students of all academic disciplines using a convenience sampling technique. Inclusion criteria included being 18 years and above, currently enrolled at university, able to comprehend the English language and consenting to participate.

Primary and secondary outcome measures

Primary outcomes: MHL scores, using the Mental Health Literacy Scale (MHLS); and Global Barriers to Counselling score, using the Revised Fit, Stigma and Value Scale (RFSV). Secondary analysis examined factors associated with MHLS score and Global Barriers to Counselling scores using multivariable linear regression.

Results

A total of 572 participants (65.0% female; mean age 21.1±3.7 years) were included. Most were Lebanese (87.4%). The median MHLS score was 86 (IQR 77–95), indicating generally good MHL. Factors associated with lower MHLS were male gender (β=−4.17, 95% CI −7.18 to −1.16, p=0.007) and being of non-Lebanese nationality (β=−6.26, 95% CI −11.06 to −1.46, p=0.011). Presence of a previous mental health diagnosis was associated with a higher MHLS score (β=5.32, 95% CI 1.43 to 9.22, p=0.008). The Global Barriers to Counselling score had a median of 28.7 (IQR 23.21–36.21). Male gender was significantly associated with a higher barrier score (β=3.44, 95% CI 4.85 to 5.04, p<0.001). Factors associated with lower barrier score were attending a mental health seminar in the past (β=−2.00, 95% CI −3.91 to −0.09, p=0.04), and having a higher MHLS score (β=−0.14, 95% CI −0.21 to −0.07).

Conclusion

This study highlights good overall MHL among undergraduate university students in Lebanon, with variations based on gender, nationality and prior mental health exposure. Higher mental health literacy was associated with fewer perceived barriers to seeking counselling. These findings emphasise the need for tailored mental health initiatives in Lebanese universities that promote literacy, reduce stigma and enhance help-seeking behaviour across diverse student populations.

Correspondence to Dr Samar Younes; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• This study included a large and diverse sample of university students from multiple disciplines across Lebanon using a validated questionnaire to assess mental health literacy and help-seeking attitudes.

• The study employed multivariable regression to account for potential confounders and identify independent associations.

• The online survey method may have excluded students with limited internet access or poor English proficiency, introducing selection bias.

• The cross-sectional nature of the study limits the ability to infer causal relationships.

Introduction

Mental health burden in university students

Mental health issues account for nearly one-third of illnesses in adolescence and young adulthood. These conditions, if left untreated, often persist into adulthood and contribute to diminished professional achievement, impaired interpersonal relationships and reduced life expectancy.¹ Mental health is defined as a dynamic state of internal equilibrium. Its essential components include cognitive and social skills, the capacity to identify, express and regulate one’s emotions and the ability to empathise with others. Additionally, it is characterised by flexibility and resilience in facing challenging life events, the ability to perform social roles effectively and maintaining a harmonious balance between the mind and body.²

Higher education is a pivotal phase for young adults, filled with opportunities for personal and intellectual growth. However, it also presents challenges such as identity formation, emotional regulation and stress management.³ University students, particularly those lacking emotional literacy education, often experience depression, anxiety and feelings of isolation.⁴ Institutions are working to support mental health, but stigma, concerns about confidentiality and access issues remain significant barriers.⁵ The prevalence of mental health issues among university students has become a major public health concern. The transition to university life, characterised by newfound independence and academic pressures, often leads to stress, anxiety and depression. According to surveys done by the American College Health Association, 40% of American college students report severe depression, while 60% suffer from overwhelming anxiety.⁶ Substance abuse, including alcohol and drug use, is also common and often linked to mental health issues.⁷

Role and importance of mental health literacy

One of the key elements in promoting mental health, preventing mental disorders and providing research-backed mental healthcare is mental health literacy (MHL).⁸ MHL, initially derived from the concept of health literacy, was introduced by Jorm and colleagues who defined it as “knowledge and beliefs about mental disorders which aid their recognition, management, or prevention”.⁹ Over time, this definition has been expanded to encompass four key components: understanding how to achieve and maintain good mental health, comprehending mental disorders and their treatments, reducing the stigma associated with mental disorders and improving help-seeking efficacy.¹⁰

The fact that young adults have the highest rates of mental illness but the lowest access to mental healthcare highlights the need for improved MHL and better access to care. Increased MHL among young adults and the general public is crucial for early detection and appropriate response to psychological issues.¹¹ Studies have linked higher MHL to reduced stigma, improved identification and treatment of mental illnesses, and a greater willingness to disclose mental health problems. Consequently, higher MHL can lead to earlier intervention, better outcomes and more positive attitudes toward seeking help.¹² Universities can support students by fostering a culture that values well-being and providing mental health education, training and support networks. Addressing barriers such as financial concerns, lack of providers, logistical challenges, cultural and language barriers, fear of medication and absence of social support is essential for improving access to mental healthcare.¹³

Barriers to help-seeking and gender/cultural influences

In the Lebanese society, and according to Abi Doumit et al, Lebanese families often deny the existence of mental illness, and many individuals avoid seeking professional help due to fear of societal reactions. Similar to other Arab countries, misconceptions and stigma about mental illness are prevalent in Lebanon. Religion significantly influences beliefs about sin, the causes and treatment of mental illness. Families are responsible for caring for mentally ill individuals and generally hold negative attitudes towards psychiatric services, taking considerable time to accept the need for professional care. Indeed, better attitudes are associated with greater knowledge, and familiarity with mental illness, whether through friends or acquaintances, also correlates with more positive attitudes. Abi Doumit et al recommended further research to assess the relationship between age and knowledge about mental illness, since it remained controversial.¹⁴ Another study revealed that while the Lebanese population has an average understanding of mental health, certain stigmatising attitudes persist alongside sympathetic views toward those affected. Incorporating mental health into the national education curriculum and running anti-stigma campaigns, in collaboration with non-governmental organisations (NGOs) and local healthcare centres, are essential strategies to enhance MHL in Lebanon, since it was found that a positive relationship exists between taking mental health courses and improved knowledge and beliefs.¹⁵ One study dived in MHL of Lebanese university students, this study showed similar results to the previous studies regarding gender and religious factors. It showed no association between parental education and MHL of the university students. Most importantly, it assured again that direct education in psychology is the most effective predictor of MHL among university students compared with other variables.¹⁶

Mental health issues are prevalent among university students in Lebanon due to unique stressors such as academic pressure and political instability. These students are a part of the Lebanese population who are expected to suffer from poor mental health due to immense challenges, distress and adverse events on the social, political and financial aspects.¹⁷ Furthermore, the higher education system in Lebanon comprises more than 40 universities, with a mix of public and private institutions offering instruction primarily in English or French. While some universities provide basic counselling services, the availability of structured mental health support remains inconsistent and underused. Moreover, the stigma associated with mental illness in Lebanese society often translates into low awareness, underfunded mental health programmes and a lack of trained staff within student services. These systemic gaps further compound students’ mental health burdens and make research on this population especially critical. This study is crucial for several reasons. It aims to bridge knowledge gaps by assessing MHL among Lebanese university students, which is essential for enhancing mental health management and outcomes. By identifying the barriers to seeking counselling services, the study seeks to implement targeted interventions that reduce stigma and encourage more students to seek the help they need. The findings can inform policymakers and educational institutions, guiding them in creating supportive environments and programmes tailored to students’ mental health needs, thereby fostering a healthier campus culture. Additionally, the study provides valuable insights specific to the Lebanese context.

The objective of this study was to evaluate the level of MHL and its associated factors among undergraduate university students across various regions in Lebanon. Additionally, the research aimed to evaluate barriers to seeking counselling, its associated factors and its relationship with MHL.

Methods

Study design

This study employed a cross-sectional survey design to assess mental health literacy and barriers to seeking help among undergraduate university students across various regions in Lebanon. The study was conducted between February and May 2024, knowing that the questionnaire was sent online via an electronic link (Google Form).

Patient and public involvement

This study did not involve patients or members of the public in the design, conduct, reporting or dissemination plans of the research. The research team independently designed the study, collected data and performed the analysis.

Participants

The study involved undergraduate students who were recruited from various academic disciplines to ensure a diverse sample. A convenience sampling approach was used. Participants were recruited from multiple public and private universities across Lebanon through email invitations, faculty coordinators, student WhatsApp groups and social media platforms to ensure diverse institutional representation. Inclusion criteria were as follows: students who were enrolled in an undergraduate programme in a private or public university in Lebanon during the spring semester 2023–2024, aged 18 years or older and able to comprehend and respond to the survey in English. Exclusion criteria included students who were not enrolled at the time of the study or those who did not provide informed consent.

Data collection

Data collection was conducted through an online survey using the Google platform, ensuring easy access and anonymity for participants. To ensure data quality, survey settings restricted participants to a single submission using their university email address. All questions were mandatory, which resulted in a fully complete dataset. No duplicate or suspicious entries were identified. The survey remained open for 4 months to allow adequate time for participation.

The structured questionnaire consisted of questions that covered several areas divided into three sections. The first section addressed the participants’ sociodemographic data. In the second and third sections, two scales that served the purpose of the study were included, which are the Mental Health Literacy Scale (MHLS) and the Revised Fit, Stigma and Value Scale (RFSV) (online supplemental file 1).

Demographic information

This section collected essential demographic data to contextualise the findings. The variables included: age, gender, nationality, place of living, marital status, major and year of study, smoking status, alcohol status, monthly household income and health insurance. Furthermore, participants were asked about their experience with mental health (ie, have they previously attended any lecture or seminar about mental health, have any mental health conditions been diagnosed, has anyone in their family or circle of friends received a mental health diagnosis and which resources did they use to learn about mental health disorders).

Mental Health Literacy Scale

This shortened version of the scale consists of 27 questions to assess MHL. It evaluates the ability to recognise mental health disorders, understand symptoms, risk factors, effective treatments and self-help strategies. It also measures knowledge of seeking information and professional help, recognising mental health terms and understanding the prevalence and impact of mental health conditions. Participants were presented with variations of Likert scales for each instrument question. The scale has a minimum score of 27 and a maximum grade of 120. A higher score indicates that the respondent has high MHL, while lower scores indicate less understanding of MHL.¹⁸

Revised Fit, Stigma and Values Scale

This scale comprises 14 questions aimed at evaluating individuals’ barriers to seeking counselling. This scale assesses several key areas: perceived stereotypes and prejudices against individuals with mental health conditions, personal attitudes towards those experiencing mental health issues and the willingness to engage and interact with individuals affected by mental health problems. Additionally, the RFSV includes questions that explore the values and cultural beliefs that might influence one’s perceptions of mental health. A composite score, referred to as the Global Barriers to Counselling Scale, was computed by averaging responses across the three subscales. This global score served as a summary measure of perceived help-seeking barriers in the present analysis.

The English versions of both instruments were used, given that English is the primary language of instruction in most participating institutions. Prior to deployment, a bilingual panel of public health experts reviewed the scales for cultural appropriateness, item clarity and local relevance. Although the MHLS and RFSV had not been previously validated in Lebanon, both scales demonstrated satisfactory internal consistency in our sample.

Sample size calculation

The CDC Epi-Info software for population surveys was used to calculate the required minimum sample size. Assuming 80 000 students are registered in the Lebanese universities, the required calculated sample size was 383 with a confidence level of 95% and a 5% margin of error. A total of 572 students were recruited in the present study. A larger sample size was targeted in order to allow for additional analyses and account for missing variables.

Statistical analysis

Variables were described as mean±SD or median (IQR) for continuous variables, and as frequency (percentage) for categorical variables. Bivariate analysis was conducted using Student’s t-test or one-way analysis of variance as appropriate to determine association with the MHLS scores and the Global Barriers to Counselling Scales score. Correlations between the two scores and with other variables were evaluated using Spearman’s correlation coefficient. The internal consistency of MHLS and Global Barriers to Counselling Scales was tested by computing Cronbach’s α. Multivariable analysis was conducted using two linear regression models to identify independent associations with MHLS score and the Global Barriers to Counselling Scales score. Variables yielding p values less than 0.2 in the bivariate analysis were included in the multivariable analysis. Statistical significance was set at 0.05. There were no missing data in the dataset; thus, all analyses were conducted on complete cases without the need for imputation or data exclusion. All statistical analyses were done using SPSS V.27. Forest plots were constructed using R V.4.4.1.

Results

Demographic, socioeconomic and mental health-related characteristics

Characteristics of the study population are summarised in table 1. The study sample comprised a total of 572 participants, with the majority being female (65.0%, n=372). Mean age (±SD) was 21.1±3.7 years. Regarding nationality, the predominant group was Lebanese, accounting for 87.4% (n=500), while 12.6% (n=72) represented other nationalities. The participants were distributed across various academic schools, with the majority (n=242, 42.3%) enrolled in arts and sciences, 17.3% and 17% in business and pharmacy, respectively, 11.0% (n=63) in engineering, 4.5% (n=26) in education, 1.0% (n=6) in medicine and 6.8% (n=39) in other fields. When considering the academic year, most participants were in their first year (37.1%, n=212), followed by second-year students (24.8%, n=142) and a smaller proportion in their fifth year or above (3.1%, n=18).

Table 1

Demographic, socioeconomic and mental health-related characteristics of the study participants (N=572)

Variable	N (%)
Gender
Female	372 (65.0)
Male	190 (33.2)
Nationality
Lebanese	500 (87.4)
Other	72 (12.6)
School
Arts and sciences	242 (42.3)
Business	99 (17.3)
Pharmacy	97 (17.0)
Engineering	63 (11.0)
Others	39 (6.8)
Education	26 (4.5)
Medicine	6 (1.0)
Academic year
First	212 (37.1)
Second	142 (24.8)
Third	149 (26.0)
Fourth	51 (8.9)
Fifth and above	18 (3.1)
Monthly income (N=273)
<6 000 000 LBP	54 (19.7)
6 000 000–15 000 000 LBP	76 (27.8)
>15 000 000 LBP	143 (52.3)
Health insurance
Yes	324 (56.6)
No	248 (43.4)
Marital status
Married	26 (4.5)
Separated/divorced/widowed	5 (0.9)
Single	541 (94.6)
Smoking status*
No	313 (54.7)
Yes, current smoker	146 (25.5)
Yes, previous smoker	113 (19.8)
Alcohol consumption
No	478 (83.6)
Yes, frequently†	15 (2.6)
Yes, occasionally‡	79 (13.8)
Sources of information on mental health
None	21 (3.7)
Scientific sources	471 (82.3)
Media	411 (71.9)
Family/friends	427 (74.7)
Multiple sources	481 (84.1)
Previously attended a lecture or seminar about mental health	142 (24.8)
Previously diagnosed with a mental health disorder	110 (19.2)
Family member/friend previously been diagnosed with a mental health disorder	187 (32.7)

*Smoking included cigarettes, e-cigarettes, nargileh, vaping devices.

†Frequently: more than once weekly.

‡Occasionally: once weekly or less.

In terms of socioeconomic status, 19.7% (n=54/273) reported a monthly income of less than 6 000 000 LBP, and the majority of participants (56.6%) had health insurance.

Smoking status showed that 54.7% (n=313) were non-smokers, 25.5% (n=146) were current smokers and 19.8% (n=113) were previous smokers. In terms of alcohol consumption, 83.6% (n=478) did not consume alcohol, 2.6% (n=15) reported frequent consumption and 13.8% (n=79) consumed alcohol occasionally.

Participants’ sources of information on mental health were varied, with the majority (84.1%, n=481) relying on multiple sources. Scientific sources were used by 82.3% (n=471), information from family and friends by 74.7% (n=427) and media by 71.9% (n=411). Additionally, 24.8% (n=142) had previously attended a lecture or seminar on mental health, 19.2% (n=110) had been diagnosed with a mental health disorder and 32.7% (n=187) reported that a family member or friend had been diagnosed with a mental health disorder.

Mental Health Literacy Scale scores

The MHLS score ranged between 47 and 112 and had a median (IQR IQR) of 86 (77–95), indicating good MHL among study participants. MHLS showed good internal consistency with Cronbach’s α=0.736.

Bivariate analysis for factors associated with MHLS score

Bivariate associations with the MHLS scores are presented in table 2. Females scored significantly higher than males, with a mean of 87.53±11.63 for females and 82.08±12.76 for males (p<0.001). Lebanese participants had significantly higher MHLS scores (86.47±12.29) compared with non-Lebanese participants (81.15±11.88) (p=0.001). Significant differences were found between academic disciplines (p<0.001) with medicine students having the highest MHLS scores (90.17±11.79), and engineering students having the lowest scores (81.51±11.81). There were no significant differences in MHLS scores across different academic years (p=0.998).

Table 2

Bivariate associations with MHLS and global barriers to counselling scale

Variable	MHLS			Global Barriers to Counselling score
	Mean	±SD	P value	Mean	±SD	P value
Gender
Female	87.53	±11.63	<0.001	27.90	±9.74	<0.001
Male	82.08	±12.76		32.66	±9.94
Nationality
Lebanese	86.47	±12.29	0.001	29.46	±9.98	0.547
Other	81.15	±11.88		30.22	±10.36
School
Arts and sciences	87.69	±11.69	<0.001	29.47	±9.75	0.150
Business	84.59	±14.10		29.43	±10.00
Education	89.92	±11.65		25.89	±8.68
Engineering	81.51	±11.81		32.09	±9.98
Medicine	90.17	±11.79		31.57	±9.74
Others	80.79	±12.32		30.88	±11.28
Pharmacy	85.75	±11.43		28.55	±10.36
Academic year
First	85.54	±12.54	0.998	29.82	±10.22	0.312
Second	85.78	±12.63		29.32	±8.85
Third	86.24	±12.32		29.65	±10.31
Fourth	85.67	±11.26		30.66	±10.92
Fifth	85.86	±12.20		23.74	±10.49
Sixth	85.55	±13.07		24.56	±11.40
Monthly income
<6 000 000 LBP	82.03	±12.26	0.140	30.05	±10.80	0.208
6 000 000–15 000 000 LBP	85.64	±11.94		27.84	±9.26
>15 000 000 LBP	85.81	±12.94		29.61	±9.48
Health insurance
Yes	87.61	±12.29	<0.001	29.32	±10.43	0.520
No	83.43	±12.05		29.86	±9.46
Marital status
Married	85.77	±11.20	0.845	31.00	±12.29	0.74
Separated/divorced/widowed	89.00	±11.90		19.87	±7.45
Single	85.77	±12.43		29.57	±9.89
Smoking status
No	85.73	±12.01	0.210	29.34	±9.79	0.218
Yes, current smoker	85.92	±13.08		30.23	±11.02
Yes, previous smoker	85.82	±13.99		29.25	±9.49
Alcohol consumption
No	85.44	±12.17	0.044	29.36	±9.86	0.06
Yes, frequently	82.00	±15.20		35.60	±12.63
Yes, occasionally	88.72	±12.56		29.54	±10.19
Sources of information on mental health
None	80.19	±13.98	0.140	31.48	±11.92	0.481
Scientific sources	84.90	±11.57		30.01	±9.58
Media	91.25	±13.13		24.92	±11.08
Family/friends	86.22	±16.54		30.06	±10.94
Multiple sources	85.94	±12.00		29.53	±9.89
Previously attended a lecture or seminar about mental health
No	85.41	±11.98	0.190	30.20	±9.68	0.007
Yes	86.98	±13.40		27.59	±10.78
Previously been diagnosed with a mental health disorder
No	84.19	±12.00	<0.001	29.87	±9.75	0.123
Yes	92.55	±11.53		28.23	±11.02
Family member or friend previously been diagnosed with a mental health disorder
No	84.33	±12.00	<0.001	30.11	±9.79	0.054
Yes	88.82	±12.55		28.39	±10.40

MHLS, Mental Health Literacy Scale.

Participants who had been diagnosed with a mental health disorder had significantly higher MHLS scores (92.55±11.53) than those without a diagnosis (84.19±12.00) (p<0.001). Also, participants with a family member or friend previously diagnosed with a mental health disorder had significantly higher MHLS scores (88.82±12.55) compared with those who did not (84.33±12.00) (p<0.001). Participants with health insurance had significantly higher MHLS scores (87.61±12.29) than those without (83.43±12.05) (p<0.001). Participants who reported occasional alcohol consumption had higher MHLS scores, compared with non-drinkers and frequent drinkers (p=0.044).

No significant correlation was found with age (table 3). No significant association was found between MHLS scores and income, marital status or smoking status. Also, no significant difference in score was found according to sources of information on mental health, or for participants who attended a mental health lecture/seminar.

Table 3

Correlation matrix of global barriers to counselling score, MHLS score and age

	Global Barriers to Counselling score	MHLS score
Global barriers to counselling score
MHLS score	r=−0.230 p <0.001
Age	r=−0.015 p=0.718	r=−0.065 p=0.123

MHLS, Mental Health Literacy Scale.

Multivariable analysis for factors associated with MHLS score

On multivariable analysis (figure 1), variables that had significant associations with MHLS scores were gender, nationality and having a previous mental health disorder diagnosis.

Figure 1. Forest plot of the multiple linear regression with MHLS score as dependent variable. Method: enter, analysis of variance p value: 0.003, r²=0.128. Residuals were approximately normally distributed with no extreme outliers. All variance inflation factors were below 2.75. MHLS, Mental Health Literacy Scale.

Being male was associated with a decrease in the MHLS score by 4.17 units compared with females (95% CI −7.18 to −1.16, p=0.007). Also, being non-Lebanese was associated with a 6.26-unit reduction in MHLS score (95% CI −11.06 to −1.46, p=0.011). On the other hand, having a previous mental health disorder diagnosis increased MHLS score by 5.32 units (95% CI 1.43 to 9.22, p=0.008).

Global Barriers to Counselling Scale

The mean scores (±SD) obtained on the RFSV subscale were as follows: 12.61±4.82 on the Fit subscale, 10.13±4.72 on the Stigma subscale and 9.06±3.71 on the Value subscale. The Global Barriers to Counselling Scale, which is the average composite score across the three Fit, Stigma and Value subscales, had a median (IQR) of 28.7 (23.21–36.21). The Global Barriers to Counselling Scale showed a good internal consistency with Cronbach’s α=0.892.

Bivariate analysis for factors associated with Global Barriers to Counselling score

Bivariate associations with the Global Barriers to Counselling score are presented in table 2. Males had significantly higher global barriers scores (32.66±9.94) compared with females (27.90±9.74) (p<0.001), indicating a greater reticence to seek counselling. Participants who had attended a mental health seminar had significantly lower global barriers scores (27.59±10.78) compared with those who had not (30.20±9.68) (p=0.007).

There was a statistically significant but weak inverse relationship between the global barriers scores and MHLS score (Spearman’s rho=−0.23, p<0.001) (table 3). This means that as the MHLS score increases, the global barriers score tends to decrease, indicating less reticence to seeking mental health counselling.

No significant differences were observed between participants with and without a mental health diagnosis, or participants with a family member/friend previously diagnosed with a mental health disorder. In addition, no significant differences were found for nationality, school, academic year, income, health insurance, marital status, smoking status, alcohol consumption or sources of information on mental health. Also, no significant correlation was found with age.

Multivariable analysis for factors associated with Global Barriers to Counselling score

Multivariable analysis (figure 2) showed that three variables were significantly associated with the global barriers score: MHLS score, gender and participation in a mental health lecture or seminar. For every one-unit increase in MHLS score, the global barriers score decreased by 0.14 units (95% CI −0.21 to −0.07, p<0.001). Also, participation in a mental health lecture or seminar decreased the global barriers score by 2.00 (95% CI −3.91 to −0.09, p=0.04). On the other hand, being a male increased the global barriers score by 3.44 units compared with females (95% CI 4.85 to 5.04, p<0.001).

Figure 2. Forest plot of the multiple linear regression with Global Barriers to Counselling score as the dependent variable. Method: enter, analysis of variance p value <0.001), r²=0.092. Residuals were approximately normally distributed with no extreme outliers. All variance inflation factors were below 4.3. MHLS, Mental Health Literacy Scale.

Discussion

The purpose of this study was to evaluate the MHL of undergraduate students from various parts of Lebanon and investigate the obstacles that prevent them from obtaining professional assistance in this area. Females in our sample had a substantially higher literacy than males, with scores of 87.53±11.63 and 82.08±12.76 (p<0.001), respectively. Medical students, students with mental health illnesses and students who consume alcohol were also shown to have significantly higher literacy levels. Males were more reluctant to seek counselling. Gender, literacy score and attending mental health seminars were significant variables contributing to hindrance in seeking counselling.

The gender gap in MHL identified in our study aligns with extensive literature showing that females consistently demonstrate higher MHL and greater recognition of mental health symptoms than males. In other investigations, the gender gap in MHL was also seen, and those studies revealed that females had a better level of knowledge than males.¹⁹ This striking disparity may be explained by the fact that it was discovered that males stigmatise mental health concerns more than women do and that they are less able to recognise the symptoms of mental illness that they experience.²⁰ The results of another study showed that men who adhered to traditional notions of masculinity had lower levels of health literacy in terms of both their ability to connect with others and communicate with them.²¹ It was shown that males in our sample were substantially less likely to seek the assistance of a professional than females. These results were consistent with those seen in other investigations.

Our findings also reinforce prior research indicating that male students are less likely to seek counselling services, often due to heightened stigma and scepticism about counselling benefits. Consistent with prior studies on counselling attendance and gender theory, our findings indicate that males exhibit a lower propensity to pursue counselling and are especially vulnerable to the barriers of Stigma, Fit and Value in comparison to females.^{22 23} Men’s susceptibility to stigma may lead to avoidance of counselling due to emotions of shame or humiliation.²⁴ Men exhibited more sensitivity to the Fit and Value obstacles compared with women, suggesting they may assign less significance to the expected advantages of counselling and may be especially apprehensive about locating a suitable counsellor. These gender disparities may account for men’s inadequate use of counselling services; however, alternative explanations may also be valid.

Elevated MHL scores and participation in mental health education were associated with reduced perceived barriers to seeking help, underscoring the potential of targeted interventions to promote service use. The findings, in conjunction with those of Milin et al, underscore the efficacy of MHL treatments in alleviating obstacles to support-seeking by lowering stigma and improving comprehension.²⁵ In our study, elevated MHL scores correlated with diminished perceived barriers, while engagement in mental health lectures or seminars further alleviated these barriers, reinforcing the notion that focused education might cultivate more favourable help-seeking attitudes. Nonetheless, males indicated significantly greater obstacles than females, implying they may have distinct difficulties in obtaining mental health assistance. Collectively, these findings suggest that enhancing mental health literacy via educational programmes is an effective method for reducing stigma and other obstacles to seeking assistance, but gender-specific methods may also be necessary.

Nationality emerged as a significant factor influencing MHL, with non-Lebanese students exhibiting notably lower literacy levels compared with their Lebanese peers. In addition to gender, nationality was a significant predictor of MHL. Our findings showed that non-Lebanese students had significantly lower MHL scores than their Lebanese counterparts. This mirrors observations in multicultural education settings where minority or foreign-national students may have less exposure to culturally tailored mental health resources or may experience unique barriers such as language, acculturation stress and limited integration into local health education initiatives.^{14 15} Literature suggests that international students often face a ‘double stigma’: not only navigating general mental health stigma but also grappling with unfamiliar healthcare systems and lack of trust in services.²⁶ For non-Lebanese students in our sample, these cultural and systemic factors might explain the lower literacy scores, highlighting a need for universities to expand targeted MHL programmes that address diverse student populations and promote inclusion through multilingual and culturally sensitive approaches.

Medical students in our sample demonstrated significantly higher MHL than non-medical students, likely reflecting their greater curricular exposure to mental health topics. Our study has found a significantly higher MHL among medical students compared with their non-medical counterparts. Studies have found conflicting results in that regard. While the study by Baklola et al found no significant difference between the students, Chaudhuri et al found that medical students had higher MHL literacy overall.^{27 28} This significant difference could be explained by the academic exposure to mental health-related subjects provided in the curricula, which equips the students with knowledge and skills to recognise and address these issues more effectively.

Students with personal or familial experience of mental health issues displayed higher literacy, suggesting that direct exposure motivates greater understanding and information-seeking. Furthermore, students who disclosed that they were suffering from mental health conditions or had family members with such conditions demonstrated higher levels of literacy. It is possible that people who have personal experience with mental health issues will be motivated to obtain further information in order to better understand and manage their symptoms. A study by Lam found contradicting results that inadequate MHL was associated with the presence of mental health issues, notably depression.²⁹ The low MHL could be attributed to the respondents’ young age. It is also possible that there is a paucity of mental health education specifically geared for young people.

The relationship between alcohol use and MHL in our study was inconsistent, with initial associations disappearing after adjustment, indicating a complex interplay between coping behaviours and MHL. Our study revealed a significant association between alcohol intake and MHL in bivariate analysis; however, this association was not evident in multivariate analysis, indicating contradictory results when controlling for additional variables. Prior studies indicated a correlation between alcohol consumption and diminished MHL, observing that teenagers who refrain from alcohol typically exhibit elevated MHL.²⁶ This may indicate that individuals with lower MHL are more prone to adopt maladaptive coping strategies, such as alcohol consumption, which can hinder the pursuit of assistance. The inconsistency with our findings may stem from the comparatively low percentage of alcohol consumers in our sample (around 16%), thus diminishing the statistical power in multivariate analysis. The intricate relationship between MHL and coping behaviours may indicate that other elements, such as social or environmental effects, are involved, affecting the relationships variably among different adolescents and regions.

Comparative analysis with other Arab and MENA countries reveals similar patterns of gender and educational influences on MHL, highlighting the regional relevance of culturally tailored interventions. Our results correspond with research undertaken in other Arab nations. A national survey in Egypt, comprising 1740 undergraduates, revealed that medical students exhibited superior MHL ratings compared with their non-medical counterparts, with females demonstrating a greater propensity to seek mental health information.²⁸ In Saudi Arabia, research conducted at Jazan University indicated moderate MHL levels among students, characterised by misunderstandings on the aetiology of mental disease and ambivalent attitudes towards individuals with mental health issues.³⁰ These studies emphasise the impact of cultural, educational and socioeconomic aspects on MHL in the MENA area, underscoring the necessity for culturally customised mental health education initiatives.

Multiple variables may elucidate the increased obstacles to consultation identified in our study. Inadequate MHL is recognised to perpetuate negative attitudes and beliefs, leading to heightened perceived stigma and diminished trust in mental healthcare. Students with a poor comprehension of mental health may find it difficult to identify symptoms and may question the efficacy or confidentiality of professional aid, so deterring them from pursuing care. Cultural norms significantly influence male students, who may encounter societal expectations of emotional stoicism and self-reliance; these pressures might exacerbate feelings of shame or weakness related to seeking psychiatric assistance. Moreover, non-Lebanese students may encounter supplementary problems, including language barriers, unfamiliarity with the local healthcare system and apprehensions regarding prejudice, all of which might exacerbate psychological and practical impediments to seeking counselling services. The interplay of these elements emphasises the intricacy of help-seeking behaviour and underscores the necessity for comprehensive, culturally attuned solutions.

Multiple variables, such as alcohol intake, health insurance status and monthly income, failed to demonstrate significance in the multivariate models. This presumably indicates the impact of confounding variables; for instance, alcohol consumption may be associated with other traits such as gender or individual mental health history, which exert a more significant and direct effect on MHL. Likewise, although health insurance and income are frequently presumed to enhance access to mental healthcare, their impact may be overshadowed by psychological factors such as stigma or personal health views, which are not exclusively influenced by economic status. These findings demonstrate that when critical predictors are considered, certain characteristics may not have an independent impact on MHL or perceived obstacles.

Clinical implications and recommendations

These findings highlight the necessity of focused, multidimensional interventions to connect MHL with help-seeking behaviours. The gender disparity in help-seeking indicates that physicians and university counselling services should implement specific outreach for male students, who may encounter cultural or societal restrictions that inhibit seeking assistance. Incorporating MHL with pragmatic skills, such as scenario-based training and resilience-enhancing exercises, may facilitate students’ transition from awareness to action. Furthermore, clinician evaluations must consider maladaptive coping strategies, including substance use, that may stem from low MHL, while providing healthier coping alternatives. Integrating peer support into clinical programmes should augment these initiatives, as peer-led groups and mentorship may normalise the pursuit of assistance and render mental health resources more accessible. This method offers a more extensive support framework that tackles both informational and social obstacles to mental healthcare for students.

Furthermore, colleges must integrate MHL as an essential element of their academic and student support systems. This entails incorporating MHL instruction into orientation sessions and general education curriculum to guarantee widespread exposure across disciplines. Prioritisation of service accessibility necessitates the expansion of counselling availability via bilingual services, after-hours support and digital/tele-mental health options to mitigate logistical and cultural constraints. Implementing systematic campus-wide mental health awareness initiatives and screening events can facilitate the early identification of at-risk pupils. Additionally, educating teachers, administrative personnel and student leaders to identify and address early indicators of psychological distress helps foster a climate where mental health is consistently supported and normalised. Enhancing partnerships with national mental health organisations and NGOs can offer students an integrated referral system for specialised care when necessary.

Although these recommendations offer a thorough framework for enhancing student mental health outcomes, their execution presents problems. Integrating MHL education into the academic curriculum may encounter opposition due to existing substantial course loads and a deficiency of qualified teachers to impart mental health topics. Expanding multilingual and tele-mental health services necessitates financial commitment and a workforce proficient in culturally appropriate care—resources that may be scarce in numerous institutions. Moreover, the stigma associated with mental health constitutes a significant obstacle; students may be reluctant to engage in awareness programmes or peer support activities, especially in conservative or male-dominated contexts. Coordinating collaborations with external mental health organisations can be administratively intricate and reliant on institutional commitment, financing accessibility and national healthcare infrastructure. To overcome these obstacles, implementation must be gradual, contextually aware and guided by ongoing student feedback to guarantee adaptability and longevity.

Future research

Subsequent research ought to use mixed-methods designs, integrating quantitative surveys with qualitative interviews or focus groups to obtain a more profound understanding of the contextual elements influencing MHL and help-seeking behaviours. Longitudinal studies are important to evaluate causal linkages and monitor changes in MHL over time, especially in reaction to specific interventions. Incorporating non-university youth and students from technical and vocational institutions into research could enhance representativeness and yield a more comprehensive understanding of MHL across various educational contexts. Moreover, subsequent research should investigate the effects of culturally customised and multilingual interventions to meet the requirements of varied student demographics, encompassing non-Lebanese and foreign students.

Limitations

Our research possesses various limitations that must be recognised. The utilisation of an English-language online survey may have resulted in selection bias by omitting students with weak English proficiency, hence potentially under-representing specific demographic groups and limiting the generalisability of the results. The dependence on voluntary participation and convenience sampling raises concerns regarding sampling bias; students with a prior interest in mental health themes may have been more motivated to participate, so skewing the sample towards higher literacy levels. The cross-sectional methodology constrains our capacity to determine causal links among MHL, demographic characteristics and help-seeking behaviours, hence confining conclusions to mere associations. Fourth, self-reported data are intrinsically susceptible to biases, such as social desirability bias, which may have prompted participants to exaggerate favourable views towards mental health, and recollection bias, which could undermine the precision of reported behaviours and exposures. Ultimately, the emphasis on university students in Lebanon, however enlightening, may not accurately represent the experiences of adolescents and young adults beyond the academic environment, hence constraining external validity.

Conclusion

This study found that overall MHL among Lebanese university students was generally good, particularly among females, Lebanese nationals and those with prior exposure to mental health education or experiences. While gender differences were significant—with males reporting lower literacy and higher barriers to seeking counselling—other important factors included the academic discipline, personal or familial history of mental illness, and participation in mental health seminars. Higher MHL was associated with reduced stigma, improved attitudes towards counselling, and lower perceived barriers to seeking help. These findings emphasise the need for universities to implement comprehensive, culturally tailored mental health programmes that promote literacy, reduce stigma and improve access to services for all students, not just specific subgroups.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and the Lebanese International University School of Pharmacy Research and Ethics committee approved the study protocol (2024RC-007-LIUSOP). Informed consent was sought from all participants, who were provided with a detailed information sheet outlining the purpose of the study and the voluntary nature of their participation. To ensure confidentiality, all data were anonymous, and no personally identifiable information was collected. Survey responses were accessible only to the research team. Participants were also informed that their responses would be used solely for research purposes and that the findings would be reported in aggregate form to prevent the identification of individual respondents. In case of any concerns or questions regarding the study, participants were given contact information for the principal investigator and the institutional ethics committee. This ethical framework ensures that the study upholds the highest standards of integrity, respect and responsibility towards the participants.

Footnote

Contributors SNY conceptualised and designed the study. SNY, DA, RB, AS, LY, NA and NM wrote the first draft of the manuscript; SNY, LY and NA acquired the data and designed the methodology; DA carried out the analysis; DA and AS interpreted the results, SNY and MR were responsible for project administration and supervision. All authors read and approved the final version of the manuscript. SNY is the guarantor of this work and accepts full responsibility for the integrity of the study and the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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