Mental Health Service Use Among University Students: How Barriers and Social Support Matter

Mental Health Service Use Among University Students: How Barriers and Social Support Matter | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mental Health Service Use Among University Students: How Barriers and Social Support Matter Yu Qian Madeline Tseng, Minglee Yong, Yue Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7332113/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Understanding university students’ use of mental health services can help us evaluate if access to mental health services is adequate and appropriate. This study examined how depressive symptoms, perceived barriers, and social support (from family and friends) jointly associated with mental health service use (MHSU), including potential mediation and moderation effects. Methods A cross-sectional online survey was conducted with a sample of 769 undergraduate students in Singapore (18–29 years, 61.77% female). Path analyses using probit regression tested direct, mediated, and moderated associations among depressive symptoms, perceived barriers, social support (family and friends), and past-year MHSU. Results 18.60% of the sample reported using mental health services in the past 12 months. Depressive symptoms predicted an increased likelihood while barriers predicted a reduced likelihood of using mental health services. Higher social support from family and friends was associated with lower depressive symptoms, in turn predicting lower likelihood of using mental health services. Additionally, a significant interaction indicated that at high levels of depressive symptoms, greater friend support directly predicted a lower likelihood of MHSU. Gender did not moderate these associations. Conclusion Depressive symptoms, perceived barriers, and social support jointly relate to MHSU among university students. While family support consistently served as a stable informal resource, friend support became particularly important at high symptom levels, potentially substituting for formal care. Reducing access barriers and enhancing social support networks, especially family-based support, remain important strategies for promoting psychological well-being and appropriate service use in young adults. Mental health service use Social support Barriers Depressive symptoms University students Figures Figure 1 Figure 2 Figure 3 Introduction Mental health service use (MHSU) can provide insights to access to mental health services [ 1 ]. Despite a sizable need for mental health services, the usage of mental health services has been consistently shown to be low. The World Health Organisation (WHO) reported that approximately 4.4% of the global population suffers from depressive disorders [ 2 ]. Amongst university students worldwide, 35% are found positive for one common mental disorder in their lifetime [ 3 ], however; multi‑country evidence indicates that only about a quarter to a third of students who need help receive professional treatment within a year [ 61 ]. There is a persistent gap between the number of individuals in need of mental health services and the number of individuals who access professional care [ 4 , 5 ]. Delay and failure in seeking treatment for mental disorders have adverse consequences. Globally, mental disorders accounted for 7.4% of years of life lost due to premature mortality and was the leading source of years lived with disability (YLDs) [ 6 ]. Moreover, major depressive disorder was the principal reason for reduced quality of life among the younger 18–34 age group [ 7 ]. Untreated symptoms were also associated with a higher risk of suicide, impaired academic or occupational functioning, and greater economic hardship. [ 62 , 63 ]. Understanding the factors affecting an individuals’ decision to seek or delay mental health services is crucial for promoting timely utilization of resources [ 1 ]. Even when the need for care is evident, psychosocial and structural barriers often impede service use [ 1 , 60 ]. Beliefs, including attitudes, values and knowledge people possess about mental health and mental health services influence the perceived need of mental health services while financial considerations, such as income level and insurance coverage influence the affordability of mental health services [ 1 ]. Past studies have identified several prominent barriers to seeking treatment: lack of knowledge of where to get professional help; preference for self-help; fear of involuntary hospitalization; fear of stigma; belief that they do not have a problem; financial costs; scepticism on treatment effectiveness [ 8 – 11 ]. Clarifying how these barriers modify the association between depressive symptoms and MHSU will help target interventions [ 60 ]. Social support from family and friends plays a complex role in influencing MHSU [ 1 ]. Social support from family and friends have been found to be negatively associated with depressive symptoms as it serves as a protective factor against depression by helping individuals feel supported [ 56 ], in turn reducing MHSU. On the other hand, conflictual or strained relationships with family or friends resulting in lower perceived support predict higher levels of depressive symptoms [ 59 ] which may increase the need for MHSU. Moreover, low levels of social support have been associated with greater odds of accessing professional care, especially among those who were diagnosed with a mental disorder [ 13 ]. However, while strong social support may diminish the perceived need for professional help, strong social support can also encourage help-seeking as symptoms intensify and persist [ 12 ]. Research consistently indicates gender disparities in MHSU. Male adults are significantly less likely to seek treatment than female adults [ 16 ]. This same pattern was observed among university students. Among first‑year university students, women are about one‑third more likely than men to receive treatment. [ 58 ]. Several factors attribute to this disparity. Males tend to put off seeking professional help as they found emotional disclosure in therapy difficult [17]. In addition, men are more likely to be recommended self-care options as a form of treatment by the laymen due to cultural expectations regarding masculinity [ 18 ]. Males also held higher perceived stigma associated with seeking help and attributed more shame to having mental illness as compared to females [ 18 ]. Consequently, any research on MHSU should account for gender differences. Aims and Hypotheses of the Study We aim to understand the factors that could affect treatment seeking among undergraduate students. Given the high academic demands in tertiary education and the pressure of transitioning to full-time employment at a time when social relationships may be in flux, these young adults may face an increased risk of depressive symptoms [ 22 ]. Moreover, early adulthood is a critical developmental period that often marks onset of mental health problems [ 19 , 20 ] and individuals who are tertiary educated are more likely to have a treatment gap compared to the less educated [ 21 ]. Hence, understanding their patterns of MHSU could provide insights about the underutilization of mental health services. Based on our review of the literature, we hypothesized that higher levels of depressive symptoms would be associated with a higher likelihood of MHSU. We also hypothesized that greater perceived barriers would be associated with a lower likelihood of MHSU. We hypothesized that higher social support from family or friends would be associated with a lower likelihood of MHSU [ 36 , 37 ]. Given the complex interactions among different factors in determining MHSU, we also tested the potential moderating role of barriers in the association between depressive symptoms and MHSU. We also investigated how depressive symptoms may play moderating or mediating roles in the associations between different sources of social support and MHSU. All structural paths may differ by gender; therefore, each hypothesis will be tested in multiple-group models and constraints will be retained only if gender invariance is supported. Methods Participants Our sample consists of 769 university undergraduate students currently enrolled in universities in Singapore where 61.77% were female and 99.38% were full-time students. The mean age of participants was 21.94 years (18 to 29 years). There were 89.86% Chinese, 2.21% Malay, 6.24% Indian and 1.69% Others. In terms of household income, there were 10.53% below $ 2,000 per month, 17.81% $ 2,000 to $ 3,999 per month, 18.86% $ 4,000 to $ 5,999 per month, 14.56% $ 6000 to $ 7,999 per month, 13.39% $ 8,000 to $ 9,999 per month and 24.84% $ 10,000 & above per month participants. Procedure To recruit participants, the study was advertised on communication applications (Telegram channels and WhatsApp groups). Eligible participants were then emailed a link to an anonymous Qualtrics survey to complete. Data collection spanned from September to November 2022. After survey completion, 70% of the respondents were randomly selected to receive an S $ 5 cash reimbursement via electronic transfer. Measures Mental Health Service Use MHSU was measured by a response to the question “Which of the following health care providers did you see in the past 12 months? Please select all that apply.” Options provided were general practitioner, medical specialist, TCM practitioner, dentist, psychiatrist, psychologist, counsellor or therapist, social worker, other health care provider and none. Participants who saw a psychiatrist, psychologist, counsellor or therapist or social worker in the past 12 months were coded as having utilized mental health services. Patient Health Questionnaire-8 (PHQ-8) The PHQ-8 was used to assess the depressive symptoms. Participants were asked to rate their experience of eight symptoms on a 4-point Likert scale “over the last 2 weeks” (0 = Not at all, 1 = Several days, 2 = More than half the days, and 3 = Nearly every day). The scale demonstrated good reliability and validity across multiple studies [ 23 , 26 – 27 ]. Using Cronbach’s alpha, the internal consistency of the scale was good (α = 0.80). Composite mean scores were calculated and used in subsequent analyses. High mean scores indicated higher number of depressive symptoms endorsed. A cut-off score of 10 or greater on the PHQ-8 has been used in various studies to identify individuals at risk for major depressive disorder [ 23 – 25 ]. In our sample, 238 participants out of 769 (30.95%) scored at or above this cut-off, indicating significant levels of depressive symptoms. Barriers to Mental Health Services Scale-Revised (BMHSS-R) The Barriers to Mental Health Services Scale-Revised (BMHSS-R) measures the reasons that hinder individuals from using mental health services. In this study, we administered a truncated version of the scale with 31 items, measuring belief towards mental health or mental health services (help-seeking attitudes; stigma; knowledge and fear of psychotherapy; belief about inability to find a psychotherapist; and belief that depressive symptoms are normal and one extrinsic subscale – concerns about psychotherapist’s qualifications) and financial concerns about costs of mental health services (insurance and payment concerns). Participants were required to rate the extent to which they agree or disagree to 31 barrier items on a 4-point Likert scale (1 = Strongly Disagree, 2 = Disagree, 3 = Agree, 4 = Strongly Agree). The reliability and validity of the scale were also supported across studies [ 28 , 29 ]. In this study, the Cronbach’s alpha for the truncated version of the scale was 0.91. We investigated barriers as a composite. High mean scores indicated experiencing more barriers in accessing mental health services. Multidimensional Scale of Perceived Social Support-12 (MSPSS-12) The MSPSS-12 evaluates perceived social support across three subscales – family, friends and significant other. We chose to exclude the significant other subscale in our models because the identification of a significant other may vary among participants, or they might not feel that they have a significant other did not have a choice to omit answering the items from this subscale. Participants were required to indicate how they feel towards 12 statements such as “I get the emotional help and support I need from my family” and “I have friends with whom I can share my joys and sorrows” on a 7-point Likert scale (1 = very strongly disagree, 2 = strongly disagree, 3 = disagree, 4 = neither agree or disagree, 5 = agree, 6 = strongly agree, 7 = very strongly agree). The scale demonstrated good reliability and validity across multiple studies [ 30 – 32 ]. Higher mean scores indicated experiencing higher levels of social support. Using Cronbach’s alpha, the internal consistency of the full scale (α = 0.90) was excellent. The friends (α = 0.91) and the family subscale had good internal consistency (α = 0.89). Analysis Descriptive statistics, correlations, and gender difference were computed in SPSS 29. Given that MHSU was a binary outcome (0 = no; 1 = yes), path analyses were based on probit regression with weighted least squares means and variance (WLSMV) estimation and theta parameterization conducted in Mplus 8.11. All predictors were standardized (z-scored) before analysis. Multiple-group models were run with all structural paths constrained to equality across genders. Model fit was considered acceptable if χ² was non-significant and the following indices met conventional cut-offs: RMSEA ≤ 0.06, CFI/TLI ≥ 0.95, and SRMR ≤ 0.08 criteria [ 33 – 35 ]. Nested model constraints were evaluated with DIFFTEST (WLSMV). If releasing constraints did not improve model fit, the more parsimonious gender‑invariant model was retained and re‑estimated as single-group models for the entire sample. Missing data were automatically handled through the default procedures of WLSMV estimation in Mplus. Figure 1 shows the general specifications of the models. Model 1 tested the direct effects of barriers and depressive symptoms. Model 2 (Fig. 1a) introduced the interaction term between depressive symptoms and perceived barriers. Model 3 (Fig. 1b) and Model 4 (Fig. 1c) tested whether social support from family and friends independently predicted depression symptoms, which in turn predicted MHSU. Although this study is cross-sectional, social support was considered as a predictor of depressive symptoms, based on theoretical rationale and extensive empirical evidence highlighting stronger predictive effects of social support on depressive symptoms rather than the reverse [ 36 – 38 ], Furthermore, moderated-mediation analyses (Fig. 1d and 1e) were conducted to examine whether depressive symptoms moderated the association between social support and MHSU. Results Descriptive statistics and correlations among variables are shown in Table 1 . Of the initial 800 participants, 31 had missing data on MHSU; hence, analyses included 769 participants. All continuous variables showed acceptable skewness (< |2.0|) and kurtosis (< |6.0|) [ 55 ]. Overall, 143 out of 769 participants (18.60%) reported using mental health services in the past 12 months. Female students were more likely to report using services than male students (ꭓ 2 (1) = 15.54, p < 0.01). MHSU was not associated with reported household income (χ²(5) = 4.21, p = 0.52). Additionally, female students reported experiencing higher levels of depressive symptoms than male students ( t (767) = 4.00, p < 0.01, d = 0.30). On the other hand, male students reported high levels of perceived barriers ( t (765) = 2.04, p < 0.05, d = 0.15). No gender differences were found for social support from family or friends. For both females and males, MHSU correlated positively with depressive symptoms and negatively with social support from family and friends. Barriers negatively correlated with MHSU only among females. Table 1 Descriptive Statistics and Correlations Measures Males Females 1. 2. 3. 4. 5. M ( SD ) n M ( SD ) n 1. MHSU 0.12 (0.32) 294 0.23 (0.42) 475 .18 ** − .13 ** − .24 ** − .11 * 2. Dep 6.77 (4.87) 294 8.22 (4.92) 475 .15 ** .26 ** -27 ** − .29 ** 3. Bar 78.18 (13.53) 293 76.18 (12.94) 474 − .02 .37 ** − .28 ** − .32 ** 4. SSFam 18.95 (4.70) 294 18.32 (5.24) 475 − .14 * − .18 ** − .16 ** .37 ** 5. SSFri 20.94 (3.91) 294 20.62 (4.44) 475 − .12 * − .19 ** − .25 ** .42 ** Note. Correlations for females and males are above and below the diagonal respectively. Dep = Depressive Symptoms (PHQ-8); Bar = Barriers (BMHSS-R); SSFam = Family subscale of MSPSS-12; SSFri = Friend subscale of MSPSS-12 * P < 0.05, ** P < 0.01 Barriers and Depressive Symptoms as Predictors of Service Use Model 1, with structural paths constrained equally across genders, fit the data well, χ 2 (2, N = 769) = 1.30, p = 0.522, CFI = 1.000, TLI = 1.00, RMSEA = 0.00, and SRMR = 0.02. Releasing gender constraint on either of the main effect paths did not improve fit (all DIFFTESTs non-significant). In the single-group solution, higher depressive symptoms predicted increased likelihood of MHSU ( β = 0.50, SE = 0.05, p < 0.001), whereas higher barriers predicted decreased MHSU ( β = − 0.23, SE = 0.05, p < 0.001). Table 2 presents standardized path coefficients from both multiple-group and single-group solutions. Adding the depressive symptoms × barriers interaction term in Model 2 also exhibited an excellent fit, χ 2 (2, N = 769) = 1.41, p = 0.702, CFI = 1.00, TLI = 1.00, RMSEA = 0.00, and SRMR = 0.02. Releasing gender constraint on the interaction path did not improve model fit. Consequently, Model 2 was re‑estimated as a single-group model with zero df . The interaction was non-significant ( β = − 0.03, SE = 0.05, p = 0.603), indicating that depressive symptoms did not moderate the association between barriers and MHSU. Mediating Role of Depressive Symptoms in Social Support-MHSU Relationship Model 3 fit the data well, χ²(3, N = 769) = 2.13, p = 0.546, CFI/TLI = 1.00, RMSEA = 0.00, SRMR = 0.02. Releasing gender constraints did not improve fit (DIFFTESTs non-significant); therefore, the single-group coefficients were interpreted. Higher family support predicted lower depressive symptoms, β = − 0.24, SE = 0.03, p < 0.001, and directly predicted a lower likelihood of MHSU, β = − 0.25, SE = 0.05, p < 0.001. The indirect effect of family support on MHSU via depressive symptoms was significant (Indirect Effect = -0.05, SE = 0.01, p = 0.001). Similarly, Model 4, testing friends support, fit the data well (χ²(3, N = 769) = 2.24, p = 0.524, CFI/TLI = 1.00, RMSEA = 0.00, SRMR = 0.02). Releasing gender constraints did not improve fit (DIFFTESTs non-significant). In the single-group solution, higher social support from friends predicted lower depressive symptoms, β = − 0.25, SE = 0.03, p < 0.001, and had a significant direct path to reduce MHSU, β = − 0.10, SE = 0.05, p < 0.05 The indirect effect through depressive symptoms was significant (Indirect Effect = -0.06, SE = 0.02, p < 0.001). Hence, depressive symptoms was found to be a significant mediator. Table 2 Standardised Path Coefficients for Multiple-Group and Single-Group Models Model Path Multiple-Group Model Single-Group Model Female Male β SE β SE β SE 1 Dep → MHSU 0.32 *** 0.06 0.32 *** 0.06 0.33 *** 0.05 Bar → MHSU -0.22 *** 0.05 -0.22 *** 0.05 -0.23 *** 0.05 2 Dep → MHSU 0.30 *** 0.05 0.31 *** 0.06 0.33 *** 0.05 Bar → MHSU -0.21 *** 0.05 -0.21 *** 0.05 -0.23 *** 0.05 Dep×Bar → MHSU -0.00 0.05 -0.00 0.06 -0.03 0.05 3 SSFam → Dep -0.23 *** 0.03 -0.23 *** 0.03 -0.24 *** 0.03 Dep → MHSU 0.18 *** 0.05 0.18 *** 0.05 0.20 *** 0.05 SSFam →MHSU -0.25 *** 0.05 -0.25 *** 0.05 -0.25 *** 0.05 4 SSFri → Dep -0.25 *** 0.03 -0.25 *** 0.03 -0.25 *** 0.03 Dep → MHSU 0.21 *** 0.05 0.21 *** 0.05 0.23 *** 0.05 SSFri → MHSU -0.10 * 0.05 -0.10 * 0.05 -0.10 * 0.05 5 SSFam → Dep -0.23 *** 0.03 -0.22 *** 0.03 -0.25 *** 0.03 Dep → MHSU 0.18 *** 0.05 0.18 ** 0.05 0.20 *** 0.05 SSFam →MHSU -0.25 *** 0.05 -0.25 *** 0.05 -0.25 *** 0.05 Dep×SSFam → MHSU -0.03 0.05 -0.03 0.05 -0.05 0.05 6 SSFri → Dep -0.25 *** 0.03 -0.24 *** 0.03 -0.25 *** 0.03 Dep → MHSU 0.21 *** 0.05 0.22 *** 0.05 0.23 *** 0.05 SSFri → MHSU -0.08 0.05 -0.08 0.05 -0.07 0.05 Dep×SSFri → MHSU -0.11 * 0.05 -0.10 * 0.04 -0.12 ** 0.05 Note. Dep = Depressive Symptoms; Bar = Barriers; Dep×Bar = Interaction between Dep and Bar; SSFam = Social Support from Family; SSFri = Social Support from Friends; Dep×SSFam = Interaction between Dep and SSFam; Dep×SSFri = Interaction between Dep and SSFri * P < 0.05, ** P < 0.01, *** P < 0.001. Moderated Mediation: Depressive Symptoms as a Moderator Adding the interaction term produced moderated mediation models (Model 5 for family support and Model 6 for friends support). The constrained multiple-group Model 5 maintained the excellent fit, χ 2 (4, N = 769) = 2.31, p = 0.680, CFI = 1.00, TLI = 1.00, RMSEA = 0.00, SRMR = 0.02 and releasing gender constraints did not improve fit. In the single-group solution, the family support × depressive symptoms interaction was not significant ( β = − 0.05, SE = 0.05, p = 0.271; Fig. 2b). The constrained multiple-group Model 6 also fit well, χ 2 (3, N = 769) = 2.67, p = 0.614, CFI = 1.00, TLI = 1.00, RMSEA = 0.00, SRMR = 0.02 and releasing constraints did not improve fit. In the single-group solution, the friends support × depressive symptoms interaction was significant ( β = − 0.11, SE = 0.05, p = 0.009; Fig. 2c), Hence, depressive symptoms was a significant moderator in the association between friend support and MHSU. Simple-Slope Analysis of Friend Support × Depressive Symptoms Interaction To unpack the significant interaction, simple slopes were computed at low (–1 SD ), mean, and high (+ 1 SD ) levels of depressive symptoms. Friend support was not significantly associated with MHSU at low (− 1 SD; b = 0.037, SE = 0.066, z = 0.55, p = .579) or mean (0 SD; b = − 0.076, SE = 0.049, z = − 1.57, p = .117) levels of depressive symptoms. When depressive symptoms were high (+ 1 SD ), greater friends support significantly reduced the likelihood of MHSU ( b = − 0.19 0, SE = 0.066, z = − 2.89, p = .004). At high depressive symptoms (+ 1 SD), increasing social support from a low (–1 SD ) to a high (+ 1 SD ) decreased the probability of service use from 29.84–18.22%. Predicted probabilities are illustrated in Fig. 3 . Discussion Our findings supported the hypothesised positive association between depressive symptoms and MHSU. Experiencing more depressive symptoms was statistically associated with increased likelihood of MHSU. Other studies in Singapore and overseas have reported similar findings, in which increase in the number of depressive symptoms, symptom severity, or meeting diagnostic criteria for a disorder were associated with an increase in MHSU [ 39 – 41 ]. Consistent with expectations, perceived barriers were negatively associated with MHSU. Although we used a composite barrier score, the specific items we measured mirror those documented in earlier work from both international and Singapore studies [ 8 , 11 ]. Fear of stigma and aversive attitude towards expressing thought and feelings were prominent barriers to MHSU [ 8 ]. Moreover, qualitative data cited other barriers like the inclination to self-rely on to solve problems and downplay problems to be not as severe [ 8 ]. In the same vein, 64.9% of Singaporean respondents indicated wanting to handle problems on their own as a barrier to MHSU [ 11 ] suggesting that self-sufficiency was preferred over seeking help from mental health professionals. Another commonly endorsed reason was also the lack of knowledge as to where and who to seek help from (64.5%), indicative of poor mental health literacy in Singapore [ 11 ]. Among instrumental factors, hefty financial cost was the most frequently endorsed barrier to MHSU [ 8 ]. Similarly, in Singapore, 74.6% of participants indicated financial cost as a barrier to MHSU. This was the most strongly endorsed reason amongst other attitudinal barriers [ 11 ]. Importantly, the barriers × depressive symptoms interaction was not significant, indicating an additive rather than interactive pattern: barriers lowered the overall likelihood of MHSU, but the association between depressive symptoms and MHSU remained the same regardless of levels of perceived barriers. This suggests that barrier-reduction strategies may benefit students irrespective of symptom severity. In the simple mediation models, depressive symptoms partially mediated the associations between both sources of social support (from family and friends) and MHSU. Higher social support was associated with lower depressive symptoms, which in turn correlated with lower likelihood of MHSU, while the direct paths (c’) remained significant. This pattern is consistent with previous studies demonstrating that high perceived social support was associated with fewer depressive symptoms and improved psychological functioning, which can in turn reduce need for formal services [ 42 , 43 ]. Social support is an indicator of social acceptance which promotes positive self-evaluation and self-esteem, which subsequently leads to better psychological health [ 44 ]. Thus, greater social support from friends and family provides a protection against psychological distress which in turn, diminishes people’s pursuit for formal help. Once we added the interaction between social support and depressive symptoms, the two sources of support diverged. For family support, the interaction with depressive symptoms was not significant and the direct path to MHSU (c′) remained significant, indicating partial mediation without moderation. Family support related to MHSU both directly and indirectly, and this association did not depend on current symptom severity. This stable, direct negative association aligns with the broader Asian literature documenting cultural norms that prioritise family interdependence which may influence preference towards informal coping over professional help to manage distress [ 14 , 45 , 57 ]. Despite developmental expectations that young adults increasingly rely on peers [ 15 ], our data suggest that family remains a salient, symptom-invariant source of support that can substitute for formal services among Singaporean university students. For friend support, the picture was different. When the interaction term was included, the direct path from friend support to MHSU became non-significant, but the friend support × depressive symptoms interaction was significant. Simple-slope analyses showed that friend support was unrelated to MHSU at low or mean levels of depressive symptoms but predicted a lower likelihood of MHSU at high symptom levels. Thus, the net association between friend support and MHSU depends on symptom severity. One plausible interpretation is a substitution mechanism: when distress is severe, peers can meet immediate emotional needs, normalise distress, or reinforce hesitations about professional care, thereby dampening formal help‑seeking. Our results indicate that this substitution effect operates similarly across genders; multiple-group analyses showed that models constrained to gender equality fit as well as unconstrained models. Thus, our findings suggest that despite documented gender differences in emotional expressiveness and peer support orientation [ 50 – 52 ], these gender-specific tendencies may not translate into differences in how friend support and depressive symptoms jointly relate to MHSU among our sample. In our study, MHSU in females was higher than males in the past 12 months. This has been replicated in other studies [16, 17]. This is consistent with past literature which reported that females experience more depressive symptoms as compared to males, hence were more likely to use mental health services [ 53 , 54 ]. Males reported more barriers accessing mental health services than females, hence were less likely to use mental health services. Existing literature attributed low MHSU among men to male negative attitudes towards help-seeking and conformity to masculine social norms, in which males are expected to have better emotional control and self-reliance [ 18 ]. However, the models we tested all showed no gender differences, which indicated these pathways may not be differ across gender in Asian background. A few limitations of this study merit attention. First, the sample comprised university students, which constrains generalisability to young adults who did not receive tertiary education and other age groups. Second, the cross-sectional design precludes temporal, and thus causal, inferences about the relations among depressive symptoms, barriers, social support, and MHSU. Third, all variables were assessed by self-report, which introduces shared-method variance and potential reporting biases. Fourth, barriers were analysed as a single composite index, which may have obscured domain-specific effects. Despite these limitations, the study has notable strengths. First, the sample size is relatively large, which increases the precision of the statistical estimates. Second, the simultaneous consideration of depressive symptoms, perceived barriers, and two sources of social support within a single structural framework provides a more integrated picture of correlates of MHSU in Singaporean young adults, a population for which empirical data remain limited. Future research should employ longitudinal or prospective cohort designs to establish time order; disaggregate barriers into theoretically distinct domains to test domain-specific pathways; and evaluate whether targeted interventions causally increase appropriate service uptake. In summary, our findings suggest that depressive symptoms, perceived barriers, and sources of social support are jointly related to MHSU among Singaporean university students. This study suggests that reducing modifiable barriers helps increase appropriate service use and improving mental-health literacy especially within families helps ensure the mental health of young adults in Singapore are more appropriately cared for. Declarations Conflict of interest The authors declare no competing interests. Ethical approval The study received ethical approval from the Institutional Review Board at Nanyang Technological University (IRB-2022-555). Signed informed consent was also obtained from all participants. Funding Statement This research / project is supported by the Ministry of Education, Singapore, under its Academic Research Fund Tier 2 (ARC 1/22 YML). Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not reflect the views of the Ministry of Education, Singapore. Author Contribution Conceptualization and original draft writing: Madeline Tseng and Minglee Yong. Investigation: Madeline Tseng. Formal analysis: Minglee Yong and Xu Yue. Review and editing: All authors. Methodology, funding acquisition and resources: Minglee Yong. Acknowledgement We thank all the participants in the study. Data Availability The data that supports the findings of this study is available on request from the corresponding author or the data repositories of National Institute of Education/Nanyang Technological University. References Andersen RM, Rice TH, Kominski GF (2014) Improving access to care. In: Kominski GF (ed) Changing the us health care system: Key issues in health services policy and management, 4th ed. Jossey-Bass, pp 33–69 World Health Organization (2017) Depression and other common mental disorders: Global health estimates Auerbach RP, Mortier P, Bruffaerts R et al (2018) WHO world mental health surveys international college student project: prevalence and distribution of mental disorders. 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10:46:54","extension":"xml","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":151730,"visible":true,"origin":"","legend":"","description":"","filename":"1ae7400c90e845948f8af1e7902a30f61structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7332113/v1/850b6e3b29284eff60f75b56.xml"},{"id":94753884,"identity":"c706a36c-80da-4aa3-b4d6-839e7f43e305","added_by":"auto","created_at":"2025-10-30 10:46:54","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165396,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7332113/v1/896016c4b580bf59038e11c6.html"},{"id":94753859,"identity":"fd9dbec0-e5d6-46ba-9144-907d81f54e3d","added_by":"auto","created_at":"2025-10-30 10:46:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56548,"visible":true,"origin":"","legend":"\u003cp\u003eSpecifications of Models\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7332113/v1/a4b651be463ec6f7c5e41ba8.png"},{"id":94753860,"identity":"9564f8c9-b951-40c2-92ea-adf09b02af85","added_by":"auto","created_at":"2025-10-30 10:46:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":51824,"visible":true,"origin":"","legend":"\u003cp\u003eRoles of Depressive Symptoms, Barriers, and Social Support Predicting MHSU\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7332113/v1/57415bbd4a075b77983511e2.png"},{"id":94824146,"identity":"a0f1203f-2df7-408d-bd25-9c774987d7a9","added_by":"auto","created_at":"2025-10-31 06:48:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":104642,"visible":true,"origin":"","legend":"\u003cp\u003eSimple-Slope Plot of Social Support from Friends × Depressive Symptoms\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7332113/v1/507f6ea0ba3ea13cfe40c87e.png"},{"id":98451970,"identity":"1e4222b0-f96e-4730-ab62-87043d2ca9be","added_by":"auto","created_at":"2025-12-17 17:34:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1092938,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7332113/v1/bd3c4aad-5ac0-49a4-82b3-58fc5f4eb34f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mental Health Service Use Among University Students: How Barriers and Social Support Matter","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental health service use (MHSU) can provide insights to access to mental health services [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite a sizable need for mental health services, the usage of mental health services has been consistently shown to be low. The World Health Organisation (WHO) reported that approximately 4.4% of the global population suffers from depressive disorders [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Amongst university students worldwide, 35% are found positive for one common mental disorder in their lifetime [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], however; multi‑country evidence indicates that only about a quarter to a third of students who need help receive professional treatment within a year [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. There is a persistent gap between the number of individuals in need of mental health services and the number of individuals who access professional care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDelay and failure in seeking treatment for mental disorders have adverse consequences. Globally, mental disorders accounted for 7.4% of years of life lost due to premature mortality and was the leading source of years lived with disability (YLDs) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, major depressive disorder was the principal reason for reduced quality of life among the younger 18\u0026ndash;34 age group [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Untreated symptoms were also associated with a higher risk of suicide, impaired academic or occupational functioning, and greater economic hardship. [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Understanding the factors affecting an individuals\u0026rsquo; decision to seek or delay mental health services is crucial for promoting timely utilization of resources [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEven when the need for care is evident, psychosocial and structural barriers often impede service use [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Beliefs, including attitudes, values and knowledge people possess about mental health and mental health services influence the perceived need of mental health services while financial considerations, such as income level and insurance coverage influence the affordability of mental health services [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Past studies have identified several prominent barriers to seeking treatment: lack of knowledge of where to get professional help; preference for self-help; fear of involuntary hospitalization; fear of stigma; belief that they do not have a problem; financial costs; scepticism on treatment effectiveness [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Clarifying how these barriers modify the association between depressive symptoms and MHSU will help target interventions [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSocial support from family and friends plays a complex role in influencing MHSU [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Social support from family and friends have been found to be negatively associated with depressive symptoms as it serves as a protective factor against depression by helping individuals feel supported [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e56\u003c/span\u003e], in turn reducing MHSU. On the other hand, conflictual or strained relationships with family or friends resulting in lower perceived support predict higher levels of depressive symptoms [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e59\u003c/span\u003e] which may increase the need for MHSU. Moreover, low levels of social support have been associated with greater odds of accessing professional care, especially among those who were diagnosed with a mental disorder [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, while strong social support may diminish the perceived need for professional help, strong social support can also encourage help-seeking as symptoms intensify and persist [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eResearch consistently indicates gender disparities in MHSU. Male adults are significantly less likely to seek treatment than female adults [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This same pattern was observed among university students. Among first‑year university students, women are about one‑third more likely than men to receive treatment. [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Several factors attribute to this disparity. Males tend to put off seeking professional help as they found emotional disclosure in therapy difficult [17]. In addition, men are more likely to be recommended self-care options as a form of treatment by the laymen due to cultural expectations regarding masculinity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Males also held higher perceived stigma associated with seeking help and attributed more shame to having mental illness as compared to females [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Consequently, any research on MHSU should account for gender differences.\u003c/p\u003e\n\u003ch3\u003eAims and Hypotheses of the Study\u003c/h3\u003e\n\u003cp\u003eWe aim to understand the factors that could affect treatment seeking among undergraduate students. Given the high academic demands in tertiary education and the pressure of transitioning to full-time employment at a time when social relationships may be in flux, these young adults may face an increased risk of depressive symptoms [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Moreover, early adulthood is a critical developmental period that often marks onset of mental health problems [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and individuals who are tertiary educated are more likely to have a treatment gap compared to the less educated [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Hence, understanding their patterns of MHSU could provide insights about the underutilization of mental health services.\u003c/p\u003e\u003cp\u003eBased on our review of the literature, we hypothesized that higher levels of depressive symptoms would be associated with a higher likelihood of MHSU. We also hypothesized that greater perceived barriers would be associated with a lower likelihood of MHSU. We hypothesized that higher social support from family or friends would be associated with a lower likelihood of MHSU [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Given the complex interactions among different factors in determining MHSU, we also tested the potential moderating role of barriers in the association between depressive symptoms and MHSU. We also investigated how depressive symptoms may play moderating or mediating roles in the associations between different sources of social support and MHSU. All structural paths may differ by gender; therefore, each hypothesis will be tested in multiple-group models and constraints will be retained only if gender invariance is supported.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eOur sample consists of 769 university undergraduate students currently enrolled in universities in Singapore where 61.77% were female and 99.38% were full-time students. The mean age of participants was 21.94 years (18 to 29 years). There were 89.86% Chinese, 2.21% Malay, 6.24% Indian and 1.69% Others. In terms of household income, there were 10.53% below \u003cspan\u003e$\u003c/span\u003e2,000 per month, 17.81% \u003cspan\u003e$\u003c/span\u003e2,000 to \u003cspan\u003e$\u003c/span\u003e3,999 per month, 18.86% \u003cspan\u003e$\u003c/span\u003e4,000 to \u003cspan\u003e$\u003c/span\u003e5,999 per month, 14.56% \u003cspan\u003e$\u003c/span\u003e6000 to \u003cspan\u003e$\u003c/span\u003e7,999 per month, 13.39% \u003cspan\u003e$\u003c/span\u003e8,000 to \u003cspan\u003e$\u003c/span\u003e9,999 per month and 24.84% \u003cspan\u003e$\u003c/span\u003e10,000 \u0026amp; above per month participants.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003e To recruit participants, the study was advertised on communication applications (Telegram channels and WhatsApp groups). Eligible participants were then emailed a link to an anonymous Qualtrics survey to complete. Data collection spanned from September to November 2022. After survey completion, 70% of the respondents were randomly selected to receive an S\u003cspan\u003e$\u003c/span\u003e5 cash reimbursement via electronic transfer.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eMental Health Service Use\u003c/h2\u003e\u003cp\u003eMHSU was measured by a response to the question \u0026ldquo;Which of the following health care providers did you see in the past 12 months? Please select all that apply.\u0026rdquo; Options provided were general practitioner, medical specialist, TCM practitioner, dentist, psychiatrist, psychologist, counsellor or therapist, social worker, other health care provider and none. Participants who saw a psychiatrist, psychologist, counsellor or therapist or social worker in the past 12 months were coded as having utilized mental health services.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePatient Health Questionnaire-8 (PHQ-8)\u003c/h2\u003e\u003cp\u003eThe PHQ-8 was used to assess the depressive symptoms. Participants were asked to rate their experience of eight symptoms on a 4-point Likert scale \u0026ldquo;over the last 2 weeks\u0026rdquo; (0\u0026thinsp;=\u0026thinsp;Not at all, 1\u0026thinsp;=\u0026thinsp;Several days, 2\u0026thinsp;=\u0026thinsp;More than half the days, and 3\u0026thinsp;=\u0026thinsp;Nearly every day). The scale demonstrated good reliability and validity across multiple studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Using Cronbach\u0026rsquo;s alpha, the internal consistency of the scale was good (α\u0026thinsp;=\u0026thinsp;0.80). Composite mean scores were calculated and used in subsequent analyses. High mean scores indicated higher number of depressive symptoms endorsed. A cut-off score of 10 or greater on the PHQ-8 has been used in various studies to identify individuals at risk for major depressive disorder [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our sample, 238 participants out of 769 (30.95%) scored at or above this cut-off, indicating significant levels of depressive symptoms.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eBarriers to Mental Health Services Scale-Revised (BMHSS-R)\u003c/h3\u003e\n\u003cp\u003eThe Barriers to Mental Health Services Scale-Revised (BMHSS-R) measures the reasons that hinder individuals from using mental health services. In this study, we administered a truncated version of the scale with 31 items, measuring belief towards mental health or mental health services (help-seeking attitudes; stigma; knowledge and fear of psychotherapy; belief about inability to find a psychotherapist; and belief that depressive symptoms are normal and one extrinsic subscale \u0026ndash; concerns about psychotherapist\u0026rsquo;s qualifications) and financial concerns about costs of mental health services (insurance and payment concerns). Participants were required to rate the extent to which they agree or disagree to 31 barrier items on a 4-point Likert scale (1\u0026thinsp;=\u0026thinsp;Strongly Disagree, 2\u0026thinsp;=\u0026thinsp;Disagree, 3\u0026thinsp;=\u0026thinsp;Agree, 4\u0026thinsp;=\u0026thinsp;Strongly Agree). The reliability and validity of the scale were also supported across studies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In this study, the Cronbach\u0026rsquo;s alpha for the truncated version of the scale was 0.91. We investigated barriers as a composite. High mean scores indicated experiencing more barriers in accessing mental health services.\u003c/p\u003e\n\u003ch3\u003eMultidimensional Scale of Perceived Social Support-12 (MSPSS-12)\u003c/h3\u003e\n\u003cp\u003eThe MSPSS-12 evaluates perceived social support across three subscales \u0026ndash; family, friends and significant other. We chose to exclude the significant other subscale in our models because the identification of a significant other may vary among participants, or they might not feel that they have a significant other did not have a choice to omit answering the items from this subscale. Participants were required to indicate how they feel towards 12 statements such as \u0026ldquo;I get the emotional help and support I need from my family\u0026rdquo; and \u0026ldquo;I have friends with whom I can share my joys and sorrows\u0026rdquo; on a 7-point Likert scale (1\u0026thinsp;=\u0026thinsp;very strongly disagree, 2\u0026thinsp;=\u0026thinsp;strongly disagree, 3\u0026thinsp;=\u0026thinsp;disagree, 4\u0026thinsp;=\u0026thinsp;neither agree or disagree, 5\u0026thinsp;=\u0026thinsp;agree, 6\u0026thinsp;=\u0026thinsp;strongly agree, 7\u0026thinsp;=\u0026thinsp;very strongly agree). The scale demonstrated good reliability and validity across multiple studies [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Higher mean scores indicated experiencing higher levels of social support. Using Cronbach\u0026rsquo;s alpha, the internal consistency of the full scale (α\u0026thinsp;=\u0026thinsp;0.90) was excellent. The friends (α\u0026thinsp;=\u0026thinsp;0.91) and the family subscale had good internal consistency (α\u0026thinsp;=\u0026thinsp;0.89).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics, correlations, and gender difference were computed in SPSS 29. Given that MHSU was a binary outcome (0\u0026thinsp;=\u0026thinsp;no; 1\u0026thinsp;=\u0026thinsp;yes), path analyses were based on probit regression with weighted least squares means and variance (WLSMV) estimation and theta parameterization conducted in Mplus 8.11. All predictors were standardized (z-scored) before analysis. Multiple-group models were run with all structural paths constrained to equality across genders. Model fit was considered acceptable if χ\u0026sup2; was non-significant and the following indices met conventional cut-offs: RMSEA\u0026thinsp;\u0026le;\u0026thinsp;0.06, CFI/TLI\u0026thinsp;\u0026ge;\u0026thinsp;0.95, and SRMR\u0026thinsp;\u0026le;\u0026thinsp;0.08 criteria [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR32\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Nested model constraints were evaluated with DIFFTEST (WLSMV). If releasing constraints did not improve model fit, the more parsimonious gender‑invariant model was retained and re‑estimated as single-group models for the entire sample. Missing data were automatically handled through the default procedures of WLSMV estimation in Mplus.\u003c/p\u003e\u003cp\u003eFigure 1 shows the general specifications of the models. Model 1 tested the direct effects of barriers and depressive symptoms. Model 2 (Fig.\u0026nbsp;1a) introduced the interaction term between depressive symptoms and perceived barriers. Model 3 (Fig.\u0026nbsp;1b) and Model 4 (Fig.\u0026nbsp;1c) tested whether social support from family and friends independently predicted depression symptoms, which in turn predicted MHSU. Although this study is cross-sectional, social support was considered as a predictor of depressive symptoms, based on theoretical rationale and extensive empirical evidence highlighting stronger predictive effects of social support on depressive symptoms rather than the reverse [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e38\u003c/span\u003e], Furthermore, moderated-mediation analyses (Fig.\u0026nbsp;1d and 1e) were conducted to examine whether depressive symptoms moderated the association between social support and MHSU.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDescriptive statistics and correlations among variables are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the initial 800 participants, 31 had missing data on MHSU; hence, analyses included 769 participants. All continuous variables showed acceptable skewness (\u0026lt; |2.0|) and kurtosis (\u0026lt; |6.0|) [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Overall, 143 out of 769 participants (18.60%) reported using mental health services in the past 12 months. Female students were more likely to report using services than male students (ꭓ\u003csup\u003e2\u003c/sup\u003e(1)\u0026thinsp;=\u0026thinsp;15.54, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). MHSU was not associated with reported household income (χ\u0026sup2;(5)\u0026thinsp;=\u0026thinsp;4.21, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.52). Additionally, female students reported experiencing higher levels of depressive symptoms than male students (\u003cem\u003et\u003c/em\u003e(767)\u0026thinsp;=\u0026thinsp;4.00, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.30). On the other hand, male students reported high levels of perceived barriers (\u003cem\u003et\u003c/em\u003e(765)\u0026thinsp;=\u0026thinsp;2.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.15). No gender differences were found for social support from family or friends. For both females and males, MHSU correlated positively with depressive symptoms and negatively with social support from family and friends. Barriers negatively correlated with MHSU only among females.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive Statistics and Correlations\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMeasures\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMales\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eFemales\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e3.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e4.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e5.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.12 (0.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.23 (0.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e475\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.18\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.13\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.24\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.11\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Dep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.77 (4.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.22 (4.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e475\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.15\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.26\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-27\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.29\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Bar\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e78.18 (13.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e293\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e76.18 (12.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e474\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.37\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.28\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.32\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. SSFam\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18.95 (4.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18.32 (5.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e475\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.14\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.18\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.16\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e.37\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. SSFri\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20.94 (3.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20.62 (4.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e475\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.12\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.19\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.25\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.42\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"11\"\u003eNote. Correlations for females and males are above and below the diagonal respectively. Dep\u0026thinsp;=\u0026thinsp;Depressive Symptoms (PHQ-8); Bar =\u0026thinsp;Barriers (BMHSS-R); SSFam\u0026thinsp;=\u0026thinsp;Family subscale of MSPSS-12; SSFri\u0026thinsp;=\u0026thinsp;Friend subscale of MSPSS-12\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003csup\u003e**\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eBarriers and Depressive Symptoms as Predictors of Service Use\u003c/h2\u003e\u003cp\u003eModel 1, with structural paths constrained equally across genders, fit the data well, χ\u003csup\u003e2\u003c/sup\u003e(2, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;769)\u0026thinsp;=\u0026thinsp;1.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.522, CFI\u0026thinsp;=\u0026thinsp;1.000, TLI\u0026thinsp;=\u0026thinsp;1.00, RMSEA\u0026thinsp;=\u0026thinsp;0.00, and SRMR\u0026thinsp;=\u0026thinsp;0.02. Releasing gender constraint on either of the main effect paths did not improve fit (all DIFFTESTs non-significant). In the single-group solution, higher depressive symptoms predicted increased likelihood of MHSU (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.50, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas higher barriers predicted decreased MHSU (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.23, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents standardized path coefficients from both multiple-group and single-group solutions.\u003c/p\u003e\u003cp\u003eAdding the depressive symptoms \u0026times; barriers interaction term in Model 2 also exhibited an excellent fit, χ\u003csup\u003e2\u003c/sup\u003e(2, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;769)\u0026thinsp;=\u0026thinsp;1.41, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.702, CFI\u0026thinsp;=\u0026thinsp;1.00, TLI\u0026thinsp;=\u0026thinsp;1.00, RMSEA\u0026thinsp;=\u0026thinsp;0.00, and SRMR\u0026thinsp;=\u0026thinsp;0.02. Releasing gender constraint on the interaction path did not improve model fit. Consequently, Model 2 was re‑estimated as a single-group model with zero \u003cem\u003edf\u003c/em\u003e. The interaction was non-significant (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.03, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.603), indicating that depressive symptoms did not moderate the association between barriers and MHSU.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eMediating Role of Depressive Symptoms in Social Support-MHSU Relationship\u003c/h2\u003e\u003cp\u003eModel 3 fit the data well, χ\u0026sup2;(3, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;769)\u0026thinsp;=\u0026thinsp;2.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.546, CFI/TLI\u0026thinsp;=\u0026thinsp;1.00, RMSEA\u0026thinsp;=\u0026thinsp;0.00, SRMR\u0026thinsp;=\u0026thinsp;0.02. Releasing gender constraints did not improve fit (DIFFTESTs non-significant); therefore, the single-group coefficients were interpreted. Higher family support predicted lower depressive symptoms, \u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.24, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and directly predicted a lower likelihood of MHSU, \u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.25, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001. The indirect effect of family support on MHSU via depressive symptoms was significant (Indirect Effect = -0.05, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eSimilarly, Model 4, testing friends support, fit the data well (χ\u0026sup2;(3, N\u0026thinsp;=\u0026thinsp;769)\u0026thinsp;=\u0026thinsp;2.24, p\u0026thinsp;=\u0026thinsp;0.524, CFI/TLI\u0026thinsp;=\u0026thinsp;1.00, RMSEA\u0026thinsp;=\u0026thinsp;0.00, SRMR\u0026thinsp;=\u0026thinsp;0.02). Releasing gender constraints did not improve fit (DIFFTESTs non-significant). In the single-group solution, higher social support from friends predicted lower depressive symptoms, \u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.25, SE\u0026thinsp;=\u0026thinsp;0.03, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and had a significant direct path to reduce MHSU, \u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.10, SE\u0026thinsp;=\u0026thinsp;0.05, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 The indirect effect through depressive symptoms was significant (Indirect Effect = -0.06, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hence, depressive symptoms was found to be a significant mediator.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStandardised Path Coefficients for Multiple-Group and Single-Group Models\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003eMultiple-Group Model\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eSingle-Group Model\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.32\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.32\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.33\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBar \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.22\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.22\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.30\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.31\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.33\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBar \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.21\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.21\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep\u0026times;Bar \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSFam \u0026rarr; Dep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.18\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.18\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.20\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSFam \u0026rarr;MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSFri \u0026rarr; Dep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.21\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.21\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSFri \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.10\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.10\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.10\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSFam \u0026rarr; Dep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.22\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.18\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.18\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.20\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSFam \u0026rarr;MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep\u0026times;SSFam \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSFri \u0026rarr; Dep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.21\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSSFri \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDep\u0026times;SSFri \u0026rarr; MHSU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.11\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.10\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.12\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote. Dep\u0026thinsp;=\u0026thinsp;Depressive Symptoms; Bar =\u0026thinsp;Barriers; Dep\u0026times;Bar =\u0026thinsp;Interaction between Dep and Bar; SSFam\u0026thinsp;=\u0026thinsp;Social Support from Family; SSFri\u0026thinsp;=\u0026thinsp;Social Support from Friends; Dep\u0026times;SSFam\u0026thinsp;=\u0026thinsp;Interaction between Dep and SSFam; Dep\u0026times;SSFri\u0026thinsp;=\u0026thinsp;Interaction between Dep and SSFri\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003csup\u003e**\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003csup\u003e***\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eModerated Mediation: Depressive Symptoms as a Moderator\u003c/h2\u003e\u003cp\u003eAdding the interaction term produced moderated mediation models (Model 5 for family support and Model 6 for friends support). The constrained multiple-group Model 5 maintained the excellent fit, χ\u003csup\u003e2\u003c/sup\u003e(4, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;769)\u0026thinsp;=\u0026thinsp;2.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.680, CFI\u0026thinsp;=\u0026thinsp;1.00, TLI\u0026thinsp;=\u0026thinsp;1.00, RMSEA\u0026thinsp;=\u0026thinsp;0.00, SRMR\u0026thinsp;=\u0026thinsp;0.02 and releasing gender constraints did not improve fit. In the single-group solution, the family support \u0026times; depressive symptoms interaction was not significant (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.05, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.271; Fig.\u0026nbsp;2b).\u003c/p\u003e\u003cp\u003eThe constrained multiple-group Model 6 also fit well, χ\u003csup\u003e2\u003c/sup\u003e(3, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;769)\u0026thinsp;=\u0026thinsp;2.67, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.614, CFI\u0026thinsp;=\u0026thinsp;1.00, TLI\u0026thinsp;=\u0026thinsp;1.00, RMSEA\u0026thinsp;=\u0026thinsp;0.00, SRMR\u0026thinsp;=\u0026thinsp;0.02 and releasing constraints did not improve fit. In the single-group solution, the friends support \u0026times; depressive symptoms interaction was significant (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.11, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009; Fig.\u0026nbsp;2c), Hence, depressive symptoms was a significant moderator in the association between friend support and MHSU.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSimple-Slope Analysis of Friend Support\u003c/b\u003e \u0026times; \u003cb\u003eDepressive Symptoms Interaction\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo unpack the significant interaction, simple slopes were computed at low (\u0026ndash;1 \u003cem\u003eSD\u003c/em\u003e), mean, and high (+\u0026thinsp;1 \u003cem\u003eSD\u003c/em\u003e) levels of depressive symptoms. Friend support was not significantly associated with MHSU at low (\u0026minus;\u0026thinsp;1 SD; \u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037, SE\u0026thinsp;=\u0026thinsp;0.066, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.55, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.579) or mean (0 SD; \u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.076, SE\u0026thinsp;=\u0026thinsp;0.049, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.57, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.117) levels of depressive symptoms. When depressive symptoms were high (+\u0026thinsp;1 \u003cem\u003eSD\u003c/em\u003e), greater friends support significantly reduced the likelihood of MHSU (\u003cem\u003eb\u003c/em\u003e = \u0026minus;\u0026thinsp;0.19 0, SE\u0026thinsp;=\u0026thinsp;0.066, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.89, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.004). At high depressive symptoms (+\u0026thinsp;1 SD), increasing social support from a low (\u0026ndash;1 \u003cem\u003eSD\u003c/em\u003e) to a high (+\u0026thinsp;1 \u003cem\u003eSD\u003c/em\u003e) decreased the probability of service use from 29.84\u0026ndash;18.22%. Predicted probabilities are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings supported the hypothesised positive association between depressive symptoms and MHSU. Experiencing more depressive symptoms was statistically associated with increased likelihood of MHSU. Other studies in Singapore and overseas have reported similar findings, in which increase in the number of depressive symptoms, symptom severity, or meeting diagnostic criteria for a disorder were associated with an increase in MHSU [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConsistent with expectations, perceived barriers were negatively associated with MHSU. Although we used a composite barrier score, the specific items we measured mirror those documented in earlier work from both international and Singapore studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Fear of stigma and aversive attitude towards expressing thought and feelings were prominent barriers to MHSU [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Moreover, qualitative data cited other barriers like the inclination to self-rely on to solve problems and downplay problems to be not as severe [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the same vein, 64.9% of Singaporean respondents indicated wanting to handle problems on their own as a barrier to MHSU [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] suggesting that self-sufficiency was preferred over seeking help from mental health professionals. Another commonly endorsed reason was also the lack of knowledge as to where and who to seek help from (64.5%), indicative of poor mental health literacy in Singapore [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Among instrumental factors, hefty financial cost was the most frequently endorsed barrier to MHSU [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, in Singapore, 74.6% of participants indicated financial cost as a barrier to MHSU. This was the most strongly endorsed reason amongst other attitudinal barriers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Importantly, the barriers \u0026times; depressive symptoms interaction was not significant, indicating an additive rather than interactive pattern: barriers lowered the overall likelihood of MHSU, but the association between depressive symptoms and MHSU remained the same regardless of levels of perceived barriers. This suggests that barrier-reduction strategies may benefit students irrespective of symptom severity.\u003c/p\u003e\u003cp\u003eIn the simple mediation models, depressive symptoms partially mediated the associations between both sources of social support (from family and friends) and MHSU. Higher social support was associated with lower depressive symptoms, which in turn correlated with lower likelihood of MHSU, while the direct paths (c\u0026rsquo;) remained significant. This pattern is consistent with previous studies demonstrating that high perceived social support was associated with fewer depressive symptoms and improved psychological functioning, which can in turn reduce need for formal services [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Social support is an indicator of social acceptance which promotes positive self-evaluation and self-esteem, which subsequently leads to better psychological health [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Thus, greater social support from friends and family provides a protection against psychological distress which in turn, diminishes people\u0026rsquo;s pursuit for formal help.\u003c/p\u003e\u003cp\u003eOnce we added the interaction between social support and depressive symptoms, the two sources of support diverged. For family support, the interaction with depressive symptoms was not significant and the direct path to MHSU (c\u0026prime;) remained significant, indicating partial mediation without moderation. Family support related to MHSU both directly and indirectly, and this association did not depend on current symptom severity. This stable, direct negative association aligns with the broader Asian literature documenting cultural norms that prioritise family interdependence which may influence preference towards informal coping over professional help to manage distress [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Despite developmental expectations that young adults increasingly rely on peers [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], our data suggest that family remains a salient, symptom-invariant source of support that can substitute for formal services among Singaporean university students.\u003c/p\u003e\u003cp\u003eFor friend support, the picture was different. When the interaction term was included, the direct path from friend support to MHSU became non-significant, but the friend support \u0026times; depressive symptoms interaction was significant. Simple-slope analyses showed that friend support was unrelated to MHSU at low or mean levels of depressive symptoms but predicted a lower likelihood of MHSU at high symptom levels. Thus, the net association between friend support and MHSU depends on symptom severity. One plausible interpretation is a substitution mechanism: when distress is severe, peers can meet immediate emotional needs, normalise distress, or reinforce hesitations about professional care, thereby dampening formal help‑seeking. Our results indicate that this substitution effect operates similarly across genders; multiple-group analyses showed that models constrained to gender equality fit as well as unconstrained models. Thus, our findings suggest that despite documented gender differences in emotional expressiveness and peer support orientation [\u003cspan additionalcitationids=\"CR51\" citationid=\"CR49\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e52\u003c/span\u003e], these gender-specific tendencies may not translate into differences in how friend support and depressive symptoms jointly relate to MHSU among our sample.\u003c/p\u003e\u003cp\u003eIn our study, MHSU in females was higher than males in the past 12 months. This has been replicated in other studies [16, 17]. This is consistent with past literature which reported that females experience more depressive symptoms as compared to males, hence were more likely to use mental health services [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Males reported more barriers accessing mental health services than females, hence were less likely to use mental health services. Existing literature attributed low MHSU among men to male negative attitudes towards help-seeking and conformity to masculine social norms, in which males are expected to have better emotional control and self-reliance [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the models we tested all showed no gender differences, which indicated these pathways may not be differ across gender in Asian background.\u003c/p\u003e\u003cp\u003eA few limitations of this study merit attention. First, the sample comprised university students, which constrains generalisability to young adults who did not receive tertiary education and other age groups. Second, the cross-sectional design precludes temporal, and thus causal, inferences about the relations among depressive symptoms, barriers, social support, and MHSU. Third, all variables were assessed by self-report, which introduces shared-method variance and potential reporting biases. Fourth, barriers were analysed as a single composite index, which may have obscured domain-specific effects.\u003c/p\u003e\u003cp\u003eDespite these limitations, the study has notable strengths. First, the sample size is relatively large, which increases the precision of the statistical estimates. Second, the simultaneous consideration of depressive symptoms, perceived barriers, and two sources of social support within a single structural framework provides a more integrated picture of correlates of MHSU in Singaporean young adults, a population for which empirical data remain limited. Future research should employ longitudinal or prospective cohort designs to establish time order; disaggregate barriers into theoretically distinct domains to test domain-specific pathways; and evaluate whether targeted interventions causally increase appropriate service uptake.\u003c/p\u003e\u003cp\u003eIn summary, our findings suggest that depressive symptoms, perceived barriers, and sources of social support are jointly related to MHSU among Singaporean university students. This study suggests that reducing modifiable barriers helps increase appropriate service use and improving mental-health literacy especially within families helps ensure the mental health of young adults in Singapore are more appropriately cared for.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eEthical approval\u003c/h2\u003e\n\u003cp\u003eThe study received ethical approval from the Institutional Review Board at Nanyang Technological University (IRB-2022-555). Signed informed consent was also obtained from all participants.\u003c/p\u003e\n\u003ch2\u003eFunding Statement\u003c/h2\u003e\n\u003cp\u003eThis research / project is supported by the Ministry of Education, Singapore, under its Academic Research Fund Tier 2 (ARC 1/22 YML). Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not reflect the views of the Ministry of Education, Singapore.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualization and original draft writing: Madeline Tseng and Minglee Yong. Investigation: Madeline Tseng. Formal analysis: Minglee Yong and Xu Yue. Review and editing: All authors. Methodology, funding acquisition and resources: Minglee Yong.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe thank all the participants in the study.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe data that supports the findings of this study is available on request from the corresponding author or the data repositories of National Institute of Education/Nanyang Technological University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAndersen RM, Rice TH, Kominski GF (2014) Improving access to care. In: Kominski GF (ed) Changing the us health care system: Key issues in health services policy and management, 4th ed. 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PLoS One 12:e0185119. https://doi.org/10.1371/journal.pone.0185119\u003c/li\u003e\n\u003cli\u003eGhio L, Gotelli S, Cervetti A et al (2015) Duration of untreated depression influences clinical outcomes and disability. J Affect Disord 175:224-228. https://doi.org/10.1016/j.jad.2015.01.014\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental health service use, Social support, Barriers, Depressive symptoms, University students","lastPublishedDoi":"10.21203/rs.3.rs-7332113/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7332113/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eUnderstanding university students\u0026rsquo; use of mental health services can help us evaluate if access to mental health services is adequate and appropriate. This study examined how depressive symptoms, perceived barriers, and social support (from family and friends) jointly associated with mental health service use (MHSU), including potential mediation and moderation effects.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional online survey was conducted with a sample of 769 undergraduate students in Singapore (18\u0026ndash;29 years, 61.77% female). Path analyses using probit regression tested direct, mediated, and moderated associations among depressive symptoms, perceived barriers, social support (family and friends), and past-year MHSU.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e18.60% of the sample reported using mental health services in the past 12 months. Depressive symptoms predicted an increased likelihood while barriers predicted a reduced likelihood of using mental health services. Higher social support from family and friends was associated with lower depressive symptoms, in turn predicting lower likelihood of using mental health services. Additionally, a significant interaction indicated that at high levels of depressive symptoms, greater friend support directly predicted a lower likelihood of MHSU. Gender did not moderate these associations.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eDepressive symptoms, perceived barriers, and social support jointly relate to MHSU among university students. While family support consistently served as a stable informal resource, friend support became particularly important at high symptom levels, potentially substituting for formal care. Reducing access barriers and enhancing social support networks, especially family-based support, remain important strategies for promoting psychological well-being and appropriate service use in young adults.\u003c/p\u003e","manuscriptTitle":"Mental Health Service Use Among University Students: How Barriers and Social Support Matter","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 10:46:49","doi":"10.21203/rs.3.rs-7332113/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a3136bc4-6d74-4cef-9128-5d02aa101f11","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-17T17:33:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-30 10:46:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7332113","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7332113","identity":"rs-7332113","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}