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The college condition : the impact of post-secondary academic environments on undergraduate student mental… Malette, Nicole Solanges 2020

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      The College Condition: The Impact of Post-Secondary Academic Environments on Undergraduate Student Mental Health Stigma, Service Use and Illnesses  by   Nicole Solanges Malette  B.A. (Honours), McMaster University, 2009 M.A., McMaster University, 2013  A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREEE OF   DOCTOR OF PHILOSOPHY   in   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES   (Sociology)    The University of British Columbia  (Vancouver)   November 2020  © Nicole Solanges Malette, 2020      ii   The following individuals certify that they have read, and recommended to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: The College Condition: An Examination of the Impact of Post-Secondary Academic Environments on Undergraduate Student Mental Health Stigma, Service use and Illnesses    Submitted by Nicole Solanges Malette in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Sociology.  Examining Committee:   Neil Guppy, Sociology Supervisor   Rima Wilkes, Sociology  Supervisory Committee Member   Yue Qian, Sociology  Supervisory Committee Member  David Tindall, Sociology  University Examiner   Alison Taylor, Education Studies University Examiner                   iii  Abstract   I test three aspects of student mental health as impacted by academic environments: variations in mental health stigma, mental health service use and mental illnesses (e.g. depression and anxiety). In order to bring evidence to bear on how stigma and school environment are related I built a multi-level dataset by combining several years of data (2007 to 2014) from the University of Michigan‘s Health Minds Survey (HMS) and the Integrated Postsecondary Education Data System (IPEDS). This unique dataset consisted of 52,469 student respondents from 59 higher education institutions for the years 2007, 2009, 2010, 2011, 2012, 2013 and 2014. My analytic strategy employed multi-level mixed-effects linear models of individual and school level influences to investigate links between school environments and student stigma. This work demonstrates that 1) institutional contexts do influence students‘ stigmatization of others and 2) students at less selective schools, schools perceived to be more competitive and schools with more stigmatizing climates are all more likely to stigmatize others.       I next investigated rates of mental health service use among Canadian and American university students. Using the 2014/2015 HMS dataset, analysis for this work focuses on undergraduate mental health service use from two Canadian universities and three American universities (N = 4,158), using logistic regression models. Findings from this research demonstrate that 1) the overall proportions of Canadian and American undergraduate mental health service use are significantly different,  and 2) there are no significant variations in service use by individual characteristics, perceptions‘ of school environment, feelings of stigma, financial situations or knowledge of were to seek help.   iv  I also compared Canadian and American undergraduate student mental health. Using logistic regression models to test whether social determinants of health and perceptions of school environments influence the likelihood for experiencing mental illnesses (N = 4,158),  I find that 1) the proportions of experiencing anxiety and depression is not significantly different for Canadian and American undergraduate students, 2) potential social determinants of health, such as discrimination, economic difficulties and healthcare access, all have significant negative relationships with anxiety and depression for both Canadian and American undergraduate students.                     v  Lay Summary   Using data from the University of Michigan‘s Healthy Minds Survey (HMS) and the Integrated Postsecondary Education Data System (IPEDS), I examine how school environments and students‘ perceptions of these spaces impact their own stigma for mental illnesses, mental health service use and the likelihood for experiencing mental illnesses (e.g. depression and anxiety). I find that 1) school environments do impact students‘ stigma for those with mental illnesses, 2) perceptions of school environments influence the likelihood of students using mental health services, and that the overall proportion of service use is significantly different for Canadian and American undergraduate students and 3) that the likelihood for experiencing mental illnesses are similar for both Canadian and American undergraduate students. These findings highlight the importance of examining the social influences for student wellbeing and demonstrate a larger need for a Canadian-based student wellbeing dataset.                    vi  Preface   All of the work presented in this dissertation was created by Nicole Malette. Data for chapter two comes from the publicly available Integrated Postsecondary Education Data System (IPEDS). Additional student-level data for chapters two, three, and four come with permission from University of Michigan‘s Health Minds Survey (HMS).  In addition to conducting all statistical analysis and interpretations for this dissertation, Nicole Malette wrote and revised the entire manuscript. Neil Guppy, Rima Wilkes and Yue Qian provided feedback on data interpretation and reviewed the final manuscript. Daniel Eisenberg, with the department of Health Management and Policy at the University Of Michigan School Of Public health in Ann Arbor, Michigan and the Population Studies Centre at the University of Michigan Institute for Social Research in Ann Arbor, Michigan, collected the original data. This work was deemed exempted from approval by the University Research Ethics Board (REB) (application H18-0087), as outlined in the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2): ―REB review is not required for research that relies exclusively on secondary use of anonymous information or anonymous human biological materials, so long as the process of data linkage or recording does not generate identifiable information‖.            vii  Table of Contents  Abstract .......................................................................................................................................... iii Lay Summary .................................................................................................................................. v Preface............................................................................................................................................ vi Table of Contents .......................................................................................................................... vii  List of Tables .................................................................................................................................. x List of Abbreviations ..................................................................................................................... xi Acknowledgements ....................................................................................................................... xii Chapter 1: Introduction ................................................................................................................... 1 Student Mental Health Today ................................................................................................. 6 Academic Contexts ................................................................................................................. 8 Higher Education and Student Mental Health ...................................................................... 10 Research Questions ............................................................................................................... 14 Chapter 2: American College Settings and Student Mental Illness Stigma.................................. 16 Stigma ....................................................................................................................................... 18 Methods..................................................................................................................................... 22 Data ....................................................................................................................................... 22 Measures ............................................................................................................................... 22 Sample Characteristics .......................................................................................................... 25 Weighting .............................................................................................................................. 27 Analysis................................................................................................................................. 28 Findings..................................................................................................................................... 29 Discussion ................................................................................................................................. 36 Implications of Research........................................................................................................... 40 Chapter 3: Canadian and American Undergraduate Student Mental Health Service Use ............ 42 National Contexts...................................................................................................................... 44 Competition in Canadian and American Higher Education Systems ................................... 47 Stigma in Canada and America............................................................................................. 48 Methods..................................................................................................................................... 50 Data ....................................................................................................................................... 50 Sample Characteristics .......................................................................................................... 51 Measures ............................................................................................................................... 53 Weighting .............................................................................................................................. 56 viii  Statistical Analysis ................................................................................................................ 57 Findings..................................................................................................................................... 57 Implications of Research........................................................................................................... 65 Chapter 4: Canadian and American Undergraduate Student Experiences of Depression and Anxiety .......................................................................................................................................... 68 Social Determinants of Student Mental Health ........................................................................ 70 National Contexts and Social Determinants of Mental Health ............................................. 72 Depression and Anxiety ........................................................................................................ 75 Methods..................................................................................................................................... 76 Data ....................................................................................................................................... 76 Sample Characteristics .......................................................................................................... 77 Measures ............................................................................................................................... 79 Weighting .............................................................................................................................. 82 Limitations ............................................................................................................................ 83 Analysis................................................................................................................................. 83 Findings .................................................................................................................................... 84 Implications of Research........................................................................................................... 94 Chapter 5: Conclusions ................................................................................................................. 96 Contributions to Existing Research .......................................................................................... 99 Stigma and Student Wellbeing.............................................................................................. 99 National Variation in Mental Health Service use ............................................................... 101 National Similarities in Mental Illness ............................................................................... 102 Strengths and Limitations of Research ................................................................................... 104 Future Research and Conclusions ........................................................................................... 105 References ................................................................................................................................... 108 Appendix 1: Control for Previous Mental Health Problem ........................................................ 137 Appendix 2: Healthy Minds Schools 2014/2015 by Population, Funding and Sample Size ...... 138 Appendix 3: Variance of Inflation Factors for Independent Measures and Service Use ............ 139 Appendix 4: Logistic Regression of All Students‘ Mental Health Service Use (Excluding Students with a Previously Diagnosed Mental Illness)  ................................................................................................................................................. 140 Appendix 5: Variance of Inflation Factors for Independent Measures and Anxiety/Depression 141 Appendix 6: Logistic Regression of All students Experiencing Anxiety (Excluding Students with a Previously Diagnosed Mental Health Problem) ....................................................................... 142 ix  Appendix 7: Logistic Regression of Canadian and American Students Experiencing Anxiety (Excluding Students with a Previously Diagnosed Mental Health Problem) ............................. 143 Appendix 8: Logistic Regression of All Students Experiencing Depression (Excluding Students with a Previously Diagnosed Mental Health Problem) ............................................................... 144 Appendix 9: Logistic Regression of Canadian and American Students Experiencing Depression (Excluding Students with a Previously Diagnosed Mental Health Problem) ............................. 145    x  List of Tables   Table 2.1: Student Sigma Sample Characteristics (Individual Level)…………………………………… 26  Table 2.2: Distribution of Stigmatizing Views Variable……………………………………………………… 28 Table 2.3: Levels of Stigma……………………………………………………………………………………………. 30  Table 2.4: Multi-level Regression (Personal Stigma)…………………………………………………………. 32  Table 3.1: Sample Characteristics as Percentages……………………………………………………………… 52  Table 3.2: Percent of Canadian and American Undergraduate Students Using Mental Health Services………………………………………………………………………………………………………………………. 58 Table 3.3: Proportions of Canadian and American Undergraduate Students Using Mental Health Services…………………………………………………………………………………………. 59  Table 3.4: Logistic Regression of Mental Health Service Use…………………………………………….. 62 Table 3.5: Logistic Regression of Mental Health Service Use across Schools………………………. 64   Table 4.1: Mental Illness Sample Characteristics by Percentage…………………………………………. 78  Table 4.2: Proportions of Canadian and American Students Experiencing Mental illnesses……. 84  Table 4.3: Proportions for Canadian and American Students Experiencing Anxiety and Depression…………………………………………………………………………………………………………………… 85 Table 4.4: Logistic Regression of All Students Experiencing Anxiety…………………………………. 89  Table 4.5: Logistic Regression of Canadian and American Students Experiencing Depression.. 92         xi  List of Abbreviations  CND     Canada HMS    Healthy Minds Survey IPEDS   Integrated Postsecondary Education Data System LGBTQ+   Lesbian, Gay, Bisexual, Transgender, Queer, Questioning OR    Odds Ratio SES    Socioeconomic Status US    United States                           xii  Acknowledgements   I am deeply thankful for everyone on my dissertation committee for their guidance, constructive feedback and support. My supervisor, Dr. Neil Guppy, answered my continuous onslaught of questions, encouraged me to work independently and always pushed me to consider different theoretical perspectives. Dr. Rima Wilkes consistently supported my work, tirelessly reviewed my writing and has been instrumental in shaping the scholar I have become. Dr. Yue Qian introduced me to new quantitative methods and helped me better formulate my methodology. Your time and energy on this project is very deeply appreciated.     I would also like to recognize the contributions of my friends and family. Dr. Hana Saab and Jad Saab were the first to suggest that I could complete a PhD program. Your continued support has meant a lot to me. I am also so grateful for the encouragement (and statistical help) Cary Wu provided and laughs shared with Tanvi Sirari and Dr. Ed Haddon. Those first couple years of PhD coursework would have been truly miserable without your commiseration. Dr. Kerry Greer, May Chan and Cecilia Federizon provided guidance through the quagmire of university processes, without which I would have been lost. Special thanks to Adge Brodyn, Natasha Stetcy-Hildebrant, Kate Jaffe, Kelsea Perry and all the Coffee Outside YVR cycling crew for our rides, walks, animal talks and sanity preserving excursions. And to my nerd-herd, Dr. Hélène Frohard-Dourlent, Kelenn Frohard-Dourlent, Leela Steiner, Valerie Berseth and Dr. Glen Berseth, from whom I‘ve received a tremendous amount of love and support throughout this degree. Thank you all for being such amazing friends!  xiii   I could not have anticipated the time, energy and emotional challenges I was going to encounter when I started this degree, and the amount of love and support I would get from my family. Claude and Brenda Malette (Ben, Samantha, Brittany and Zoe) tirelessly listened, supported and fed me through my undergrad and Masters studies. The strong foundation they provided me with at McMaster made it possible for me to continue to PhD studies at UBC.   Throughout it all, Kris Clark and Rachelle Malette provided consistent encouragement, despite the sacrifice of weekends, holiday get-togethers, travel plans and family time. I think you are two of the most compassionate people I know, and this whole thing wouldn‘t have been possible without your help. I would also like to recognize the contributions of my parents (Diane Malette-Brownson and Chris Malette) and mother-in-law Grace Clark. Mom and Dad, you read chapters, listened to my complaints, shared laughs and always made fun of my spelling. You pushed me to do better and be better, and for that I am infinitely grateful. And Grace, whenever I was down, you promised to fight my battles and showed me how far pure determination could get you. You are a force of nature and a constant inspiration. Alicia, Paul, Solange, Jacqui and Bryn Malette (West Coast Malettes), our time shared on hikes, dinners and Machi Koro rounds got me through the hard times. And Grandma, I‘m sorry you couldn‘t see this ending. I did it and your letters (and ice cream money) helped. Thank you, everyone!  1  Chapter 1: Introduction   In October 2019, protests erupted across Ontario universities. A third student had committed suicide on The University of Toronto (UofT) campus, mirroring problems occurring at other schools (Mancini & Roumeliotis, 2019). Undergraduate students were calling for greater transparency regarding university mental health protocols, better mental health literacy among staff and more counseling services for students.    Universities, however, are generally reluctant to report on suicides and other markers of student mental health. The rationale for curtailing information about these two practices is two-fold. First, universities‘ want to stem suicide contagion effects among students; a process by which one suicide becomes a compelling model for successive events (Gould & Davidson, 1988; Velting & Gould, 1997). Studies have demonstrated that both fictional and non-fictional portrayals of suicide in the media can have an imitative effect on individual suicidal actions (Velting & Gould, 1997). Second, universities have reputations to protect. Our post-secondary institutions are more socially embedded in our society than ever before (Christensen & Gornitzka, 2017). They reach out to more stakeholders in everyday society and public actors have greater influences on them. This derives not only from changes in public policy toward universities, which has generally become more proactive, but also from the fact that universities are now expected to find extra financial resources from private actors (Hemsley-Brown & Oplatka, 2006). The increased dependence and interconnectedness of universities in our day-to-day life means that no institution wants to highlight troubles students are experiencing on their campus. Unfortunately, this means that we know far less about mental health challenges in higher education than we should.  2    Mental health is an important part of our physical and personal wellbeing1. According to the Public Health Agency of Canada (2020), mental illnesses are characterized by changes in moods, thinking or behaviour associated with significant distress and impaired functioning. The list of conditions that fall under the mental illness umbrella is extensive, but the most common disorders effecting student populations tend to be mood disorders and anxiety disorders. Mood disorders are a group of mental illnesses that affect how you feel and think about yourself, other people and life in general (American Psychiatric Association, 2013). There are different types of mood disorders, including depression, dysthymic disorder and bipolar disorder. Other disorders commonly affecting student populations are anxiety disorders. Anxiety disorders are when cognitive, physical and behavioural symptoms of stress are persistent and severe (American Psychiatric Association, 2013). This strain is critical when it causes distress in a persons‘ life to the point that it negatively affects his/her/their ability to study, socialize and manage daily tasks. Different types of anxiety disorders include panic disorder, generalized anxiety disorder and social anxiety disorder. In the general population, one in five Canadians will experience some type of mental illness in their lifetime (Canadian Mental Health Association, 2020). The proportion for undergraduate students is twice as large (Ontario College Health Association, 2016).  Despite how common these issues are among student groups, mental illnesses continue to be met with widespread stigma. Stigma is a socially constructed mark of disapproval, shame or                                                  1 Mental health and mental illness are sometimes used interchangeably in public discourse. The American Psychological Association (2031) defines mental illnesses as ―health conditions involving changes in emotion, thinking or behavior (or a combination of these things).‖ Mental health refers to ones‘ overall mental well-being - our emotions, social connections, thoughts and feelings, ability to solve problems and overcome difficulties and understand the world around us.  Mental illnesses can impact multiple aspects of ones‘ mental health. Everyone has mental health, just as everyone has health. 3  disgrace (Goffman 1962; Link & Phelan 2001). For Erving Goffman (1962) one‘s physical and emotional attributes are not inherently negative in themselves. They become stigmatized through the negative meanings that society attaches to those characteristics (ibid). These types of fears and misunderstandings often lead to prejudice against people with mental illnesses. Stigma is also why many people don‘t consider mental illnesses to be a real health concern. This prejudice and discrimination can lead to feelings of hopelessness and shame for those struggling to cope with their situation, creating a serious barrier to diagnosis and treatment among populations. To better serve undergraduate students, we need to better understand how mental illnesses are influenced at school and how stigma shapes those feelings and student help-seeking behaviours.     Mental health researchers have previously focused on individual level influences for symptoms or genetic determinants of student health. The individual level is defined as a students‘ personal physical, cognitive and emotional situation. This can refer to internal influences and individual capacities such as self-esteem, coping abilities, and competencies (Byrd & McKinney, 2012). Individual level influences can also include identities and personal attributes like gender, race/ethnicity, sexuality or financial situation. Studies have shown that these types of factors can have a significant influence on certain mental illnesses. For example, students of certain racial/ethnic backgrounds are at risk of experiencing minority status stress. Minority status stresses are the unique stressors experienced by minority students in primarily white institutions, which may include experiences with racism, discrimination, insensitive comments and questions of belonging on a college campus (Spencer, 1999). Studies have found that students who experience minority status stress are more likely to experience poor mental health outcomes (Kessler, Mickleson & Williams, 1999).  4    Previous research has also focused on the genetic determinants of student mental health. Efforts to understanding how genes and experiences work in concert to shape risk for mental illnesses across a lifetime are key to increasing knowledge about the etiology of these disorders and informing efforts to prevent and treat them (Dunn, Wang & Perlis, 2020). There is strong evidence demonstrating that these types of genetic variations confer risk for psychiatric disorders. For example, major depressive disorder is known to run in families. People with this diagnosis are three times more likely than those without the disorder to have a first degree relative who has depression (Sullivan, Neale & Kendler, 2000). Family history is something school health professionals and counselors take into account when creating on-campus support and programming for students.    Sociologists add nuance to the discussion of student mental health by investigating the contextual reasons for mental illnesses. Sociologists believe contexts matter (your milieu or environment or setting or family) and have the potential to influence individual behaviours and feelings. Durkheim‘s study of suicide (Durkheim, 1897) began a long tradition of exploring the association between the social environment and individual wellbeing. He noted that rates of suicide across nations varied depending on the majority religion of that place (Durkheim, 1897). Countries where the predominant faith was Protestant Christian had higher rates of suicide than Catholic nations. He postulated that this was because the Protestant faiths place greater value on individual thought and interpretation, resulting in less communal or cohesive environments than their Catholic faith peers enjoyed. Durkheim‘s (1897) work is so influential because it was the first to link large-scale environmental contexts with negative mental health outcomes, such as 5  suicide. Faris and Dunham (1939) built on those findings to link neighbourhood effects with certain mental health outcomes. They noted that varying levels of ―social disorganization‖ in home-neighbourhoods could be associated with higher rates of schizophrenia and substance use disorders. They argued that disorganized neighbourhoods increased social isolation, as positive relationships were more difficult to develop and maintain in those spaces (Faris & Dunham, 1939). These studies emphasized that individuals are embedded within contextual social structures that determine exposure to stress, stress mediators and their perceptions of stress.    Research has begun to make similar associations for university campuses. Eisenberg, Hunt and Speer (2013) were among the first to note that mental illnesses vary across campus contexts. In an evaluation of 72 different post-secondary institutions in America, they found that there were differences in the prevalence of mental illnesses experienced across schools according to funding and enrolment numbers. Elaborating on this work, Ketchen-Lipson, Gaddis, Heinze, Beck and Eisenberg (2015) explored potential variations in the prevalence of mental illnesses and the treatment utilization of students across different American colleges. They found that treatment utilization was lowest in institutions with large enrolments, public funding, non-residential students and low graduation rates. These works are important because they represent a first step in understanding how university contexts can differently impact the mental health experiences of students. This focus on institutional effects, remains, however, a very understudied area. Eisenberg, a social psychologist, is the principal investigator of the Healthy Minds Survey, and one of the few scholars in this area to pursue this contextual influence.    6   My aim for this dissertation research is to build on the works of Eisenberg, Hunt and Speer (2013) and Ketchen-Lipson et al. (2015) to further elucidate the impact of campus environments on undergraduate student mental health and help-seeking behaviour. In this first chapter, I provide a framework for understanding how environmental contexts within higher education institutions, in both Canada and The United States, impact student mental health. My dissertation research also consists of three distinct papers examining different, but related aspects of mental health issues in higher education. My first paper discusses how mental health stigma is directly impacted by students‘ environments, net of individual factors. The second paper examines how student mental health service utilization is experienced by Canadian and American undergraduate students. Finally, my third research paper discusses the mental illnesses of Canadian and American students, influenced by individual and institutional factors. In concluding this dissertation, I summarize my findings and make recommendations for future research.    Student Mental Health Today  Understanding how post-secondary environments influence student mental health has important consequences for student academic outcomes and institutions themselves (Malette, 2020). Mental illnesses can influence diminished academic returns for students (Eisenberg, Goldberstien & Hunt, 2009; Hunt & Eisenberg, 2010; Kadison & DiGeronimo, 2004). Students with high levels of psychological distress have been shown to experience greater test anxiety, lower academic self-efficacy, and less effective time management skills (Brackney & Karabernick, 1995; Kitzrow, 2003). Overall, 11.4% of students prematurely end their educational careers due to psychological disorders each year (Mojtabi et al., 2015). This means that 7  undergraduate students who are experiencing mental illnesses are more likely to struggle with their schoolwork and are more likely to drop-out than their non-afflicted peers (Brackney & Karabernick, 1995; Kitzrow, 2003).    Student mental illnesses also impact higher education institutions in terms of legal challenges. In the United States, several institutions have been the targets of lawsuits alleging inadequate or negligent treatment of their students‘ mental illnesses. In 2000, after the suicide of MIT student Elizabeth Shin, her family filed a 27-million-dollar lawsuit against the university, claiming a failure on the institutions behalf to provide adequate care for their daughter (Sontag, 2002). MIT and campus police officers were cleared of wrong-doing in June 2005, and the remaining suit against MIT administrators and mental health services employees was settled out of court (Sontag, 2002). During this time, MIT announced an upgrade to its student mental health services, including more staff and longer hours of availability (Sontag, 2002). George Washington University is currently under investigation for wrongful death and negligence after a freshman student committed suicide after attending campus-based counseling services (Smith, 2016). Princeton University was also sued by an undergraduate student who attempted suicide in their dormitories (Baker, 2014). Legal cases like these highlight the complexities of the roles and responsibilities of higher education institutions for providing care for undergraduate students. Understanding how different academic environments influence student mental illnesses and treatment use translates not only into improved academic situations for students, but also reduced burdens for university staff and administrations.   8   Effectively addressing students‘ mental illnesses requires understanding not only student-specific factors, but also the institutional contexts in which these students are enrolled. However, few studies have examined how higher education institutional contexts contribute to students‘ mental health and mental health service use (Hunt & Eisenberg, 2010). We know that institutional differences among colleges and universities in the United States and Canada are large, in terms of size, resources per student, and institutional priorities on teaching and learning (Stevens, Armstrong, & Arum, 2008). Not knowing how these contextual differences impact student wellbeing is an important knowledge gap and holds key developmental, academic and economic consequences for students across North America.   Academic Contexts    The experiences of students entering North American post-secondary institutions have changed over the last half-century. A major milestone in educational programming was reached when the majority of high school graduates started enrolling in colleges and universities in the early 2000s (National Center for Education Statistics [NCES], 2002, p. 220; Butlin,1999). This effectively meant that a major portion of the sorting and selecting function of education moved from the secondary to the post-secondary level. As knowledge, cognitive abilities, and communication skills became more and more important to gain well-paid jobs, and those abilities came to be marked or signaled by post-secondary schooling, the campus academic climate started to change. More and more students became concerned with getting good grades to get first entry into the best post-secondary institutions and to enter specialized fields of study. The average SAT scores needed to enter the top American schools rose and US national data shows that top-ranking American students became increasingly concentrated in the most prestigious 9  colleges and universities (Davies & Hammack, 2005). In Canada, the required high school grades for entrance into university have also steadily risen over the past decade (Davies & Hammack, 2005). Canadian universities, like their US counterparts, are increasing their entrance standards and tuition, ―… gaining repute not only by admitting top students but also by rejecting large numbers of qualified students‖ (Davies & Hammack, 2005). These examples suggest that competition has intensified among students across post-secondary institutions and that selection shifted to higher education. However, the post-secondary system is not a black box wherein all schools are alike. There is variation in institutional context (e.g. research-intensive institutions, private versus public funding). These differing contexts ought to matter for student mental health outcomes – unless all schools are able to put in supports that soften competitive academic ethos.    While both American and Canadian students experience similar pressures to enter university, the institutional responses between those two countries differ. The American post-secondary system is extremely large and diverse. It consists of an older private sector and a newer public sector, generalist universities and specialized institutions, small liberal arts schools and large state flagship universities (Davies & Guppy, 2018). Not only does the sheer size of the American higher education system set it apart from others, but the US system can also be distinguished by its steep prestige hierarchy. The hierarchy of post-secondary institutions in the United States has become so entrenched that institutions rarely change position or rankings (Larson, 2016; Martin, 2015). Elite colleges and universities select among the top range of increasingly exclusive national and international pools of students (Lee & Wright 2016; Dahill-Brown et al. 2016), encouraging many students to travel out of state for school (Epple, et al. 10  2016; Groen & White, 2004). The top students in the United States compete for placement in the most prestigious institutions (Davies & Hammack, 2005).    The Canadian higher education system is structured quite differently. Canada lacks a notable private sector and has nothing equivalent to the steep prestige hierarchy that dominates American colleges and universities. Our higher education system is comprised mostly of generalist public universities that, for the past half-century, have been formally funded by the public (Davies & Guppy, 2018; Davies & Hammack, 2005). These national differences are notable in student expenditures. Outside Quebec and Newfoundland where tuitions are even lower, most Canadian full-time tuition costs $6,373 CDN per year (Statistics Canada, 2017). US undergraduate tuitions are typically much higher (e.g. the average tuition for an in-state public university student in 2016/2017 was $9,650 USD per year, while out-of-state average public tuition was $24,930 per year and private college tuition was $33,480 per year (College Data, 2017). However, with the increasing influence of globalization affecting our schools, some Canadian universities have begun defining themselves as world-class in an effort to differentiate themselves from others (Cramer et al., 2016). In both Canada and the US, the enduring unevenness of higher education institutions bolsters competition that preserves inequalities among students.  Higher Education and Student Mental Health   College pathways provide a heuristic model for explaining why some students in certain higher education contexts fare better than others. Armstrong and Hamilton (2013) argue that the college experience is not only shaped by ones‘ academic environment, but also by the fit between 11  individual characteristics (e.g. resources associated with class backgrounds and orientations to higher education) and organizational characteristics. Students from similar class backgrounds share financial, cultural and social resources that shape their orientations to college and the agendas they pursue (Armstrong & Hamilton, 2013). Individuals seek out higher education contexts where they can cultivate the skills, interests, tastes, appearances and interaction styles deemed essential by their social class to achieve economic security (Armstrong & Hamilton, 2013).    Many members of the working and middle class view higher education as the primary vehicle to securing social mobility. However, the educational investments by those groups come at a large cost (Blanchard & Willmann, 2016; Lehmann, 2016). Individuals from lower class backgrounds tend to be isolated from the university experience, often over-burdened by the expense of tuition, residence and books (Geiger, 2015; Berg, 2016). Attending a higher-education institution requires high levels of parental funding, and one‘s studies often leave little time to engage in paid employment (Berg, 2016). Since the educational investments of low socioeconomic groups tend to come at a great cost, they tend to choose more pragmatic and vocational oriented schools over their higher socioeconomic peers (Armstrong & Hamilton, 2013; Hastings, et al. 2015). This is particularly true at public universities where social origins have played far less of a role in admissions than at elite private schools. However, those schools tend to have less social and academic resources freely available to students, potentially influencing the mental health outcomes of students.   12   Mental health has a reciprocal relationship with competition within higher education institutions. According to Nelson and Dawson (2015), ―competition is the fulcrum around which one person‘s happiness is dependent on another‘s failure; where every winner has a loser as a counterpart‖. Students compete with one another for the highest marks, for limited academic resources, scarce scholarships and for a better place in the post-graduate job market. While Nelson and Dawson (2015) may exaggerate the zero-sum nature of competition in higher education – there is not a direct winning and losing scenario around grades - for some students, it does feel like a win-lose competition at nearly every turn even if this overplays the extent of resource allocations in higher education. Maintaining a discourse of winners and losers in higher education has the potential to sustain fears and disappointment for those who do not succeed, exacerbating emotional problems and mental health issues. Insecure striving to compete is associated with psychological harm such as anxiety, depression and suicidal ideation (Nelson & Dawson, 2015).    Unsuccessful experiences in higher education can also feel stigmatizing, a mark of failure associated with mental health. Link and Phelan (2006) define stigma as ―the co-occurrence of its components - labeling, stereotyping, separation, status loss and discrimination‖. Building off Goffman‘s (1962) traditional definition, they note that stigma is a socially constructed mark of disapproval, shame or disgrace that can cause significant disadvantage (Link & Phelan, 2006). Much of the problem around help-seeking behaviour in undergraduate populations appears to be due to the enduring stigma of mental illness. Of students diagnosed with a mental illness, 65% said that they would advise others not to disclose their diagnosis and regret having done so themselves (Martin, 2010). For some individuals with mental illnesses, the social impacts of 13  stigma can cause more harm than the actual illness itself (Corrigan & Watson, 2002; Drapalski et al., 2013). This often translates to feelings of disempowerment in terms of one‘s academic, social, cultural and economic situation, aggravating emotional problems and preventing outreach (Martin, 2010). Treatment avoidance and unwillingness to disclose emotional problem can increase rates of mental illness among campus populations. However, stigmatizing processes can be also mediated by one‘s cultural, social and environmental surroundings (Link & Phelan, 2006).    Post-secondary environments have the potential to impact the stigma experienced by student populations. In some institutions the focus on research productivity eclipses teaching and student help resources. In these cases, one could imagine the campus life to be more alienating in large research-based institutions than in small liberal arts colleges that strive to nurture community. Conversely, students at large and competitive research-based institutions might be less likely to experience mental illnesses as a function of selection effects. Elite schools are highly adept at choosing students who thrive in competitive environments. These are students who understand the rigors of education, are skilled at accessing academic resources and know how to advocate for themselves. Students at highly competitive institutions might be less likely to seek treatment, because they experience less mental illnesses as a function of being selected into an appropriate academic environment. Unfortunately, students at lower-ranked institutions might not be as skilled at navigating academic institutions. This means that students at less competitive institutions might experience more mental illnesses because they are less proficient at handling the demands of higher education.    14  Research Questions   Considering the separate literatures on student mental health and higher education discussed above, I use a series of empirically-testable questions to create three unique research papers. The first paper examines how school contexts impact students‘ feelings of stigma towards others with mental illnesses. Few studies investigate how broader institutional contexts, such as perceived competition, institutional size, type and available mental health resources, impact undergraduate student mental health stigma. For the first paper of my dissertation research, I aim to fill this gap by asking: How is mental health stigma directly impacted by institutional context and students’ perceptions of the emphases that universities place on competition, net of individual factors?  After investigating how institutional contexts impact undergraduate students‘ feelings of stigma toward others with mental illnesses, I next elaborate on those findings to investigate how individual and institutional settings impact student mental health service use. Variations in institutional competition across national settings are important to consider because they have the potential to impact students‘ feelings of stigma, and therefore differently affect their likelihood for seeking mental health support. With these potential influences in mind, my second dissertation research paper focuses on the research question: How is variation in student mental health service utilization directly impacted by the demographics and perceptions of Canadian and American universities?   In addition to national contexts of competition impacting stigma and mental health service use, these environments can also influence students‘ experiences of mental illnesses. 15  Unfortunately, most of the research that Canadian on-campus mental health service providers rely on is acquired in-house or from American sources. There is little information about how national contexts impact Canadian undergraduate student mental health experiences overall, or how those outcomes vary from our American peers. The impact of these variations, however, has not been investigated with relation to students‘ experiences of mental illnesses. For my third dissertation paper, my research addresses the question: How are student mental illnesses (anxiety and depression) influenced by demographics and student perceptions’ of stigma at Canadian and American universities?   Although each of my three dissertation papers addresses a distinct research question, they are inextricably linked. Understanding the contextual influences for individual problems is at the backbone of sociological research, but is not one that is commonly applied to psychological problems. As a result, our knowledge of the influences for undergraduate student mental health outcomes and help-seeking behaviour is limited. Through each of my research questions I aim to unpack some of the contextual causes of student mental health, with the aim of effectively contributing to a gap in student-based mental health literature and to help inform more effective on-campus student programming.              16  Chapter 2: American College Settings and Student Mental Illness Stigma  Approximately one in three undergraduate students report experiencing a mental health problem at some point during their undergraduate career (Eisenberg, Hunt & Speer, 2011; Kirsch, Doefler & Truong, 2015). Mental illnesses among students pose a serious problem for administrators, not only because they are associated with poor health outcomes but also diminishing graduation rates and grade point averages (Bruffaerts et al., 2018). More troubling is that most college students who experience mental illnesses never visit their on-campus health service centers (Eisenberg, Hunt & Speer, 2011). One of the main reasons students don‘t visit their on-campus mental health service centres is because they are ashamed of the emotional problems they are experiencing. A common misconception of people with mental illnesses is that they are dangerous to themselves and others (Corrigan & Watson, 2002; Crisp, Gelder, Rix, Meltzer & Rowland, 2000) and are emotionally unstable, untrustworthy and dangerous (Gelder, Rix, Meltzer & Rowland, 2000). Like individuals with other illnesses, people with depression, suicidal ideation, anxiety and psychosis often feel uncomfortable disclosing their mental illnesses to others because of the stigma associated with those conditions. Being around others with stigmatizing views of certain health problems can also lead to internalized stigma (Hatsenbluer et al., 2014; Corrigan et al., 2005). Although only a small proportion of individuals hold stigmatizing attitudes about others with mental illness (Eisenberg et al., 2009), it still has important implications for student mental health.  To date mental health stigma has primarily been studied by psychologists and others in healthcare fields. I build on this work using a sociological lens. A sociological approach to understanding student mental health stigma is useful because the discipline takes into account 17  both individual and institutional influences for student outcomes. Sociologists understand that a major part of institutional settings are the social rules, written or unwritten, governing how an institution operates. These rules are symbolic outlines featured in things like mission statements, priority mandates, and institutional logics (Powell & DiMaggio, 1985). In practical terms, a university that is student-centered, that encourages faculty teaching expertise, and that prioritizes funds for learning provides a far different institutional context for students than does a university that is principally research-focused, emphasizes faculty incentives for grant-getting, and funds industrial liaison offices. One of the signature contributions of sociology has been to document how these institutional contexts shape students‘ lives (Mullen, 2011; Stevens, 2009; Steinberg, 2009). Armstrong and Hamilton (2013, p. 224) claim that in higher education, when comparing the impacts of individual characteristics and organizational contexts: ―For most, the probability of success depends on organizational context.‖ Yet,in the field of mental health research, an understanding of how institutional context matters is missing.   This research examines how different institutional contexts influence stigma about mental illnesses. Aligning my measures with previous research on stigma (Eisenberg et al., 2009; Pyne et al., 2004, Komiya, Good & Sherrod, 2000), I address the following research questions: 1) Do institutional contexts effect the likelihood that students will stigmatize others?  2) ‗What schools are more likely to have students who stigmatize others?‘ and 3) ‗What are the effects of school context on individual perceptions of others with mental illnesses?‘. I find that 1) institutional contexts do influence students‘ stigmatization of others, 2) students at less selective schools, schools perceived to be more competitive and schools with more stigmatizing climates are all 18  more likely to stigmatize others and 3) that school‘s stigmatizing climate has the largest impact on students own views of others with mental illnesses. Stigma  Stigma is a socially constructed mark of disproval, shame or disgrace (Goffman, 1962; Link & Phelan 2001). For Goffman, (1962) one‘s physical and emotional attributes are not inherently negative in themselves. They become stigmatized through the negative meanings that society attaches to those characteristics (ibid).  For example, there is nothing inherently negative about having big ears or wearing glasses, yet on many playgrounds these are negatively evaluated by children, in ways that often lead to others being ostracized.   Much of the current focus on stigma investigates individual influences (Gulliver, Griffiths & Christensen, 2010, Link & Phelan 2001). For example, Leong, Gupta & Kim (2011) demonstrate that cultural values, class-bound values and language bias culminate in stigmatizing attitudes toward certain mental illnesses and help-seeking for Asian students. Asian American college students fear being identified as someone with a mental health problem because of the negative cultural connotations associated with that label and the loss of face that they would experience if they sought treatment for their emotional problems (Leong, Gupta & Kim, 2011). Differences in stigmatizing attitudes towards mental illnesses and help-seeking behaviour have also been attributed to gender socialization. One of the most cited studies on gender and mental health stigma notes that although men and women tend to express somewhat similar attitudes toward others with mental illnesses, they behave toward stigmatized individuals in different ways (Farina 1981). Women act in a much more benign and favourable way towards others experiencing mental illnesses than men do. Similar outcomes are replicated in recent research. Chandra & Minkovitz, (2006) demonstrate that female students are more likely to accept others 19  with mental illnesses and help them, in comparison to their male peers. That research cites parental disapproval and perceived stigma for help-seeking behaviour as a main factor in gender based mental health stigma (Chandra & Minkovitz, 2006).   Some research has begun to investigate the link between organizational contexts and stigma in university settings. The highly competitive atmospheres of medical and legal studies programs are linked to higher rates of perceived stigma of mental illnesses (Boyd et al. 2016; Givens & Tjia, 2002; Levin, 2014; Schenk, Davis & Wimsatt, 2010). In an evaluation of burnout and mental illnesses across six medical schools, nearly half of the students enrolled in those programs believed that residency program directors would pass over their applications if they knew the student had an emotional/mental health problem (Dyrbye al., 2015). Students enrolled in legal programs face similar fears. Bar examiners inquire about prospective law students‘ mental health and sometimes refuse to allow them to practice law based on their mental health history (Jolly-Ryan, 2010). As a result, law students who mentally suffer during their pre-law time in school tend to be less forthcoming about their mental illnesses than other post-graduate students (Jolly-Ryan, 2010). These studies are exceptionally important because they are some of the first to make connections between the culture or organization of academic settings and mental health stigma. However, much of the current literature on contextual influences for mental health stigma is program-specific, focusing only on graduate students. Few studies investigate how broader institutional contexts impact undergraduate student mental health stigma.   Stigmatizing processes take place on multiple levels, including the structural level (e.g., institutional norms and practices) (Hatsenbluer et al., 2014). Structural stigma is a combination of the social conditions, cultural norms and institutional practices that work together to limit 20  access to health opportunities for stigmatized groups (Hatsenbluer et al., 2014; Corrigan et al., 2005). Indeed, structural stigma operates mainly where practices have consequences influencing members in unplanned ways (Corrigan, Markowitz & Watson, 2004). Although no American university has policies that are intended to directly limit the rights or welfare of individuals with mental illnesses, some of their academic practices can affect those students in unintended ways.  One way that these institutional structures negatively impact student mental health is by reinforcing personal stigma.   Personal stigma is negative prejudice or stereotypes about others that are held by individuals (Corrigan, Markowitz & Watson, 2004). Previous research demonstrates that personal attitudes are strongly shaped by prevailing public attitudes (Corrigan et al., 2006; Eisenberg et al., 2009; Link, 1987). That research demonstrates that awareness of negative opinions of others is a precursor to agreement with them (Corrigan et al., 2006). And even if perceptions do not match reality, the fact that they are perceived as real can have meaningful consequences for individuals. This idea relates back to the Thomas Theorem, first described by WI Thomas and Dorothy Swayne Thomas (1928: p 572): ―If men define situations as real they are real in their consequences‖. For college students, the academic atmosphere they work and live in has the potential to shape their own opinions of others. For example, students in more competitive academic environments might translate the social strain they feel for maintaining high averages into negative feelings toward others. If they encounter peers who are struggling to meet the same demands they are, they might be less sympathetic to their emotional challenges (e.g., I‘m coping, why aren‘t you?)  21  Settings that students perceive to be competitive and less accepting might also influence how they think of others through a process of fitting in. Elfenberg and O‘Reilley (2009) argue that institutional cultures play a large role in the transmission of values to individuals within them. In workplace settings, these mechanisms have been studied to investigate worker productivity and employee turn-over. Workers who share the same values as the institution they work for produce more and are less likely to quit (Moynihan & Pandy, 2007). Institutional value alignment can also impact student outcomes. For example, Tao, Dong, Pratt, Hunsberger, & Pancer, (2000) note that students who shared the same values as others within their school experienced better social adjustment in their transition to university life. Students who shared common values with others on campus exhibit higher academic motivation and lower attrition rates (Beyers & Goossens, 2002). In terms of settings that students perceive to be competitive and less accepting, the values they perceive their peers to have might negatively influence their own beliefs about others in their school.    To assess the influence of school organization on stigma, I merge two existing datasets, one composed of institution-level indicators and the other focused on student-level characteristics. The first dataset gives me information on institutional settings, at the school level, including: funding sector, selectivity, and the availability of medical services on campus. The second dataset consists of student responses to a common survey that measures a range of personal identities and mental health challenges, giving a wealth of individual level indicators that can be merged with the school level data. Findings from this analysis highlight the importance of investigating the contextual influences for student mental health stigma across college campuses. 22  Methods  Data   Data for this research comes from the Healthy Minds Survey (HMS). The HMS was created and coordinated by The University of Michigan. It provides data on college students‘ mental health and wellbeing and includes information on more than 150,000 respondents from 125 post-secondary institutions in the United States and internationally (Healthy Minds Network, 2016). The analysis for this research is based on responses from 52,469 undergraduate students from 59 schools across 6 waves from 2007 to 2014. The sample was created by including only students who studied at four-year bachelor degree-granting post-secondary institutions that were located in America.    The HMS collects limited data on the characteristics of the schools at which student respondents are studying.  To better understand the influence of school contexts on stigma I created a multi-level dataset that combines HMS (2007-2014) individual level student survey data with corresponding institutional level data from the Integrated Postsecondary Education Data System (IPEDS). The IPEDS data is an integrated system of interrelated surveys conducted annually by the U.S. Department of Education‘s National Centre for Education Statistics (IPEDS 2016). IPEDS gathers information from every post-secondary institution in the United States, as mandated by the Higher Education Act of 1965 (IPEDS 2016).  Measures  Stigma scales used in this analysis were created from the HMS data. The individual stigma scale used in this research mirrors the scale used by Eisenberg et al. (2009), which is an 23  adaptation of the Discrimination Devaluation (D-D) scale developed by Link (1987) and others (Link, Cullen, Struening, Shrout & Dorhenwent, 1989). Although Eisenberg et al‘s (2009) adapted D-D scale asked individuals how much they agreed with 12 statements (e.g. I would think less of someone with a mental health problem‖), only two of those statements were reproduced in the HMS surveys across all years of data collection. As such, this research uses student responses to the two statements: ―I would willingly accept someone who has received mental health treatment as a close friend‖ and ―I would think less of a person who has received mental health treatment‖. Students‘ responses to these statements were originally described in an index ranging from 1-6. However, the responses did not correspond with similar feelings of stigma for others. I therefore recoded both measures, with higher numbers referring to students‘ feelings of greater stigma. To do this I reversed the codes for ―I would think less of a person who has received mental health treatment‖.  For example, a student who responded “strongly disagree” to the statement “I would think less of a person who has received mental health treatment” was given a response of six. A student who responded “strongly agree” to “I would think less of a person who has received mental health treatment” would also receive a score of six. After ensuring the responses provided equivalent feelings of stigma, I averaged the responses across the two measures. The inter-item correlation between the two questions was .65.  A similar aggregate institutional measure using students’ responses to the perceptions of stigma questions is also used in this analysis, but as an independent measure. Eisenberg et al. (2009) adapted two measures from the perceived stigma scale to create a scale for perceptions of stigma, which they used as a dependent variable. Only two of those measures were replicated over every year of data collection. The Perceived Stigma scale featured in this analysis uses 24  students‘ responses to the following two statements: ―Most people would willingly accept someone who has received mental health treatment as a close friend‖ and ―Most people would think less of a person who has received mental health treatment‖. Students‘ responses to these statements were recoded as an index from 1-6, with higher numbers referring to students‘ views that most people stigmatize others. As with the individual stigma scale, I reversed the codes for ―Most people would think less of a person who has received mental health treatment‖ and averaged the responses across the two measures, resulting in a correlation of .64.   After creating the perceived stigma scale, I then used it to create an aggregate measure for a particular school, by taking the individual responses about ‘perceived stigma’ and averaging them for each school in the sample. This process resulted in an aggregate measure for each institution that represents the average level of perceived stigma that exists on campus.  Similar methods were used to create aggregate measures for competition across schools. For the single question asking students about their perceptions of competition at their school, ―How would you rate the overall competitiveness between students in your classes?‖ responses also ranged from 1-6 with one indicating ―very competitive and six indicating ―very uncompetitive‖. Responses were then reversed and split into a bivariate response with students responding as ―very uncompetitive‖, ―not competitive‖ or ―somewhat uncompetitive‖ as 0 and responses ―very competitive‖, ―competitive‖ or ―somewhat competitive‖ as 1.   To better understand how institutional contexts influence stigma I also used three additional institutional level measures from the IPEDS dataset. These include:  25  1. Institution Type (Private or Public): This is a binary variable for privately or publicly funded post-secondary institutions.  2. Selectivity (1-39% 40-69% and 70-100%): This variable is broken into three categories representing the percent of students who applied that were admitted to a school each year.  3. Hospital: This is a binary variable for whether or not the school has a hospital on campus. Individual-level independent variables used in this analysis include age, gender (female, male), race (White, Black, Hispanic, Asian, Other (South Pacific Islander, Native American, Arab)), sexuality (heterosexual, homosexual/bisexual/questioning), current financial situation (experiencing financial struggle, tight but fine, no financial problems) and survey year (2007, 2009, 2010, 2011, 2012, 2014). To control for a previous mental illnesses I also use the survey question ―Have you ever been diagnosed with any of the following conditions by a health professional (e.g. primary care doctor, psychiatrist, psychologist, etc.)?  depression, anxiety, attention disorder or learning disability, eating disorder, psychosis, personality disorder, Substance abuse disorder‖2 (See Appendix 1 for full list of conditions). These measures were introduced in the multi-level analysis to control for individual influences of personal stigma.  Sample Characteristics Of the 52,469 students surveyed for this research, most undergraduates were aged 18-22 (67%), female (64%), heterosexual (91%), White (73%), financially stable (82%) and had not                                                  2 The responses are represented as a binary variable to make a distinctive cut between having a diagnosis and not previously being diagnosed.  26  been previously diagnosed with a mental health problem (74%). Most students also strongly disagreed with the statement ―I would think less of a person who has received mental health treatment‖ (56%) and the largest proportion of surveys were collected in 2010 (32%).  Full details of these measures are provided in Table 2.1.  Table 2.1: Student Sigma Sample Characteristics (Individual Level)  Variables  Percent Variables Percent Dependent Variable    Stigmatizing Views of Others  Level-2 Variables      Strongly Disagree  56.33 Sector      Disagree 30.48   Private 54.00    Somewhat Disagree 11.26   Public 46.00    Somewhat Agree  1.68 Percent Admitted      Agree 0.21   1-39% 17.00    Strongly Agree  0.03   40-69% 37.00 Level-1 Variables     70-100% 46.00 Control Variables   Hospital   Age     With Hospital 2.00   18-22 66.91   Without Hospital  98.00   23-25 13.18 Perceptions of   Competition    26-30 11.21   Is Competitive 11.00   31+ 8.7   Not Competitive 89.00 Gender  Stigmatizing Climate    Female 64.11    Strongly Disagree  0.00   Male 35.89    Disagree 0.00 Race      Somewhat Disagree 23.00   White  72.82    Somewhat Agree  70.00   Asian/Asian-American  13.42    Agree 7.00   Hispanic/Latino  7.21    Strongly Agree  0.00   Black  4.72 N (Schools)  59   Other 1.08   Sexuality       Heterosexual  91.14     LGBQ 8.86   Current Financial Situation       Financially Stable  82.2     Financial Troubles  17.8   Mental Health Diagnosis     27    Previous Mental Health Diagnosis 25.9     No Previous Mental Health Diagnosis  74.1   Survey Year        2007 7.27      2009 9.61      2010 32.63      2011 8.94      2012 25.12      2014 16.43   N (Individuals)  52,469       In terms of institutional settings (see Table 2.1), most students in this sample are enrolled in private post-secondary institutions (54%), in less selective institutions (admit 60-100% of applicants), schools without a hospital on campus (98%), schools they do not report as being competitive (89%) and at schools where the average student somewhat agrees that others stigmatize those with mental illness (70%).   Weighting  Previous research using the HMS data incorporated response propensity weights to adjust for student non-response. Eisenberg et al. (2009) created their weights by obtaining nonresponse information from universities‘ administrative data, including information on student demographics like sex, race/ethnicity, academic level and grade point average. The creation of these weights was instrumental for ensuring that their analysis was representative in terms of individual characteristics across schools. However, weighting was tested in my analysis but ultimately not applied. Sensitivity testing demonstrates the same effect for individual characteristics with the incorporation of weights and without. Also, those previous weights were created to ensure representation at the individual level, not the school level. Since this research is 28  aimed at better understanding the school-level effects on stigma, while controlling for individual effects, incorporating response propensity weights for individual characteristics remains unreasonable (Winship & Randbill, 1994). I do account for possible design effects by incorporating survey year as a control variable. Furthermore, the factors used by the University of Michigan to apply design weights in the HMS dataset were all incorporated in my analysis as independent variables, hence they are all controlled for in the statistical analysis.  Analysis  For this research I replicate the initial analysis conducted by Eisenberg et al. (2009) by testing for differences in mean levels of stigma across subgroups using T tests (two tailed). Next I used multi-level mixed-effects linear models to examine the influence of school contexts on personal stigma, controlling for individual level effects. To do this I use, as the dependent variable, the scale variable ―stigmatizing views‖ that draws on responses to the HMS statements ―I would willingly accept someone who has received mental health treatment as a close friend‖ and ―I would think less of a person who has received mental health treatment‖ (see Table 2.2).  The term ―stigmatizing views‖, for this study, is a measure of students‘ own stigmatizing views toward others with mental illnesses.  Table 2.2: Distribution of Stigmatizing Views Variable  Stigmatizing Views % Strongly Disagree  56.70 Disagree 30.21 Somewhat Disagree 11.16 Somewhat Agree  1.70 Agree 0.20 Strongly Agree  0.03   29  Findings I begin by asking which students are more likely to hold stigmatizing views of others. Table 2.3 provides a systematic review of overall levels of stigmatizing views by individual level effects. The findings demonstrated in this analysis are similar to the work by Eisenberg et al. (2009). The mean level of stigmatization is 1.76, on a six point scale (where six is the highest level of stigmatization and one is the lowest), with a relatively small standard deviation (0.82). Older students (31+) tended to be less accepting of others with mental illnesses (2.90) than their older peers. Consistent with the literature I also find that men are more likely to have stigmatizing views (1.89) compared to women (1.68) and Asian students are more likely to have stigmatizing views than other racial groups (2.14).  Moving beyond Eisenberg et al.‘s (2009) work, I also investigated the relationship between stigmatizing views and sexuality, current financial situation, having a previous mental health diagnosis and survey year. Heterosexual (1.78) students have more stigmatizing views toward others than their LGBQ peers as do (1.57). Students with no previous mental health diagnosis (1.84) are more stigmatizing. Another notable finding from this analysis is that students‘ average tendency to stigmatize also decreased monotonically over the years in which the survey was in the field. From 2007-2014 the average for personal stigma decreased from 1.88 to 1.63 (statistically significant). One reason for the decrease in personal stigma over time might be the increase in mental health dialogue in popular media and across campus spaces (Sampogna, Bakolis, Evans-Lacko, Robinson, Thornicroft, & Henderson, 2017). With increased mental health awareness the average rate of personal stigma across American college campuses seems to be decreasing.  30  Table 2.3: Levels of Stigma    Mean SD t p Dependent Variable     Stigmatizing Views of Others  1.76 0.82   Level-1 Variables      Control Variables      Age        18-22 1.77 0.81 (Reference) (Reference)   23-25 1.75 0.83 -1.46    26-30 2.80 1.01 -5.64 ***   31+ 2.90 1.03 -3.31 ** Gender       Female 1.68 0.87 (Reference) (Reference)   Male 1.89 0.78 -28.68 *** Race        White  1.69 0.78 (Reference) (Reference)   Asian/Asian-American  2.12 0.93 -4.18 ***   Hispanic/Latino  1.71 0.80 -5.99    Black  1.68 0.78 -5.48 ***   Other 1.78 0.80 4.04 *** Sexuality        Heterosexual  1.78 0.82 (Reference) (Reference)  Gay, Lesbian, Bisexual 1.53 0.73 19.6 *** Current Financial Situation        Financially Stable  1.77 0.82 (Reference) (Reference)   Financial Troubles  1.70 0.80 -7.56 *** Mental Health Diagnosis        No Previous Mental Health Diagnosis  1.84 0.83 (Reference) (Reference)   Previous Mental Health Diagnosis 1.51 0.71 -40.62 *** Survey Year     2007 1.88 0.86 (Reference) (Reference) 2009 1.78 0.83 -5.35 *** 2010 1.80 0.84 5.49 *** 2011 1.78 0.79 -5.82 *** 2012 1.71 0.79 -11.5 *** 2014 1.63 0.77 -16.13 *** N (Individuals)  52,469          Level-2 Variables      Sector        Private 1.72 0.81 (Reference) (Reference) 31    Public 1.79 0.82 -9.96 *** Percent Admitted        1-39% 1.72 0.81 (Reference) (Reference)   40-69% 1.77 0.82 5.95 ***   70-100% 2.00 0.82 4.93 *** Hospital        With Hospital 1.75 0.81 (Reference) (Reference)   Without Hospital  1.80 0.87 -3.59 ** Perceptions of   Competition       Is Competitive 1.78 0.82 (Reference) (Reference)   Not Competitive 1.65 0.78 14.62 *** Stigmatizing Climate        Strongly Disagree  1.03 0.19 (Reference) (Reference)    Disagree 1.40 0.48 37.95 ***    Somewhat Disagree 1.82 0.72 85.27 ***    Somewhat Agree  2.18 0.89 96.73 ***    Agree 2.36 1.10 66.07 ***    Strongly Agree  2.45 1.44 28.44 *** N (Schools)  59         I next investigate the relationships between five institutional level measures and stigmatization. Findings in Table 2.3 also demonstrate that students at public institutions have higher stigmatization (1.79) than their private school peers (1.72) and that students enrolled in schools that admitted more students (40%-60% and 70-100%) had higher rates of personal stigma (1.77 and 2.00) than students at schools that admitted between 1-39%.   Further investigating the relationship between institutional factors and stigmatization, I measured average stigma for students with a hospital on campus and competition. Students without a hospital on campus (1.80), and who thought their school was competitive (1.78) all had slightly higher levels of stigmatization. Students who studied at schools where the average person believes that others think less of people with mental illnesses are more likely to have stigmatizing views themselves. The average for students who study at an institution with a highly 32  stigmatizing culture is also markedly larger than is the mean for students studying at schools with low stigmatizing cultures (2.45 versus 1.03). In terms of influence over student stigma, this contextual influence seems to outweigh both individual level influences and other institutional level measures, at least at the bivariate level.   To better understand how institutional settings influence students own stigmatizing views toward others I next conducted a multi-level mixed-effects linear regression of individual and institutional influences (see Table 2.4). Table 2.4 reports these estimates as fixed effects coefficients and are analogous to standard regression coefficients. For this analysis, I begin by reproducing Eisenberg et al‘s (2009) work on individual influences for stigmatizing views by examining the impact of age, gender and race on stigmatization. Measures for sexuality, current financial situation, having a previous mental health diagnosis and survey year were not included in Eisenberg et. al‘s (2009) initial investigation, but were included in this work. After investigating individual influences for persona stigma I next added institutional effects in Models 2 – 6, controlling for individual effects. Finally, Model 7 investigates the effects of all institutional and individual measures together. This analysis produced several notable findings.  Table 2.4: Multi-level Regression (Personal Stigma)  Personal Stigma        Individual Influences Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7 Age -0.00592*** -0.00605*** -0.00595*** -0.00588*** -0.00516*** -0.00615*** -0.00545***   (-4.50) (-4.60) (-4.53) (-4.47) (-3.92) (-4.70) (-4.18) Gender (Female)  -0.198*** -0.198*** -0.198*** -0.198*** -0.200*** -0.198*** -0.201***   (-27.40) (-27.41) (-27.42) (-27.40) (-27.69) (-27.45) (-27.80) Race (White)  0.0929*** 0.0928*** 0.0931*** 0.0929*** 0.0912*** 0.0924*** 0.0911***   (36.98) (36.99) (37.04) (36.99) (36.29) (36.91) (36.32) Sexuality (Heterosexual)  0.163*** 0.162*** 0.163*** 0.163*** 0.159*** 0.163*** 0.159***   (13.29) (13.26) (13.29) (13.29) (13.02) (13.29) (13.04) Current Financial Situation  -0.0359*** -0.0359*** -0.0363*** -0.0360*** -0.0394*** -0.0356*** -0.0399*** 33    (-3.96) (-3.96) (-4.01) (-3.97) (-4.35) (-3.93) (-4.41) Mental Health Diagnosis  -0.245*** -0.245*** -0.245*** -0.245*** -0.244*** -0.244*** -0.243***   (-30.52) (-30.50) (-30.54) (-30.53) (-30.41) (-30.46) (-30.38) Survey Year -0.0300*** -0.0299*** -0.0307*** -0.0303*** -0.0301*** -0.0258*** -0.0264***   (-11.02) (-11.15) (-11.41) (-11.11) (-11.08) (-9.48) (-10.00) Institutional Influences        Type (Private)   -0.0563**     -0.012    (-2.85)     (-0.74) Selectivity (% Admitted)    0.0345**    0.0292**     (2.62)    (2.89) Hospital     0.0437   0.0347      (1.02)   (1.09) Perceived Competition      0.0917***  0.0926***       (10.70)  (10.83) Stigmatizing Climate      0.280*** 0.268***        (5.79) (5.82) N 52,469 52,469 52,469 52,469 52,469 52,469 52,469 Wald chi2 3,966.94 3,984.62 3,982.81 3,969.44 4,091.66 4,037.94 4,224.21 BIC 123,025.50 123,020 123,021.20 123,026.50 122,913.20 123,001.80 122,881.40 AIC 123,114.20 123,117.50 123,118.70 123,124.00 123,010.80 123,099.30 123,014.50 Fixed Effects Coefficients with t statistics in parentheses * p < 0.05, ** p < 0.01, *** p < 0.001   First, Model 1 investigates individual level effects on stigmatization. All individual level measures had a statistically significant effect, consistent with previous research using the Healthy Minds Survey data (Eisenberg et al. 2009). Measures that were not included in previous research were also statistically significant, with heterosexual students being more likely to hold stigmatizing views toward others than their LGBQ peers (0.163, p < 0.05).  Students who are financially stable are more likely to stigmatize others (-0.0359, p < 0.05) and so are students who have not been previously diagnosed with a mental health problem (-0.245, p < 0.05). This research corroborates the argument that certain minority groups (e.g. females, LGBQ and those with previous mental health diagnosis) are more accepting of others presumably because they 34  draw on personal experiences of marginalization that majority populations (e.g. financially stable, students without a previous mental health diagnosis) do not experience.   Controlling for individual influences for stigmatization, Model 2 begins to add institutional level influences for stigma. It is notable that the addition of these variables adds to the explanatory power of the model, and they do not diminish the explanatory power of the individual factors. Model 2 adds the effect of studying at a public or private institution. Students in public post-secondary institutions are more likely to hold stigmatize views against those with mental illnesses (-0.0563, p < 0.05) than their peers in private schools. This effect, however, it is not significant with the inclusion of other institution variables in Model 7. In short, the effect of school funding source is more fully explained by the effect of other institutional factors.    Expanding on the institutional effects for stigmatization, Model 3 introduces selectivity, controlling for individual influences. Results from this model demonstrate that students who study at schools that admit a larger proportion of students who apply each year are more likely to have stigmatizing views of others with mental illnesses themselves (0.0355, p < 0.05). Models 5 introduces students‘ average perceptions of competition on stigmatization of others with mental illnesses, demonstrating that students who study at schools with higher perceived competition are more likely to stigmatize others (0.0917, p < 0.05). Next, analysis in Model 6 demonstrates that students at schools where most students have stigmatizing views of people with mental illnesses are more likely to have those feelings too (0.280, p < 0.05). This effect was the largest in comparison to other institutional level variables and remained significant with the inclusion of other institutional measures in Model 7.  35   The focal question for this research was, ―do institutional contexts effect the likelihood of students stigmatizing others?‖ A number of indicators demonstrate that contextual measures do add to the explanatory power of this analysis. Not only are several of the institutional variables statistically significant in my multi-level regression analysis, but the parameter tests and fit criteria that I used also demonstrates the importance of contextual influences. In effect Model 1, with only individual level measures, is the baseline standard against which Models 2 through 7 can be compared.  The Wald Chi² test for each model is large and generally consistent across models, except Model 3 for schools with hospitals. Model 7 has the largest Wald Chi² value of all at 4,224.21. Since this type of investigation is used as a way to test a null hypothesis, and if explanatory variables in a model are significant, the large value for Model 7 (and previous models with institutional variables included) indicate that institutional contexts do have a significant effect on students‘ stigmatization of others. The Bayesian Information Criteria (BIC) and Akaike Information Criteria (AIC) used in this analysis also demonstrate that institutional variables help explain some of the influence for students‘ stigmatizing views toward others. Both BIC and AIC values for Model 7 are lowest compared to all other models, demonstrating the strong explanatory power of institutional effects.  Finally, notice too that while the institutional level factors add to the explanatory power of the analysis, the individual level effects are not washed out.  This means that both individual identities and social organization work together in generating the levels of stigma seen on college campuses.    36  Discussion  The major finding from this research is that institutional settings do have a significant influence on students‘ stigmatizing views toward others. I used five measures to investigate the influence of institutional settings on stigmatizing views, including: funding sector, selectivity, having a hospital on campus, students‘ perceptions of competition and stigmatizing climate. Students studying at less selective schools, campuses perceived to be more competitive and institutions with more stigmatizing climates were more likely to have students who thought less of others with mental illnesses.   Students at less selective schools might be more likely to stigmatize based on the translation of institutional stigma to personal stigma. Structural stigma involves a combination of social conditions, cultural norms and institutional practices that limit the welfare of students in unplanned ways (Hatsenbluer et al., 2014). One way that these structures negatively impact student mental health is by reinforcing stigmatizing views. Less selective colleges tend to have less funding for student support programming than highly selective school (Mullen 2011; Pascarella et al., 2004). A lack of support for student programming means that these campuses are less able to afford wellbeing campaigns or online applications. If a campus doesn’t visibly support wellbeing, students at that school might interpret that to mean their school doesn’t care about mental illnesses. Those students might then adopt those cues as being part of their on-campus culture and therefore be more likely to discriminate against others with mental illnesses themselves. By embodying the perceived culture of their institution, students at these schools become less accepting of others.   37  Students at schools they perceive to be competitive might also adopt problematic views of others with mental illnesses as a function of structural stigma. Students in more competitive academic environments are often required to keep up high averages, vie for limited scholarships and take part in extracurricular programing. Doing all of these things at once, and to a high degree, places a lot of pressure on students to perform well at all times. Students at competitive schools who see others struggling might be less sympathetic to them because they see those students as not being able to keep up with the rigors of that academic environment. Their unwillingness to accept others with mental illnesses might therefore be a function of their own fears about maintaining status at school.    Although selectivity and perceived competition both impact stigmatization, school stigmatizing climate has the biggest impact. Students at schools where they think others stigmatize those with mental illnesses might adopt those feelings through their interactions on campus. Relating back to the Thomas Theorem, where ―…if situations are defined as real, they are real in their consequences‖, students perceptions of stigmatizing climates are real because they have real consequences for their feelings toward others (Thomas & Thomas, 1928: 572). An important part of fitting-in is sharing the values and opinions of those around you (Elfenbein & O'Reilly, 2007). If a student thinks that everyone else at their school stigmatizes those with mental illnesses, they might adopt those values to create solidarity between themselves and their peers. And while some students might have an exaggerated view of other‘s stigmatization, they still strongly resonate with values that discriminate and limit one‘s own likelihood for seeking help.  38  This research also builds on previous work investigating individual level influences for stigmatizing views by noting several additional individual level influences. Moving beyond Eisenberg et al.‘s (2009) work, I also investigated the relationship between stigmatizing and sexuality, current financial situation, having a previous mental health diagnosis and survey year. Heterosexual students tended to have more stigmatizing views toward others than their LGBQ peers, as do financially stable students and students with no previous mental health diagnosis. These more marginal groups might be more open to others with mental illnesses because they know what it feels like to be stigmatized or to struggle themselves. Despite widespread advances in social equalities for sexual minorities in America (e.g. legalization of same-sex marriage), prejudice against those groups still persists (Hatzenbuehler, Flores & Gates, 2017; Lai 2015, Leonard 2016). Although individuals with mental illnesses and those with financial issues have not experienced the same direct threats to their civil liberties in America, they do still experience a number of social and employment inequalities (Hatsenbluer, Phelan & Link, 2013). Being able to sympathize with the emotional, social and rights struggles that others are going through can make certain student groups more likely to accept others with mental illnesses (Cortland et al., 2017; Craig & Richeson, 2016).   Another notable finding from this analysis is that students‘ tendency to stigmatize decreased monotonically through years of the survey. From 2007-2014 the average for personal stigma decreased from 1.88 to 1.63. This decline is statistically significant. One reason for a decrease in stigmatizing views over time is perhaps the increase in mental health dialogue in popular media and across campus spaces. Television and online media campaigns aimed at de-stigmatizing mental illnesses have increased in numbers over the last decade (Sampogna, 39  Bakolis, Evans-Lacko, Robinson, Thornicroft, & Henderson, 2017). Campaigns like World Mental Health Day, MakeItOkay and Elephant in the Room now have support from multinational companies and government agencies alike. Similar movements have also spread across American college campuses. Most campuses now have wellness centers and mental health awareness campaigns that provide information about mental illnesses and free or reduced-cost mental health services available to students. In an attempt to reach more students in need, some campuses have even turned to social media to spread their message. For example, Colorado State University (2019) is using the online application ―YOU at College‖ to teach students about how to recognize and seek help for mental illnesses. Increased conversations about mental health issues, both in the media and on campus, have the potential to decrease the stigmatization of others with mental illnesses over time. More mental health literacy means less misunderstandings and more compassion from student populations (Thornicroft et al. 2016; Thornicroft, Brohan, Kassam, & Lewis-Holmes 2008).  This study is unique in that it combines individual stigmatization of others with institutional settings. However, because the Healthy Minds Survey focuses more on social psychological issues rather than structural and campus cultural factors, there are limitations to the explanatory power of this work. Although my findings demonstrate relationships between institutional factors and individual stigma, other factors might also be at play. Selection effects may explain some of the relationship between school settings and stigmatization. Perhaps students who hold stigmatizing views are more likely to select into lower selectivity public schools over more progressive private liberal arts colleges because they feel their opinions are more accurately represented in those spaces. Selection based on assumed on-campus cultures 40  demonstrates the need to incorporate more institutional level measures in research on student mental health. With more contextual information we will be able to more systematically represent the influences for those outcomes.   Implications of Research  A sociological approach to understanding mental health stigma is useful because it shows us that social organization has important consequences for student mental health stigmatization. Findings from this research confirm that institutional settings do impact students‘ stigmatization of others with mental illnesses. In response to the research question ―What schools are more likely to have students who stigmatize others?‖, I find that students at less selective schools, schools perceived to be more competitive and schools with more stigmatizing climates are all more likely to stigmatize others. Building on previous research by Eisenberg et al. (2009) I also note that heterosexual, financially stable students and those without a previous mental health diagnosis are also more likely to stigmatize others.    Of these findings, a school‘s stigmatizing climate seems to have the largest impact on students own views of others with mental illnesses. Perhaps as an attempt to fit in with their campus space, students at schools with more stigmatizing climates adopt those feelings themselves. One way perceptions of stigma can be addressed on college campuses is through the implementation of anti-stigma campaigns. Campus-wide interventions have been useful in the past for raising awareness and challenging misrepresentation about a range of social issues (Snyder et al., 2004).  A systematic review of anti-stigma campaigns for college students found that both knowledge and attitudes have the potential to be interrupted with these types of 41  interventions (Henderson, Evans-Lucko & Thornicroft, 2013; Pace, Silk, Nazione, Fournier & Collins, 2018; Thornicroft et al., 2016). Since certain institutional contexts, like atmospheres with greater stigma, seem to trigger greater stigmatization among student populations, anti-stigma campaigns may be one way that school administrators can combat these effects.                                    42  Chapter 3: Canadian and American Undergraduate Student Mental Health Service Use  Approximately 20% of Canadians will suffer from a mental illness at some point in their life, with our undergraduate students demonstrating similar self-reported rates of mental illness (Hanlon, 2012). A Canada-wide prevalence survey, conducted by The Centre for Addiction and Mental Health in 2004, indicated that 29% of undergrad students reported four or more symptoms of distress at school, including feeling they are under constant strain (47%), losing sleep over worry (32%) and feeling unhappy or depressed (31%) (Adlaf, Demers & Gliksman, 2005). The sole Canadian study on mental health service use, conducted in 2004/2005 by The Canadian Counselling Centre, found that 92% of post-secondary counselling center directors believed there to be an increase in the number of students seeking counselling and presenting with more severe psychological issues (Cozier & Whillihnganz, 2006). However, few studies have examined the actual rates of mental health service use by Canadian students, or have compared those numbers with their American counterparts (Nunes et al. 2014; Linden & Jurdi-Hage, 2017; Wilkes et al. 2019; Condra et al. 2015).   The Canadian national healthcare system tends to result in the overall better health of Canadian populations and increase likelihood for service use overall (Sanmartin et al., 2006). Americans are more likely to have unmet health needs and are less likely to seek help than Canadians, with the most commonly cited reason being cost (O‘Neill & O‘Neill, 2018). Access to healthcare might similarly impact American student populations, but not for Canadian students. Access to universal healthcare might offset some of the help seeking deterrents for Canadian students, making them more likely to get help when needed than their American peers. However, better access to health care is shown to only account for a small proportion in the overall health of Canadians (Keon & Pepin, 2008). The Lalonde Report (1974) and subsequent 43  works have demonstrated that individual attributes and social environments also play a significant role in individual health (Terris, 1984; Foth & Holmes, 2018; Hancock, 2017; Jackson & Huston, 2016). Although the overall wellbeing and mental health service use of Canadian and American students may be different, patterns of service use across groups might be similar.  Other factors that can impact student mental health service use include competition and stigma. The Canadian higher education system has traditionally been much less hierarchical than the American one. We have fewer schools per capita, are less focused on rankings and the majority of Canadian post-secondary students go to whatever school is closest to them (Davies & Hammack, 2005). There is the potential for Canadian students to be less burdened by feelings of competition and have greater likelihood for seeking mental health services as a result of these contextual differences. However, there are changes among Canadian post-secondary institutions, including increasing enrollment averages and higher tuition rates (Milian, Davies & Zarifa 2016), that might make experiences of competition and service use more alike across national contexts.  These academic contexts might also similarly impact experiences of stigma for mental illnesses among undergraduate students, negatively affecting their mental health service use. Stigma, those negative beliefs or opinions held towards a particular topic or group of people (Corrigan, 2000; Goffman, 1962; Link & Phelan, 2001), can be inadvertently supported through institutional programming and policies. This is referred to as structural stigma (Hatsenbluer et al., 2014; Corrigan et al., 2005) and it can influence individual perceptions of their institution and others around them. Institutional stigma can also translate into public stigma (Corrigan & Shapiro, 2010), influencing students‘ own feelings of others with mental illnesses. If students think others think less of those with mental illnesses or they themselves start to stigmatize those 44  with mental illness, they may be reluctant to seek help (a practice that requires individuals to recognize their own mental wellbeing). Combined, contextual influences have the potential to limit students‘ willingness to seek help for both Canadian and American students.   The dearth of research examining mental health service use by Canadian post-secondary students, compared to American populations, substantiates a need for further study. This research aims to fill that gap by evaluating the survey responses from 2,250 Canadian and 1,908 American undergraduate students about mental health service use. To do this I ask the following research questions: (1) How does the overall likelihood of Canadian students using mental health services compare to their American counterparts? and (2) How do individual characteristics influence the mental health service use of Canadian students and their American peers? Findings from this study demonstrate that Canadian students are more likely to use mental health services than American students and that variations remain among certain student groups.   National Contexts  National contexts have the potential to differently impact the health and well-being of citizens. Although there are a number of geographic and economic similarities between Canada and the United States, there are considerable health differences between our two populations. Americans are generally more likely to have unmet health needs, especially amongst their lower socioeconomic populations (Sanmartin et al., 2006). Americans are also more likely to experience higher rates of illnesses related to cardiovascular health and obesity than their Canadian peers (O‘Neill & O‘Neill, 2018). In an international study on stress, physical activity, and health demonstrated that both American females and Canadian females were more likely to report higher levels of stress than their male peers, but that Canadians were less likely to 45  experience adverse health problems with relation to stress (St-Pierre et al. 2019). Canadians also experience less mental illnesses and are more likely to seek help when needed (Biji et al., 2003, Lasser, Himmelstein & Wollhandler, 2006).   Differences in Canadians‘ and Americans‘ health are often attributed to variations in available healthcare. Canadians have universal access to publicly funded health care services, primarily physician and hospital services. The majority of American citizens require private insurance to cover the cost of medical care services; while public insurance is provided for the poor (Medicade) and for those over the age of sixty-five (Medicare). Canada‘s national universal healthcare system spends about half as much on health care, per capita, as the United States (who until recently did not have national health insurance plan) (Lasser, Himmelstein & Woolhandler, 2006), but experiences lower rates of morbidity and mortality among our populations. For Americans, healthcare costs act as a key barrier to help-seeking (Lasser, Himmelstein & Wollhandler, 2006). Although both groups demonstrate hesitation for seeking medical attention when needed, Americans commonly cite a fear of debt and healthcare costs for their reluctance. Canadians more frequently demonstrate frustration with wait-times as a reason for help-seeking avoidance (Lasser, Himmelstein & Wollhandler, 2006).  These differences in outcomes among our general populations could translate into disparities between undergraduate students and their help-seeking behaviors. If Americans are more likely to have unmet problems and are less likely to seek help for them, American college students may be similarly less likely to seek mental health treatment than their Canadian peers. Canadians‘ lower likelihood for experiencing mental illnesses and increased likelihood for seeking medical treatment, overall, has the potential to translate into our undergraduate students being more likely to seek help too. 46   However, the Lalonde Report of 1974 served as a catalyst for widespread recognition that health is determined more by social, cultural, economic and gender-based determinants than by access to healthcare in Canada (Glouberman & Miller, 2003). The contribution of available health services to the overall health of Canadians is estimated to only be 25% (Keon & Pepin, 2008), meaning that other social detriments including gender, sexuality and economic situation are worth consideration. In addition to a variety of social influences for health disparities, Canadians also do not have access to outpatient mental health services or prescription drug coverage under the Medicare (Martin et al. 2018). For the general population and for students, access to coverage for these types of services is only accessible through private insurance. Most Canadian universities do provide students with personal insurance plans through student fees, but few of these plans provide full coverage for mental health supports or prescription medication (Nunes et al., 2014). Students are often limited to less than 10 visits with a mental health professional or partial prescription drug coverage, with a fee cap, under student health insurance plans (Findlay & Sunderland, 2014; Nunes et al., 2014). Despite the differences in available healthcare between Canada and the United States, access to available health services have a much weaker effect on overall health than generally assumed and access to mental health services are infrequently covered. Although Canadian and American healthcare systems are very different, they might not impact national differences in help-seeking as much as one would expect. Instead, personal characteristics or perceptions of ones‘ environment might play a larger role influencing the help-seeking behaviors of people here.    47  Competition in Canadian and American Higher Education Systems  The higher education contexts of Canada and the United States contain variations that have the potential to impact student mental-health service use. The American post-secondary education system is a diverse mix of old private institutions, new public universities and specialized schools (Bujak et al., 2012, Davies & Guppy, 2018, Mullen, 2010). Beyond the sheer size and diversity of schools available in the United States, what distinguishes the American system from others is a steep prestige hierarchy (Davies & Hammack, 2005). There are several segments of highly unequal public and private institutions across America (Mullen, 2010). Ranging from Ivy League schools, elite four-year liberal arts colleges and flagship public universities, to open admission 2-year colleges, the competitive post-secondary system is extremely entrenched in the Sates. The division among schools sparks a distinctive form of competition that is not mirrored by any other global academic system (Davies & Guppy, 2018).   Post-secondary rankings are relatively new to the Canadian higher education system (Davies and Guppy, 2018). Canadian universities are much less differentiated overall. In Canada, all schools are expected to respond to federal and provincial policies in a like manner. Under increasing conceptions of education as a human right and virtually everyone being deserving of academic instruction, Canadian post-secondary intuitions have worked to respond to the growing needs of students by creating a wide array of programming and policies (Davies and Guppy, 2010). This has resulted in a more students going to university and a growing number of service programs providing support for them. Most Canadian students also select institutions that are within their own province, and some of the biggest universities in the country (e.g., The University of Toronto, McGill University, The University of British Columbia) have large 48  numbers of commuter populations (Davies & Hammack, 2005). However, differentiation is creeping into the Canadian higher education system.   In 2013, Ontario‘s Ministry of Training, Colleges and Universities identified differentiation as a key priority for higher education institutions in that province (MTCU, 2013, pp. 4–6). This meant that schools needed to aim to have ―sufficiently distinct strategic mandates, research profiles, and academic programs.‖ The common rational for differentiation is to reduce unnecessary duplication, promote efficiency, and encourage effectiveness by incentivizing each institution to build on its strengths (Weingarten & Deller, 2010). However, an unintended consequence of differentiation is emulation of more elite institutions, resulting in more competition between schools and among students. These changes are evident in the rise of averages required for enrollment across Canadian universities over the past decade (Milian, Davies & Zarifa, 2016). The Canadian higher education system has traditionally been less competitive than its American counterpart, but institutional changes may translate into student experiences that are more similar today.   Stigma in Canada and America  Canadian and American post-secondary contexts can impact students‘ feelings toward mental illnesses, influencing variations in mental health service use between these groups. Broadly speaking, stigma refers to any negative beliefs or opinions held towards a particular topic or group of people (Corrigan, 2000; Goffman, 1962; Link & Phelan, 2001). Researchers have studied multiple dimensions of stigma and have developed theoretical models to explain how these processes impact individual behaviors regarding mental illness. Structural stigma is a 49  combination of the social conditions, cultural norms and institutional practices that work together to limit access to health opportunities for stigmatized groups (Hatsenbluer et al., 2014; Corrigan et al., 2005). It has the potential to impact the attitudes and behaviours of individuals who interact within an institution in unplanned ways (Corrigan, Markowitz & Watson, 2004). For example, students who share common values with others on campus are more likely to graduate and have higher grade-point averages than their peers to don‘t feel like they fit in (Beyers & Goossens, 2002). The combination of social structures and academic programming can accumulate to form public stigma.   Public stigma is the most common form of stigma and involves stereotyping, prejudice and discrimination against people with mental illness in the general public (Corrigan & Shapiro, 2010). In combination with structural stigma, public stigma helps transmit common feelings and stereotypes about individuals with mental illnesses across a wide group of students. When individuals become aware of public stigma and agree with it, this becomes personal stigma (Corrigan & Rao, 2012). These types of feelings can inhibit mental health service use through processes described by Link et al. (1989) as ―modified labeling theory‖. This theory argues that individuals, in anticipation of a stigmatizing response from others, may adopt harmful coping strategies for dealing with their problems (e.g. secrecy, withdrawal, service use avoidance), leading to worse psychological symptoms, diminished social networks and reduced life opportunities. Personal and public stigma can develop in these spaces through the norms and policies of different institutions. Although few institutions have policies that are intended to directly limit the rights or welfare of individuals with mental illnesses, some of their practices can accumulate to influence the development of public or personal stigma.  50   Highly competitive post-secondary environments might also inhibit students from seeking help through experiences with stigma. Hierarchical post-secondary environments place large amounts of pressure on students to maintain high academic standards. Highly competitive academic environments, like medicine and law, are already known for fostering mental health stigma (Dyrbye al., 2015; Jolly-Ryan, 2010). Students enrolled in Canadian and American undergraduate programs, which they perceive to be competitive, might also develop greater feelings of stigma. That some of the competitive environments they participate in are unforgiving of those with academic or emotional struggles. Thinking their institution will not tolerate or help those with their life challenges might perpetuate public stigma, transferring into personal stigma if those feelings are internalized. Both types of attitudes have the potential to limit help-seeking behavior and therefore equate to differences in service use between Canadian and American student populations. This research aims set the foundation for understanding how students across national context differently engage mental health service use, as influenced by individual and academic contextual factors.  Methods  Data   The data for this study came from The Healthy Minds Network data, based at the University of Michigan. This data represents a cross-sectional survey of American and Canadian students‘ mental health and mental health service use. The Healthy Minds Data set has been fielded as a web-based survey every year since 2007. Sampling methods for this data vary depending institution size. If an institution has more than 4,000 students, 4,000 students are 51  randomly sampled. If an institution has fewer than 4,000 students, The Healthy Minds Network invites the full student population to participate.   Sample Characteristics   Using the 2014/2015 Health Minds Dataset, analysis for this paper focused only on undergraduate mental health service use from two Canadian universities and three American universities. For privacy reasons the schools chosen for this sample cannot be identified. To match the characteristics of the two Canadian schools, American universities with similar enrolment numbers, geographic locations and physical campuses were selected in those years (see Appendix 2). Other American schools were not used in this analysis because they were either privately funded, categorized as a liberal arts or graphic design school, were a community college or did not have similar populations/sample sizes. Three American schools were used to match the two Canadian schools to make up for lower sampling numbers from American schools in the original dataset.  Of the 2,250 Canadian students surveyed for this research, most undergraduate students were 21-25 years old (40%), had a B grade average (41%), female (67%), heterosexual (86%), White (87%) and are experiencing financial problems (86%) (see Table 3.1). Sample characteristics for the American population are similar. Of the 1,908 American undergraduate students surveyed most were 21-25 years old (40%), had an A grade average (48%), were female (74%), heterosexual (86%), White (67%) and were experiencing financial problems (77%).     52  Table 3.1: Sample Characteristics as Percentages    Canadian American  Age      18-20 Years Old 34.89 31.08    21-25 Years Old  39.64 39.83    26+ Years Old  25.47 29.09 GPA       A 37.73 48.43    B 40.89 38.36    C 20.13 12.68    D to Fail  1.24 0.52 Gender       Male 32.86 26.06    Female 67.14 74.94 Sexuality       Gay, Lesbian, Bisexual  13.56 13.89    Heterosexual 86.44 86.11 Previous Mental Health Problem      No previous mental health problem 72.49 71.07    Has a previous mental health problem 27.51 28.93 Personal Stigma       Agree  5.70 9.21    Disagree 94.3 90.79 Perception of Stigma       Disagree 53.15 53.49    Agree 46.85 46.51 Competitive Perception       Is not Competitive 17.48 15.96    Is Competitive  82.52 84.04 Current Financial Situation       Financial Troubles  19.66 22.53    Financially Stable  80.34 77.47 Know Where      Don’t  Where to Go  29.46 38.35    Know Where to Go 70.54 61.65 N (Individuals)  2,250 1,908  Proportions of Canadian students with a previous mental illness were also comparable to American proportions. About 28% of Canadian undergraduate students had a previous mental 53  illness diagnosis, while 29% of Americans had a previous mental illness diagnosis. In terms of perceptions of school environment, both lager proportions of Canadians and American students disagree with stigmatizing views of others and think their school is competitive. For both Canadian and American students, larger proportions were financially stable and knew where to seek mental health support.  Measures  The dependent variable in this study is a binary measure of mental health service use, using one indicator from the Health Minds Dataset. This measure uses responses to the survey question: ―In the past 12 months have you received counseling or therapy for your mental or emotional health from a health professional?‖. Students who answered yes to that question were considered treatment users. The original response format of a 6 point scale has been converted into a binary variable by splitting the responses. Anyone who indicated for the responses ―Strongly Agree‖, ―Agree‖ and ―Somewhat Agree‖ were considered individuals who knew where to seek treatment. Students who indicated for the responses ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖ were considered individuals who do not know where to seek treatment.   The following explanatory variables were also isolated to examine how individual characteristics influence the mental health service use of Canadian and American students: age (18-20 years old, 21-25 years old, and 26+ years old), GPA (A, B, C, D to fail), gender (female, male), sexuality (straight, gay/lesbian/bisexual) and having a previous mental illness diagnosis. To measure whether students had a previous mental illness diagnosis, the HMS asks students ―Have you ever been diagnosed with any of the following conditions by a health professional (e.g. primary care doctor, psychiatrist, psychologist, etc.)?‖ The survey then provides students 54  with a list of mental illnesses, including depression, anxiety, attention disorders, eating disorders, psychosis, personality disorders, and substance use disorders.  Students were asked to respond with either ―none‖ or ―any diagnosis‖.   To better understand how students‘ perceptions of others and their school environment impact mental health service use I utilized the following measures from the HMS: personal stigma, perception of stigma and perception of competition. Personal stigma was evaluated using responses to the survey statement ―I would think less of someone with a mental health problem‖. Responses to the statement included ―Strongly Agree‖, ―Agree‖, ―Somewhat Agree‖, ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖. Responses to this statement were recoded into binary measures, with ―Strongly Agree‖, ―Agree‖, ―Somewhat Agree‖ indicating that students did hold stigmatizing views toward others with mental illnesses and ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖ indicating that they didn’t hold stigmatizing views toward others. In addition to evaluating students‘ individual feelings of stigma toward others I also examined their perception of stigma. The Perceived Stigma measure used students‘ responses to the following statement: ―Most people would think less of a person who has received mental health treatment‖. Again, responses to this variable were coded as ―Strongly Agree‖, ―Agree‖, ―Somewhat Agree‖, ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖. This variable was also recoded as a binary response, with students who responded with ―Strongly Agree‖, ―Agree‖, ―Somewhat Agree‖ indicating that those students felt that others at their school did hold stigmatizing views toward those with mental illnesses, and ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖ as students who didn’t feel that others at their school held stigmatizing views toward those with mental illnesses.  55   Also included in this analysis is a measure of students‘ perceptions of competition at their school. To examine how individual perceived competition influences student‘s mental health service use I used the following survey question: ―How would you rate the overall competitiveness between students in your classes?‖ Responses for this question were formatted in a 6 point scale, including responses of ―Very Competitive‖, ―Competitive‖, ―Somewhat Competitive‖, ―Very Uncompetitive‖ and ―Not Competitive‖. Responses for this variable were recoded as a binary measure, with ―Very Competitive‖, ―Competitive‖ and ―Somewhat Competitive‖ indicating that students did think their school was competitive and ―Very Uncompetitive‖ and ―Not Competitive‖ indicating that students didn‘t think their school was competitive.  In addition to measures for students‘ perceptions of their school environment, I also used measures to unpack the influence of economic situation and knowledge of where to seek help for mental health service use. To demonstrate how students‘ economic situations impact their use of mental health services I used the HMS question ―How would you characterize your current financial situation?‖ Students were able to respond to this question with ―It‘s a financial struggle‖, ―It‘s tight but I‘m doing fine‖ or ―Finances aren‘t really a problem‖. Responses for this variable were recoded, with students indicating ―It‘s a financial struggle‖ or ―It‘s tight but I‘m doing fine‖ as those experiencing financial troubles and students who responded ―Finances aren‘t really a problem‖ as financially stable.   56  Students knowledge of were to access help comes from the HMS statement ―If you needed to seek professional help for your mental or emotional health while attending [insert institution], you would know where to go.‖ Responses to the statement included ―Strongly Agree‖, ―Agree‖, ―Somewhat Agree‖, ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖. Responses to this statement were recoded to a binary response, with ―Strongly Agree‖, ―Agree‖, ―Somewhat Agree‖, as knowing where to go for help and ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖ as not knowing where to go for help.   To check for multicollinearity between measures, I conducted a variance of inflation analysis (VIF) for each factor (see Appendix 3). No measure had a VIF above 1.5 and the average VIF for independent measures and mental health service use was 1.11.   Weighting  Previous research using the HMS data incorporated response propensity weights to adjust for student non-response. Eisenberg et al. (2009) created their weights by obtaining nonresponse information from universities‘ administrative data, including information on student demographics like sex, race/ethnicity, academic level and grade point average. The creation of these weights was instrumental for ensuring that their analysis was representative in terms of individual characteristics across schools. The same weights are used in this analysis to ensure representation across Canadian and American samples.     57  Statistical Analysis   For this research I first investigated proportional differences in service use between Canadian students and American students. I next examined the variations in proportional use by Canadian and American students across individual characteristics, perceptions of their school environment, financial situation and knowledge of where to get help. Next I used ordered logistic regression by using STATA‘s ologit function (Williams 2006) to estimate models for student mental health service use. The same analysis was done using STATA’s gologit2 and found almost identical results. This analysis was restricted to those with perceived need for help, consistent with previous research (Eisenberg et al., 2007), however similar models were conducted excluding those with previous mental illness diagnosis in Appendix 4.   Findings  To better understand how Canadian undergraduate students use mental health services, this research first examines the percent of service use by Canadian and American students. Roughly 22% of Canadian students use mental health services when they need it, while 18% of American students use mental health services when they need it (see Table 3.2). Using the prtest program for STATA, I measured the equality of service use proportions between Canadian and American students. The difference between Canadian and American mental health service use is statistically significant. These findings fall in line with overall population trends, where Americans generally are less likely than Canadians to seek treatment (Biji et al. 2003, Lasser, Himmelstein and Wollhandler 2006). One reason that a significantly larger proportion of Canadian students use mental health services could be the cost barriers associated with help seeking for American students. Although most American campuses have free or subsidized 58  mental health treatment programs, the cost of extended mental health support, limited number of counseling visits covered by insurance or pharmaceutical aids, might discourage American students from seeking help.   In addition to financial limitations, academic environments might account for some of the effect of differences between Canadian and American student mental health service use. The highly competitive academic arena in America places large amounts of pressure on students to maintain high academic standards. The strain to be successful and maintain high grades might put more stress on American students than Canadian students, who go to school in a comparatively less competitive academic environment. These environments might have a knock-on effect of causing American students to develop greater feelings of stigma. American undergraduate students might feel that some of the competitive environments they participate in are unforgiving of those with academic or emotional struggles. Thinking their institution will not tolerate or help those with their life challenges might perpetuate public stigma, transferring into personal stigma if those feelings are internalized. Both types of attitudes have the potential to limit help-seeking behavior and therefore equate to differences in service use between Canadian and American student populations.  Table 3.2: Percent of Canadian and American Undergraduate Students Using Mental Health Services Mental Health Service Use   Canadian  American  z p Did Not Use Services 78.35 82.37 (Reference) (Reference) Used Services 21.65 17.63 3.06 ** N(Individuals) 2,250 1,908   * p < 0.05, ** p < 0.01, *** p < 0.001  59  In addition to examining the general mental health service use of Canadian and American students, I also measured the effects of personal characteristics on their proportional use of mental health services (see Table 3.3). The proportions of mental health service use by individual characteristics, perceptions of school environments, financial situations and knowledge of where to get help are not significantly different between Canadians and Americans.  Table 3.3: Proportions of Canadian and American Undergraduate Students Using Mental Health Services   CND USA CND-USA Age       18-20 Years Old 21.37 18.00     21-25 Years Old  21.28 17.73     26+ Years Old  21.04 18.20  GPA    ***    A 20.17 18.91     B 20.79 18.57     C 21.44 18.85     D to Fail  21.74 17.65  Gender    **    Male 19.76 16.55     Female 20.86 21.03  Sexuality        Gay, Lesbian, Bisexual  22.47 20.29     Heterosexual 19.18 18.48  Previous Mental Health Problem   **    No previous mental health problem 16.53 14.64 **    Has a previous mental health problem 25.36 25.20  Personal Stigma    **    Agree  20.60 17.62 **    Disagree 20.43 19.86  Perception of Stigma    ***    Disagree 20.76 18.02 **    Agree 20.20 20.23  Competitive Perception    **    Is not Competitive 21.42 18.12 **    Is Competitive  19.98 19.41  Current Financial Situation     60     Financial Troubles  19.50 18.43     Financially Stable  21.80 20.23  Know Where       Don’t  Where to Go  18.31 15.07     Know Where to Go 22.35 22.09  N (Individuals)  2,250 1,908    Using STATA‘s prtest software to test the equality of proportional service use by Canadian and American students, I note several significant differences across national groups. There are significant differences in the proportions of Canadian and American undergraduate students who use services according to their GPA, gender, feelings of stigma toward others with mental illnesses, perception of stigma and perceptions of competition at their school. Differences in these proportions support the finding of an overall smaller proportion of American undergraduate students using mental health services when needed. For each measure, a larger proportion of Canadian undergraduate students use mental health services, when in need, than their American peers.   Regression Analysis  To expand on the influences of student mental health service use, I next conducted a logistic regression analysis of mental health service use by Canadian and American undergraduate students, investigating the impact of individual characteristics on service use for both groups (see Table 3.4).  For this analysis age and students‘ GPA had no effect on mental health service use for both Canadian and American undergraduate students. I also included measures for gender and sexuality in each model. Canadian and American undergraduate students who self-identify as female are both more likely to use mental health services than their male peers.  Canadian students who identify as gay, lesbian and bisexual are more likely to use 61  mental health services than their heterosexual peers (OR = 0.48, p < 0.05), mirroring previous research on American undergraduate students (Eisenberg et al., 2010). This effect was the same for American undergraduate students, where female undergraduate students were more likely to use services than their male peers (OR = 0.74, p < 0.05). There were also similarities in Canadian and American help-seeking behaviors among those with previous mental illness diagnoses. Canadian students with a previous mental illness diagnosis were 5.9 times more likely to use services than their peers without a previous diagnosis, while the same group of American students was 6.1 times more likely to use services than their undiagnosed peers.   Perceptions of school environments also impacted both Canadian and American undergraduate student mental health service use. Canadian students who thought that others stigmatized those with mental illnesses were 1.56 times more likely to seek services than their peers who didn‘t perceive others to be stigmatizing. The same effect was mirrored among American populations, with the odds of students who thought others stigmatized those with mental illness seeking help being 1.45 times greater than their peers who did not perceive others to be stigmatizing of mental illness. Again, these findings support the idea that students who do not find their school environment to be supportive may be more likely to experience mental illnesses, culminating in greater likelihood for seeking help. However, for both Canadian and American undergraduate students, feelings of competition and personal stigma towards others had no impact on their mental health service use.   After investigating how personal perceptions impacted Canadian and American undergraduate student mental health service use, I next introduced measures that investigated the 62  impact of students‘ financial situations and knowledge of mental health services on the likelihood of their own service use. Financial challenges had no impact on mental health service use for both Canadian and American undergraduate students in this sample. However, knowledge of on-campus mental health services did positively impact both Canadian and American students‘ mental health service use. Both national student groups who know where to seek help were roughly 4 times more likely to use services when they need it than their peers who did not know where to get help.   Table 3.4: Logistic Regression of Mental Health Service Use    Model 1  Model 2  Model 3  Model 4  Variable CND USA CND USA CND USA CND USA Age            18-20 Years Old 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    21-25 Years Old  1.14 0.96 1.11 0.87 1.07 0.86 1.06 0.90    26+ Years Old  1.51 1.14 1.38 1.07 1.3 1.04 1.24 1.21 GPA             A 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    B 1.01 1.08 0.10 1.06 0.96 1.05 0.95 1.09    C 1.16 1.01 1.17 1.06 1.13 1.03 1.12 1.09    D to Fail  0.81 2.06 0.52 2.46 0.46 2.52 0.68 2.51 Gender             Male 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    Female 2.15*** 2.18*** 1.93*** 2.29*** 1.93*** 2.28*** 1.86*** 2.14*** Sexuality             Heterosexual  1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    Gay, Lesbian, Bisexual 0.48*** 0.74*** 0.48*** 0.76*** 0.49*** 0.76*** 0.46*** 0.71*** Previous Mental Health Problem            No previous mental health problem 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    Has a previous mental health problem 6.88*** 6.50*** 7.13*** 6.64*** 6.92*** 6.59*** 5.99*** 6.08*** Personal Stigma             Agree    1.00 1.00 1.00 1.00 1.00 1.00    Disagree   0.58 0.56 0.57 0.56 0.72 0.58 Perception of Stigma             Disagree   1.00 1.00 1.00 1.00 1.00 1.00 63     Agree   1.56** 1.45* 1.55** 1.45* 1.55** 1.57** Competitive Perception             Is not Competitive   1.00 1.00 1.00 1.00 1.00 1.00    Is Competitive    1.31 1.12 1.28 1.12 1.17 1.06 Current Financial Situation             Financial Troubles      1.00 1.00 1.00 1.00    Financially Stable      0.71 0.87 0.72 0.8 Know Where            Don’t  Where to Go        1.00 1.00  Know Where to Go             4.04*** 4.29*** N 2,250 1,908 2,250 1,908 2,250 1,908 2,250 1,908 Wald chi2 250.43 32.89 237.16 153.82 234.54 156.34 230.38 186.56 Odds Ratios  * p < 0.05, ** p < 0.01, *** p < 0.001    To better understand the effect of school setting on mental health service use I next created models that introduced the effect of students being in each school independently into my analysis (see Table 3.5). Models 2 and 3 introduce students from my two Canadian schools independently. When I introduced each of these measures to the analysis they had little effect my other independent measures‘ influences on service use and had no significant effect on students‘ service use themselves. In Models 4, 5 and 6, I also individually introduce my three American schools into my equations. With the introduction of these schools, I also note that there is little change in the influence of my other independent measures for students‘ mental health service use. The influence of those schools on student mental health service use is also not significant. I interpret this lack of effect to mean that the difference in rates between American and Canadian students cannot be explained away by individual school influences.       64  Table 3.5: Logistic Regression of Mental Health Service Use across Schools Variable Model 1 Model 2 Model 3 Model 4  Model 5 Model 6 Age          18-20 Years Old 1.00 1.00 1.00 1.00 1.00 1.00    21-25 Years Old  0.95 0.92 0.92 0.9 0.93 0.96    26+ Years Old  1.19 1.20 1.20 1.16 1.12 1.13 GPA           A 1.00 1.00 1.00 1.00 1.00 1.00    B 1.04 1.03 1.14 1.04 1.05 1.05    C 1.14 1.11 1.13 1.13 1.15 1.12    D to Fail  1.38 1.32 1.37 1.36     1.36 1.28 Gender           Male 1.00 1.00 1.00 1.00 1.00 1.00   Female 2.02*** 1.99*** 2.01*** 2.02*** 2.04*** 2.01*** Sexuality           Gay, Lesbian, Bisexual  1.00 1.00 1.00 1.00 1.00 1.00    Heterosexual 0.58*** 0.58*** 0.58*** 0.58*** 0.58*** 0.58*** Previous Mental Health Problem       No previous mental health problem 1.00 1.00 1.00 1.00 1.00 1.00 Has a previous mental health problem 6.01*** 6.13*** 6.01*** 6.02*** 6.06*** 6.31*** Personal Stigma           Agree  1.00 1.00 1.00 1.00 1.00 1.00    Disagree 0.61 0.65 0.66 0.66 0.65 0.64 Perception of Stigma           Disagree 1.00 1.00 1.00 1.00 1.00 1.00    Agree 1.53*** 1.54*** 1.53*** 1.53*** 1.53*** 1.56*** Competitive Perception           Is not Competitive 1.00 1.00 1.00 1.00 1.00 1.00    Is Competitive  1.09 1.02 1.04 1.04 1.03 1.03 Current Financial Situation           Financial Troubles  1.00 1.00 1.00 1.00 1.00 1.00    Financially Stable  0.77 0.70 0.71 0.71 0.71 0.70 Know Where           Don't Know Where to  Go  1.00 1.00 1.00 1.00 1.00 1.00    Know Where to Go  4.40*** 4.30*** 4.38*** 4.40*** 4.40*** 3.14*** Canadian University 1   1.00        1.34     Canadian University 2    1.00        1.01    65  American University 1     1.00        0.81   American University 2     1.00        0.99  American University 3       1.00        0.65 N 4,158 4,158 4,158 4,158 4,158 4,158 Wald chi2 387.52 389.05 389.91 388.20 388.94 396.83 Odds Ratios * p < 0.05, ** p < 0.01, *** p < 0.001   Overall, patterns of mental health service use among Canadian and American undergraduate students are very similar, and were sustained when students‘ with previous mental illnesses were removed from the sample (see Appendix 4). Personal identities, perception of school environment, economic stability and knowledge of available mental health services all impacted students in similar ways. Being in a particular school also seems to have no influence on these patterns of service use. However, one major difference between Canadian and American undergraduate students is that a larger proportion of Canadians use services, when in need, than their American peers (See Table 3.2). Not only are these findings important because they demonstrate how student mental health service use mirrors differences in general population service use trends (Sanmartin et al., 2006), but they are also some of the first to recognize similar patterns in service use across national student groups in terms of personal characteristics, perceptions of school environment, economic situation and knowledge of where to get help.   Implications of Research   Canadians are supported by a universal healthcare system that offsets some of the help-seeking reluctance among our general population, compared to Americans (Sanmartin et al. 2006). And this might contribute to similar overall differences in help-seeking among our student populations. This research demonstrates that the overall proportion of mental health service use 66  for Canadian and American undergraduate students is significantly different. A larger proportion of Canadian undergraduate students use mental health services than their American counterparts. However, there are no significant variations in service use by individual characteristics, perceptions of school environment, financial situations or knowledge of were to seek help between Canadian and American undergraduate students. Student groups for both countries seem to use mental health services similarly.     Cross national similarities in service use may be attributable to social, cultural and economic determinants that are shared between the two countries (Glouberman & Miller, 2003). Among Canadian students, personal characteristics did differently influence their help seeking behaviors. Female and sexual minority students were more likely to use services than their male and heterosexual peers. Students with a previous mental illness diagnosis were also significantly more likely to use mental health services than their peers without a previous diagnosis. In terms of perception of campus environments, Canadian students who thought others at their school held stigmatizing views toward those with mental illnesses were more likely to use services themselves. Perceptions of competition and students‘ own feelings toward mental illnesses had no impact on their mental health service use in this analysis. Students‘ financial situation did not significantly impact Canadian students‘ mental health service use, but knowledge of where to get help did. Those students, who knew where to get help for their mental wellbeing, when they needed it, were more likely to access services.   67   The findings from this research are meaningful for two reasons. First this work is some of the first to examine how individual characteristics and perceptions of school environment influence the mental health service use of Canadian undergraduate populations. Up until this point, there is very little research examining the actual help-seeking behaviors of Canadian students and how they vary by group identity. Second, this work is useful because it compares these outcomes with American students. Much of the literature on undergraduate help-seeking behavior currently used by Canadian campus practitioners is created in-house or uses American based data without an understanding of our similarities or differences. My findings are important for starting the conversation about similarities in student help-seeking behaviors. However, an expansion of national undergraduate student datasets in Canada, to include more demographic information for students and their overall wellbeing would be exceptionally beneficial for helping researchers and policy makers better understand student needs and for creating effective on-campus interventions.                     68  Chapter 4: Canadian and American Undergraduate Student Experiences of Depression and Anxiety   Canadian universities are seeing a growing demand for on-campus mental health support. In 2019, the University of British Columbia spent $3.3 million, in addition to the $2.5 million it regularly spends on mental health programming, to physically expand its on-campus mental health services center (Chan, 2019). The University of Toronto also witnessed a number of protests by student groups calling for more effective mental health resources after a student committed suicide on campus in October 2019 and another was arrested, as standard police preventative procedures, after admitting to having suicidal ideation while seeking services (Mancini & Roumeliotis, 2019). A report by the Ontario College of Health Association (2016) found Ontario post-secondary students to be more than twice as likely to report mental illness symptoms and elevated distress than non-university youth. Another study of 16,123 Ontario university students found that the majority indicated that mental health was a significant concern (ACHA, 2013). In that study, 51% of Canadian undergrads reported feeling hopeless, 40% reported feeling so depressed they were not able to function and 11% seriously considered suicide in the last 12 months (ACHA, 2013). Rates of mental illnesses among Canadian student populations have been increasing (OCHA, 2016), potentially mirroring trends with American counterparts, however there is little evidence to compare student experiences.   Much of the current student mental health research is based on American data (Drapeau & Hunsley, 2014; Hunsley, Ronson & Cohen, 2013; Jaimes, Laroes-Hubert & Moreau, 2015). The shortage of Canadian-based research seems to favour the idea there are no national differences in student experiences. However, many Canadians believe they have experiences and an identity that are unique from Americans (Arat-Koc, 2005; Barnet & McPhail, 1980; Kalbach 69  & Kalbach, 1999). Canada bears a number of dissimilarities from America (Lipset, 1996). Social welfare programming (like universal healthcare), and subsidized higher education mean that economic security is much more accessible to the wider public in Canada than it is in the United States. Canadians take on these institutional differences as symbolic of a national identity based on openness and acceptance (Bebbington, 1997).Combined, these social factors have the potential to impact the ways Canadian and American undergraduate students experience mental illnesses.    Social, demographic, economic and behavioural factors play a large role in shaping the mental health of students. These factors can accumulate to place certain individuals at greater risk for experiencing health problems, known as the social determinants of health (Prus, 2011). Social determinants of health include the macro-level social factors, such as discrimination, socioeconomic situation or access to health care, which can influence disparate health outcomes (Berkman & Kawachi, 2000; Link& Phelan, 1995; Phelan & Link, 2005; Wilkinson & Marmot, 2003). The social determinants of health for Canadian and American students are important to consider because they can impact both physical and mental health. For example, a study of European medical students found that the incidence of psychological distress was highest among those who perceived their academic environment to be unsupportive (Btrio, Balajti, Adany & Kosa, 2008).  Another study of university student living conditions found that those with unstable home environments were more likely to experience mental distress at school (Sailaja et al. 2016). However, the research on the social determinants of student mental health is limited (Becerra & Becerra 2020; Btrio, Balajti, Adany & Kosa, 2008; Debate, Gatto & Rafal, 2018; Sailaja et al. 2016 ). The lack of understanding about the social determinants of student mental 70  health and Canadian undergraduate student mental health, generally, warrants further investigation.     Within this debate there are others who argue that although there are a number of differences between Canadians and Americans, there are similarities in the social determinants of health for our general populations that span the border (Prus, 2011). With these differences of opinion in mind, are we right to assume mental health experiences, such as depression and anxiety, are similar across students in the two different national contexts? This research aims to address this question by analyzing 4,158 responses by Canadian and American undergraduate students at five schools. I investigate proportion of anxiety and depression among Canadian and American undergraduate students, with special focus on the social determinants of these health outcomes. I do this, not only to address a considerable gap in cross-national mental health research, but to also elucidate the variations in mental health experiences among Canadian undergraduate students.     Social Determinants of Student Mental Health   The World Health Organization (WHO) defines the social determinants of health as the conditions in which ―people are born, grow, live, work and age‖ and notes that these determinants are shaped by the multilevel distribution of wealth and other forms of opportunity within society (World Health Organization, 2008). Generally, these determinants might include access to and quality of healthcare or employment for adults.  Understanding health as influenced by these types of conditions places the responsibility of health and health equity firming within realms of social policies and institutional programming. It also suggests that 71  illnesses that are commonly considered only through their biological determinants should also be similarly considered through social and environmental influences as well (Compton & Shim, 2015). By examining certain health outcomes, in terms of their social influences, research can better understand the risk and resilience for disease at the community level.    One such area of disease includes mental illnesses. Psychiatrists and other mental health professionals are aware of the fact that the sources of mental illnesses are at least partly driven by social risk factors. Although biological and genetic models have served as a structure for investigating the influence of mental illness across different populations for many years, evidence to support a biopsychosocial model has increased over time (Engel, 2012). Largely stemming from physical health research, linking chronic health conditions like hypertension, diabetes and congestive heart disease with social risk factors, psychological research has begun to do the same (Havarnek et al. 2015; Marmot & Wilkinson 2005; Walker et al. 2014; WHO 2008; Wilkinson & Marmot 2003). For example, a robust body of research supports the association between income inequality and poor mental health, increased risk for mental illnesses and worsening outcomes among people affected by mental illness (Compton & Shim, 2015). There is also a positive correlation between state income inequality, depression prevalence and substance-use disorders (Assari, 2017; Nandi et al., 2006). A study based in New York City found that the risk of death from drug overdose was significantly higher in neighbourhoods with greater income inequality (Nandi et al., 2006). Other work has also shown an association between income inequality and schizophrenia, with individuals diagnosed with that disorder predominantly coming from low income backgrounds (Lund, Stansfeld & De Silva 2014). Each of these studies understands poor mental health as stemming directly from an unequal 72  distribution of opportunity across different realms of society, and demonstrates how those inequities relate to disparate mental health outcomes.   National Contexts and Social Determinants of Mental Health  There are several ways in which national contexts might affect the social determinants of mental health for Canadian and American students. Seymour Martin Lipset (1968, 1990, 1996) long argued that institutional differences between Canada and the US dramatically shape the character of those two populations. That Canadian customs are strongly based on traditions of Toryism stemming from our colonial roots, making Canadians more accepting, deferential and obedient (Bebbington, 1997; Lipset 1968, 1990, 1996). Conversely, American independence created a national society with a greater focus on rebellion, personal autonomy and capitalist gain. For students, these differences have the potential to translate into variations in the experiences of key social determinants of health. Compton and Shim‘s (2015) description of nine core social determinants of health (e.g. discrimination, adverse life experiences, poor access to food, unemployment, economic inequality, poor housing, adverse features of the built environment and poor access to health care) provide a theoretical framework for explaining how these types of differences impact individual mental health. In particular, discrimination, economic inequalities and poor access to healthcare have the potential to play an important role in the mental health experiences of undergraduate students.   Individual identities that are actively discriminated against in society can place particular student groups at risk for experiencing mental illnesses. For example, sexual minorities in the general population report poorer mental health functioning than heterosexuals, including higher 73  rates of anxiety, suicide, depression and depressive symptoms (Hatzenbuehler, Hilt & Nolen-Hoeksema, 2010; Marshal et al., 2011). Disparities in the LGBT mental health are understood to be a function of the excess stress that results from discrimination and victimization that they experience as a result of their stigmatizing identity (D‘Augelli, Pilkington & Hershberger 2002; Hatzenbeuhler & Davila 2012). Despite an increasing number laws and regulations protecting LGBT rights, these populations are still at risk for experiencing discrimination in both the public and private spheres of America (e.g. transgender washroom debate, state-wide Anti-LGBT business laws). Although college campuses have made increasing efforts to be inclusive of individuals of sexual minority status (Marine & Nicolazzo, 2014; McKinley et al., 2015), sexual minority students tend to experience more discrimination than others (Iarovici, 2014). LGBT students continue to face greater discrimination on college campuses than do other minority groups, and open prejudice against LGBT students continues to be socially acceptable in some realms of society (Iarovici, 2014). However, the experiences of LGBT students in Canada and America might vary. Canada was one of the first countries to support gay marriage rights and has included protections for LGBT rights national legal codes (Smith, 2005). Although gay marriage is legal in America, pushback remains in certain states. Federal level support, or lack thereof, for different identities can have the effect of compounding discrimination toward LGBT members of society, exacerbating the stress that LGBT students face, has the potential to put them at greater risk for experiencing mental illnesses at school.    In addition to discrimination, economic inequality also places certain individuals at greater or lesser risk for experiencing mental illnesses. Lipset (1996) argued that based on British Toryist tendencies, the subsidization of public institutions have greater support and society sees 74  less economic inequality than in America. These differences are especially evident in the higher education systems of Canada and America. Although Canadian tuition costs have been steadily increasing for undergraduate students over the past two decades, the average cost of a degree still remains much lower in Canada than America. The average cost of tuition for a Bachelor of Arts degree (the most common undergraduate degree in Canada) is about $6,463 per year, compared to the American equivalent at $36,420 per year ($10,230 for in-state public university students) (Stats Can, 2018). This means that not only are Canadian student debt loads smaller, but there is potential for greater disposable income during their years in school. Debt and financial troubles are one of the strongest correlates for depression and anxiety in general populations (Fitch, Hamilton, Bassett & Davey, 2011). For students this is no different. Among American undergraduate populations, those experiencing financial challenges were 2.15 times more likely to experience mental health challenges than their financially stable peers (Eisenberg, Hunt & Speer, 2013). And student debt differs greatly by family socioeconomic status. The affordability of higher education in Canada may mean that there is less difference in mental health outcomes among certain groups of Canadian undergraduates than American students.   Finally, American and Canadian higher education contexts also differ in terms of access to health care. Emergent and generalized health issues are covered by universal health care in Canada, while individual private insurance plans subsidize the health fees of Americans. These differences translate into Canadians, on average, being more likely to seek help for their health and mental illnesses than their American peers (Lasser, Himmelstein & Woolhandler, 2006). However, most American and Canadian post-secondary institutions provide free or subsidized 75  mental health care, potentially making American post-secondary students less deterred from treating their mental health conditions on campus, resulting in equal effects borders.   Depression and Anxiety   To better understand how social determinants of health impact undergraduate student mental health, I focus on students experiences of depression and anxiety. Depression and anxiety are two of the most common mental illnesses among student populations. Both illnesses represent a significant health concern, with on average, nearly 1/3 of students being affected (Ibrahim, Kelly, Adams & Glazebrook, 2013). Depression and anxiety, while affecting large proportions of students, have very different characteristics. Depression is considered a multi-problematic disorder that leads to impairment in interpersonal, social and occupational functioning (Sadock & Kaplan, 2007). The basic characteristic of depression is a loss of positive affect which can manifest in a number of different ways. Individuals experiencing depression can demonstrate symptoms including sleep disturbance, lack of self-care, poor concentration, and a lack of interest in everyday experiences (NICE, 2009). These symptoms can be especially debilitating for students, commonly hindering their academic progress and decreasing overall academic standing by approximately half a grade (Hysenbegasi, Hass & Rowland, 2005).    Anxiety disorders can also negatively impact students‘ lives. These types of mental illnesses are characterized by feelings of nervousness, insomnia, avoidance behaviors and physical disturbances such as increased heart rate, hyperventilation, and sweating (Ruscio et al., 2017). Research shows that anxiety disorders increase one‘s risk for experiencing health problems such as substance abuse, disordered eating and other mood disorders (Antony, Federici 76  & Stein, 2009). The impacts of anxiety can also be severe in both private and professional domains and can place students‘ academic progress at risk. Students suffering from anxiety have some of the lowest academic outcomes of those dealing with major mental health disorders (Olfson et al., 2000).    Considering the potential contextual influences for Canadian and American mental health issues, this research asks several questions. First, given overall national differences in institutional settings, do social determinants of health have the same impact in both settings?  Here my intent is a descriptive exercise investigating whether the influence of social determinants of mental health differs across national settings. In addition to this question, I also ask: How do the social determinants of health impact Canadian student mental health outcomes generally? The second research question I focus on in this work is how do different social determinants of health impact Canadian undergraduate students‘ mental health. There is very little information on Canadian student mental illnesses and influences (Drapeau & Hunsley, 2014; Hunsley, Ronson & Cohen, 2013; Jaimes, Laroes-Hubert & Moreau, 2015). Having a better understanding of these issues may help us more effectively address this growing health problem across Canadian campuses.   Methods  Data   The data for this study comes from The Healthy Minds Network data, based at the University of Michigan. This data represents a cross-sectional survey of American and Canadian students‘ mental health and mental health service use. The Healthy Minds data set has been 77  fielded as a web-based repeated cross-sectional survey every year since 2007. Sampling methods for this study vary by institution size. If an institution has more than 4,000 students, 4,000 students are randomly sampled. If an institution has fewer than 4,000 students, The Healthy Minds Network invites the full student population to participate.   Sample Characteristics   Using the 2014/2015 Health Minds dataset, analysis for this paper focuses on undergraduate mental health outcomes from two Canadian universities and three American public universities. Because the survey gathered information from both graduate and undergraduate students, the sample sizes used for this research were considerably reduced when graduate student and missing responses were removed. The Canadian schools included in this sample were the only ones that participated in the Health Minds Study. To match the characteristics of those schools, American universities with similar enrolment numbers, geographic locations and physical campuses to the two Canadian schools were selected in those years. Schools from the 2014 sample were used because that was the only year of participation for Canadian schools. Other American schools in those survey years were not used in this analysis because they were either privately funded, categorized as a liberal arts or graphic design schools, were a community college or did not have similar populations/sample sizes. Three American schools were used to match the two Canadian schools to make up for lower sampling numbers from American schools in the original dataset. Each school participating in the Healthy Minds dataset agreed to a confidentiality agreement whereby public identification of individual campuses was masked and therefore cannot be identified in this research.  78  Of the 2,250 Canadian students surveyed for this research, most undergraduate students were female (67%), heterosexual (86%), and were experiencing financial problems (80%) (see Table 4.1). Sample characteristics for the American population are similar. Of the 1,908 American undergraduate students surveyed, most were female (74%), heterosexual (86%), and were experiencing financial problems (77%). Although national data is available on proportions of students by demographic background in America, similar data are not available in Canada. The only national level information on the proportion of undergraduate students available in Canada is by gender (Statistics Canada 2017). According to Statistics Canada (2017) the percent of female undergraduate students enrolled in Canadian post-secondary institutions in 2014/15 was 56.3%. My sample proportions, at least for gender, are similar to national representations.   Table 4.1: Mental Illness Sample Characteristics by Percentage  Variable                CND                   USA Age       18-20 Years Old 34.89 31.08    21-25 Years Old  39.64 39.83   26+ Years Old  25.47 29.09 GPA        A 37.73 48.43    B 40.89 38.36    C 20.13 12.68    D to Fail  1.24 0.52 Gender       Female 67.14 73.94    Male 32.86 26.06 Sexuality       Heterosexual 86.44 86.11    Gay, Lesbian, Bisexual  13.56 13.89 Previous Mental Health Problem      Has a previous mental health problem 27.51 28.93    No previous mental health problem 72.49 71.07 79  Current Financial Situation       Financially Stable  19.66 22.53    Financial Troubles  80.34 77.47 Stigmatizing Climate       Agree  46.85 46.51    Disagree 53.15 53.49 Know Where       Know Where to Go  70.54 61.65    Don't Know Where to Go 29.46 38.35 N(Individuals)  2,250 1,980   Measures   The two dependent variables in this study are binary measure of depression and anxiety, using two indicators from the Health Minds Network dataset, derived from an in-survey diagnostic tool. The Patient Health Questionaire-9 (Kroenke et al. 2001) is a widely used and clinically validated depression screening instrument. Students were recognized as experiencing depression if they had a positive screen for either major depression or ―other‖ depression (dysthymia or depression not otherwise specified), according to previous work using this measure (Zivin, Eisenberg, Gollust & Golberstien, 2009). Similar measures for anxiety were also used for this study. The Patient Health Questionaire-9 embedded in the Healthy Minds Network Student Survey also screened students for experiences of anxiety. Students who screened positive for anxiety (generalized, social or panic disorder) were recognized as experiencing anxiety for this research.  The following explanatory variables were isolated to examine how individual characteristics influence the mental health of Canadian and American students: age (18-20 years old, 21-25 years old and 26+ years old), GPA (A, B, C, D and fail) and gender (female and male). 80  A measure for student race/ethnic identity was not included in this analysis because it was not collected for one of the Canadian schools.   To measure students experiences of discrimination on campus I use three measures in my analysis. First, I investigated the effect of student sexuality (straight and gay/lesbian/bisexual). This measure is used as a social determinant of mental health because LGBT students are more likely to experience discrimination and stress, as a result of their sexuality, than heterosexual students (Fields & Wotipka 2020; Gonzales & Gavulic, 2020; Kerr et al., 2004; Ketchen Lipson et al., 2015).  In addition to using sexuality to understand how discrimination relates to students‘ experiences of mental illnesses, I also a measure for students‘ previous mental illnesses. Like sexuality, having a mental illness is something that is still highly stigmatized in North American society (Link and Phelan 1980; Wright, Gronfein and Owens 2000). Students for this study were asked ―Have you ever been diagnosed with a mental illness (list) or disorder (list)‖. Students who responded in the affirmative are considered individuals with previous mental illnesses.   In addition to using identities to measure the impact of discrimination on mental illnesses, I also use students‘ perception of stigma for mental illness at their school. Allport (1957) defines discrimination as “an aversive or hostile actions toward a person who belongs to a group, simply because they belong to that group, and is therefore presumed to have the objectionable qualities ascribed to the group (p.7)”. This definition bears similarities to Goffman’s (1963) definition of stigma, as “an attribute that links a person to an undesirable stereotype, leading other people to reduce the bearer from a whole and usual person to a tainted, discounted one (p.11)” Key to both works is similarities in the experiences of stigma and discrimination, including exposure to 81  negative attitudes, structural and interpersonal experiences of unfair treatment and violence perpetuated against persons who belong to the disadvantaged group. This measure is designed to gauge students’ perceptions of these occurrences towards individuals’ with mental illnesses at their school. The stigmatizing climate variable in this analysis uses students‘ responses to the following statement: ―Most people would think less of a person who has received mental health treatment‖. Students‘ responses to this statement were coded as an index ranging from 1-6, with higher numbers referring to students‘ perceptions of greater stigma. This variable was recoded as a binary response, with students who responded with ―Strongly Agree‖, ―Agree‖, ―Somewhat Agree‖ indicating that those students felt that others at their school did hold stigmatizing views toward those with mental illnesses, and ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖ as students who didn‘t feel that others at their school held stigmatizing views toward those with mental illnesses.    Next, to better understand how economic situation influences mental illnesses among student populations I used a measure for students‘ current financial situation. For this measure students were asked ―Which of the following best describes your current financial situation?‖ Students‘ responses to this question were originally coded in an index, indicating ―It‘s a financial struggle‖, ―It‘s tight, but I‘m doing fine.‖ and ―Finances aren‘t really a problem‖. Outcomes for this variable were recoded as a binary variable, with 0 demonstrating financial stability and 1 indicating that a student is experiencing financial troubles.   Finally, to measure how access to healthcare influences student mental health, I also utilized a measure for students‘ knowledge of mental health services. Students were asked ―If 82  you needed to seek professional help for your mental or emotional health while attending [insert institution], would you know where to go?‖. Student responses for this measure also ranged from 1-6 with higher numbers referring to students agreeing that they knew where to go for help. This variable was recoded as a binary response, with students who responded with ―Strongly Agree‖, ―Agree‖, ―Somewhat Agree‖ indicating that those students knew where to go for help, and ―Strongly Disagree‖, ―Disagree‖ and ―Somewhat Disagree‖ as students who didn‘t feel that they knew where to get help.   To check for multicollinearity between measures, I conducted a variance of inflation analysis (VIF) for each factor (see Appendix 5). No measure had a VIF above 1.5 and the average VIF for independent measures and anxiety was 1.12. Conducting the same analysis for depression, none of the VIFs were above 1.5 and the average VIF was 1.11.  Weighting  Previous research using the HMS data incorporated response propensity weights to adjust for student non-response. Eisenberg et al. (2009) created their weights by obtaining nonresponse information from universities‘ administrative data, including information on student demographics like sex, race/ethnicity, academic level and grade point average. The creation of these weights was instrumental for ensuring that their analysis was representative in terms of individual characteristics across schools. The same weights were used in this analysis to ensure representation across Canadian and American samples.    83  Limitations  Several limitations should be kept in mind when interpreting the outcomes of this research. First, mental health outcomes for this study were measured using validated screening tools. Although these tools have been rigorously tested, they are limited in their ability to consider history and scope of illness and are not the same as a clinical diagnosis. Another limitation of this research is the range of students who took part. Only two Canadian schools participated in the Health Minds study in one year of data collection for the survey, giving me a small sample of Canadian students to infer outcomes from. The findings from these student populations are therefore not representative of Canadian undergraduate students overall and over time. However, they do allow us to take a snapshot of the experiences of Canadian undergraduate students and their mental health needs. Despite this limitation, the data used here is some of the more recent evidence available on mental health issues among Canadian undergraduates.    Analysis   For this research I first investigated proportional differences in mental health outcomes between Canadian and American students. Next, I used logistic regression to better understand how social determinants of health impacted student mental health in Canada and America. Again, this involved considering the social determinants of health for student groups combined, and then breaking down the analysis to look at differences in experiences of social determinants of health among both student populations in Canada and America. I also conducted the same analysis excluding all students who had previously been diagnosed with a mental health problem, to control for selection effects (see Appendix 6,7,8 and 9). The results for that work mirror the findings in this research. 84  Findings and Discussion Proportions   To better understand how national contexts impact student mental health, I first examined the proportions of anxiety and depression experienced Canadian and American students, using the prtest program for STATA (see Table 4.2). This analysis demonstrates that there is no statistically significant difference between the two populations. However, the proportions do mirror previous research (Eisenberg et al., 2009) and general population proportions (Hanlon, 2012). Despite social differences between Canada and America, the overall proportion of depression and anxiety experienced by students is relatively similar.   Table 4.2: Proportions of Canadian and American Students Experiencing Mental Illnesses Proportions  Canada % USA%  p Anxiety  22.50 22.22 0.509 Depression  20.92 20.07 0.832 N (Individuals) 2,250 1,908         After examining the overall proportions of mental illnesses experienced by the two groups, I next investigated differences in the proportions of anxiety and depression experienced by Canadians and American students based on social determinants of health (see Table 4.3). None of the differences in the proportions of anxiety and depression experienced by Canadian and American undergraduate students were statistically significant, aside from having a failing grade or having no previous mental health problem. The proportional difference for students experiencing anxiety was significantly different between Canadians and Americans who experienced anxiety. A larger proportion of Canadian students who had a failing GPAs experienced anxiety than their American peers. Similarly, the proportion of students who experience depression and who do not have a previous mental health problem is also 85  significantly different between Canadians and Americans.  A larger proportion of Canadian students who had a previous mental illness experienced depression than their American peers.   Table 4.3: Proportions for Canadian and American Students Experiencing Anxiety and Depression    Anxiety    Depression    Variable      CND     USA CDN-USA            CND       USA CDN-USA Age          18-20 Years Old 26.34 22.55  26.55 21.20     21-25 Years Old  22.75 24.09  18.48 20.16     26+ Years Old  16.36 19.15  16.77 18.70  GPA          A 19.49 20.79  16.47 15.52    B 22.91 22.84  20.34 22.11    C  26.51 26.83  30.77 35.33    D to Fail  51.85 23.08 * 55.56 30.00  Gender           Female 18.63 17.69  21.33 22.42     Male 24.51 23.56  19.79 18.97  Sexuality           Heterosexual 31.60 35.78  19.11 18.53     Gay, Lesbian, Bisexual  21.35 20.43  35.32 31.73  Previous Mental Health Problem          Previous mental health  problem 34.64 35.95  27.63 30.73     No previous mental health problem 17.35 15.96  18.12 15.33 * Current Financial Situation           Financially Stable  19.13 18.64  17.34 16.04     Financial Troubles  36.39 34.69  35.77 34.00  Stigmatizing Climate           Agree  25.29 26.23  23.78 24.56     Disagree 19.76 17.69  18.30 15.52  Know Where           Know Where to Go  20.96 19.13  18.09 17.43     Don't Know Where to Go 25.97 27.01  27.38 24.66  N (Individuals) 2,250 1,908 4,158 2,250 1,908 4,158   86   Despite a large body of literature discussing the ways Canadians and Americans differ, proportions of mental illnesses among student groups is not one of them. Our overall rates of mental illnesses are more or less the same and there is not a significant difference in mental health outcomes according to individual student traits or social determinants of health (aside from having a failing grade or experiencing a previous mental health problem). These findings begin to suggest that despite the possibility of variation, Canadian and American students‘ experiences mental illnesses are relatively similar.   Logistic Regression of Student Anxiety   To build on these findings, I next conducted a logistic regression analyzing the impact of individual influences on anxiety for both Canadian and American undergraduate students (see Table 4.4). The results in Table 4.3 indicate that, although social determinants have considerable effects on health within each country, the size of the effects do not differ significantly across the two nations. The columns CND and USA show associations between each variable and anxiety, within Canada and the United States respectively. The results for both countries are generally consistent with the social determinants of health model, where the associations between discrimination, economic inequality and health care access factors are significant and related to increased risk for mental illness.   Model 1 demonstrates the impact of individual characteristics on anxiety for both Canadian and American students, with older students and female students all being more likely to experience anxiety than their younger and male peers. This model also shows Canadian students with higher GPAs are more likely to experience anxiety (OR = 0.17, p < 0.05), but that 87  grades do not have an effect for American students. In other words, compared to students with the highest grades, students with the lowest grades in Canada are 83% less likely to experience anxiety.    Elaborating on the impact of social determinants of health for both Canadian and American students, Model 2 introduces discrimination measures for students‘ experiences of anxiety. Both Canadian and American undergraduate students identifying as gay, lesbian or bisexual are 1.5 times more likely to experience anxiety than their heterosexual peers. There is also little variation in the experience of anxiety based on sexuality between students in Canada and America. These findings are consistent with previous literature noting the increased risk for mental illness based on LGBT identity (Kerr et al. 2004; Ketchen Lipson et al. 2015). Having a previous mental health problem diagnosis also impacts the likelihood of experiencing a mental health problem in university. Canadian students who have a previous mental health problem are 2.63 times more likely to experience anxiety than their peers without a previous mental illness diagnosis, while American students who have a previous mental health diagnosis are 2.81 times more likely to experience anxiety than their peers without a previous mental illness diagnosis. Reasons for this outcome can be twofold. Many mental illnesses are reoccurring and comorbid, meaning that if you are diagnosed with anxiety at a younger age, it is likely that you will continue to experience that mental health problem later in life or experience another mood disorder (Maneka, Watson & Clark 1998). However, having a mental health problem is still a highly stigmatized identity in today‘s society (Corrigan & Watson 2002; Crisp, Gelder, Rix, Meltzer & Rowland 2000). Students with a previous mental illness diagnosis might be more likely to experience anxiety than their peers who do not hold a previous diagnosis because of the 88  discrimination they face related to that identity. This also relates to students‘ perceptions of others. In Model 3 I also introduce a measure for students‘ perceptions of others’ discrimination towards those with mental illnesses. For both Canadian and American students, those who think others stigmatize those with mental illnesses are 1.49 and 1.77 times more likely to experience anxiety than those who do not think others stigmatize those with mental illnesses, respectively. Each measure for discrimination has a significant effect on both Canadian and American students‘ experiences of anxiety. Although there is little variation in these outcomes, they meaningfully demonstrate the potential enduring effect of discrimination as social determinant of mental health for both Canadian and American undergraduate students.  Model 3 next introduces economic determinants for anxiety. Canadian students who are experiencing financial problems are 2.19 times more likely to experience anxiety than their financially stable peers, while financially struggling American students are 2.22 times more likely to experience anxiety than their financially stable peers. With little variation between the two outcomes, Model 3 demonstrates that although the costs of higher education are much different between our two countries, the effect of experiencing financial challenges is consistent.   Looking at Model 4, these findings also demonstrate that access to health care has a similar influence for both Canadian and American undergraduate students. Students who do not know where to seek mental health support in Canada are 1.6 times more likely to experience anxiety than their peers who know where to get help. Similarly, American students who don‘t know where to access help for their mental illnesses are 1.9 times more likely to experience anxiety than their peers who do know where to go for help. Although Canadian students have 89  arguably easier access to health care through universal funding, this doesn’t‘t seem to influence great variation in their overall experiences of anxiety, compared to American students.    Table 4.4: Logistic Regression of Canadian and American Students Experiencing Anxiety    Model 1  Model 2  Model 3  Model 4  Variable CND USA CND USA CND USA CND USA Age            18-20 Years Old 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    21-25 Years Old  1.12 0.96 1.17 1.04 1.28 1.12 1.27 1.15    26+ Years Old  1.62** 1.17* 1.85*** 1.57* 2.14*** 1.84** 2.08*** 1.95*** GPA              A 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    B 0.88 0.88 0.94 0.97 0.99 0.99 0.99 1.01    C 0.66 0.78 0.74 0.87 0.81 1.03 0.82 1.07   D to Fail  0.17** 1.42 0.22** 2.43 0.28** 2.35 0.30** 2.53 Gender             Female 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    Male 0.69* 0.67** 0.73** 0.66** 0.74* 0.67* 0.72* 0.62** Sexuality             Heterosexual   1.00 1.00 1.00 1.00 1.00 1.00    Gay, Lesbian, Bisexual    1.49* 1.56* 1.38* 1.54* 1.34* 1.53*           Previous Mental Health Problem            No previous mental health problem   1.00 1.00 1.00 1.00 1.00 1.00    Has a previous mental   health problem   2.63*** 2.82*** 2.48*** 2.72*** 2.75*** 3.05*** Stigmatizing Climate          Disagree    1.00 1.00 1.00 1.00 1.00 1.00 Agree   1.49** 1.77** 1.48** 1.76*** 1.47** 1.72*** Current Financial Situation          Financially Stable      1.00 1.00 1.00 1.00 Financial Troubles      2.19*** 2.22*** 2.22*** 2.14*** Know Where          Know Where to Go        1.00 1.00 Don't Know Where to Go             1.63*** 1.94*** N (Individuals) 2,250 1,908 2,250 1,908 2,250 1,908 2,250 1,908 Odds Ratios  90  * p < 0.05, ** p < 0.01, *** p < 0.001   Depression  After examining the effects of individual and national contexts on anxiety for undergraduate students I next ran the same analysis for Canadian and Americans, investigating their experiences of depression (see Table 4.5). Model 1 demonstrates individual influences for students‘ experiences of depression. Older Canadian and American students are more likely to experience depression than their younger peers. Canadian students with higher grades are also more likely to experience depression than their peers with lower grades, but this has no effect for American students. Lastly, gender has no effect on the experiences of depression for both Canadian and American undergraduate students in this model.    In Model 2, my first measures for discrimination as a social determent of health are introduced. First, I examine students‘ sexual identity on the likelihood of experiencing depression. These results demonstrate that gay, lesbian and bisexual Canadian students are 1.77 times more likely to experience depression than their heterosexual peers. Similarly, American gay, lesbian and bisexual students are 1.37 times more likely to experience depression than their heterosexual peers. These findings are consistent with previous research demonstrating that sexual minority peers are more likely to experience a range of mental illnesses than their heterosexual peers (Kerr et al., 2004; Ketchen Lipson et al., 2015). These studies have also attributed the greater likelihood for gay, lesbian and bisexual students experiencing mental illnesses to the discrimination they face in heteronormative campus environments (Kerr et al., 2004; Ketchen Lipson et al., 2015). In addition to investigating experiences of depression based on sexual identity, this model also introduces measures for having a previous mental illness 91  diagnosis. Canadian students with a previous diagnosis are 1.5 times more likely to have depression while at school than their peers with no previous diagnosis. The effect for American students follows the same path, however with slight variation. American students with a previous diagnosis are 2.1 more likely to experience depression than their peers without a previous diagnosis.   Canadian students who think that others at their school stigmatize those with mental illnesses are more likely to experience depression, as are American students. There is also some variation in these proportions. Canadian students who do think others stigmatize those with mental illnesses are 1.47 times more likely to have depression than their peers who do not perceive others as being stigmatizing. American students who think others stigmatize those with mental illnesses are 2.07 times more likely to have depression than their peers who do not perceive others to be stigmatizing. Thinking others at your school discriminate against people with mental illnesses, regardless of your own mental health status, might make increase your likelihood for having depression because you feel your school climate is unwelcoming. Studying and living in unsupportive environments can put strain on your experiences, increasing the likeliness of feeling hopeless, disconnected and agitated, all contributors to depression (Lindsey, Fabiano & Stark, 2009).   Next, Model 3 considers economic influences for student mental health. For both student groups, experiencing financial challenges is associated with approximately 2.6 times greater likelihood for experiencing depression than not having financial challenges. One reason for this similarity might be rising tuition costs for both American and Canadian undergraduate students. 92  Although Canadians, pay less tuition than their American counterparts, the rates of tuition have steadily increased over the last decade (Davies and Hammock, 2005). Despite cost differences, Canadian students might similarly feel economically burdened by academic costs.      Table 4.5: Logistic Regression of Canadian and American Students Experiencing Depression   Model 1  Model 2  Model 3  Model 4  Variable CND USA CND USA CND USA CND USA Age            18-20 Years Old 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    21-25 Years Old  1.25 1.11 1.27 1.26 1.42* 1.39* 1.41* 1.42*    26+ Years Old  1.68** 1.07 1.81** 1.32 2.18** 1.57* 2.12*** 1.64** GPA             A 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    B 0.83 0.68* 0.84 0.68* 0.91 0.70* 0.92 0.71*   C 0.40*** 0.37*** 0.41*** 0.39*** 0.45*** 0.46*** 0.45*** 0.47**   D to Fail  0.14*** 0.88 0.17*** 1.28 0.23*** 1.25 0.25** 1.30 Gender             Female 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    Male 0.98 1.14 1.03 1.16 1.06 1.21 0.989 1.15 Sexuality             Heterosexual   1.00 1.00 1.00 1.00 1.00 1.00   Gay, Lesbian, Bisexual    1.77** 1.37** 1.61* 1.35** 1.55* 1.33* Previous Mental Health Problem            No previous mental health problem   1.00 1.00 1.00 1.00 1.00 1.00   Previous mental health problem   1.52** 2.10*** 1.39* 2.01*** 1.62** 2.18*** Stigmatizing Climate             Disagree    1.00 1.00 1.00 1.00 1.00 1.00    Agree   1.47** 2.07*** 1.46** 2.09*** 1.46** 2.04*** Current Financial Situation             Financially Stable      1.00 1.00 1.00 1.00    Financial Troubles      2.69*** 2.54*** 2.76*** 2.47*** Know Where To Get Help            Know Where to Go        1.00 1.00   Don't Know Where to Go       2.08*** 1.67*** 93  N 2,250 1,908 2,250 1,908 2,250 1,908 2,250 1,908 Odds Ratios  * p < 0.05, ** p < 0.01, *** p < 0.001     To further enhance our understanding of the social determinants of Canadian and American undergraduate student mental illnesses, I introduced a measure for health access (knowledge of where to seek help).  The outcomes for both Canadians and Americans demonstrate that students who do not know where to seek help are more likely to experience depression than their peers who are aware of the mental health supports available to them. Canadians who do not know where to seek help are 2.08 times more likely to have depression than their peers who know where to go. American students who don‘t know where to access help are 1.7 times more likely to experience depression than their peers who are aware of the services available to them.    Overall, the findings from this research demonstrate that there is little difference in the proportions or experiences of mental illness between Canadian and American undergraduate students. It also demonstrates that social determinants of health, including discrimination, economic inequality and access to healthcare have the potential to similarly impact anxiety and depression for both student groups. Despite the overall lack of differences between these two populations in terms of their mental health outcomes, this research is vitally important for shedding more light the contextual influences for Canadian student mental health outcomes. Up to this point, there have been very few studies examining the influences of Canadian undergraduate student mental illness, especially outside of Ontario (ACHA, 2013; Ontario 94  College of Health Association 2016). These findings contribute to a much-needed body of research.   Implications of Research  As Canadians, we like to think of ourselves as being fundamentally different from Americans. One of the ways in which we are dissimilar is in our institutional settings. Canadian schools have lower tuition costs, are less hierarchically competitive and provide students with free access to health care. However, there are also many ways in which we are similar to Americans. The histories and values of Canadians and Americans tend to be relatively the same (Baer, Grabb and Johnston, 1993; Noll, 1992; Reimer & Sikkink, 2020). A growing body of research also shows that our cultures are also continuing to converge through the melding of media, industries and populations across the 49th parallel (Reimer & Sikkink, 2020). Despite our institutions and feelings about being different from Americans, in many ways we are similar to our southern neighbours. And the mental health outcomes of undergraduate students seem to be no different.    This research is some of the first to demonstrate the similarities between Canadian and American student mental illnesses. The first major finding of this research is that the proportional differences in depression and anxiety between Canadian and American students are not significantly different. Investigating the social determinants of health for students‘ experiences of anxiety and depression showed little variation between Canadians and Americans. Although Canadian higher education contexts might be very different from their American counterparts, 95  for this group of students, national contexts do not seem to impact significant variations in their experiences of mental illnesses.     Although there is little variation in the mental illnesses of Canadian and American undergraduate students, knowing about mental health outcome patterns across national borders is important. A large portion of Canadian on-campus mental health programming is informed by American-based literature. There is also a lack of information available on the mental health outcomes of Canadian undergraduate students generally. A more comprehensive collection of mental health data for Canadian students will help researchers and campus administrators better address this growing health problem in our schools.                            96  Chapter 5: Conclusions  I started this dissertation research concerned with how different campus environments shape undergraduate student wellbeing. My aim has been to expand existing on-campus mental health literature by linking campus environments to student mental health. To do this, I formulated a number of predictions from sociological conversations pertaining to higher-education landscapes and national contexts. I empirically tested these predictions with respect to student mental health stigma, service use and mental illnesses (anxiety and depression). These three areas are exceptionally important to consider due to their relevance to student academic, social and economic success. Students who experience mental illnesses and don‘t seek treatment for them are less likely to graduate, move on to post-grad programming and to experience mental illnesses later in life (Bruffaerts et al., 2018; Eisenberg, Hunt & Speer, 2011). By analyzing data from two, large, US surveys on student mental health and campus environments, my dissertation research yields three distinct research papers to address these problems.   In chapter two I outline how different institutional contexts influence students‘ own stigma toward others with mental illnesses. In doing this I employed a sociological approach to understanding personal stigma. Mental health stigma, primarily studied by psychologists and others in the healthcare field, rarely considers environmental influences. I fill this gap by using a sociological approach to investigate the ways that school contexts influence student stigma for mental illnesses in two ways. First, sociology, as a discipline, has a rich history of taking into account both individual and institutional influences for individual outcomes (Durkheim, 1897; Davies & Hammack, 2005; Faris & Dunham, 1939). One of its key mantras is that context matters; how we organize life makes a difference for how people act. Thinking about this in 97  organizational terms can help us think about how our institutions enable or constrain student wellbeing. Secondly, it provides us with a more nuanced discussion of stigma and how it influences individual behaviors, especially around help-seeking (Biddle, Donovan, Sharp & Gunnell, 2007; Johnson, Oliffe, Kelly, Galdas & Ogrodniczuk, 2012). I found that institutional contexts do influence students‘ stigmatization of others. More specifically, students at less selective schools, schools where students feel that their academic environment is competitive and schools where students, on average, feel that others were less accepting of those with mental illnesses are all more likely to stigmatize against those with mental illnesses themselves. In addition to noting how different school contexts impact students‘ feelings of stigma toward others, I also demonstrate that a school‘s stigmatizing climate has the largest impact on students‘ own views of others with mental illnesses. That those students at schools with larger proportions of those who think less of others with mental illnesses, are more likely have the same views themselves. This work illustrates how social contexts have the ability to influence the views of students that can have detrimental impacts on their overall wellbeing.   After investigating the impact of school contexts on student‘s feelings of stigma towards those with mental illnesses, I extend this conversation to consider the way contexts (including stigma) influence student mental health service use. I also move the discussion of context beyond the school setting to include the national environment. To do this, I introduced two Canadian schools into my analysis. There is a distinct lack of Canadian-based research on undergraduate student mental health service use. Of the few studies that do investigate Canadian student mental health services, they are either conducted from the perspective of service use providers or only focus on Ontario students (Cozier & Whillihnganz, 2006). From my analysis I first note that 98  Canadian students are more likely to use mental health services than their American peers. This outcome is somewhat unsurprising because it mirrors general help-seeking behavior differences between Canadians and Americans (Lasser, Himmelstein & Woolhandler, 2006). However, while I demonstrate an overall proportional difference in help-seeking behavior between Canadian and American undergraduate students, I did not find significant variations in service use by student groups or by perceptions of school environment. Both Canadian and American undergraduate students who identify as female, gay/lesbian/bisexual and have a previous mental health problem are significantly more likely to use mental health services. In terms of perceptions of their school context, students who perceived others to be stigmatizing of those with mental illnesses were more likely to use mental health services themselves. Students who know where to go for help are also more likely to use it.   For my third dissertation research paper I expanded on national context conversations to investigate variations in Canadian and American students‘ experiences of mental illness (e.g. anxiety and depression). In addition to a shortage of Canadian based undergraduate mental health service use research, there is also a dearth of information regarding Canadian undergraduate student mental health outcomes. Using the same schools as previous analysis, I find that there are similarities between Canadian and American student mental health outcomes. The proportional differences in mental health outcomes between Canadian and American students are not significant. There is also no variation based on individual characteristics or perceptions of one‘s school. That is, both Canadian and American female, gay/lesbian/bisexual, students with previous mental illnesses and those with financial troubles are more likely to experience anxiety. Both Canadian and American students who think others at their school stigmatize those with 99  mental illnesses are more likely to experience anxiety themselves. Similarities also occur for Canadian and American undergraduate student experiences of depression. Canadian and American students who identify as gay/lesbian/bisexual or who have a previous mental illness diagnosis are more likely to experience depression than their heterosexual peers and those without a previous mental illness diagnosis. Both students who did not know where to get help and who were experiencing financial troubles were also more likely to experience depression, as were students who think others at their school stigmatize those with mental illnesses.   The findings from these three unique research papers culminate in offering insights into several areas of scholarship – with respect to school environments and student mental health. In this concluding chapter, I summarize these key research contributions and consider the larger theoretical and program-oriented implications of my findings, while acknowledging the strengths and weaknesses of my approach, and identifying directions for future research.   Contributions to Existing Research This dissertation makes contributions to the research literature on undergraduate student mental health in three main ways: 1) It expands current discussions on stigma, pertaining to student wellbeing, 2) It demonstrates national variation in mental health service use, and 3) It establish similarities in Canadian and American student experiences of mental illnesses.   Stigma and Student Wellbeing  My dissertation research expands the current literature on stigma and student wellbeing beyond the individual level. Much of the previous work on student mental health and stigma 100  investigates individual identities and feelings. Sociological research extends this discussion by looking at the ways stigma exists different environments. For example, in higher education spaces recent research has documented how stigma is maintained in highly competitive academic programing, such as medicine and law (Jolly-Ryan, 2010; Dyrbye et al., 2015). These investigations are important because they set the tone for investigated student wellbeing at the institutional level. That social spaces and student interactions are shaped by overarching institutional structures that can inadvertently harm student mental health. My work extends this discussion by not only investigating the experiences of undergraduate students, but also by looking at how school contexts, overall, influence students‘ experiences of stigma and wellbeing.   This work contributes to current mental health literature by drawing connections between school environments and the creation of structural and personal stigma. Although previous work in university settings has demonstrated how competitive academic contexts can influence stigma formation, those works do not make the theoretical connection between student experiences, structural stigma and personal stigma. One way that our schools seem to do this is by reinforcing personal stigma. Since personal opinions can be heavily influenced by prevailing public attitudes, school environments that seem unwelcoming, highly competitive can foster social discourse that is unfriendly to those suffering from mental illnesses. My work demonstrates not only that students who think their school is competitive are more likely to stigmatize others, but those who study at schools where they think the average student stigmatizes those with mental illnesses are more likely to hold stigmatizing beliefs too. These findings indicate that, to some extent, institutional contexts play a part in shaping the attitudes of students.  101  National Variation in Mental Health Service use Differences in mental health help-seeking behavior across national contexts remain an important area for theoretical testing and expansion. My research adds to the existing literature by enhancing understandings of the extent to which mental health service use varies between Canadian and American students. However, it also demonstrates that across individual characteristics and perceptions of school environments, Canadian and American students are very similar in their help-seeking behaviors.   Chapter 3‘s findings, in particular, suggest that Canadian and American undergraduate mental health service use is dissimilar. A significantly larger proportion of Canadian undergraduate students, in this dataset, sought help when needed than their American peers. There are a number of reasons for why Canadian undergraduate students might engage in more help-seeking behaviors than their American peers. Our welfare state makes access to healthcare more easily accessible (aside from long wait times) the private healthcare system in America. As a result, American general public is less likely to seek out medical health than the Canadian population. This effect might trickle down in the behaviors of students. American students might be reluctant to seek help (even if many universities provide free or subsidized care) because they fear incurring additional healthcare fees. Hence, national contexts seem to play an influential role in shaping the help-seeking behaviors of the general population and for students.   However, the Lalonde Report of 1974 served as a catalyst for widespread recognition that health is determined more by social, cultural, economic and gender-based determinants than by access to healthcare in Canada (Glouberman & Miller, 2003). The contribution of available 102  health services to the overall health of Canadians is estimated to only be 25% (Keon & Pepin, 2008), meaning that other social detriments including gender, sexuality and economic situation are worth consideration. Although none of the social factors measured in this study were significantly different between Canadian and American students, in terms of service use, other social factors might be contributing the overall variation.    National Similarities in Mental Illness  Although my work outlines the overall difference between Canadian and American undergraduate student help-seeking behaviors, it also notes a number of similarities that are important to consider. Specifically, Chapter Four represents one of the first studies to explicitly compare the rates of anxiety and depression among Canadian and American students. I find that there is no proportional difference in the experiences of these illnesses between nations.   First, Canadian and American undergraduate students appear to be equally likely to experience depression and anxiety. These outcomes mirror proportions for experiencing mental illnesses in the general population. Canadian and Americans are generally equally likely to experience these illnesses (Eisenberg et al., 2009; Hanlon, 2012). Although Canadians often compare themselves to Americans to highlight our differences, noting ways that we are similar is also extremely important. It is meaningful because it helps us know what research and programming is suitable across national contexts and what is not. In this case, mental health programming aimed at stemming rates of depression and anxiety among American student populations might be similarly effective in Canadian contexts.   103  There were also a number of similarities in mental illness experiences for Canadian and American undergraduate students based on individual backgrounds. In this chapter I attribute many of the patterns in mental illness to social determinants of health (Link & Phelan, 1995 Phelan & Link, 2005; Wilkinson & Marmot, 2003). The social determinants of health for Canadian and American students are important to consider because they can impact both physical and mental health. Both Canadian and American undergraduate students who identify as female or gay/lesbian/bisexual are more likely to experience anxiety than their male or heterosexual peers. Similarly, both student groups who have a previous mental illness, who are experiencing financial challenges or who don‘t know where to go for help are more likely to experience anxiety. In terms of perceptions of school environment, despite national context differences, both Canadian and American students who think others at their school stigmatize those with mental illnesses are more likely to experience anxiety themselves.   Similar patterns of depression also occur for both Canadian and American undergraduate students. Students who identify as gay/lesbian/bisexual, who have a previous mental illness diagnosis, who are experiencing financial troubles and who don‘t know where to go for help are all more likely to experience depression themselves. Canadian and American undergraduate students who perceive others on campus to be stigmatizing of those with mental illnesses are also more likely to experience depression. These findings are collectively important because they demonstrate that while there is generally little variation in the experiences of mental illnesses across Canadian and American student groups, and that context plays a role in mental health experiences for undergraduate students.   104  Strengths and Limitations of Research  There are a number of strengths and limitations associated with my dissertation research. A key strength of my research is my methodological approach. For this work I was able to leverage two large datasets, focused specifically on student mental health and post-secondary contexts. While these datasets allowed me the opportunity to analyze some of the best available data on student mental health, the methods I used also pose some limitations.    Overall, my data spanned a seven-year period, between 2007 and 2014. Unfortunately the data did not include the same students or schools over multiple years. The Canadian schools used for my research were also only included in one of the sample years. Inconsistencies in student and school involvement put my data at risk for period and cohort effects. That as mental health rhetoric and programming becomes more commonplace, students perceptions of stigma and service use might change. While my analysis are useful for documenting differences in stigma, help-seeking and mental illnesses across campuses and national settings, as conversations about mental health issues become more mainstream, it is reasonable to expect these patterns will change. Continuing to follow the impact of school and national settings on stigma and service use is necessary for documenting long-term trends.    Another challenge my research faces is that the data is not generalizable to national student populations. My national comparisons only include two schools for Canada. Comparable information from universities across the country settings is not currently available. To better understand how national and school contexts impact Canadian student mental health and help-seeking behavior, more nationally representative data is required.  105    It is also important to acknowledge the overarching limitations of my choice to rely solely on quantitative methods to answer my research questions. While a quantitative approach is useful for documenting large-scale differences among students, it does so at the expense of more in-depth understandings of why such differences occur. For example, while I was able to document some variations in student feelings of stigma toward others with mental illnesses, I was not able to assess the accuracy of their feelings or how different groups understood stigma.  Qualitative inquiry investigating students‘ personal feelings of towards others with mental illnesses and help-seeking behavior would undoubtedly complement my findings by adding greater understanding.    Despite the overarching limitations of my research, this dissertation makes a novel contribution to the sociological literature and explores relatively understudied areas for future expansion in the field of sociology of education:  context and mental health. Moreover, it acknowledges not only the differences in campus contexts leading to negative help-seeking behaviors, but also national variations in mental health outcomes.   Future Research and Conclusions   This dissertation points to three key directions for future research. First, future research should aim to further articulate the role of campus contexts in the formation of student mental health stigma. My analysis suggests that, indeed, context can influence some of the pathways through which school environments influence students‘ feelings of stigma. Additional analysis focused on documenting a) what policies impact those feelings, b) how those feelings change 106  over time and c) if there are other campus environmental influences impact undergraduate student mental health stigma. As noted above, longitudinal and qualitative data may be useful in this endeavor.    Second, future research on student mental health help-seeking behaviors and mental health outcomes should consider difference in campus cultures across national settings. The creation of large-scale Canadian datasets, documenting variations in undergraduate student help-seeking and mental illnesses across university campuses would be particularly helpful in this endeavor. Additionally, given the student group influence for variations in Canadian and American student outcomes, further analysis of how gender, race, sexuality and financial situation combine with context to impact student mental health is also warranted.    Third, given the significant differences in American and Canadian help-seeking behaviors, future research should focus on how to best leverage these variations into on-campus mental health outreach programming. For example, future research could examine how access to free health care on campus or in the community differently impacts students‘ feelings toward getting help and actually using the services available. This work could be used to call for more subsidized care, on campuses where access to care may be limited.    In conclusion, this dissertation identifies several pathways underlying the relationship between context and undergraduate student stigma, help-seeking behavior and mental illnesses. Specifically, it identifies how school-level contexts – including funding, selectivity, size and competition -  shape students‘ perceptions of others with mental illnesses. 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Depression (e.g., major depressive disorder, bipolar/manic depression, dysthymia) Anxiety (e.g., generalized anxiety disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder) Attention disorder or learning disability (e.g., attention deficit disorder, attention deficit hyperactivity disorder, learning disability) Eating disorder (e.g., anorexia nervosa, bulimia nervosa) Psychosis (e.g., schizophrenia, schizoaffective disorder) Personality disorder (e.g., antisocial personality disorder, paranoid personality disorder, schizoid personality disorder) Substance abuse disorder (e.g., alcohol abuse, abuse of other drugs)‖                         138  Appendix 2 Healthy Minds Schools 2014/2015 by Population, Funding and Sample Size  School Number  Student Pop Public/Private Sample Size Canada 1 9,410 Public 1,600 Canada 2 41,200 Public  1,509 America 1 18,256 Public 650 America 2 19,108 Public 781 America 3 14,852 Public 664 America 4 26,740 Public 271 America 5 11,574 Private 2,983 America 6 1,200 Private 591 America 7 19,725 Public 773 America 7 46,002 Public 889 America 9  3,493 Public 660 America 10 4,816 Public 1,002 America 11 1,419 Private 287 America 13 21,087 Private 750 America 14 16,520 Private 1,162 America 15 13,581 Private 1,123 America 16 11,614 Private 1,175 America 17 15,558 Public  471 America 18 34,262 Private 2,551 America 19 16,446 Private 1,311 America 20 75,756 Private 1,115 America 21 3,653 Private 1,358 America 22 46,002 Public 1,763 America 23 21,657 Public 1,251 America 24 30,896 Public 2,569 America 25 4,131 Private 1,059 America 26 16,520 Private 1,274 America 27 11,489 Private 1,140 America 28  8,484 Public 1,823 America 29  44,413 Public 7,326           139  Appendix 3  Variance of Inflation Factors for Independent Measures and Service use VIF  Variable Service use Age     18-20 Years Old 1.00    21-25 Years Old  1.35    26+ Years Old  1.41 GPA      A 1.00    B 1.14    C 1.13    D to Fail  1.03 Gender      Female 1.00    Male 1.04 Sexuality      Heterosexual 1.00    Gay, Lesbian, Bisexual  1.04 Previous Mental Health Problem 1.00    Has a previous mental health       problem 1.08    No previous mental health problem 1.08 Personal Stigma      Agree 1.00    Disagree 1.08 Stigmatizing Climate      Agree  1.00    Disagree 1.07 Perceived Competition     Competitive 1.00    Not Competitive 1.02 Current Financial Situation      Financially Stable  1.00    Financial Troubles  1.05 Know Where      Know Where to Go  1.00    Don't Know Where to Go 1.03 Mean VIF 1.11   140  Appendix 4 Logistic Regression of All Students’ Mental Health Service Use (Excluding Students with a Previously Diagnosed Mental Illness)  Variable Model 1 Model 2 Model 3 Model 4  Age        18-20 Years Old 1.00 1.00 1.00 1.00    21-25 Years Old  1.14 1.04 1.01 1.01    26+ Years Old  1.69** 1.63* 1.52* 1.58* GPA         A 1.00 1.00 1.00 1.00    B 0.89 0.96 0.95 0.96    C 0.93 0.86 0.80 0.87    D to Fail  0.33 0.43 0.36 0.44 Gender         Male 1.00 1.00 1.00 1.00   Female 1.95** 2.33*** 2.30*** 2.06** Sexuality         Gay, Lesbian, Bisexual  1.00 1.00 1.00 1.00    Heterosexual 0.70 0.80 0.82 0.77 Personal Stigma         Agree   1.00 1.00 1.00    Disagree  0.65 0.65 0.68 Perception of Stigma         Disagree        Agree  1.53* 1.52* 1.58** Competitive Perception         Is not Competitive  1.00 1.00 1.00    Is Competitive   0.81 0.80 0.74 Current Financial Situation         Financial Troubles    1.00 1.00    Financially Stable    0.68* 0.63* Know Where         Don't Know Where to Go     1.00    Know Where to Go     3.86***     141  Appendix 5 Variance of Inflation Factors for Independent Measures and Anxiety/Depression Variable Anxiety VIF Depression VIF Age      18-20 Years Old 1.00 1.00    21-25 Years Old  1.34 1.35    26+ Years Old  1.40 1.41 GPA       A 1.00 1.00    B 1.18 1.14    C 1.13 1.13    D to Fail  1.15 1.03 Gender       Male 1.00 1.00    Female  1.04 1.04 Sexuality       Gay, Lesbian, Bisexual  1.00 1.00     Heterosexual  1.04 1.04 Previous Mental Health Problem       Has a previous mental health problem 1.00 1.00     No previous mental health problem 1.08 1.08 Current Financial Situation       Financially Stable  1.00 1.00    Financial Troubles  1.05 1.05 Personal Stigma       Disagree  1.00 1.00    Agree 1.08 1.08 Stigmatizing Climate       Disagree  1.00 1.00    Agree 1.07 1.07 Know Where       Know Where to Go 1.00 1.00    Don't Know Where to Go 1.03 1.03     Mean VIF 1.12 1.11        142   Appendix 6 Logistic Regression of All Students Experiencing Anxiety (Excluding Students with a Previously Diagnosed Mental Health Problem)  Anxiety     Variable Model 1  Model 2 Model 3 Model 4  Age        18-20 Years Old 1.00 1.00 1.00 1.00    21-25 Years Old  1.04 1.07 1.16 1.16    26+ Years Old  1.35* 1.42** 1.70*** 1.71*** GPA         A 1.00 1.00 1.00 1.00    B 0.88 0.89 0.93 0.92    C 0.71* 0.74* 0.84 0.85    D to Fail  0.38* 0.45* 0.53 0.56 Gender         Female 1.00 1.00 1.00 1.00    Male 0.67*** 0.64*** 0.65*** 0.63*** Sexuality         Heterosexual  1.00 1.00 1.00    Gay, Lesbian, Bisexual   1.87*** 1.77*** 1.77*** Stigmatizing Climate         Disagree   1.00 1.00 1.00    Agree  1.64*** 1.64*** 1.62*** Current Financial Situation         Financially Stable    1.00 1.00    Financial Troubles    2.33*** 2.31*** Know Where         Know Where to Go     1.00    Don't Know Where to Go    1.48***         143   Appendix 7 Logistic Regression of Canadian and American Students Experiencing Anxiety (Excluding Students with a Previously Diagnosed Mental Health Problem) Anxiety  Model 1  Model 2  Model 3  Model 4  Variable CND USA CND USA CND USA CND USA Age            18-20 Years Old 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    21-25 Years Old  1.37 0.96 1.41 1.01 1.65* 1.08 1.63* 1.09    26+ Years Old  1.88** 1.17 1.95** 1.29 2.48*** 1.54* 2.36*** 1.59* GPA             A 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    B 0.88 0.88 0.86 0.89 0.92 0.92 0.92 0.92    C 0.35*** 0.78 0.34*** 0.81 0.39*** 0.97 0.41*** 0.99    D to Fail  0.12*** 1.42 0.15*** 1.61 0.26* 1.71 0.27* 1.82 Gender             Female 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    Male 0.68** 0.67** 0.75** 0.63** 0.75** 0.65** 1.10** 0.61** Sexuality             Heterosexual   1.00 1.00 1.00 1.00 1.00 1.00     Gay, Lesbian, Bisexual    1.70* 1.85** 1.67* 1.80** 1.55* 1.81** Stigmatizing Climate             Disagree    1.00 1.00 1.00 1.00 1.00 1.00    Agree   1.84*** 1.74*** 1.87*** 1.74*** 1.84*** 1.71*** Current Financial Situation              Financially Stable      1.00 1.00 1.00 1.00     Financial Troubles      3.49*** 2.33*** 3.57*** 2.28*** Know Where             Know Where to Go        1.00 1.00    Don't Know Where to Go       2.29*** 1.63***       144    Appendix 8 Logistic Regression of All Students Experiencing Depression (Excluding Students with a Previously Diagnosed Mental Health Problem)  Depression     Variable Model 1  Model 2 Model 3 Model 4  Age        18-20 Years Old 1.00 1.00 1.00 1.00    21-25 Years Old  1.17 1.25* 1.40** 1.41**    26+ Years Old  1.27 1.35* 1.66*** 1.68*** GPA         A 1.00 1.00 1.00 1.00    B 0.74** 0.72** 0.75** 0.74**    C 0.38*** 0.38*** 0.43*** 0.44***    D to Fail  0.28** 0.33** 0.40* 0.42* Gender         Female 1.00 1.00 1.00 1.00    Male 1.07 1.06 1.11 1.05 Sexuality         Heterosexual  1.00 1.00 1.00    Gay, Lesbian, Bisexual   1.71*** 1.61*** 1.61*** Stigmatizing Climate        Disagree   1.00 1.00 1.00    Agree  1.80*** 1.81*** 1.78*** Current Financial Situation         Financially Stable    1.00 1.00    Financial Troubles    2.68*** 2.66*** Know Where         Know Where to Go     1.00    Don't Know Where to Go    1.63***         145    Appendix 9  Logistic Regression of Canadian and American Students Experiencing Depression (Excluding Students with a Previously Diagnosed Mental Health Problem)  Depression Model 1  Model 2  Model 3  Model 4  Variable CND USA CND USA CND USA CND USA Age            18-20 Years Old 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    21-25 Years Old  1.17 1.11 1.26 1.23 1.40** 1.36 1.40** 1.37    26+ Years Old  1.26 1.07 1.35* 1.17 1.66*** 1.42 1.67*** 1.45* GPA             A 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    B 0.74** 0.69* 0.71** 0.65** 0.75** 0.66** 0.74** 0.67**    C 0.38*** 0.37*** 0.38*** 0.38*** 0.43*** 0.45*** 0.44*** 0.46***    D to Fail  0.28** 0.88 0.33** 0.95 0.40* 1.01 0.42* 1.04 Gender             Female 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00    Male 1.07 1.14 1.06 1.12 1.11 1.17 1.03 1.12 Sexuality             Heterosexual   1.00 1.00 1.00 1.00 1.00 1.00    Gay, Lesbian,   Bisexual    1.71*** 1.56* 1.60*** 1.52* 1.63*** 1.53* Stigmatizing Climate             Disagree    1.00 1.00 1.00 1.00 1.00 1.00    Agree   1.80*** 2.05*** 1.81*** 2.08*** 1.78*** 2.04*** Current Financial Situation             Financially Stable      1.00 1.00 1.00 1.00    Financial Troubles      2.68*** 2.63*** 2.66*** 2.58*** Know Where             Know Where to Go        1.00 1.00    Don't Know Where to Go       1.63*** 1.49**  

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