Intersecting burdens: Anxiety and depression among nursing undergraduates at a rural South African university

The rigours of academic demands, clinical obligations, and socioeconomic pressures disproportionately cause anxiety and depression among nursing students. Nonetheless, there is a paucity of empirical evidence regarding the mental health status of nursing undergraduates at historically disadvantaged institutions in South Africa. This study fills a critical evidence gap by examining an underrepresented rural cohort and addressing geographic and socioeconomic biases in nursing student mental health research. Guided by a social determinants of health perspective, this study aimed to assess the prevalence and comorbidity of anxiety and depressive symptoms among undergraduate nursing students at a rural institution in South Africa, and to investigate how these conditions are patterned by socio-demographic, educational and clinical attributes. A descriptive cross-sectional survey was conducted with 145 undergraduate nursing students. Participants filled out self-administered questionnaires, including the Generalised Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire (PHQ-9). Data were analysed using SPSS Version 30, incorporating descriptive statistics, independent-samples t-tests, analysis of variance, and multiple regression. More than half of the participants were female (57.2%) and predominantly aged 18-21 years (84.2%). Most identified culturally as Pedi (46.9%), followed by Tsonga (17.2%) and Venda (11.0%). Over a half (51.7%, 95% CI: 43.2-60.2) exhibited moderate-to-severe anxiety (GAD-7), while 58.6% (95% CI: 50.1-66.7) met criteria for moderate-to-severe depression (PHQ-9). The comorbidity between the two conditions was significant, with 40.7% exhibiting concurrent moderate-to-severe symptoms of both anxiety and depression. Multiple regression analysis revealed that age ( B : 1.89; 95% CI: 0.77, 3.01; p < 0.001 and household income ( B : −1.12; 95% CI: −2.09, −0.15; p = 0.02) were significantly associated with anxiety, with older students and individuals from lower-income households exhibiting higher scores. Age ( B : 2.73; 95% CI:1.33, 4.14; p < 0.001) and religious affiliation ( B : 2.75; 95% CI: 0.27, 5.24; p = 0.03) were identified as factors significantly associated with depression. A strong correlation between GAD-7 and PHQ-9 scores ( r = 0.717, CI: 0.63, 0.79; p < 0.001) highlighted the significant interconnection between anxiety and depression in this cohort. The results highlight a significant mental health burden among nursing students at the rural university, which is characterised by elevated rates of comorbid anxiety and depression. These findings highlight the pressing need for routine screening, stress management curriculum, and targeted support for older and low-income nursing students in rural and under-resourced academic environments.