Predicting Attitudes toward Professional Help-Seeking: The Role of Self-Stigma and Mental Health Literacy

doi:10.21203/rs.3.rs-5301696/v1

Background:
Mental health disorders are prevalent worldwide, yet treatment-seeking behaviors, especially in low-middle income countries like Indonesia, remain limited. Barriers such as stigma, cultural beliefs, and low mental health literacy (MHL) often inhibit individuals from seeking professional help. This study examines whether MHL and self-stigma predict attitudes toward professional psychological help-seeking in Indonesian adults.

Method:
A convenience sample of 887 Indonesian adults (aged 18–40) was recruited through online surveys. Participants were assessed using translated versions of established scales, including the Mental Health Literacy Scale, Self-Stigma of Seeking Help Scale, and the Attitudes Toward Seeking Professional Psychological Help Scale. Data were analyzed using hierarchical multiple regression to evaluate the predictive roles of MHL and self-stigma on help-seeking attitudes, controlling for sociodemographic factors.

Results:
Self-stigma stood out as the strongest predictor of help-seeking attitudes, accounting for nearly all of the explained variance (partial η² = .25). A post-hoc power analysis confirmed a substantial R² increase in the linear regression, with an effect size (f²) of .33 derived directly from the partial R². Notably, self-stigma significantly influenced negative attitudes toward seeking professional help, explaining 25.2% of the variance in these attitudes. In contrast to initial expectations, mental health literacy (MHL) did not significantly impact help-seeking attitudes, and sociodemographic factors such as age, sex, and education showed no meaningful relationship with these attitudes after controlling for stigma.

Conclusion:
The findings highlight the importance of addressing self-stigma to improve help-seeking behavior in collectivistic cultures like Indonesia. While enhancing MHL is important, interventions should reduce anticipated self-stigma to foster positive attitudes toward professional psychological help-seeking.

Well-being

professional help-seeking

mental health literacy

self-stigma

Indonesia

Mental disorders are common and experienced by people in both developed and developing countries (Kessler et al., 2009; Steel et al., 2014). In Indonesia, a low middle-income country in Southeast Asia, the most recent national survey of the National Institute of Health Research and Development of the Indonesian Ministry of Health (Badan Penelitian dan Pengembangan Kesehatan, 2018) reported lifetime prevalence rates of 6.7‰ (95% CI [6.2–7.1]) for psychotic disorders, 6.1‰ (95% CI [6.0–6.2]) for depressive disorders, and 9.8‰ (95% CI [9.7–10.0]) for neurotic disorders, up from 5‰ and 3.8‰ for psychotic and neurotic disorders. Yet, patients are more likely to be left untreated in less developed countries (Demyttenaere et al., 2004); it is immensely important to understand the particular challenges in reducing the treatment gap in Southeast Asia countries such as Indonesia.

In Indonesia, barriers to seeking and obtaining professional help for mental disorders include traditional forms of treatment for mental illness. Since mental and other illnesses are often perceived as a “village sickness,” fate, or God’s punishment, professional treatments are frequently secondary to traditional or spiritual non-medical alternatives (Nasriati and Oktobriani, 2019; Widayanti et al., 2020). Other reasons for delayed or absent professional help-seeking include sociodemographic characteristics (e.g., sex, age, and education), stigmatization, misconceptions about mental disorders and their causes, limited access to mental institutions, financial boundaries, and a generally low willingness to seek psychological help (Aguirre Velasco et al., 2020; Gough and Novikova, 2020). Among these factors, educational anti-stigma campaigns can moderate mental health literacy (MHL) and stigma (Brooks et al., 2019a, 2019b; Clay et al., 2020; Waqas et al., 2020).

Mental Health Literacy - MHL is a set of knowledge and beliefs about mental disorders, including recognizing different forms of mental illness, their causes, and understanding of their treatments (Jorm et al., 1997). Stigma is defined as a negative label for a group of people with particular characteristics (Hayward and Bright, 1997) and is commonly divided into public, personal, and self-stigma, as well as negative attitudes toward help-seeking (Schnyder et al., 2017). Public stigma is defined as a community’s negative stereotypes and prejudices about people with mental illness, while personal stigma is defined as an individual’s stereotypes and prejudices. In more collectivistic cultures, such as Indonesia (Yu et al., 2021).

This study examines whether MHL and anticipated self-stigma predict attitudes toward psychological help-seeking in a convenience sample of Indonesian adults after controlling for age, sex, and education. As preferences for professional help may differ across different mental disorders (Coles and Coleman, 2010), the study also included different vignettes of mental disorders as a confounding factor.

This study was conducted as survey research among Indonesians. We used convenience sampling through online advertisements to recruit 887 adults (aged 18–40) from Indonesia for our online survey. The participants provided their informed consent before completing the questionnaire.

Materials

Mental Health Literacy

This study used the Indonesian translation of two vignettes from Jorm et al. (1997) that met the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for (1) major depression and (2) schizophrenia (see Appendix 1). Participants were randomly assigned to one of the two vignettes and then required to identify the condition depicted. The following options were given for both vignettes: “depression,” “schizophrenia,” “anxiety,” “anorexia nervosa,” “stress,” “mental disorder,” “no disorder is present,” and “no proper diagnosis is listed.” Responses were dichotomized into correct (1) when participants chose “depression” or “schizophrenia” for the major depression and schizophrenia vignette, respectively, and incorrect (0) for all other responses to determine an MHL index.

Self-stigma

This study used the self-stigma of seeking help scale (SSOSH; Vogel et al., 2006) to assess self-stigma associated with psychological help-seeking. It is a 10-item unidimensional scale that assesses the perception that seeking psychological help would harm one’s self-esteem and self-worth (e.g., “It would make me feel inferior to ask a therapist for help”). Items are scored on a 5-point Likert scale ranging from 5 = “Strongly agree” to 1 = “Strongly disagree,” with the scores of items 2, 4, 5, 7, and 9 reversed. Lower total scores indicate less anticipated self-stigma. The SSOSH was adapted for the Indonesian language (see Appendix 2a). This study obtained a fairly satisfactory internal consistency reliability estimate (Cronbach’s α = 0.69, 95% CI [0.66 0.72]).

Attitudes toward professional help-seeking

An Indonesian version (see Appendix 2b) of the attitudes toward seeking professional psychological help scale-short form (ATSPPH-SF; Fischer and Farina, 1995) assessed the participants’ attitudes toward psychological help-seeking. ATSPPH-SF consists of 10 items (e.g., “I might want to have psychological counseling in the future”). Items are scored on a 4-point Likert scale ranging from 4 = “Agree” to 1 = “Disagree”, with the scores of items 2, 4, 8, 9, and 10 reversed. Higher total scores indicate more positive attitudes toward seeking professional help. We obtained an adequate internal consistency reliability estimate (Cronbach’s α = 0.72, 95% CI [0.70 0.75]).

Statistical analysis

Statistical analysis was conducted using hierarchical multiple regression analysis with the R “stats,” “psych,” “lm.beta,” “lmSupport,” “rcompanion,” and “effsize” and a 5% significance level. We computed (1) age, sex, education level, and vignette as correlates and (2) MHL and self-stigma as the independent variables to predict attitudes toward professional help-seeking. A post-hoc power analysis was computed using G*Power (Faul et al., 2007).

The descriptive sample characteristics

Table 1 summarizes the descriptive statistics of the variables and correlations between the predictors. While the vignettes were relatively equally distributed, there were more female participants. Most participants were young adults with 12 years of education; only 31.7% correctly identified the disorders depicted in the vignettes (Table 1).

Table 1

Sociodemographic characteristics of the sample (N = 912) and correlation between predictors
Variables (value)	n (%)	Range	\(\:\underset{\_}{x}\)	SD	Correlation
Variables (value)	n (%)	Range	\(\:\underset{\_}{x}\)	SD	1	2	3	4	5	6
1. Sex		-	-	-	-	.05	− .06	.11	− .02	.03
Male (0)	353 (38.7%)
Female (1)	559 (61.3%)
2. Education level		-	-	-		-	− .01	− .40	− .01	− .01
9 years (0)	4 (0.4%)
12 years (1)	663 (72.7%)
Higher education (2)	245 (26.9%)
3. Vignette		-	-	-			-	.01	.08	.03
Depression (0)	458 (50.2%)
Schizophrenia (1)	454 (49.8%)
4. Age		18–55	22.07	4.65				-	− .04	.07
5. MHL		-	-	-					-	− .04
Incorrect (0)	623 (68.3%)
Correct (1)	289 (31.7%)
6. Self-stigma		10–43	24.53	5.67						-
7. Attitude towards help-seeking		13–40	28.40	4.53
Note. n = count; \(\:\underset{\_}{x}\) = mean; SD = standard deviation; MHL = dichotomized score of recognition of mental disorder; Self-stigma= sum of SSOHS scores; Attitudes towards help-seeking = sum of ATSPPH-SF scores.

Examination of model assumptions

Before the regression analyses were conducted, screening of outlier data and testing assumptions for multiple regression were met. To detect outliers, we calculated three indices: (1) Mahalanobis distance, (2) leverage, and (3) Cook’s distance. Twenty-five cases exceeded the cut-off points in more than one index and were excluded, leaving 887 participants for the final analyses. Excluded participants were mainly older and had a lower education level (Table 3). MHL, self-stigma, and attitudes toward help-seeking scores did not significantly change following the outlier exclusion. Regarding the assumptions of multiple regression, we found that the assumption of additivity or multicollinearity (Table 2), normality of the residuals, linearity of the residuals, and homoscedasticity were met (Fig. 1, Fig. 2, Fig. 3).

Table 2

Summary of hierarchical multiple regression predicting attitudes towards psychological help-seeking (N = 887)
Variables	b (SE)	t (p-value)	β	Partial η²	VIF	R²	ΔR²
Step 1				-		.007	-
Female	.34 (.31)	1.10 (.269)	.04	.00	1.025
Higher education	− .07 (.38)	− .19 (.848)	− .01	.00	1.206
Vignette: Schizophrenia	.64 (.30)	2.11 (.036)*	.07	.01	1.003
Age	.01 (.06)	.13 (.901)	.00	.00	1.218
Step 2				.247		.252**	.246**
Female	.21 (.27)	.75 (.453)	.02	.00	1.027
Higher education	− .03 (.33)	− .09 (.933)	.00	.00	1.206
Vignette: Schizophrenia	.48 (.26)	1.82 (.069)	.05	.00	1.012
Age	− .05 (.05)	-1.02 (.309)	− .03	.00	1.226
MHL: Correct	− .21 (.28)	− .74 (.455)	− .02	.00	1.011
Self-stigma	− .40 (.02)	-16.94 (< .001) **	− .50	.25	1.009
Note. SE = standard error; VIF = Variance inflation factor; MHL = dichotomized score of recognition of mental disorder; Self-stigma = sum of SSOHS scores; * significant at p < .05; ** significant at p < .001.

Table 3

Descriptive statistics after excluding outliers (N = 887)
Variables	n (%)	Range	\(\:\underset{\_}{x}\)	SD	Group Difference ^a
Variables	n (%)	Range	\(\:\underset{\_}{x}\)	SD	Statistics	Effect Size [95% Confidence Intevral]
1. Sex		-	-	-	X²(1, N_total = 912) = 5.40 × 10^− 3, p = .941	Φ = 0.00 [0.00–0.06]
Male (0)	344 (38.8%)
Female (1)	543 (61.2%)
2. Education level		-	-	-	X²(NA, N_total = 912) = 153.82, p < .001	V = .41 [.34 – .47]
9 years (0)	0 (0%)
12 years (1)	655 (73.8%)
Higher education (2)	232 (26.2%)
3. Vignette		-	-	-	X²(1, N_total = 912) = 0.69, p = .405	Φ = 8.93 ×10^− 3 [0.00–0.09]
Depression (0)	448 (50.5%)
Schizophrenia (1)	439 (49.5%)
4. Age		18–40	21.51	2.79	W = 1569.5, p < .001	r = − .86 [-.91 – − .78]
5. Literacy index		-	-	-	X²(1, N_total = 912) = 1.11, p = .291	Φ = 0.03 [0.00–0.10]
Incorrect (0)	603 (68.0%)
Correct (1)	284 (32.0%)
6. Self-stigma		10–42	24.53	5.60	W = 11486, p = .759	r = − .04 [-.19 – .26]
7. Attitudes toward help-seeking		13–40	28.43	4.51	W = 12428, p = .301	r = .12 [-.11 – .34]
Note. ^a between the final sample and the outliers; n = count; \(\:\underset{\_}{x}\) = mean; SD = standard deviation; Literacy index = dichotomized score of recognition of mental disorder; Self-stigma = sum of SSOHS scores; Attitudes toward help-seeking = sum of ATSPPH-SF scores.

Predictors of attitudes toward professional help-seeking

We conducted a two-step hierarchical multiple regression to investigate if MHL and self-stigma predict attitudes toward professional help-seeking after controlling for age, sex, education, and type of vignette. In the first step, only the vignette significantly predicted help-seeking attitudes (\(\:b=2.11,\:\beta\:=\:.07,\:t\left(882\right)=2.11,\:p=\:.036\)), with better attitudes associated with the schizophrenia vignette; however, this model was not significant (\(\:F\left(4,\:882\right)=1.5,\:p=\:.200\)) and explained only 0.7% of the total variance.

Adding self-stigma and MHL in the second step made the model significant (\(\:F\left(6,\:880\right)=49.48,\:p<\:.001\)) and explained 25.2% of the total variance. This significantly increased the total explained variance of 24.6% (partial η² = .25) compared to the model in the first step (\(\:F\left(2,\:880\right)=144.47,\:p<\:.001\)). Self-stigma was the exclusive predictor of help-seeking attitudes in the model, and virtually all the variance was explained by the model (partial η² = .25). The vignette was no longer a significant predictor, and MHL did not significantly predict attitudes toward seeking psychological help (Table 2).

Power analysis and effect size

A post-hoc power analysis was conducted to test the R² increase in the linear multiple regression. An effect size (f²) of .33 was estimated directly from the partial R².

The critical role of anticipated self-stigma in assessing other types of public or personal stigma was in line with the reported significant impact of different stigma types on active help-seeking (Liddon et al., 2018; Schnyder et al., 2017; Wendt & Shafer, 2016; Clement et al., 2015;). In one meta-analysis by Schnyder et al. (2017), it was found that personal stigmatizing attitudes toward people with a mental illness, along with individuals’ negative attitudes toward mental health help-seeking, which is the outcome in the current study, most significantly reduced active help-seeking behavior. Stigma as a barrier in professional mental health care (Larkings & Brown, 2018; Haugen et al., 2017; Kohn et al., 2004).

Public stigma, however, did not play a significant role. Yu et al. (2021) found that self-stigma was a significant mediator in the relationship between experienced stigma and perceived stigma, well-being, and recovery, so it could also be an important moderator between public and personal stigma and help-seeking attitudes. The fact that the correlation between experienced and perceived stigma and self-stigma increases with a culture’s level of collectivism (Ran et al., 2021; Yu et al., 2021) and that Indonesia has a collectivistic culture (Rasyida, 2019; Irawanto, 2009; Kurihara et al., 2006; Setiawan, 2006) makes the critical moderating role of self-stigma in the current study more likely. This view is supported by a study that found higher levels of self-stigma in patients with severe mental illness in Southeast Asia (39.7%) and the Middle East (39%) (Dubreucq et al., 2021). In this respect, our findings align with an Indonesian study (Novianty and Rochman Hadjam, 2017) that found public stigma a more robust predictor of help-seeking attitudes than MHL. This contrasts studies in the United States (Cheng et al., 2018) and Indonesia (Puspitasari et al., 2020).

The first model, whereby the schizophrenia vignette, was related to better help-seeking attitudes. This model is in line with a qualitative Indonesian study of help-seeking in families of psychiatric inpatients; some factors related to timely help-seeking behavior include being a well-educated family, living closer to health facilities, and thus having good access to healthcare, having previous successful therapy experience, and more positive symptoms of psychosis. In contrast, low MHL and false beliefs about the causes of the illness (e.g., the belief that mental illness is a “village sickness,” stigmatization, the role of extended family, financial problems, and long distance to the psychiatric hospitals) were factors that delayed psychiatric treatment (Soebiantoro, 2017; Marthoenis et al., 2016; Whiteford et al., 2013; Wright et al., 2007).

Another Indonesian qualitative study on mental health stated common symptoms of poor mental health (e.g., stress, loneliness, and poor sleep) and common mental disorders (e.g., depression and anxiety); did not involve continuum perspectives between good and poor mental health in discussions of mental (ill-)health. Poor mental health was predominantly described as behavioral and physical manifestations of severe levels of mental illness, while good mental health was conceptualized as emotional well-being and happiness. Mental health was seen as having two opposites, good and bad (Willenberg et al., 2020) and negative stereotypes (Efstathiou et al., 2019; Doll et al., 2022).

In line with the association between stigma and poor MHL indicated by these studies as well as in an earlier Indonesian community study; however, in this study, self-stigma and MHL were uncorrelated (r=-0.04). Furthermore, age, sex, and education were unrelated to both MHL and stigma and not predictors of help-seeking attitudes. This was also in contrast to the earlier study (Hartini et al., 2018) in Indonesia, which found that better MHL was associated with lower public stigma. In contrast, male sex, younger age, married status, a lower middle income, former contact with a mentally ill person or a positive family history of mental disorder, and a supportive attitude to pasung were related to higher stigma.

However, all information or anti-stigma campaigns should be guided by careful, in-depth research into the interplay of sociodemographic characteristics, MHL, and attitudes assessed by culturally adapted instruments to develop programs that adequately consider cultural values, meanings, and practices (Javed et al., 2021; Mascayano et al., 2020; Rayan et al., 2020).

Despite its excellent statistical power, this study’s failure to demonstrate a significant link between overall MHL and help-seeking attitudes might reflect a type III error (Kraemer, 2013), namely, asking the wrong question (for the label rather than for mental ill-health).

Self-stigma was linked to more negative attitudes toward help-seeking, while sociodemographic characteristics, type of disorder, and an overall binary measure of MHL showed no such association. Thus, the promotion of professional help-seeking attitudes should focus on reducing anticipated self-stigma rather than simply educating persons about mental disorders. To do so, it will be necessary for a more collectivistic culture to alter public stigma first, as this was shown to have a substantial effect on self-stigma.

Acknowledgments

We thank our research assistants, Ayu Anggraini and Afifah Nuha Nandela, who helped collect data.

Author contributions

Nurul Hartini designed the study and drafted the article. Nipo Dipo Wardhan collected data, performed data analysis, and drafted the article. Tri Kurniati Ambarini contributed to the interpretation and drafting of the article. Dewi Retno Suminar, Tiara Diah Sosialita, Melati Binti Sumari, and Valia Khiarin contributed to collecting data and formatting the article. Frauke Schultze-Lutter contributed to the drafting and the critical revision of the article. All authors approved the paper for submission and contributed to the revisions.

Funding

The research was funded under the International Research Collaboration Top #100 Universitas Airlangga scheme. The contract number is 2578/UN3.LPPM/PT.01.01/2023.

Availability of data and materials

Upon request to the corresponding author.

Ethics approval and consent to participate

This study has obtained ethical approval from the Faculty of Nursing review board, Universitas Airlangga (No. 2624-KEPK). The review committee carefully assessed and approved the protocol to protect human subjects. All participants consented to participate in this study voluntarily, without any coercion.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.

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No competing interests reported.

Predicting Attitudes toward Professional Help-Seeking: The Role of Self-Stigma and Mental Health Literacy

Status:

Version 1

Abstract

Figures

Background

Methods

Materials

Mental Health Literacy

Self-stigma

Attitudes toward professional help-seeking

Statistical analysis

Results

The descriptive sample characteristics

Examination of model assumptions

Predictors of attitudes toward professional help-seeking

Power analysis and effect size

Discussion

Limitations

Conclusions

Declarations

Acknowledgments

References

Additional Declarations

Supplementary Files

Status:

Version 1