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).