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30Oriental Renaissance: Innovative, educational, natural and social sciences
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THE MEDIATING EFFECT OF MENTAL HEALTH LITERACY ON THE RELATIONSHIP BETWEEN STIGMA AND ATTITUDES TOWARDS PSYCHOLOGICAL HELP-SEEKING AMONG UNIVERSITY STUDENTS IN
TURKEY
Isik E. a*, Kalan A. b, Arat E. D., and Bayrakci Y.a
^Department of Psychology, Ankara Haci Bayram Veli University, Ankara, Turkey; ^Department Psychology, Ibn Haldun University, Istanbul, Turkey; c Addictions MSc
Program, Kings Collage London, London, UK
Corresponding Author Esra ISIK, PhD
Department of Psychology Ankara Haci Bayram Veli University, Faculty of Letters, Ankara, Turkey
esra.isik@hbv.edu.tr
Aleynanur Kalan
Department of Psychology Ibn Haldun University, Shool of Hummanities and Social Sciences, Istanbul, Turkey
aleynanur.kalan@ihu.edu.tr
Esra Dudu Arat Addictions MSc Program (Student) Kings Collage London, London, UK esra dudu.arat@kcl.ac.uk
Yilmaz Bayrakci
Department of Psychology Ankara Haci Bayram Veli University, Faculty of Letters, Ankara, Turkey
yilmaz.bayrakci@hbv.edu.tr
ABSTRACT
Evidence suggest that college students may face many psychological problems. However, rates of help seeking remains relatively low when compared to the prevalence of mental health problems in university students. Low levels of mental health literacy and increased stigma are important factors to address in order to facilitate help-seeking behaviors. This study aimed at examining whether mental health literacy mediated the relationship between social and self-stigma and
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psychological help-seeking attitudes among college students in Turkey. In this cross-sectional study, 243 students from different universities in Turkey participated the study. The survey included self-report measures of mental health literacy, social stigma, self-stigma, and psychological help seeking attitudes, and a sociodemographic information form. Results showed that mental health literacy partially mediated the relationship between social and self-stigma and attitudes towards psychological help-seeking. It is concluded that mental health literacy can reduce stigmatization of psychological problems and increase university students' positive attitudes towards seeking professional help for mental health problems. It is important to implement intervention programs to increase the levels of mental health literacy and reduce stigma related to psychological problems in universities. Academic institutions should support student counseling services to be able to realize these interventions.
Keywords: Help-seeking attitudes; mental health literacy; self-stigma; social stigma
INTRODUCTION
The collage period, which can be considered as the transition from adolescence to adulthood, can contain many stressful circumstances for students. Academic responsibilities, separation from family and familiar environment, and future anxiety may be associated with adaptation problems, increased anxiety levels, or behavioral problems in young people (Pedrelli et al., 2015). When these problems cannot be coped with, psychological disorders may occur. A study conducted by the World Health Organization revealed that approximately one-third of first-year students had at least one of the common psychological (mood, anxiety or substance use disorder) problems (Auerbach et al., 2016). Likewise college students in Turkey have similar rates of psychological problems. For example, a recent study conducted with students of a university in Istanbul, was found that 30.1% of the students had depression, 25.2% had generalized anxiety disorder, 9% had bipolar disorder, and 2.9% had psychotic symptoms (Cengiz and Topuzoglu, 2021). Despite these high rates of psychological problems, studies revealed that the rate of help seeking remains relatively low when compared to the prevalence of psychological problems in university students (Gulliver et al., 2010; Kim et al., 2020; Lipson et al., 2022; Okansen et al., 2017). Instead of seeking professional help, students tend to solve their problems themselves or get support from non-professional channels (Ba§er and Ak5ay, 2019). Studies have shown that psychological problems experienced during the university period may be associated with decreased academic success, as well as
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problems in business life, relationships and general health after graduation (Cuijpers et al., 2019). Therefore, it is extremely important to seek professional psychological help to reduce the both short and long-term negative effects of problems experienced during the university years (Rickwood, Deane, & Wilson, 2007).
The concept of psychological help seeking involves recognizing the psychological problem being experienced, awareness about help is needed, and seeking psychotherapy or counseling services for this purpose (Wuthrich and Frei, 2015). Studies have revealed that there are many factors that prevent seeking psychological help. Concerns about confidentiality issues (Fletcher et al., 2020; Gulliver et al., 2010; Rickwood, Deane, and Wilson, 2007), accessibility of psychological support services or extended wait times (Sareen et al., 2007; Mojtabai et al., 2010), negative beliefs about the efficacy of mental health interventions (Bayer and Peay, 1997), lack of knowledge or understanding about psychological problems and how to get help, or belief that they do not need psychological help (Gulliver et al., 2010; Reardon et al., 2017)) can be counted among these factors. Besides all these, a major barrier is the stigma associated with mental health issues, which may hinder individuals from seeking psychological help (Clement et al., 2015). Stigma regarding mental health problems can occur in two dimensions; social stigma and self-stigma. Social stigma refers to society's negative attitudes towards individuals with mental health problems, and self-stigma refers to the internalization of these negative attitudes by individuals (Michaels et al., 2017). Studies revealed that both self-stigma (Sibicky & Dovidio, 1986; Komiya et al., 2000; Corrigan, 2004; Vogel et al., 2006; Topkaya, 2014; Ina & Morita, 2015; Da§tan et al., 2019) and social stigma ( Komiya et al., 2000; Corrigan, 2004; Topkaya, 2014; Heath et al., 2016; Da§tan et al.; 2019) are frequently seen as barriers to seeking professional help.
On the other hand, mental health literacy is a concept that positively associated with help-seeking behavior. It was first defined by Jorm et al. (1997) as the knowledge and beliefs that help people recognize, manage or prevent emergence of certain mental disorders. More specifically it refers to an individual's ability to recognize mental disorders, knowledge on how to search for mental health information; understanding of possible risk factors, knowledge on self-help strategies and available professional help, and attitudes that encourage proper help-seeking. Studies have shown that people with high levels of mental health literacy have more positive attitudes and behaviors regarding seeking professional psychological help (Cheng et al., 2018; Gorczynski, 2017; Smith & Shochet, 2011). Therefore, individuals who better understand mental health issues are more likely to access mental health services and less likely to have stigmatizing attitudes.
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The evidence from various studies consistently highlights somatization may hinder help-seeking behavior and there is a positive correlation between mental health literacy and help-seeking behavior. Based on this, the objectives of this research is to examine (i) the relationship between psychological help seeking attitudes and self-stigma and social stigma in university students and (ii) the role of mental health literacy level in these relationships.
METHOD
Procedure
Data were obtained via a cross-sectional study by using convenience sampling method. Convenience sampling is a method that provides ease of access to participants and time flexibility to researchers (Kiliç, 2013). Inclusion criteria included the following; (a) >18 years of age; (b) enrolled in college by the time of data collection; and (c) enrolled in a college located in Turkey. A total of 243 university students participated in the research. 210 of the participants were women (86.4%) and 33 were men (13.6%). There were 231 participants (95.1%) between the ages of 18-25, and 12 participants (4.9%) aged 26 and over. Ethical approval from the Uskudar University Ethics Committee was obtained prior to the commencement of the study. Information about the research was provided to students and informed consent was obtained. The research instruments were transferred to into an online survey and data was collected via the internet.
Instruments
Sociodemographic Information Form: It is developed by researchers and includes information about age, gender, marital status, socio-economic status and the department studied.
Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (ATSPPH-SF): ATSPPH-SF, developed by Fischer & Farina (1995), is a 10-item questionnaire that assesses beliefs and attitudes on seeking professional psychological help with personal or emotional problems. Respondents indicate their level of agreement with items on a 4-point Likert scale (1-disagree to 4-agree). The obtained score could range from 10 to 40. Higher scores indicate more positive attitudes toward seeking psychological help. The internal reliability was reported as .84. The test-retest reliability for the short form was reported as .80. In the current study, Turkish version of the scale, adapted by Topkaya (2011) was used. In the Turkish adaptation study, the correlation coefficient of the 4th item was below .30 and removed from the Turkish version. The validity and reliability analysis of the scale was conducted with the other 9 items. The internal consistency for the Turkish version of the ATSPPHS-SF was .76.
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Stigma Scale for Receiving Psychological Help (SSRPH): This 5-item scale, originally developed by Komiya et al. (2000) was used to measure participants' perceptions of social stigma due to receiving psychological help. The 4-point Likert rating scale responses range from strongly disagree (1) to strongly agree (4). The highest score could be obtained is 20 and the lowest score is 5. Higher scores indicate a greater perception of social stigma associated with receiving professional psychological help. The internal consistency is reported as .72. In this study, Turkish version of the scale, adapted by Topkaya (2011) was used. The internal consistency for the Turkish version of the SSRPH was .80.
Self-Stigma of Seeking Help Scale (SSOSH): It is a 10-item scale developed to measure individuals' tendency to stigmatize themselves due to seeking psychological help (Vogel et al., 2006). Items are rated on a 5-point scale ranging from strongly disagree (1) to strongly agree (5). Scores obtained from the scale could range from 10 to 50. Higher scores indicate greater self-stigma. The SSOSH has produced an internal consistency range from .86 to .90. In this study, Turkish version of the scale, adapted by Kapikiran & Kapikiran (2013) was used. The internal consistency for the Turkish version of the SSOSH was .71. In the Turkish adaptation study, the10th item produced low correlation coefficient value and removed from the scale. The validity and reliability analysis of the scale was conducted with the other 9 items.
Mental Health Literacy Scale (MHLS): Mental Health literacy was measured using a 26-item scale developed by Jung et al. (2016). The items are rated on 6 point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree, and I don't know). The obtained scores could range from 0 to 26, with higher scores indicating higher mental health literacy level. The MHLS has produced an internal consistency of 0.83. The Turkish adaptation were carried out by Goktas et al. (2019). It consists of three sub-scales and 22 items. There are 11 items in the Knowledge-Oriented MHL sub-scale, 8 items in the Beliefs-Oriented MHL sub-scale, and 4 items in the Resource-Oriented RSOY sub-scale. The score that can be obtained from the scale varies between 0-22. The 18 questions in the first two sub-scales of the scale are of six-point Likert type. The answers to the 4 questions in the resource-oriented MHL sub-scale are "yes" and "no". The internal consistency for the Turkish version of the MHLS was .71.
Data Analysis
The analysis of the data collected was performed using SPSS version 25.0 for Windows. Descriptive statistics were used to summarize the characteristics of the participants and run on all sum scores to ascertain mean, standard deviation, and range. Kurtosis and skewness scores and cut-off values of these scores were used for
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the assumption of normality (Tabachnick and Fidell, 2007). Pearson correlation analysis was used to determine the relationship between variables. To test the mediating effect, Model 4 analysis was carried out using the bootstrap technique included in the PROCESS macro modeling tool (Preacher and Hayes, 2004).
RESULTS
Data analysis started with missing value, outlier and normal distribution analysis. No missing value or outlier data were found. Kurtosis and skewness analysis showed that the scores obtained from the scales were within the range of ±1.5 and that the data met the normality assumption. Pearson Correlation Analysis was performed to examine the relationship between the variables of the study, namely psychological help seeking attitude, self-stigmatization, social stigmatization and mental health literacy. All variables were significantly related to each other. There is a negative and significant relationship between the attitude of seeking psychological help, which is the dependent variable of the study, and self-stigmatization and social stigmatization (p<.01). When the relationship between psychological help-seeking attitude and mental health literacy were positively correlated with each other (p<.01). The results of the analysis are presented in detail in Table 1.
Table 1. Pearson's correlation coefficients between all study variables and descriptive statistics
1 2 3 4
1. Attitudes towards psychological 1 -.326** -.619** .574**
help seeking
2. Self-stigma 1 .362** -.572**
3. Social stigma 1 -.183**
4. Mental Health Literacy 1
x 18.436 19.531 9.625 74.457
SS 4.055 5.990 2.942 10.090
Min. 2.00 9.00 5.00 48.00
Max. 27.00 41.00 20.00 100.00
Skewness -.393 .326 .332 -.008
Kurtosis .424 -.139 -.081 -.147
*p<.05 **p<.01
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In order to determine the mediating role of mental health literacy in the relationship between self and social stigma and psychological help-seeking attitude, Model 4 analysis was performed using the bootstrap technique in the PROCESS Macro. In Model A, a negative association detected between self-stigma and mental health literacy (B=-.964, p<.01) and a positive association was found between self-stigma and psychological help-seeking attitude (B= .132, p<.01) Mental health literacy had a partial mediating effect on the relationship between self-stigmatization and psychological help-seeking attitude (B= -.127, 95% CI [-.178, -.078]). The model is presented in Figure 2.
Mental Health Literacy
ai= b=-.964, p<.01
bi= b= .132, p<.01
ci= b=.-419, p<.01
C1= b=-.292, p<.01
Attitudes Towards Psychological Help Seeking
Figure 1. Model A: The mediating role of mental health literacy in the relationship between self-stigmatization and psychological help-seeking attitude
In Model B, a negative association detected between social stigmatization and mental health literacy (B=-.628, p<.01) and a positive association found between social stigmatization and psychological help-seeking attitude (B =.214, p<.01). As in Model A, mental health literacy had a partial mediating effect on the relationship between social stigmatization and psychological help-seeking attitude (B= -.134, 95% CI [-.230, -.040]). The model is presented in Figure 2.
Mental Health Literacy
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a2= b=-.628, p<.01
X
c2= b=.-449, p<.01
b2= b= .214, p<.01
X
c2= b=-.315, p<.01
Attitudes Towards Psychological Help Seeking
Figure 2. Model B: The mediating role of mental health literacy in the relationship between social stigmatization and psychological help-seeking attitude
Discussion
This study investigated the relationships between mental health literacy, social and self-stigma, and attitudes towards psychological help seeking in sample consisting of college students in Turkey. Results showed that higher levels of social and self-stigma is associated with more negative attitudes towards seeking psychological help. This finding supports the results of many studies in the literature (Sibicky & Dovidio, 1986; Komiya et al., 2000; Corrigan, 2004; Vogel et al., 2006; Ina & Morita, 2015; Da§tan et al.; 2019; Topkaya, 2014; Heath et al., 2016). Individuals with higher levels of self-stigma might label themselves as socially unacceptable when they experience psychological distress, think that seeking professional psychological help may lead to discrimination, and their self-esteem and self-worth are decreased (Chen et al, 2022). Considering social stigma, anxiety about being stigmatized in the community in relation to counseling and therapy might be manifested as decreased willingness to seek professional help (Choi & Miller, 2014). These findings suggest that stigmatization, whether self-imposed or influenced by cultural and social factors, significantly prevents individuals from seeking psychological help.
It was found that more positive attitudes towards seeking psychological help is associated with higher levels of mental health literacy. This finding reconfirms existing literature (Cheng et al., 2018; Dogan et al., 2021; Gorczynski, 2017; Iswanto & Ayubi, 2023; Sari & Asiyah, 2022; Smith & Shochet, 2011). In addition, similar to the findings of other studies, it was observed that people with higher mental health literacy levels had low levels of social and self-stigmatization (Cheng et al., 2018 Fleary et al., 2022; Lopez et al., 2018). This might indicate that individuals with high level of mental health literacy have an understanding of psychological distress, recognize it when they experience it, and are more knowledgeable about where they
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can get help. This may increase the likelihood of seeking professional help for psychological problems.
Mental health literacy was found to have a partial mediating effect for both models. It was observed that higher levels of mental health literacy were associated with lower levels of stigmatization, which in turn may lead to more positive attitudes towards seeking psychological help. This finding supports the results of previous studies (Millin et al., 2016; Lopez et al., 2018; Whitley, Smith, & Vaillancourt, 2013). This finding might suggest that mental health literacy can affect individuals' attitudes, beliefs, and self-stigmatization about seeking psychological help, and plays an important role in shaping help-seeking behaviors and alleviates the impact of stigma in psychological support. Individuals' high levels of knowledge and awareness about psychological problems, knowing where and how they can get help are likely to prevent the effects of negative attitudes of the society towards seeking help and the internalization of these attitudes.
The results of study show that mental health literacy can reduce stigmatization of psychological problems and increase university students' positive attitudes towards seeking professional help for mental health problems. It may be useful to implement intervention programs to increase mental health literacy and reduce stigma related to mental health problems in universities. In order to increase the mental health literacy levels of students, trainings and awareness-raising activities should be carried out. These activities should be provided to the students starting from their first year in university, encouraged by faculty staff and be supported by various in or out campus activities. Studies revealed that such intervention practices for university students result in higher levels of mental health literacy and more positive attitudes towards getting psychological help (Chow et al., 2020; Wei et al., 2013). Many colleges have student counselling services. They should be supported and integrated into these activities. Colleges missing counselling services should be supported to establish professional help centers. Universities should provide financial, physical and human resources for these centers and services.
Although there are some studies on psychological help-seeking attitudes, mental health literacy and stigmatization among university students, this study aimed to identify the pathways and relationships between these variables. To our knowledge, it was the first study to address help-seeking attitude together with two dimensions of stigmatization related to psychological problems and to reveal the role of mental health literacy in this relationship. However, the study has some limitations. First of all, since the study is cross-sectional and descriptive, no cause and effect relationship can be identified. In addition, convenience sampling method was used instead of
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random sampling methods. Therefore, it is not possible to generalize the findings to all university students. Future research should work with a larger sample, address help-seeking behavior along with help-seeking attitudes, and consider issues such as cultural differences.
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