Predictors of Psychological Help Seeking Behaviours towards Mental Illness in University Students in Jordan vs UK

Predictors of Psychological Help Seeking Behaviours towards Mental Illness in University Students in Jordan vs UK

Qais Rahhal, Ilhan Raman*

Eastern Mediterranean University, Cyprus

Running Head: Predictors of psychological help seeking

*Correspondence Author

DOI: https://doi.org/10.51584/IJRIAS.2024.90113

Received: 11 December 2023; Revised: 08 January 2024; Accepted: 12 January 2024; Published: 12 February 2024

ABSTRACT

The adverse effect of self-stigma on psychological help seeking behaviours in mental illness is well documented with factors such as gender and socio-economic status often determining whether or not help is sought. While self-stigma is a complex and multifaceted concept, understanding how it is predicted by factors including but not limited to culture, education, socio-economic background, and knowledge, is elemental in raising awareness and reducing its impact. We explored the influence of culture and educational background on knowledge and self-stigma towards mental illness in university students in the UK and in Jordan. Jordanian participants were expected to be less knowledgeable with higher self-stigma towards help seeking behaviours in mental illness than the UK participants. Surprisingly, contrary to the extant literature there were no significant effects for culture or for educational background on self-stigma towards mental illness nor on the amount of knowledge between the two samples. The implications of the pattern of results are promising as debated in the discussion.

Keywords: Self‐stigma of psychological help seeking behaviours, SSOSH, mental illness, mental health knowledge, university students, Jordan and UK.

INTRODUCTION

A review of the literature shows that more than 52% of people who suffer from mental disorders, do not receive the needed treatment in Europe and the United States (Clement et al., 2015; Kessler et al., 2005a; Wittchen & Jacobi, 2005). Also, it was reported that the rate of untreated mental illness is higher in people with lower financial economic classes (Clement et al., 2015; Wang et al., 2007). Studies have shown that the delay in seeking mental help would cause greater consequences in some cases such as, in individuals who are suffering from psychosis, bipolar disorder, and major depressive and anxiety disorders (Boonstra et al., 2012; Clement et al., 2015). The U.S. Surgeon General’s Report (1999) on mental health is regarded as a landmark report which states that the way the society addresses mental health and mental illness, supports the misconception of mental health being unrelated to physical health, but the truth is, both concepts are connected to each other and can never be separated (General, U. S., 1999). The Report also addresses the issue of mental health stigma which can have an adverse effect on people’s decisions when it comes to seeking help for mental health issues and mental illness, to the point that it can stop them from seeking professional help when they need it (General, U. S., 1999).

In addition to having to deal with all the difficulties and the struggles that come with their illnesses, such as depression, hallucinations, delusions and anxiety, mentally ill individuals also have to deal with the stereotypes and the misjudgments forced upon them by the society, because of the general lack of knowledge about mental illness (Corrigan & Watson, 2002; Rüsch, Angermeyer & Corrigan, 2005). Such stereotypical misjudgment can be one of the main factors behind creating stigmas in society towards people with mental illnesses which can deprive them from many opportunities that could grant them a good quality of life (Corrigan & Watson, 2002).

The Role of Stigma, Self-Stigma and Help Seeking in Mental Illness

The term stigma in general may be defined as a process based on prejudice, labelling, isolation, and discrimination in a context where power is used in ways to harm a person based on his/her group membership (Link & Phelan 2001; Gray, 2002).

Mental health stigma can come in many different forms (Eisenberg, Eisenberg, Golberstein, & Zivin, 2009). Public stigma can be defined as the society’s prejudicial attitudes towards people with mental illnesses (Corrigan & Watson, 2002; Vogel, Wade, & Haake 2006: Zolezzi, Alamri, Shaar, & Rainkie, 2018). In this respect, self-stigma develops because of the general attitudes of the society towards mental illness in that the people who are suffering from mental illness might internalize these attitudes and see themselves as less important than others in society because of their psychological and mental problems (Corrigan & Watson, 2002; Vogel, Wade, & Hackler, 2007). According to a study conducted by Rüsch et al., (2005) on the effects of mental health stigma on people suffering from mental illness, stigmatising attitudes toward people with mental illness could cause harmful effects on different life domains such as working, studying, and forming friendships. Previous studies also suggest that self-stigma and the fear of being judged by others can be a big contributor in stopping people from taking opportunities that can better their lives (Link, Struening, Rahav, Phelan & Nuttbrock, 1997; Vogel et al., 2007; Cheng, Wang, McDermott, Kridel, & Rislin, 2018).

One of the questions which has preoccupied researchers in the past is the extent to which stigma is embedded in culture, but the general consensus is that stigma is not a culture specific phenomenon (Murthy, 2002). The vast majority of research conducted on the topic of mental stigma and help seeking behaviour is mostly concentrated on Western cultures, that is why the amount of research conducted on the topic of stigma and help seeking behaviour is considered to be fairly limited in cultures such as in Middle-Eastern and Arabian cultures (Al-Adawi et al., 2002). Emerging evidence, however, suggests that mental health stigma exists to a considerable level in the Middle East (Sewilam et al., 2015). Although some studies have been conducted on understanding stigma in different cultures, there are limitations to the extent which the results can be generalised (Al-Krenawi, Graham, Dean & Eltaiba, 2004). In this respect, one suggestion is to conduct cross-cultural comparisons as the best way to understand the role of stigma in help-seeking behaviours (Griffiths et al., 2006).

The Psychology of Mental Wellbeing in Western vs Middle Eastern Arabian Cultures

Unlike in the Western cultures where the focus is on both physical as well as psychological aspects of health, in Middle Eastern especially in Arabian cultures the concept of health is primarily focused on physical wellbeing (El-Islam, 1982; El-Islam & Ahmed, 1971). Moreover, evidence from research suggests that in Arabian cultures individuals cannot differentiate between the physical and the psychological aspects of their health problems and that they are more likely to treat both problems as if it were a physical one (Al-Krenawi & Graham, 2000; El-Islam, 1982; El-Islam & Ahmed, 1971). Although some studies such as El-Islam (1982) and Al-Krenawi and Graham (2000) have highlighted these issues in the Arabian cultures, these finding were from over two decades ago.

To the best knowledge of the authors, the subject has not been addressed recently in any academic study to investigate if these issues still exist in the newer generations in Arabian cultures, considering that during the past 22 years many things have changed with the development of technologies and easier access to the internet which made it easier for the current generation to have access to information in comparison to the past generations.

According to Okasha (1999) the idea of presenting an emotional or mental health problem as a physical one, namely, psychosomatisation, is one of the most prevalent mental health issues among Arabs. When it comes to psychology as a profession, some studies found that most Arabs have a problem differentiating between different psychology professions and the services provided, such as psychotherapy and counselling (Al-Krenawi & Grahm, 1999; Erickson & AL-Timimi, 2001). Al-Krenawi et al., (2009) argued that the process of help seeking behaviour is highly affected by cultural beliefs as barrier to help seeking. Okasha, Karam and Okasha (2012) stated that, traditional Middle Eastern cultures are having problems with accepting mental illnesses, furthermore, they argued that the strong social connections between families in the Middle East means that providing mental health care to a family member will not just cause an embarrassment to the person him/herself, but it would cause an embarrassment to the family as a whole. Recently, it was reported that in a country like Jordan the decision of seeking mental help is highly affected by the family and the friends of the person with mental illness (Aldalaykeh, Al-Hammouri & Rababah, 2019).

Knowledge of psychological approaches towards mental illness is relatively new in most Arabian cultures which could be responsible for the negative attitudes and the low level of help seeking behaviour. According to Aldalaykeh et al., (2019) the severity of the mental illness and the amount of knowledge about mental health could determine the level of help seeking behaviour when it comes to mental health problems. Moreover, it was argued that Arabs’ attitudes towards seeking mental help are usually negative not just due to their lack of knowledge about the subject but also because of the fear of being judged (Al-Adawi et al., 2002). In some cultures (not specifically Arabian cultures), individuals are raised to believe that mentally ill people are dangerous and to be feared which might lead people to avoid being labelled as one (Caplan, 2019). Al-Adawi et al., (2002) also argued that in Arabian cultures the fear of being judged led people to describing visiting a psychiatrist or seeking psychological help as a shameful act (Al-Adawi et al., 2002). Being labelled as mentally ill in some of the Arabian countries is shameful to the point of lowering the person’s chances in marriage and in landing future jobs (Scull, Khullar, Awadhi, & Erheim, 2014). This suggests that these negative attitudes towards mental health in the Arabian cultures can be one of the main reasons behind the low level of help seeking behaviour when it comes to mental health. Rüsch, Zlati, Black, and Thornicroft (2014), supported the claim by stating that adults who associate mental health issue with shame are less likely to seek professional help.

Al-Krenawi et al., (2009) further argued that cultural beliefs about mental health services could be influenced by socio-economic factors such as nationality/culture and educational level. Religion has also been identified as a cultural factor that influences attitudes towards mental health and mental health stigma across cultures. When it comes to mental health, religion is considered to be an important factor with studies showing that religion might have an influence on mental health (Haque, 2004). For example, according to Sewilam et al., (2015), in some areas such as in the Middle East (Southwest Asia and North Africa), although 90% of the population are practicing Islam as a religion, there are also other religions such as Christianity and Judaism which are considered similar and share the same roots of Islam. Sewilam et al., (2015) argued that, even if people are practicing different religions, they might still be sharing the same beliefs and attitudes, which might also shape their attitudes towards mental health and help seeking behaviour in general. In some cultures, religion and mental illness are strongly connected in that it is hard in some cases to separate religious beliefs and mental health as religion and science can disagree on the label to use for some of the cases (Peteet, 2019). The realisation of the importance of religion in relation to mental health was acknowledged by the American Psychological Association’s Ethical Code of Conduct, where they stated that psychologists need to be aware of the religious views of their clients, and in case they could not, they should refer the client to another psychologist who can (APA, 1992; Peteet, 2019). It has been established that, in some religions, such as Islam, individuals usually consult with an Imam (the person who leads the prayer) to treat their mental illness or seek traditional or faith healers as a first option (Haque, 2004; Okasha & Karam, 1998; Zolezzi, Alamri, Shaar & Rainkie, 2018). Moreover, research conducted in the United Arab Emirates showed that 44.8% of the people suffering from psychiatric disorders chose to seek help from traditional healers as a first option before seeking help from professional mental health services (Salem, Saleh, Yousef, & Sabri, 2009). According to (Sewilam et al., 2015) the reason behind people seeking traditional help as a first option over professional help services might be derived from religious beliefs, such as that mental illness might be caused by envy or evil-eye. According to Haque (2004) this is problematic because these practitioners who are offering traditional help are not qualified and are not licensed by any monitoring professional body. Haque (2004) also argued that some Muslims might find it hard to go to a psychologist who does not have knowledge about their religion and as a result, their mental illnesses might be left untreated. Sewilam et al., (2015) suggest improving communication and collaboration between the traditional (religious) healers and the professionals in the mental health sector could offer a solution by reducing mental health stigma in the community and encourage people from different religions to seek professional mental help when needed.

MENTAL WELLBEING AND SELF-STIGMA IN UNIVERSITY STUDENTS

One of the emerging areas in this field is the mental wellbeing of university students and the importance of supporting their mental health while studying at university (Kitzrow, 2003; Zivin, Eisenberg, Gollust, & Golberstein, 2009). When one considers the future potential of university graduates’ economical and general societal input amongst other things into their community, one can begin to appreciate the significance of this move. Earlier studies showed that the benefits of such support towards students is beneficial in terms of improving their educational levels and their future achievements (Kitzrow, 2003). University student populations is considered to be important for mental health policy development, because most mental health issues especially psychiatric ones tend to occur between the ages of 15 to 24 (Kessler et al., 2005b). The influence of studying and better understanding of university student populations’ mental health and associated issues can be substantial in reducing and controlling the time gap between the first onset and treatment (Eisenberg, Golberstein, & Gollust, 2007).

Previous studies on help seeking behaviour in university students reported that there is a significant number of mental health needs and services that are not being provided for university students. Some of the reasons which can be considered as predictors that stop university students from getting help are reported to be their attitudes, beliefs, and the lack of knowledge about the topic (Eisenberg, Golberstein & Gollust, 2007; Hyun, Quinn, Madon, & Lustig, 2006). In the United States, a study conducted by Eisenberg et al., (2009) on stigma and help seeking behaviour among university students, found that personal stigma was negatively correlated with help seeking behaviours for mental illnesses. Kim and Omizo, (2015) provided further support by suggesting that past experiences with mental illness and help seeking behaviour can predict future help seeking behaviours due to increased knowledge about mental health and more openness towards mental health issues

There is also evidence to suggest that university students tend to avoid seeking help for mental health problems because they perceive being mentally ill as a weakness and harmful to their future career and the main reason behind these beliefs can be their fear of being misunderstood, misjudged, and stigmatised by others (Chew-Graham, Rogers, & Yassin, 2003; Warwick et al., 2008). The role of demographic variables such as gender, age and education have been the topic of research in this area. A cross-national study in Jordan, United Arab Emirates, and Arabs in Israel examined the attitudes of female university students towards seeking professional help when it comes to mental illnesses and it was reported that female university students, older students and students with higher educational levels showed more positive attitudes towards seeking professional help, while nationality had no effect when it comes to attitudes towards mental health and help seeking behaviour (Al-Krenawi et al., 2004). The study was conducted on comparing female university students in three different Arabian countries (Jordan, United Arab Emirates, and Arabs in Israel), which are considered to have similar cultures and traditional beliefs, which would make it hard to find clear differences when it comes to attitudes towards mental health on a cultural level. According to Al-Krenawi et al., (2004) the study had many limitations, such as the number of participants and sampling bias, which made it hard for the researchers to generalise their findings.

The Relationship between Knowledge and Self-Stigma

Previous studies conducted on reducing stigma suggests that in order to achieve this goal, the attitudes of people towards mental health issues should be changed by increasing their knowledge about the topic, by raising awareness about mental health issues and mental health services in general and by integrating stigma as part of the intervention in order for it to be effective (Rafal, Gatoo, & DeBate, 2018; Hocking, 2003). This further suggests that individuals with more knowledge about subjects related to mental health issues and services, such as psychology students, might show less negative attitudes towards mental health illnesses and mental health stigma.

Empirical investigations of interventions to reduce stigmatizing attitudes towards mental illnesses in psychology students by using teaching techniques, such as first-person narrative, to increase their knowledge about mental health and psychopathology showed a significant decrease in stigmatizing attitudes towards mental illnesses and mentally ill individuals after the intervention was over (Mann & Himelein, 2008). Similarly, Spagnolo, Murphy, and Librera (2008) examined children focusing on increasing their knowledge about mental illnesses, symptoms and ways of intervention and found that children who participated in the study showed an increase in their positive attitudes towards mental illnesses and reduction in stigmatizing attitudes on 7 out of 9 stigma measurements scales. In line with the previous study, Ranson and Byrne (2014) reported that in an anti-stigma intervention study to improve 7^th, 8^th and 9^th graders attitudes and knowledge towards their peers with Autism showed long-lasting knowledge and positive attitudes. Furthermore, the intervention improved the students’ behavioural intentions and reduced mental health stigma.

The effect of having more knowledge on reducing negative attitudes has been studied widely. A study conducted by Tikka, Kuitunen, and Tynys, (2000) on the effect of knowledge on the attitudes towards the environment found a significant positive correlation between knowledge and positive attitudes towards the environment on the individual level, as well as on the average level, but with less clarity on the average level. The findings of Tikka et al., (2000) showed that students who majored in fields such as biology, showed more positive attitudes towards the environment in comparison to students from other fields of education. This suggests that the field of education, as well as the amount of knowledge about a certain topic, might have an effect on increasing the positive attitudes towards it. The findings from the previous studies suggest that increasing knowledge about mental health can decrease stigmatising attitudes towards it, even at a young age, which might play a role in increasing help seeking behaviour in general.

Even though it was argued that mental health stigma can be the result of not having sufficient amount of knowledge about mental health and mental illnesses (Shah, 2004), Gureje, Lasebikan, Ephraim-Oluwanuga, Olley and Kola (2005) investigated the attitudes of Nigerian people towards mental health, found no relationship between the amount of knowledge and education with the attitudes towards mental health issues. Similarly, Pinto-Foltz, Logsdon and Myers (2011) explored increasing knowledge of adolescent girls about mental health and mental disorders by storytelling and encouraging first hand contact with individuals suffering from mental illness found that even though the knowledge of the participants about mental illnesses had increased, the increase in knowledge did not have any effect in reducing stigmatizing attitudes towards mental illnesses. The findings appear to be inconsistent at best when it comes to the subject of mental health stigma and attitudes towards mental illness in relation to the amount of knowledge a person might have about the topic.

THE PRESENT STUDY

Returning to the aim of the current study, a review of the current literature on the topic of stigma towards mental illness and related help seeking behaviour in Arabian cultures revealed that this is an understudied and a much needed area of research. The rationale is driven by several factors including a consideration of the limited number of studies conducted on this topic in Arabian cultures, especially in Jordan and the lapse of time since this subject was addressed in academic research. The study aims to investigate attitudes towards mental illnesses by measuring mental health stigma and the amount of knowledge about mental illnesses in Psychology students and comparing them to the attitudes of non-psychology students in the UK and Jordan in an attempt to develop a better understanding on the extent to which culture and educational background can affect knowledge and attitudes towards mental illness and related help seeking behaviours in relation to mental health stigma. We also wanted to investigate predictors of future intentions in visiting a professional (either a psychologist or psychiatrist) when faced with mental health issues.

METHOD

Design

In a survey design, the study examined responses to standardised questionnaires using SSOSH (Vogel et al., 2006) and Knowledge (Al-Krenawi et al., 2009) in which independent variables were manipulated orthogonally in an independent groups factorial design: 2 (Location: UK, Jordan) x 2 (Study: Psychology, Non-Psychology) x 2 (Gender: Male, Female) x 2 (First- hand experience of mental illness: Yes, No) x 6 (Religion: Islam, Christianity, Hinduism, Atheists, Spiritual, Agnostic). Dependent variables were the responses to the questionnaires.

Participants

The participants were university students, recruited from, UK and Jordanian universities. A total of 100 were recruited for the purpose of the study with 50 participants from a UK university and 50 from a Jordan university with an age range of 18-35. In addition, participants were recruited in equal numbers from Psychology (25 in UK, 25 in Jordan) and non-Psychology (25 in UK, 25 in Jordan) cohorts in both countries.

Materials

Materials consisted of Self-Stigma of Seeking Psychological Help scale (SSOSH; Vogel et al., 2006) and Knowledge about psychology in relation to mental illness scale (Al-Krenawi et al., 2009). In addition, a demographic questionnaire was used to collect data on location, age, gender, religion, and experience of mental illness from participants.

Self-Stigma of Seeking Psychological Help scale (SSOSH)

Self-stigma was measured using the 10 item SSOSH with a point Likert scale ranging between 1 = Strongly Disagree, 2 = Disagree, 3 = Agree and Disagree Equally, 4 = Agree and 5 = Strongly Agree (Vogel et al., 2006). The SSOSH scale is standardised both in English and Arabic making it an ideal scale to be used for the purpose of the study. Although reliability was not available in the Arabic version, the English version of the SSOSH scale showed a good reliability score in four different studies conducted by Vogel et al., (2006): In study 1, the scale showed a reliability score of 0.91 followed by 0.85 in study 2, 0.9 in study 3 and test-retest reliability of 0.72 in study 4. An example from the SSOSH scale is ‘I would feel inadequate if I went to a therapist for psychological help.’

Knowledge about Psychology in Relation to Mental Illnesses

The 11-item knowledge questionnaire with a five-point response scale (1-False; 2-Probably false; 3-Probably True; 4-True) by Al-Krenawi et al., (2009) with reliability reported as Cronbach’s alpha = 0.60 was employed in the study. The following is an example from the scale: ‘Some of the most important reasons that lead to mental illnesses or psychological problems are due to biological factors.’

Item number eight in the questionnaire was modified as it was reworded from ‘Mental health or psychological problems can be treated by Koranic recitation’ to ‘Mental health or psychological problems can be treated by religious recitation.’ in order to accommodate participants from non-Islamic backgrounds.

Procedure

The study commenced after ethical approval was granted by Middlesex University Psychology Ethics Committee. Participants were approached on campus in both countries, in the UK and Jordan. The consent of each participant was sought by asking them to read the information sheet and sign the consent form if they agreed to take part on a voluntary basis after reading the information sheet. The participants were informed that they can withdraw from the study at any stage without giving and explanation and that the study is about is about stigma and help seeking behaviour before they were handed the questionnaires. Care was taken to indicate that if any aspects of the study caused any discomfort that they should stop and that if it happened after they completed the study to contact the researchers and/or psychological support services indicated on the debrief form. Participants took approximately 15 minutes to complete the study and were thanked and debriefed verbally and in writing about the aims of the study.

Ethical concerns:

Participants were required to provide informed consent and due to sensitive nature of the topic were instructed to stop completing the questionnaire if they became uncomfortable during the study or afterwards and to contact the researchers and/or psychological services provided on the debrief sheet.

Analyses

Data were subjected to descriptive statistics. The data from the SSOSH and the knowledge scale subjected to a 2(UK, Jordan) x 2(Psychology, Non-Psychology) x 6(Islam, Christianity, Hinduism, Atheists, spiritual, and Agnostic) x 2 first- hand experience (Yes, NO) factorial ANOVA for SSOSH and a 2(UK, Jordan) x 2(Psychology, Non-Psychology) x 6(Islam, Christianity, Hinduism, Atheists, spiritual, and Agnostic) x 2(Male, Female) factorial ANOVA for knowledge scale. Additional analyses (Pearson’s correlation test) were conducted to investigate the relationship between the mean attitudes towards mental health and mental stigma and the total knowledge of the participants about psychology in relation to mental illnesses for the whole sample as well as for location (Jordan & the UK) and for education (Psychology & non-psychology students).

RESULTS

Data from the SSOSH and the Knowledge scales were subjected to descriptive statistics and subsequently to inferential statistics using factorial ANOVA and linear regression.

In the SSOSH questionnaire questions 2, 4, 5, 7 and 9 were reversed for data analysis.

As can be seen in Table 1, descriptive statistics for the mean SSOSH showed that the mean attitudes were more positive in non-psychology students (mean= 2.5, SD= 0.69) compared to psychology students (Mean= 2.2, SD= 0.52). Similarly, the mean attitudes towards mental health illnesses and mental stigma were more positive in Jordanian participants (Mean= 2.5, SD= 0.7) in comparison with the mean attitudes of the participants in the UK (Mean= 2.3, SD= 0.6). The results showed that males (Mean= 2.5, SD= 0.68) overall have slightly more positive attitudes towards mental illnesses and mental stigma in comparison to females (Mean= 2.3, SD= 0.6). Where religion was concerned, participants who were Muslims (Mean= 2.5, SD= 0.66) and Atheists (Mean= 2.5, SD= 1.0) showed more positive attitudes compared to other religions such as Christianity (Mean= 2.2, SD= 0.42) and Hindu (Mean= 2.1, SD= 0.92). On the other hand, participants who had a first-hand experience with mental illnesses (Mean= 2.3, SD= 0.7) showed slightly more negative attitudes towards mental illness and mental health stigma compared to participants who did not have any past experiences with mental illnesses (Mean= 2.4, SD= 0.61).

Table 1: SSOSH means and the standard deviations according to demographic variables of the participants

Subsequently, data from SSOSH were subjected to a 2(Location: UK, Jordan) x 2(Study: Psychology, Non-Psychology) x 2(Gender: Male, Female) x 2 (First-hand experience: Yes, No) x 6 (Religion: Islam, Christianity, Hinduism, Atheists, spiritual, and Agnostic) factorial ANOVA. The results showed no significant main effect for location [F (1,73) = 1.13, p= 0.29], that is, the scores on the SSOSH between Jordanian and UK students did not differ significantly, also the results have showed no significant main effect for education [(F (1,73) = 1.4, p= 0.24)], that is, there was no significant difference in the scores between psychology and non-psychology university students on the mean SSOSH scores. There was no significant effect for having a first-hand experience with mental illnesses [F (1,73) = 0.34, p= 0.56)], while religion [F (6,73) = 2.22, p= 0.05] showed a significant effect.

In order to determine the predictor variables for SSOSH, a linear regression analysis using the enter method for Education, Location, Gender, Age, Religion, Previous Consultation with Psychologist, Previous Consultation with Psychiatrist and Knowledge was employed. The overall regression equation was marginally significant, F(9,90)=1.91 p=0.06, R=0.40 with the above variables accounting for 16% of the variance. Education and Previous Consultation with Psychiatrist emerged as significant predictors of SSOSH with b = 0.25, t= 2.10, p < 0.04 and b = 0.30, t=2.31, p < 0.02, respectively.

Table 2: Means and the standard deviations about knowledge in relation to mental illnesses

As shown in Table 2, the descriptive statistics for the participants’ total knowledge about psychology in relation to mental illnesses showed that, non-psychology students (Mean= 30.0, SD= 4.7) had more knowledge about psychology and mental illnesses in comparison with psychology students (Mean= 27.4, SD= 4.6). At the same time, the results showed that participants from Jordan (Mean= 30.0, SD= 4.8) were more knowledgeable compared to participants from the UK (Mean= 26.8, SD= 3.94). Muslim participants (Mean= 30.3, SD= 4.7) had the highest scores in comparison to other religions such as Christianity (Mean= 27.1, SD= 3.97), Hindu (Mean= 25.7, SD= 4.96), and Atheists (Mean= 27, SD= 4,1). Also, females (Mean= 29.2, SD= 5.0) overall were more knowledgeable compared to males (Mean= 27.6, SD= 4.1).

Data from the knowledge questionnaire were subjected to a 2(Location: UK, Jordan) x 2(Study: Psychology, Non-Psychology) x 2(Gender: Male, Female) x 2 (First-hand experience: Yes, No) x 6 (Religion: Islam, Christianity, Hinduism, Atheists, spiritual, and Agnostic) factorial ANOVA. The results of the analysis showed that Education [F (1, 73) = 12.88, p= 0.001] and Gender [F (1.73) = 5.08, p= 0.027] were the only two variables with a significant main effect. None of the other variables reached significance for main effects nor interactions (F=1, p>0.05).

A linear regression analysis using the enter method for Education, Location, Gender, Age, Religion, Previous Consultation with Psychologist, Previous Consultation with Psychiatrist and Knowledge was employed in order to determine the predictor variables for knowledge. The overall regression equation was significant, F (9,90)=4.68 p<0.0001, R=0.56 with the above variables accounting for 32% of the variance. Education and Gender emerged as significant predictors of knowledge with b = 0.35, t= 3.42, p < 0.001 and b = 0.23, t=2.45, p < 0.02, respectively while Location had a marginal significance, b = 0.25, t=1.92, p = 0.06.

An important aspect of the research was to explore if any of the variables predicted future behaviours of help seeking in terms of visiting a psychiatrist and a psychologist. Visiting Psychiatrist/Psychologist in the Future were added to the variable list accordingly. The overall model was significant, F(10,89)=2.02 p<0.04, R=0.43 with the above variables accounting for 19% of the variance, and findings indicated that scores on the SSOSH scale were the only predictor variable for Visiting Psychologist in the Future with b = 0.30, t=2.83, p < 0.006. Finally, Visiting Psychiatrist in the Future analyses yielded a significant equation [F (10,89)=4.10 p<0.0001, R=0.56 with 32% of the variance accounted for] which was also predicted by SSOSH b = 0.38, t=3.99, p < 0.0001 and also by Gender b = -0.22, t=-2.32, p < 0.02.

Finally, data were also subjected to a correlation using Pearson’s to examine the relationship between mean attitudes towards mental illnesses in relation to mental health stigma and the total knowledge about psychology in relation to mental illnesses. The results showed no significant relationship between the two variables [r(100)= 0.12, p= 0.23].

DISCUSSION

The focus of this study was to examine predictors of psychological help seeking behaviours towards mental illness in British and Jordanian university students. Based on previous research, it was predicted that overall, the Jordanian sample would have less knowledge and higher self-stigma in psychological help seeking behaviours towards mental illness in comparison to the British sample. Surprisingly, the pattern of results showed more similarity rather than disparity across two samples with comparable attitudes and knowledge toward metal illness. Interestingly there was no main effect for location nor educational background on either knowledge or self-stigma of help seeking behaviours across the two samples.

Nevertheless, some cultural features were found to influence self-stigma as well as knowledge in mental illness thereby having an adverse effect on help seeking behaviours. For instance, the results support the claim that religion can have an influence on mental health (Haque, 2004) by showing a significant effect for religion on increasing positive attitudes of university students towards mental illnesses and related help-seeking behaviour in the UK and Jordan. The effect of religion on the attitudes towards mental illness is noteworthy due to the importance of religion in shaping the lives and attitudes of people especially in the Arabian cultures (Sewilam et al., 2015). The present findings can be beneficial when it comes to developing awareness and intervention programs to reduce mental health stigma in religious communities. For example, Sewilam et al., (2015) suggested establishing collaborative links mental health professionals and traditional/religious healers could lead to reducing stigma attached to mental illness and improve psychological help-seeking behaviours in religious communities. The findings of the current study can be taken to extend Sewilam et al.,’s (2015) findings in the creation of joint endeavours between the mental health professionals and traditional/religious healers to reduce mental health stigma in society, and to use this cooperation to encourage people from different religions to seek the professional help when needed. Our findings contribute to this important consideration given the fact that mental health stigma has been shown to play a crucial role in stopping people from seeking professional help because of the fear of being misjudged by others in the community (Corrigan & Watson, 2002; Link et al., 1997; Vogel et al., 2007).

Two reasons behind negative attitudes towards mental illnesses and seeking mental help was suggested to be firstly because of stigma and secondly, because of lack of knowledge about mental illnesses in these cultures (Al-Adawi et al., 2002). This suggests that in the UK, attitudes towards mental illnesses and help seeking behaviours should be more positive compared to the Jordanian culture. However, the findings of the present study suggest the exact opposite, showing no significant effect for culture on the attitudes towards mental illnesses and related help seeking behaviour. This further supports the findings of Al-Krenawi et al., (2004) who reported no significant effect for nationality/culture on attitudes towards help seeking behaviours on the attitudes of female university students in three different cultures regarding help seeking behaviours for mental illnesses. The analyses in the current study showed that university students in Jordan have more positive attitudes towards mental illnesses in comparison to university students from the UK which might have contributed to the nonsignificant results found in terms of the effect of location/culture on the attitudes towards mental illnesses. It is important to note that in the present study educational background and whether participants had a previous consultation with a psychiatrist emerged as significant predictors of self-stigma of psychological help seeking.

Based on previous reports by Hocking (2003) and Mann and Himelein, (2008) it was expected that the field of education (psychology, non-psychology) would have a significant effect on the attitudes of university students towards mental illnesses. We predicted that psychology university students would show more positive attitudes towards mental health illness and mental health stigma in comparison to non-psychology university students. However, our results did not support this supposition; we found that overall non-psychology students have more positive attitudes towards mental illness and lower mental health stigma than psychology students. Although these findings are surprising, previous studies have shown that the traditional way of learning was not as effective as other techniques such as first-person narrative, in increasing the positive attitudes of students towards mental illnesses (Mann & Himelein, 2008). Considering that, it is not necessary that psychology students would show a higher positive attitude towards mental illness or lower stigmatising attitudes than non-psychology students every time, because the results might be highly affected by the way the students are receiving the information.

Previous reports had shown that Arabian cultures lack knowledge when it comes to the field of psychology and mental illnesses in general, to the point that people in these cultures may have difficulties differentiating psychological and physical illnesses, as well as between different services provided by psychologists, such as counselling and psychotherapy (Al- Krenawi & Graham 2000; Al-Krenawi & Graham, 1999; El-Islam, 1982; El-Islam & Ahmed, 1971; Erickson & Al-Timimi, 2001). Based on these findings it was expected that university students in the UK will be more knowledgeable about psychology and mental illnesses compared to the university students form Jordan. The results of the study showed that Jordanian university students have more knowledge about psychology and mental illnesses than university students from the UK. These findings contradict the findings from past studies. The reason behind that could be easily attributed to the differences that have occurred in the past few years in terms of education, mobility and easier access to information which resulted in university students in Jordan developing their knowledge about the topic to the point of matching or even passing the knowledge of other cultures that used to have more knowledge about the topic such as in the UK. The results of the regression analyses on knowledge showed that educational background and gender were the key predictor variables.

One aim of the present research was to understand participants’ future intentions to seek help if faced with mental illness. Insofar as visiting a psychologist was concerned, only the scores on the SSOSH scale predicted if participants would realise this or not. Visiting a psychiatrist in the future was predicted by gender as women were more likely to visit a psychiatrist for mental issues as well as the scores on the SSOSH.

Although results showed a significant effect for religion on increasing positive attitudes towards mental illnesses and related help seeking behaviours, no effect was found where knowledge about mental illnesses is concerned. Although many studies have suggested that in order to reduce stigma about mental illnesses increasing knowledge about the topic is important to achieve that goal (Hocking, 2003; Mann & Himelein, 2008; Spagnolo et al., 2008; Ranson & Byrne, 2014), with religion as a factor, this was not the case. This suggests that religion might work in a different way than expected in shaping the attitudes without the need for increasing the knowledge about the topic. These findings could provide some basis for future studies on investigating the way religion can shape attitudes towards mental health stigma.

Previous studies have suggested that the reason behind stigmatising attitudes towards mental illness can be related to the lack of knowledge about the topic of mental illnesses (Al-Adawi et al., 2002). Many studies have also reported significant results showing that as knowledge about mental illnesses increases, positive attitudes towards mental illnesses will also increase, and increasing knowledge about mental illnesses could work as an effective intervention to reduce stigmatising attitudes towards mental illnesses (Hocking, 2003; Mann & Himelein, 2008; Spagnolo et al., 2008; Ranson & Byrne, 2014; Shah, 2004; Al-Krenawi et al., 2009). According to these findings, it was expected to find a positive relation between knowledge about psychology in relation to mental illnesses and positive attitudes towards mental illnesses in the general sample, in other words, it was expected to find that as knowledge about mental illnesses increases, the positive attitudes towards mental illnesses will also increase. The results of the study showed no significant correlation between attitudes towards mental illness and knowledge about mental illnesses in the general sample in the study. The findings of this study support the claim made by Gureje et al., (2005) in a study conducted in Nigeria to study the attitudes of Nigerian people towards mental illnesses. Gureje et al., (2005) found no relationship between the amount of knowledge about mental illnesses and the attitudes towards them. The same findings were reported in a study conducted by Pinto-Foltz et al., (2011) on schoolgirls about reducing stigmatising attitudes towards mental illnesses by increasing the knowledge about mental illnesses. Pinto-Foltz et al., (2011) reported that although there were indications on the increase of the amount of knowledge about mental illnesses after the intervention, the increase in knowledge had no effect of reducing stigmatising attitudes towards mental illnesses.

To conclude, the current study provides a fresh insight on the role of knowledge and self-stigma towards mental health and predictors of help seeking behaviours in the UK and Jordan. There could be many reasons behind the null findings one of which could be the time lapse between the previous reports and the current study. One must bear in mind the demographic changes in terms of improved access to higher education and access to digital information platforms in Jordan which makes it more comparable to the UK than anticipated. These changes in the Jordanian society might be inadvertently reflected in the pattern of findings reported here despite the cultural differences documented above.

ACKNOWLEDGEMENT

The study was conducted as part of MSc in Applied Psychology by the first author at Middlesex University, UK under the supervision of Prof Dr Ilhan Raman.

REFERENCES

1. Aldalaykeh, M., Al-Hammouri, M. M., & Rababah, J. (2019). Predictors of mental health services help-seeking behavior among university students. Cogent Psychology, 6(1), 1660520.
2. Al-Adawi, S., Dorvlo, A., Al-Ismaily, S., Al-Ghafry, D., Al-Noobi, B; Al- Salmi, A., Burke, D., Shah, M., Ghassany, H., Chand, S. (2002). Perception of And Attitude Toward Mental illness in Oman. International Journal of Social Psychiatry 48(4), 305-317.
3. Al-Krenawi, A., & Graham J. R. (1999). Gender and Biomedical/Traditional Mental Health Utilization Among the Bedouin- Arabs of Negev.Cultural, Medicine and Psychiatry 23, 219-243.
4. Al-Krenawi, A., & Graham J. R. (2000). Culturally sensitive social work practice with Arabs clients in mental health settings. Health and Social Work 25, 9-22.
5. Al-Krenawi. A., Graham. J. R., Al-Bedah. E. A., Kadri. H. M., Sehwail. A. A. (2009). Cross-National Comparison of Middle Eastern University Students: Help-Seeking Behaviors, Attitudes Toward Helping Professionals, and Cultural Beliefs About Mental Health Problems. Community Ment Health. 45. 26-36
6. Al-Krenawi, A., Graham, J. R., Dean, Y. Z., & Eltaiba, N. (2004). Cross-national study of attitudes towards seeking professional help: Jordan, United Arab Emirates (UAE) and Arabs in Israel. International journal of social psychiatry, 50(2), 102-114.
7. American Psychological Association (1992). Ethical Principles of Psychologists and Code of Conduct. American Psychologist, 47, 1597–1611.
8. Boonstra, N., Klaassen, R., Sytema, S., Marshall, M., De Haan, L., Wunderink, L., & Wiersma, D. (2012). Duration of untreated psychosis and negative symptoms—a systematic review and meta-analysis of individual patient data. Schizophrenia research, 142(1), 12-19.‏
9. Caplan, S. (2019). Intersection of cultural and religious beliefs about mental health: Latinos in the faith-based setting. Hispanic Health Care International, 17(1), 4-10.
10. Cheng, H. L., Wang, C., McDermott, R. C., Kridel, M., & Rislin, J. L. (2018). Self‐stigma, mental health literacy, and attitudes toward seeking psychological help. Journal of Counseling & Development, 96(1), 64-74.
11. Chew‐Graham, C. A., Rogers, A., & Yassin, N. (2003). ‘I wouldn’t want it on my CV or their records’: medical students’ experiences of help‐seeking for mental health problems. Medical education, 37(10), 873-880.
12. Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., … & Thornicroft, G. (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological medicine, 45(01), 11-27.
13. Corrigan, P. W., Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry 16-20
14. Eisenberg, D., Eisenberg, M. F., Golberstein, E., Zivin, K. (2009). Stigma and Help Seeking for Mental Health Among College Students. Medical Care Research and Review, 1-20.
15. Eisenberg, D., Golberstein, E., & Gollust, S. E. (2007). Help-seeking and access to mental health care in a university student population. Medical care, 45(7), 594-601.
16. El-Islam, M.F. (1982) Arabic Cultural Psychiatry. Transcultural Psychiatric Research Review 19(1), 5-24.
17. El-Islam, M.F, Ahmed, S.A. (1971). Traditional Interpretation and Treatment of Mental Illness in an Arabic Psychiatric Clinics. Journal of Cross- Cultural Psychology 2, 301-307.
18. Erickson, C. D., and Al-Timimi, N. R. (2001). Providing mental health services to Arab Americans: Recommendations and considerations. Cultural Diversity–Ethnic Minority-Psychology, 7, (4), 308-32.
19. Griffiths, K. M., Nakane, Y., Christensen, H., Yoshioka, K., Jorm, A. F., Nakane, H. (2006). Stigma in response to mental disorders: a comparison of Australiaand Japan. BMC Psychiatry, 6-21.
20. Gray, A. J. (2002). Stigma in psychiatry. Journal of the royal society of medicine, 95(2), 72-76.‏
21. General, U. S. (1999). Mental health: A report of the surgeon general. Rockville, MD: US Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.
22. Gureje, O., Lasebikan, V. O., Ephraim-Oluwanuga, O., Olley, B. O., & Kola, L. (2005). Community study of knowledge of and attitude to mental illness in Nigeria. The British Journal of Psychiatry, 186(5), 436-441.
23. Haque, A. (2004). Religion and mental health: The case of American Muslims. Journal of Religion and Health, 43(1), 45-58.
24. Hocking, B. (2003). Reducing mental illness stigma and discrimination-everybody’s business. Medical Journal of Australia, 178(9), S47.
25. Hyun, J. K., Quinn, B. C., Madon, T., & Lustig, S. (2006). Graduate student mental health: Needs assessment and utilization of counseling services. Journal of College Student Development, 47(3), 247-266.
26. Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., … & Zaslavsky, A. M. (2005a). Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine, 352(24), 2515-2523.‏
27. Kessler, R. C., Patricia Berglund, M. B. A., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005b). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry, 62, 593-602.
28. Kim, J. E., Saw, A., & Zane, N. (2015). The influence of psychological symptoms on mental health literacy of college students. American Journal of Orthopsychiatry, 85(6), 620.
29. Kitzrow, M. A. (2003). The mental health needs of today’s college students: Challenges and recommendations. NASPA journal, 41(1), 167-181.
30. Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual review of Sociology, 363-385.
31. Link, B. G., Struening, E. L., Rahav, M., Phelan, J. C., Nuttbrock, L. (1997) On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behavior, 38, 177–190.
32. Mann, C. E., & Himelein, M. J. (2008). Putting the person back into psychopathology: an  intervention to reduce mental illness stigma in the classroom. Social psychiatry and psychiatric epidemiology, 43(7), 545-551.‏
33. Murthy, R. S. (2002). Stigma is universal but experiences are local. World Psychiatry, 1(1), 28.
34. Okasha. A. (1999). Mental Health in the Middle East. An Egyptian Perspective. Clinical   Psychology Review, 19(8), 917-933.
35. Okasha, A., & Karam, E. (1998). Mental health services and research in the Arab world. Acta psychiatrica scandinavica, 98(5), 406-413.
36. Okasha, A., Karam, E., & Okasha, T. (2012). Mental health services in the Arab world. World Psychiatry, 11(1), 52-54.
37. Peteet, J. R. (2019). Approaching religiously reinforced mental health stigma: A conceptual framework. Psychiatric services, 70(9), 846-848.
38. Pinto-Foltz, M. D., Logsdon, M. C., & Myers, J. A. (2011). Feasibility, acceptability, and initial efficacy of a knowledge-contact program to reduce mental illness stigma and improve mental health literacy in adolescents. Social science & medicine, 72(12).‏
39. Rafal, G., Gatto, A., & DeBate, R. (2018). Mental health literacy, stigma, and help-seeking behaviors among male college students. Journal of American college health, 66(4), 284-291.
40. Ranson, N. J., & Byrne, M. K. (2014). Promoting peer acceptance of females with higher-functioning autism in a mainstream education setting: A replication and extension of the effects of an autism anti-stigma program. Journal of autism and developmental disorders, 44(11), 2778-2796.‏
41. Rüsch, N., Angermeyer, M. C., & Corrigan, P. W. (2005). Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. European psychiatry, 20(8), 529-539.
42. Rüsch, N., Zlati, A., Black, G., & Thornicroft, G. (2014). Does the stigma of mental illness contribute to suicidality?. The British Journal of Psychiatry, 205(4), 257-259.
43. Salem, M. O., Saleh, B., Yousef, S., & Sabri, S. (2009). Help-seeking behaviour of patients attending the psychiatric service in a sample of United Arab Emirates population. International Journal of Social Psychiatry, 55(2), 141-148.
44. Scull, N. C., Khullar, N., Al-Awadhi, N., & Erheim, R. (2014). A qualitative study of the perceptions of mental health care in Kuwait. International Perspectives in Psychology, 3(4), 284-299.
45. Sewilam, A. M., Watson, A. M., Kassem, A. M., Clifton, S., McDonald, M. C., Lipski, R., … & Nimgaonkar, V. L. (2015). Suggested avenues to reduce the stigma of mental illness in the Middle East. International Journal of Social Psychiatry, 61(2), 111-120.
46. Shah, N. (2004). Changing minds at the earliest opportunity. The Psychiatrist, 28(6), 213-215.
47. Spagnolo, A. B., Murphy, A. A., & Librera, L. A. (2008). Reducing stigma by meeting and learning from people with mental illness. Psychiatric rehabilitation journal, 31(3), 186.‏
48. Tikka, P. M., Kuitunen, M. T., & Tynys, S. M. (2000). Effects of educational background on students’ attitudes, activity levels, and knowledge concerning the environment. The journal of environmental education, 31(3), 12-19.‏
49. Vogel. D. L., Wade. N. G., & Haake. S. (2006), Measuring the Self-Stigma Associated With Psychological Help. Journal of Counseling psychology. 38(3), 325-337
50. Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54(1), 40.
51. Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Borges, G., Bromet, E. J., … & Haro, J. M. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. The Lancet, 370(9590), 841-850.‏
52. Warwick, I., Maxwell, C., Statham, J., Aggleton, P., & Simon, A. (2008). Supporting mental health and emotional well‐being among younger students in further education. Journal of Further and Higher Education, 32(1), 1-13.
53. Wittchen H, Jacobi F (2005). Size and burden of mental disorders in Europe: A critical review and appraisal of 27 studies. European Neuropsychopharmacology 15, 357-376.
54. Zivin, K., Eisenberg, D., Gollust, S. E., & Golberstein, E. (2009). Persistence of mental health problems and needs in a college student population. Journal of affective disorders, 117(3), 180-185.
55. Zolezzi, M., Alamri, M., Shaar, S., & Rainkie, D. (2018). Stigma associated with mental illness and its treatment in the Arab culture: a systematic review. International Journal of Social Psychiatry, 64(6), 597-609.