Examining the Moderating Role of Mental Health Literacy on the Relationship Between Self-Stigma, Stigma on Seeking Help, and Help-Seeking Behavior

Examining the Moderating Role of Mental Health Literacy on the Relationship between Self-Stigma, Stigma on Seeking Help, and Help-Seeking Behavior

John Gabriel A. Lasquites*, Argie Lou M. Etom, Kate Therese C. Hayag, Jason O. Manaois, and Maria Leorupee R. Barros

Xavier University – Ateneo de Cagayan, Cagayan de Oro City, Philippines

*Corresponding Author

DOI: https://doi.org/10.51244/IJRSI.2024.1101015

Received: 21 December 2023; Accepted: 02 January 2024; Published: 03 February 2024

ABSTRACT

This study explores the complex relationship between self-stigma, stigma surrounding help-seeking, and actual help-seeking behavior, highlighting the moderating role of mental health literacy. Despite being a cornerstone in mental health efforts, mental health literacy is moderately prevalent in the general population. The reluctance to seek mental health services persists due to societal stigmatization, leading individuals to avoid professional help. The research focuses on self-stigma and help-seeking stigma, emphasizing the nuanced nature of help-seeking influenced by individual attitudes and cultural norms. The study suggests that mental health literacy moderates the connection between self-stigma, help-seeking stigma, and actual help-seeking behavior. Individuals with higher mental health literacy are posited to better overcome stigma barriers and engage in seeking help. The detailed results from the moderation analyses showed the necessity for customized interventions, acknowledging the intricate interplay of factors impacting help-seeking behaviors. The study significantly contributes to the enhanced recognition of the profound link between individual and societal factors in providing widely accessible mental health support.

Keywords: Self-stigma, Stigma on seeking help, mental health literacy, help seeking behavior

INTRODUCTION

Enhancing mental health literacy serves as a crucial initial stride in promoting mental well-being among populations. The World Health Organization (WHO), in its “Mental Health Action Plan 2013–2020,” highlights mental health literacy as a pivotal strategy for both mental health promotion and prevention of mental health issues [18]. Despite indications that mental health literacy has been progressively on the rise within the general populace, empirical evidence suggests that its current level remains relatively low to moderate [13].

A primary deterrent preventing individuals from seeking counseling, treatment, and other mental health services is often attributed to the stigma surrounding mental illness and the act of seeking treatment [4]. The stigma associated with seeking mental health services is rooted in the perception that individuals pursuing psychological treatment are deemed undesirable or socially unacceptable [16].

Statistical data reveals that a significant obstacle to accessing mental health services is the reluctance of individuals to seek help, primarily due to societal stigmatization. Approximately only 11% of individuals experiencing diagnosable mental health issues actively seek psychological services within a given year [10]. Furthermore, the percentage of those with mental health concerns who actually seek assistance from a counselor or mental health professional is notably smaller [1]. These statistics underscore the persistent challenge of overcoming stigma to encourage greater utilization of mental health services within the population.

Moreover, the act of seeking treatment holds considerable influence over individuals grappling with mental illness. Those possessing higher levels of determination, hope, and optimism are more likely to experience smoother recovery processes. Given the prevalent negative perceptions associated with individuals seeking psychological services, it is not unexpected that people conceal their psychological concerns and avoid seeking treatment to mitigate the adverse consequences linked to societal stigmatization [3]. This reluctance to seek help is consistent with findings indicating that individuals are less inclined to seek assistance for issues perceived negatively by others [15]. Notably, despite a higher prevalence of mental health problems among young individuals, they exhibit a tendency to seek psychological help less frequently [11].

In light of these observations, the aim of this research is to extend the investigation into the barriers to professional help-seeking, emphasizing stigma and negative attitudes toward seeking help from professionals. Notably, a crucial factor influencing help-seeking behavior is the ability to comprehend the symptoms of mental health difficulties and effectively communicate them with others, a concept referred to as mental health literacy [8].

Self-Stigma and Stigma on Seeking Help

Theories regarding the emergence of self-stigma [17] conceptualize the process as the awareness, acceptance, and application of stigmatized beliefs to oneself. This progression, known as the Stage Model of Self-Stigma proposed by Corrigan and Rao [3], results in the internalization of negative attitudes, such as the belief that “I am weak.” The repercussions of these attitudes include diminished self-esteem, empowerment, and self-efficacy [4]. Consequently, individuals often respond to self-stigma by refraining from seeking help to safeguard their self-esteem and sense of self-efficacy [16].

For individuals grappling with mental health issues, self-stigma stemming from public stigma poses a considerable burden. Both public stigma and self-stigma encompass three core elements: stereotype, prejudice, and discrimination [6]. Self-stigma of help-seeking (SSOHS) emerges as a substantial obstacle for individuals who recognize the need to turn to mental health services for personal and emotional challenges. SSOHS involves the internalization of adverse messages related to seeking help. Despite help-seeking being generally perceived as an adaptive coping mechanism, individuals from marginalized groups often view it as a failure and a threat to their identity, thereby reducing the likelihood of seeking assistance within these communities [9].

Help-Seeking Behavior

  The decision to seek help is shaped by various factors, encompassing individual attitudes, cultural norms, and the perceived effectiveness of accessible mental health services. Essentially, help-seeking behavior entails acknowledging the need for support and depending on others for assistance. Men, in particular, may grapple with the perception that seeking help exposes a personal vulnerability, conflicting with fundamental aspects of male gender identity that stress self-reliance and emotional control [7].

Role of Mental Health Literacy

Mental health literacy involves not only knowledge and comprehension of mental health matters but also the proficiency to identify, handle, and seek assistance for mental health issues. The hypothesis of this study suggests that mental health literacy plays a vital role as a moderator in the connection between self-stigma, the stigma associated with seeking help, and the actual behavior of seeking help. In exploring the moderating influence of mental health literacy, this research seeks to pinpoint strategic intervention opportunities. The goal is to enhance individuals’ capabilities in overcoming stigma, ultimately promoting a more receptive environment for seeking help. By delving into the moderating role of mental health literacy, the study aims to identify effective strategies that can be employed to empower individuals to overcome barriers and engage in help-seeking behaviors.

Fig. 1: Moderation Model of Mental Health Literacy, Stigma on Mental Illness, Stigma on seeking help and Help seeking behavior

This research seeks to answer the following problems:

1. Is there a significant relationship between Mental Health Literacy, Self-Stigma, Stigma on Seeking Help and Help-Seeking Behavior?
2. Does Mental Health Literacy moderate the relationship between Self Stigma and Help Seeking Behaviors?
3. Does Mental Health Literacy moderate the Relationship between Stigma on Seeking Help and Help Seeking Behaviors?

METHODS

A. Participants

A total of 339 college students from Cagayan de Oro (CDO) City, Philippines, who were enrolled in diverse academic programs, were included in this study. The participant pool consisted of 150 males, representing 44.2% of the sample, and 189 females, comprising 55.8% of the total participants.

B. Measures

Mental Health Literacy Scale. This scale was developed by Jorm et al. [11]. It has 35 items which assess individual and population level differences in mental health literacy and determine the impact of programs designed to improve mental health literacy. This scale measures how knowledgeable an individual is when it comes to mental health. Items 1-5 are answerable by a 4-point Likert scale from Very unlikely to Very Likely, 16-28 is measured by a 5-point Likert scale ranging from (1) strongly disagree to (5) strongly agree (e.g., “If I had a mental illness, I would not tell anyone”) and items 29-35, is another Likert scale of 5-points ranging from (1) definitely unwilling to (5) definitely willing. 12 items are reversed-scored. The reliability, Cronbach alpha = .873.

Self-Stigma of Seeking Help Scale. This scale was developed by David L. Vogel, Nathaniel G. Wade, and Shawn Haake [17]. Although some attempts to measure perceptions of public stigma in relation to help seeking exist e.g., Komiya et al., [12], there is no direct measure of self-stigma related to seeking psychological help. Development of a self-stigma measure will make it possible to examine whether avoidance of professional help is related to the desire to avoid self-stigma or to other factors.

Furthermore, the 10-item scale measuring self-stigma related to seeking psychological help to help gauge the perceptions that seeking help might threaten one’s self-regard. The goal of this scale includes assessing reliability, factor structure and validity and exploring the role of self-stigma in help-seeking. Items were rated on a 5-point Likert Scale, with high scores indicating higher self-stigma. The scale showed good internal consistency (α = .89) in the study, making it a valuable tool for assessing interventions to reduce self-stigmatization in those considering psychological services. (Cheng, 2018).

Help-seeking behaviors scale (HSB). The HSB was initially constructed with 15 items to assess how often students seek help from parents, peers, and teachers for five types of problems: (a) general needs (e.g., “called a friend for help?”), (b) problems at school (e.g., “talked to your parents about problems at school?), (c) personal problems (e.g., ”talked to a friend about personal things?”), (d) something important in life(e.g., ”asked your parents for advice about important things in life?”), and (e) future and career goals (e.g., “talked to a teacher about your future or career goals?”). All items were preceded with “In the last few months, how often have you.” and students responded on a 5-point Likert scale (1 – almost never and 5 – very often). The HSB was designed to complement existing measures of help-seeking, which assessed attitudes, beliefs, and intentions to seek help. Cronbach’s alphas between .84 and .89 have been reported.

Internalized stigma (Dutch ISMI-10). The ISMI-10 was developed to measure internalized stigma of mental illness. It has 10 Likert scale items, with scores ranging from strongly disagree (1), disagree (2), agree (3), to strongly agree (4).The Dutch ISMI-10 showed good internal consistency (α = 0.83) and good test-retest reliability (r = 0.73). The Dutch ISMI-10 demonstrated excellent convergent validity; high correlations were found between the Dutch ISMI-10 and hope (r = -0.54), anxiety and depression (r = 0.59), self-esteem (r = -0.56), and empowerment (r = − 0.59). Acceptable divergent validity was indicated; small correlations were found between the Dutch ISMI-10 and the physical functioning subscale (r = -0.27) and the role limitation due to physical problems subscale (r = -0.21), and medium correlations were found between the Dutch ISMI-10 and the general health subscale (r = -0.36) [20].

C. Data Gathering Procedure

Participants were recruited via online channels through the posting of study invitations on social media. Those who voluntarily met the specified inclusion and exclusion criteria were ultimately included in the analysis. The survey questionnaires were given to the participants through a Google online form link presenting there the informed consent form, demographic profile, and test questionnaires. By presenting the informed consent form, demographic profile, and test questionnaires through a Google online form link, the researchers aimed to create a streamlined and efficient process for data collection while prioritizing participant understanding, privacy, and convenience.

D. Data Analysis

All statistical procedures were performed using the Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics were used in presenting the respondents’ socio-demographic profile. Regression analysis was performed and used to calculate the interaction effect (intercept) by computing the product between the independent and moderator variables. Linear regression analysis was performed to see if Mental health literacy has any effect on the relationship between Self stigma and stigma on seeking help, and Help seeking behavior.

FINDINGS AND DISCUSSIONS

The current research posited that Mental health literacy moderates the association between Self stigma and stigma on seeking help, and Help seeking behavior. This section presents the findings obtained from the data analyses of this study and delves into the sample characteristics, moderation analysis, as well as the ensuing discussion, conclusion, and implications of the research.

The descriptive statistics among the four scales in the study is summarized in Table 1.

Table 1: Descriptive Statistics of the Key Variables
	N	M	SD
Self-Stigma	339	27.23	4.559
Stigma on Seeking Help	339	37.83	7.494
Help Seeking Behavior	339	32.88	5.067
Mental Health Literacy	339	38.47	5.275

The descriptive statistics reveal insights into participants’ attitudes and behaviors regarding mental health across four distinct domains. On the Self-Stigma of Seeking Help Scale, participants demonstrated a moderate average level of internalized stigma (M = 27.23, SD = 4.559), indicating varied perceptions regarding the threat to self-regard associated with seeking psychological help. Perceptions of societal stigma on the Stigma on Seeking Help scale were notably higher, with participants averaging M = 37.83 and exhibiting considerable variability (SD = 7.494). Help-seeking behavior, assessed by a frequency scale, indicated a moderate to high average frequency (M = 32.88, SD = 5.067), with individual differences in reported behaviors. Conversely, participants displayed a relatively high level of mental health literacy (M = 38.47, SD = 5.275), suggesting a collective proficiency in understanding mental health concepts. The standard deviations across all measures underscore the diversity in participant responses, highlighting the individual variations in attitudes and experiences related to self-stigma, societal stigma, help-seeking behavior, and mental health literacy within the study cohort.

Problem 1: Is there a significant relationship between Mental Health Literacy, Self-Stigma, Stigma on Seeking Help and Help-Seeking Behavior?

Table 2: Pearson Correlation

	MHL	SS	SSH	HSB
MHL	1	.126*	.399**	.446**
SS	.126*	1	.127*	.167**
SSH	.399**	.127*	1	.526**
HSB	.446**	.167**	.526**	1

*= statistically significant at p < 0.05 level

**=statistically significant at p < 0.01 level

The results presented in Table 2 indicate several statistically significant correlations. First, there is a positive correlation between Mental Health literacy and Help seeking behavior (r = .446, p < 0.01), suggesting that an increase in Mental Health literacy is associated with an increase in Help seeking behavior. Secondly, there is a positive correlation between Self-stigma and Help seeking behavior (r = .167, p < 0.01). This implies that as Self-stigma increases, Help seeking behavior also increases. Lastly, Stigma on seeking help is positively correlated with Help seeking behavior (r = .526, p < 0.01), indicating that as Stigma on seeking help increases, Help seeking behavior also increases.

In summary, higher Mental Health literacy, increased Self-stigma, and greater Stigma on seeking help are all associated with an increase in Help seeking behavior. These findings suggest potential implications for interventions and strategies aimed at promoting mental health awareness and reducing stigma to encourage help-seeking behaviors.

Problem 2: Does Mental Health Literacy moderate the relationship between Self Stigma and Help Seeking Behaviors?

Table 3.1: Moderation Analysis (Mental Health Literacy & Self-Stigma)

	Β	SE	T	p	LLCI	ULCI
Constant	32.878	.246	133.493	.000	32.393	33.362
SS	.127	.058	2.187	.029	.013	.240
MHL	.414	.048	8.698	.000	.321	.508
SSxMHL	-.001	.007	-.084	.933	.933	.013
R			.460
R2			.212

Fig. 2: Interpolation Chat of Moderation Model 1

The moderation analysis yielded an R-squared value of 0.212, indicating that self-stigma explains 21% of the variation in help-seeking behaviors. Both self-stigma and mental health literacy exhibited individual significance, with p-values less than or equal to 0.05. This implies that, independently, self-stigma and mental health literacy are associated with variations in help-seeking behaviors.

However, the interaction term, Self-Stigma and Mental Health Literacy (SSxMHL), did not reach significance, as indicated by a p-value of 0.933. This result suggests that the joint effect of self-stigma and mental health literacy does not significantly modify the predicted impact on help-seeking behaviors. In simpler terms, the relationship between self-stigma and help-seeking behaviors remains consistent regardless of an individual’s level of mental health literacy.

Problem 3: Does Mental Health Literacy moderate the Relationship between Stigma on Seeking Help and Help Seeking Behaviors?

Table 3.2: Moderation Analysis (Mental Health Literacy & Stigma on Seeking Help)

	Β	SE	T	p	LLCI	ULCI
Constant	32.705	.233	140.135	.000	32.246	33.164
SSH	.268	.033	8.172	.000	.203	.332
MHL	.244	.047	5.171	.000	.151	.337
SSHxMHL	.011	.005	2.402	.017	.002	.020
R			.595
R2			.354

Fig. 3: Interpolation Chat of Moderation Model 2

The 2nd moderation analysis yielded an R-squared value of 0.354, indicating that the model explains 35.4% of the variation in help-seeking behaviors. Both stigma on seeking help (SSH) and mental health literacy (MHL) exhibited individual significance, with p-values less than or equal to 0.05. This implies that, independently, SSH and MHL are associated with variations in help-seeking behaviors.

Furthermore, the interaction term, SSHxMHL, reached significance, as indicated by a p-value of 0.017. This result suggests that the joint effect of stigma on seeking help and mental health literacy significantly modifies the predicted impact on help-seeking behaviors. In simpler terms, the relationship between stigma on seeking help and help-seeking behaviors varies based on an individual’s level of mental health literacy.

In essence, these findings underscore that mental health literacy plays a moderating role in shaping the impact of stigma on help-seeking behaviors, contributing to a more nuanced understanding of the complex dynamics involved in individuals’ decisions to seek help for mental health issues.

CONCLUSION AND RECOMMENDATION

Considering the outcomes of the moderation analyses, particularly in the context of self-stigma, where the joint effect with mental health literacy did not significantly modify the predicted impact on help-seeking behaviors, interventions may benefit from focusing on more targeted approaches. Drawing from the literature on self-stigma and help-seeking [16], initiatives could concentrate on dismantling individual-level barriers, such as enhancing self-esteem and self-efficacy, to encourage individuals to overcome the stigma associated with seeking mental health services.

In contrast, the moderation effect observed between mental health literacy and stigma on seeking help opens avenues for strategic interventions. The literature on mental health literacy [8] aligns with the recommendation to prioritize educational programs aimed at enhancing mental health literacy. These initiatives should not only provide knowledge about mental health matters but also equip individuals with the skills to identify, handle, and seek assistance for mental health issues. Given the significant interaction effect observed, such interventions may prove instrumental in shaping the impact of societal stigma on help-seeking behaviors.

The complexity of mental health literacy is further underscored by its role as a moderator in the relationship between self-stigma and help-seeking behaviors. The analysis revealed that while self-stigma and mental health literacy independently influence help-seeking behaviors, their joint effect did not significantly alter the predicted impact. This complexity necessitates a comprehensive approach that considers individual-level factors alongside broader societal influences.

The nuanced findings from the moderation analyses highlight the need for tailored interventions that recognize the complexity of factors influencing help-seeking behaviors. Interventions should go beyond a one-size-fits-all approach and consider the diverse individual and societal contexts that contribute to the stigma associated with mental health.

Limitations

Recommendation for future studies may investigate the comparison between people diagnosed with mental health problems that sought professional help to people who did not seek professional help. There is great need to explore how self-stigma, stigma on seeking help and mental health literacy affect those who have sought out professional help and how it affected their journey to recovery. Furthermore, a comparison study would give a more definitive and comprehensive understanding on how much self-stigma, stigma on seeking help and mental health literacy varies from one population to another. Hence, this study can be used as reference for future related studies that aim to explore the comparative factors that affect the help seeking behaviors of people who suffer from mental health problems.

Implications for behavioral science

The aim of this study is to pinpoint the interventions that augment mental health literacy, thereby equipping individuals with the tools necessary to navigate self-stigma, stigma on seeking help, and make informed decisions about seeking assistance. The ultimate goal of this undertaking is to offer concrete strategies for enhancing mental health literacy and cultivating a supportive atmosphere conducive to help-seeking behavior.

Furthermore, the study emphasizes the importance of tailoring these interventions to specific populations based on their unique needs and cultural backgrounds [19]. For example, interventions targeted towards youth may focus on building resilience skills and promoting positive coping mechanisms during times of stress. Interventions for older adults may focus on reducing social isolation and increasing access to community resources. Furthermore, human resource management offices may design organization-based structured psychosocial intervention especially targeting those employees in distress or experiencing anxiety [20].

Overall, implementing these targeted interventions can lead to significant improvements in mental health literacy and help-seeking behavior among individuals facing mental health challenges. By fostering a supportive environment that encourages seeking professional help without shame or fear of judgment, we can work towards reducing the burden of mental illness on individuals and society as a whole.

CONCLUSION

To effectively combat the pervasive self-stigma and societal stigma surrounding mental health support, a multifaceted approach is essential. Tailored interventions, addressing varying levels of mental health literacy, are needed. Prioritizing self-esteem and self-efficacy tackle self-stigma, whale comprehensive educational programs are essential for challenging societal stigma. Collaborative efforts between individuals and institutions are critical for creating a supportive mental health environment. Various interventions, such as community engagement programs, media literacy campaigns, workplace mental health initiatives, peer support networks, school-based mental health education, and longitudinal studies, play pivotal roles in addressing and combating the pervasive stigma surrounding mental health. Community engagement programs actively involve local populations in discussions, workshops, and events to raise awareness and promote a supportive environment. If programs such as these help to reduce public stigmas around mental illness, possible prejudice that a person with mental illness perceive and internalize would be reduced, thus indirectly impacting self-stigma. In addition, the people providing testimonials as part of the intervention feel empowered by the activist role they play in advocating for themselves, thereby reducing self-stigma as the program is implemented [4]. Media literacy campaigns aim to ensure responsible and accurate portrayals of mental health in the media, contributing to a more informed and compassionate public discourse. Workplace mental health initiatives focus on creating stigma-free environments, providing training for managers, and offering confidential counseling services to employees.

Peer support networks facilitate connections among individuals with lived experiences, fostering understanding and solidarity. School-based mental health education integrates comprehensive mental health curricula, normalizing discussions around mental well-being from an early age. Education strategies have largely focused on replacing the emotionally charged myths of mental illness (e.g., people with mental illness are dangerous!) with facts that counter the myths (e.g., on average people with mental illness are no more dangerous than the rest of the population) [3].

Longitudinal studies contribute valuable insights by assessing the sustained effectiveness of these interventions over time. Together, these diverse strategies form a multifaceted approach to not only challenge self-stigma but also address societal attitudes, paving the way for a more inclusive and supportive mental health landscape. Ongoing research is integral for advancing understanding, recognizing the deep connection between individual and societal factors for widespread accessible mental health support.

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