Original Article. Introduction. Maryam Damghanian, Mehran Alijanzadeh 1

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1 Original Article Theory of Planned Behavior, Self Stigma, and Perceived Barriers Explains the Behavior of Seeking Mental Health Services for People at Risk of Affective Disorders Abstract Introduction: To use the theory of planned behavior (TPB) incorporated with self stigma and perceived barriers to investigate the nature of help seeking behaviors in a community sample at risk of anxiety or depression in Iran. Methods: Participants at risk of anxiety or depression screened by Hospital Anxiety and Depression Scale (n = 1011) completed the following questionnaires at baseline: Factors in TPB, Self Stigma in Seeking Help Scale, and perceived barriers in seeking help. Two years later, their help seeking behavior (i.e., visiting a specialist) was retrieved from their medical records. Models using TPB concepts and incorporated with self stigma and perceived barriers were tested by structural equation modeling. Results: The effects of TPB concepts, self stigma and perceived barriers on help seeking behaviors (i.e., visiting a specialist for mental health problems) were supported by the excellent data model fit indices: Comparative fit index = 0.997; Tucker Lewis index = 0.965; root mean square of error approximation (RMSEA) = 0.028; and weighted RMSEA = All the path coefficients were significant, except for the path between perceived barriers and help seeking behavior. Perceived behavioral control had the strongest coefficient (standardized coefficient = 0.547); subjective norm had the weakest coefficient (standardized coefficient = 0.061). In addition, perceived barriers were indirectly associated with help seeking behaviors. Conclusion: TPB is an effective model to explain the help seeking behaviors for people at risk of anxiety or depression. In addition, self stigma and perceived barriers may be simultaneously considered when clinicians want to prevent an individual with depression or anxiety from not seeking proper help on their mental health problems. Maryam Damghanian, Mehran Alijanzadeh 1 Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, Tehran, 1 Department of Health Services Management, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran Keywords: Help seeking, perceived barriers, self stigma, theory of planned behavior Introduction People with mental illness often confront unfriendly treatments from the society or their community. [1] The unfriendly treatments are primarily due to the misunderstandings toward the mental illness that result in public stigma, including negative attitude (i.e., stereotype), prejudice, and discrimination, to people suffering from mental illness. [2 4] Under the environment filled with public stigma, people with mental illness or those with similar symptoms easily perceive or experience stigma, and are highly likely to endorse the public stigma into themselves as the self stigma (also known as internalized stigma). [5,6] Self stigma was found to be an obstacle for people with mental illness to recover: Yanos et al. [7] found that self stigma reduces one s sense of hope This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution NonCommercial ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: reprints@medknow.com and self esteem, and consequently results in social withdrawal, including using avoidant coping strategies. Similar statements have been proposed and found by Corrigan et al., [8,9] that self stigma substantially and negatively affect the self esteem and self efficacy of an individual with mental illness. Furthermore, self stigma was found to be associated with many health related outcomes and behaviors of individuals with mental illness, including their quality of life, depression, readiness to change, and adherence to treatment. [5,10 12] The negative impacts of self stigma are not limited to the above mentioned issues; it may further affect individuals with mental illness or those with similar symptoms to seek help for their symptoms. [13 16] For example, self stigma is one of the reasons that prevent these vulnerable individuals from seeking help. [14] A national survey How to cite this article: Damghanian M, Alijanzadeh M. Theory of planned behavior, selfstigma, and perceived barriers explains the behavior of seeking mental health services for people at risk of affective disorders. Soc Health Behav 2018;1: Address for correspondence: Dr. Maryam Damghanian, School of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St. Tohid Sq., Tehran, Iran. E mail: m damghanian@sina. tums.ac.ir Access this article online Website: DOI: /SHB.SHB_27_18 Quick Response Code: Social Health and Behavior Published by Wolters Kluwer - Medknow

2 in Australia showed that stigmatizing attitudes were associated with intentions to seek help in young people if they had a problem similar to the mental disorder. [16] In addition to the self stigma, other perceived barriers such as time consuming and expenditure are significantly associated with the help seeking intentions and behaviors. [17,18] Apart from the self stigma and perceived barriers, the theory of planned behavior (TPB) proposed by Ajzen [19] has been found to be a fundamental framework that well explains the help seeking intention for people with mental illness. [2,13 16] The TPB based on the principle of parsimony to postulate that three determinants (viz., attitude, subjective norm, and perceived behavioral control [PBC]) have impacts on the key component for an individual to perform a behavior, that is, behavioral intention. [19] In terms of the three determinants, attitude that generated from behavioral beliefs indicates whether an individual favors or disfavors a behavior. The subjective norm that generated from normative beliefs portrays how an individual feels the social pressure on performing a behavior. PBC generated from control beliefs means to what extent for an individual to perceive the easiness or difficulty to engage in a behavior. [20,21] With the significant identified elements, many studies found that TPB well explains many behaviors in various populations, [22 24] including people with mental health problems. [13 16] Studies on people with mental health problems found that attitude, subjective norm, and PBC in TPB could together explain 40% 60% of the help seeking intention. [13 16] However, rarely have studies on people with mental health problems examined the help seeking behaviors, that is, most studies ended up at behavioral intention in seeking help. Because the help seeking behavior is a significant element and the ultimate outcome in the TPB, we should explore the association between the behavioral intention and the help seeking behavior. Indeed, even we can enhance an individual s intention to seek help; the individual still cannot benefit from the enhanced intention if he or she does not engage in help seeking behavior. Thus, investigating the relationship between behavioral intention and help seeking behavior can provide additional information for health care providers. Specifically, to what extent the enhanced behavioral intention can convert into the real behavior. To fill with the gap of the current literature, this study aimed to use the TPB model to explain the help seeking behaviors in a sample of the Iranian people at risk of anxiety or depression. In addition, we incorporated TPB model with both self stigma and perceived barriers to investigate the nature of help seeking behaviors in people at risk of anxiety or depression. Methods Participants and procedure The study adopted a longitudinal design using two waves of data collection: One at baseline (attitude, subjective norms, PBC, self stigma in seeking help, and perceived barriers in seeking help) and another at 2 year follow up (help seeking behavior). Data collection took place from March 2014 to August 2016, and two thousand Iranian adults were randomly approached from eight urban health centers through family records in Qazvin, Iran. Participants were eligible to include in the study if they (1) aged 18 years or older, (2) were willing to participate, and (3) reported mental health problems based on the cutoffs in the Hospital Anxiety and Depression Scale (score 7 for either anxiety or depression subscales). Two trained nurses approached the potential participants by phone and asked them to visit urban health centers for an informational meeting. At the meeting, the nurses described the study purpose to the participants and asked them to complete baseline study measures (please refer to the instruments section below). Of the 2000 approached participants, 1763 (88.1%) adults agreed to participate, and they all completed the study measures accompanied by a written informed consent. More than half (n = 1011) of the participants fulfilled the third inclusion criterion, and their data were used for the following analyses. The present study was approved by the Ethics Committee of a University in Qazvin. Instruments Attitude toward help seeking Attitude toward help seeking was assessed using seven 5 point bipolar items (e.g., for me to seek mental health service is/would be: Extremely bad extremely fine, extremely negative extremely positive, extremely undesirable extremely desirable, extremely unimportant extremely important, extremely useless extremely useful, extremely disagreeable extremely agreeable, and extremely embarrassing extremely unshameful), with higher scores indicating more positive help seeking attitudes. Internal consistency of the seven items was satisfactory (α = 0.94). Subjective norms toward help seeking Subjective norms were assessed using three items (e.g., my family views mental health service very negatively). All items were rated on a 5 point scale ranging from 1 (strongly disagree) to 5 (strongly agree) with acceptable internal consistency (α = 0.79). Perceived behavioral control The PBC was assessed using three items (e.g., I am confident that I can seek mental health service if I wish to.). All items were rated on a 5 point scale ranging from 1 Social Health and Behavior Volume 1 Issue 2 October-December

3 (strongly disagree) to 5 (strongly agree) with satisfactory internal consistency (α = 0.84). Help seeking intention The help seeking intention was assessed using three items (e.g., I intend to seek mental health service). All items were rated on a 5 point scale ranging from 1 (strongly disagree) to 5 (strongly agree) with excellent internal consistency (α = 0.91). Self stigma in seeking help Self stigma was assessed using Self Stigma of Seeking Help (SSOSH) Scale. [25] The SSOSH consists of 10 items with each is rated on a 5 point scale ranging from 1 (strongly disagree) to 5 (strongly agree), and a higher score indicating a higher level of self stigma. The SSOSH Persian version has been well translated with sound psychometric properties. [26] Internal consistency of the SSOSH in this study was satisfactory (α = 0.89). Perceived barriers in seeking help The perceived barriers were assessed using six items (e.g., I think I can get the information about mental health service easily). All items were rated on a 5 point scale ranging from 1 (strongly disagree) to 5 (strongly agree) with excellent internal consistency (α =0.88). In addition, higher scores indicate higher levels of perceived barriers. Help seeking behavior The target behavior was the actual attendance of visiting a specialist (e.g., psychologist, psychiatrist, psychiatry nurse, or general practitioner) for mental health problems. Theoretically, help seeking behavior was defined in the elements of Target (mental health specialists: Psychologist, psychiatrist, psychiatry nurse, and general practitioner), Action (visiting mental health specialists), Context (at a clinic), and Time (during the eligibility period). Based on the theoretically definition, we further operationally defined the help seeking behaviors in the study as visiting a specialist. Specifically, we prospectively collected the help seeking behaviors from the clinical records at the 2 year follow up, and classified the behaviors into two categories: No, did not visit in the follow up and Yes, visited in the follow up. Hospital anxiety and depression scale The Hospital Anxiety and Depression Scale (HADS) was used to assess the depression or anxiety symptoms of a participant. [27] There are 14 items and two domains (Depression and Anxiety) in the HADS: Each domain consists of 7 items with a 4 point Likert type scale (scoring from 0 to 3). The cutoffs suggested for the HADS are 7 as normal; between 8 and 10 as mild; between 11 and 14 as moderate; 15 as severe depression/anxiety. [28] Of the 1011 participants, 321 had no depression but had anxiety problems; 396 had no anxiety but had depression problems. Statistical analysis Participants characteristics were analyzed using descriptive statistics, and the correlations between age, educational year, TPB elements, self stigma in seeking help, and perceived barriers in seeking help were analyzed using Pearson correlation. Structural equation modeling (SEM) was applied to test the three models we proposed: Model 1 [Figure 1] only examined the TPB framework with the adjustment of demographic variables (age, gender, educational years, socioeconomic status, and employment). Model 2 additionally included self stigma and perceived barriers in Model 1, and the two factors only linked to help seeking behaviors (i.e., Model 2 added two more Figure 1: Mode 1 being the theory of planned behavior structural model (Age, gender, educational level, socioeconomic status, and employment were adjusted in the model). ***P< Social Health and Behavior Volume 1 Issue 2 October-December 2018

4 paths in Model 1). The same demographic variables were also controlled in Model 2. Model 3 [Figure 2] shared the same factors with Model 2, but it additionally included two more paths (self stigma and perceived barriers to behavioral intention). That is, Model 3 additionally hypothesized that both self stigma and perceived barriers were directly and indirectly associated with help seeking behaviors. To take care of the dichotomous nature of help seeking behavior (yes vs. no) diagonally weighted least squares estimator was adopted in all SEM models. Before investigating each single association shown in the SEM paths, we first examine a series of fit indices to determine whether the model was supported: Comparative fit index (CFI) and Tucker Lewis index (TLI) were set at 0.95 or above; root mean square of error approximation (RMSEA) set at 0.08 or below; [29 31] weighted root mean square residual (WRMR) set at 0.10 or below. [32] Sobel tests were further used to determine whether the mediated effects of behavioral intention were at the significance level. [33] Descriptive statistics and Pearson correlations were analyzed using SPSS 17.0 (IBM Corp. Armonk, New York: USA); all SEM models were conducted using lavaan package in the R software. Results Table 1 demonstrates the demographic information of the participants: Slightly more than half of them were male (n = 558, 55.2%); mean (standard deviation [SD]) age was (8.22) years; mean educational year was 6.45 (3.57); nearly two thirds of them had a family size 5 (n = 628, 62.1%). Although 63.1% (n = 638) of the participants were not employed, only few (n = 17, 1.7%) were in poor socioeconomic status. In addition, Table 2 shows the correlation matrix among the age, educational year, TPB elements, self stigma, and perceived barriers. Model 1 had excellent data model fit (CFI = 0.995, TLI = 0.955, RMSEA = 0.047, WRMR = 0.568), except for the significant Chi square test (P = 0.040). Because fit indices support Model 1, we further examined the significance of each path coefficient. All the paths proposed using TPB were significant (all P < 0.001), and the PBC had the strongest association with behavioral intention (standardized coefficient = 0.656); and with help seeking behaviors (standardized coefficient = 0.516). The relationship between subjective norm and behavioral intention was the weakest (standardized coefficient = 0.074). Attitude, subjective norm, and PBC together explained 61.9% of the behavioral intention; behavioral intention and PBC together explained 60.8% of the help seeking behaviors [Figure 1]. In addition, Sobel tests showed that attitude (coefficient = 0.096, standard error [SE] =0.026, P < 0.001), subjective norm (coefficient = 0.043, SE = 0.014, P = 0.002), and PBC (coefficient = 0.281, SE = 0.052, P < 0.001) indirectly associated with help seeking behaviors through behavioral intention [Table 3]. Model 2 showed worse fit indices (CFI = 0.945, TLI = 0.711, RMSEA = 0.081, WRMR = 1.114, χ 2 = , P < 0.001) than did Model 1. In addition, most fit indices of Model 2 were not satisfactory, and we considered Model 2 was not supported. However, after correlating two additional paths (from self stigma and perceived barriers to behavioral intention), Model 3 had all fit indices substantially improved (nonsignificant Chi square test [P = 0.167], CFI = 0.997, TLI = 0.965, RMSEA = 0.028, and WRMR = 0.386). All the significant Figure 2: Model 3 being the theory of planned behavior structural model combined with self stigma and perceived barriers directly and indirectly associated with help seeking behavior (Age, gender, educational level, socioeconomic status, and employment were adjusted in the model). *p<0.05; **p<0.01; ***p<0.001 Social Health and Behavior Volume 1 Issue 2 October-December

5 paths shown in Model 1 remained significant in Model 3 [Figure 2] with the similar trend: PBC had the strongest coefficient (standardized coefficient = 0.547) and subjective norm had the weakest coefficient (standardized coefficient = 0.061). Mediated effects of behavioral intention in the associations of TBP factors were also significant [Table 3]. Model 3 additionally portrayed that self stigma (standardized coefficient = 0.112, P < 0.001) and perceived barriers (standardized coefficient = 0.099, Table 1: Participants characteristics (n=1011) Variable n (%) Gender, n (%) Male 558 (55.2) Female 453 (44.8) Age (year), mean (SD) (8.22) Educational (year), mean (SD) 6.45 (3.57) Number of family members 3 27 (2.7) (27.3) (32.1) (18.5) 7 71 (7.0) (11.9) Socioeconomic status Good 337 (33.3) Fair 654 (64.7) Poor 17 (1.7) Employment Yes 373 (36.9) No 638 (63.1) Depression a Mild 282 (27.9) Moderate 272 (26.9) Severe 136 (13.5) Anxiety a Mild 331 (32.7) Moderate 228 (22.6) Severe 56 (5.5) a Assessed using Hospital Anxiety and Depression Scale: Score between 8 and 10 is mild; between 11 and 14 is moderate; 15 is severe. SD: Standard deviation P < 0.001) were negatively correlated with behavioral intention [Figure 2], and were indirectly associated with help seeking behaviors through intention [Table 3]. Furthermore, the majority of the variances in behavioral intention (63.4%) and that in help seeking behaviors (62.4%) were explained in Model 3. In all models, age was significantly correlated with help seeking behaviors (coefficient = 0.021, SE = 0.007, P = for Model 1; coefficient = 0.017, SE = 0.007, P = for Models 2 and 3) but not with behavioral intention (coefficient = 0.002, SE = 0.002, P = for Model 1; coefficient = 0.001, SE = 0.002, P = for Models 2 and 3); gender was neither significantly correlated with behaviors (P = for Model 1 and for Models 2 and 3) nor with intention (P = for Model 1 and for Models 2 and 3). Discussion Generally speaking, our findings agree with those of studies on similar populations (people with depression or people with mental illness): The TPB well explains the behavioral intention. [13 15] We additionally extended the evidence from behavioral intention to help seeking behaviors. That is, behavioral intention and PBC together explained ~ 60% of the variance in help seeking behaviors. Thus, our results linked the TPB model to clinical practice. When healthcare providers want to enhance the help seeking behavior of individuals with anxiety or depression, increasing their willingness in help seeking is crucial. Furthermore, we demonstrated that attitude, subjective norm, and PBC were significant determinants to help seeking intention. In addition to the TPB elements, self stigma, and perceived barriers were possible obstacles associated with help seeking behaviors. The aforementioned results were also consistent with what Mo and Mak [14] and Yap et al. [16] have found. Furthermore, self stigma was directly and indirectly (through behavioral intention) associated with help seeking behaviors; perceived barriers were only indirectly associated with help seeking behaviors through behavioral intention. Table 2: Pearson correlations among age, educational year, theory of planned behavior factors, self stigma, and perceived barriers Variables Mean (SD) r Age (8.22) * 0.10** 2. Educational year 6.45 (3.57) ** 0.08** 0.08** 0.07* 0.11** 3. Attitude 4.00 (0.59) *** 0.61*** 0.55*** 0.51*** 0.43*** 0.35*** 4. Subjective norm 3.27 (0.76) *** 0.35*** 0.34*** 0.25*** 0.19*** 5. Perceived behavioral control 3.48 (1.02) *** 0.72*** 0.52*** 0.50*** 6. Behavioral intention 3.67 (1.03) *** 0.51*** 0.44*** 7. Self stigma (6.42) *** 0.46*** 8. Perceived barriers 3.38 (0.75) *** 9. Help seeking behaviors in mental health 1.25 (0.43) 1.00 *P<0.05; **P<0.01; ***P< SD: Standard deviation 58 Social Health and Behavior Volume 1 Issue 2 October-December 2018

6 Table 3: Sobel tests for mediated effects through behavioral intention Independent variable Standardized coefficient Coefficient SE P Model 1 Attitude <0.001 Subjective norm Perceived behavioral control <0.001 Model 2 Attitude Subjective norm Perceived behavioral control <0.001 Model 3 Self stigma Perceived barriers Attitude Subjective norm Perceived behavioral control <0.001 SE: Standard error Although our results generally in line with the studies adopting TPB, [13 15] slightly differences were found. Specifically, Mak and Davis [13] and we found that PBC had the strongest association with behavioral intention as compared with attitude and PBC. Both Mo and Mak [14] and Schomerus et al. [15] reported that the association between PBC and behavioral intention was the weakest. However, Schomerus et al. [15] claimed that the low correlation between PBC and behavioral intention in their study may be due to the low internal consistency in their PBC measure (α =0.54). They proposed another reason: Health system with less restricted access to mental health services (e.g., the health system in German) may decrease the association between PBC and behavioral intention. As for the weakest association between PBC and behavioral intention found in Mo and Mak, [14] it could be explained by subjective norm with salient effects in their TPB model. Because subjective norm is dominant in their model, it may take over part of the associations between PBC and behavioral intention. Nevertheless, we agree with what Mak and Davis [13] have suggested: Policies could target on external factors related to PBC (e.g., popularization, promotion and knowledge of mental health services, and affordable fee) because of the strong relationship between PBC and behavioral intention. Similar to most studies, [21,22,34,35] we found that subjective norm had the lowest relationship with behavioral intention. The associations between attitude, PBC, and behavioral intention were relatively high, which suggest that the participants generally felt positively about their help seeking intention. With such high confidence in their help seeking intention, the association between subjective norm and behavioral intention is possibly to be diminished. [36,37] In terms of the self stigma and perceived barriers, we found that self stigma played a more important role than did the perceived barriers. Many studies have discussed and demonstrated the impacts of self stigma on willingness to change. [5,11,12] A possible reason for the influence of willingness to change is the reduced hope and self esteem; both are also contributed by self stigma. [7] Hence, health care providers may want to design self stigma reduction program to handle this issue. The association between perceived barriers and behavioral intention was modest in our findings, and Mo and Mak [14] reported similar results that barriers only explained <1% of the behavioral intention. We additionally demonstrated that barriers seemed to have no relationship with help seeking behaviors. There are some limitations in the study. First, we did not have any psychiatrist to evaluate and diagnose the participants in anxiety or depression; therefore, we cannot ensure whether our proposed model is applicable for those who have a diagnosis given by psychiatrists. Future studies on people with the diagnosis are highly recommended to corroborate our findings. Second, we did not measure and control the prior help seeking behavior; therefore, we may not completely ensure that the final help seeking behavior was due to the TPB factors, or because of the prior behavior. Third, we adopted self reports for self stigma and perceived barriers, which are likely to be biased because of the social desirability. However, we justified that self reports are the best methods to collect such information, and the bias may not be serious. Finally, although we used a longitudinal design to assess the associations between our proposed model and the help seeking behavior, we still cannot ensure any causal effects. Future research using a true experimental study design to detect the causal effects is thus warranted. Conclusion Our results suggest that TPB is an effective model to explain the help seeking behaviors for people at risk Social Health and Behavior Volume 1 Issue 2 October-December

7 of depression or anxiety. In addition, self stigma and perceived barriers are significant factors which may prevent an individual with depression or anxiety from seeking proper help on the mental health problem. Using our results, healthcare providers may want to design some interventions on enhancing the behavioral intention, reducing self stigma, and minimizing the barriers for people with depression or anxiety. Thus, their help seeking behaviors may be increased, and their health and quality of life may be improved subsequently. Acknowledgment The present paper is the outcome of a research project approved at Qazvin University of Medical Sciences. Hereby, the authors would like to appreciate Research vice chancellor of Qazvin University of Medical Sciences and Health Deputy of the university, authorities of the medical centers as well as all the participants for their participation and cooperation in this project. 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