Reducing Stigma and Encouraging Help Seeking Intentions Through a Mental Health Literacy Program

Reducing Stigma and Encouraging Help Seeking

Intentions Through a Mental Health Literacy Program

Chapter 1: Introduction to the Study

One in three Canadians will experience a mental health problem during his or her

lifetime (Statistics Canada, 2015), yet stigma continues to prevent people from seeking

help early, as they would for a physical illness (Judd, Jackson, Komiti, Bell, & Fraser,

2012). Saporito, Ryan, and Teachman (2011) contended that adolescents are not immune

to stigma and may experience rejection and discrimination by their peers and social

networks. Adolescence is a developmental period that is characterized by important

biological, social, and psychological changes that may cause young people difficulty and

anxiety as they seek to adjust (Spear, 2013). Signs of mental illness can manifest as

adolescents are shaping their identities and establishing relationships with their peers.

Many adults with psychiatric disorders had the onset of their disorders in childhood and

adolescence (Copeland et al., 2009; Kessler & Walters, 1998). A rise in psychopathology

has also been reported in adolescence, with more than 22% of youth experiencing a severe

episode of mental illness, in addition to 23% experiencing a mild episode of mental illness

such as anxiety, a mood disorder, or substance abuse (Ormel et al., 2014). At the

elementary school level, more than 8% to 18% of school-age children are diagnosed with a

psychiatric disorder, yet strategies to help them are limited (Fazel et al., 2014). In Canada,

70% of mental health issues have their onset during childhood or adolescence (Statistics

Canada, 2006). Richwood et al. (2005) reported that adolescents are the demographic

group least likely to seek help for a mental health problem.

Stigma has been identified as the most significant barrier preventing adolescents

from seeking help. Moses (2010) revealed that youth who exhibit signs of mental illness

do not disclose due to fear of rejection and being branded mentally ill or “crazy” among

their peers. Peer influence was also found to play a significant role in reinforcing stigma

for people with mental illness (Grosbas et al., 2007; Yoshioka et al., 2014). Stigma is a

complex social construct that has two principal types: public stigma and self-stigma

(Bathje & Pryor, 2011; Corrigan et al., 2012). Public stigma is manifested through

negative attitudes and discrimination toward people with mental illness, who are perceived

to be dangerous and untrustworthy individuals (Corrigan, 2009; Corrigan et al., 2012).

Self-stigma is what can consume the minds of those afflicted with mental illness. Studies

have indicated that adolescents with mental illness internalize the influences of stigma and

labeling, developing “stigmatized” identities for themselves (Arria et al., 2011; Clement et

al., 2015; Corrigan, 2009; Elkington et al., 2012; Evans-Lacko et al., 2012). Faced with

prejudice, individuals with mental illness believe that they are unworthy of a good job, a

network of friends, a fulfilling life, and attainment of their potential (Corrigan, 2009;

Corrigan & Rao, 2012). They live the consequences of isolation, fear, and prejudice.

Consequently, governmental and public efforts have focused on changing public attitudes

toward people with mental illness and reducing the damaging effects of public and

selfstigma on generations of individuals.

While stigma is characterized as the predominant barrier to help-seeking, poor

mental health literacy has been recognized as a persistent challenge to address in schools

and communities. Mental health literacy has been described as “knowledge and beliefs

about mental disorders which aid their recognition, management or prevention” (Jorm et

al., 1997, p. 182). In the past decade, peer-reviewed studies have shown that low mental

health literacy among youth is an important barrier to help-seeking behavior, particularly

for those who experience mental health problems during adolescence (Milin et al., 2016;

Perry et al., 2014; Wei, Hayden, & Kutcher, 2015). During the past two decades, many

educational programs have been developed in an effort to enhance mental health

knowledge and, by association, reduce stigmatizing attitudes toward individuals with

mental illness (Kutcher et al., 2013; Logsdon, & Myers, 2011; Perry et al., 2014;

PintoFoltz; et al., 2014). Mental health literacy encompasses knowledge about various

mental illnesses, as well as the biological and psychosocial factors that contribute to the

development of an illness. Mental health literacy also involves an understanding about

stigma and the value of seeking help/early intervention for a mental health problem (Wei et

al., 2013). For many years, professionals in mental health have intuitively understood the

association of mental health literacy and stigma, yet that relationship was not fully

established in the literature (Li,Juan, Thornicroft, & Huang, 2014; Milin et al., 2016;

Schomerus et al., 2012). While Perry et al. (2014) confirmed that educational mental

health literacy programs engendered awareness and greater knowledge of mental health,

evidence to this effect was rather limited and not highly replicated. Many studies generated

mixed results (Brohan et al., 2010; Mackenzie et al., 2014). The body of evidence has been

plagued by poor research design, inconsistencies in methodology, and inconclusive results

(Kutcher et al., 2013; Perry et al., 2014; Pinto-Foltz et al., 2011;

Yoshioka et al., 2014).

Problem Statement

Emerging research is providing evidence that mental health knowledge has an

effect on stigma reduction (Busby, Bruce, & Batterham, 2015; Milin et al., 2016; Rodgers

et al., 2015). Milin et al. (2016) argued that a mental health literacy curriculum could

challenge attitudes on mental illness in youth and foster help-seeking intentions should

they experience a mental health problem. However, the evidence remains deficient with

respect to the components that constitute an effective mental health literacy program.

Programs have varied in format, ranging from a traditional educational method of

dispensing information on mental illnesses to students to a social program format where

youth listen to a person with lived experience of a mental illness share a personal journey

of recovery. Corrigan (2009) defined this approach as the contact method. Results were

found to be inconsistent and inconclusive concerning the best methods to effect stigma

reduction (Chisholm et al., 2016). To date, research has focused on comparing the

effectiveness of the educational method to the method involving contact with people with

lived experience (Chisholm et al., 2016; Wei et al., 2013). Both groups of researchers have

commented on the relatively low number of studies that use both content delivery

approaches and have questioned whether incorporating the two methods might increase the

level and depth of knowledge and thus have a greater impact on stigma reduction and

helpseeking behavior. The methods are not mutually exclusive. Wei, Kutcher, and

Szumilas (2011) argued that an effective mental health literacy program could include an

overview of the biological and psychosocial factors that contribute to the development of a

mental illness, create opportunities for interaction with people who live with mental

illness, and teach coping skills that can reduce the risk factors associated with the

development of a mental illness.

This research study measured stigma among youth and determined that a multilevel

educational program could foster mental health knowledge, address the stigma of mental

illness, and encourage help-seeking intentions in students. Very few educational programs

incorporate information on mental illnesses, direct contact with people with lived

experience, a neuroscientific explanation of the brain addressing the biological and

psychosocial factors of mental illness, and coping strategies to help youth manage

challenges of life and school. In the past, those factors have been researched separately

without consideration of the interrelationship between knowledge, attitude, and behavior

(Chisholm et al., 2012).

Purpose of the Study

This posttest-only randomized controlled quantitative study evaluated the

effectiveness of an educational mental health program in comparison to a control group in

promoting mental health knowledge as well as help-seeking intentions, and addressing

stigma around mental illness. The educational program was developed at the Royal Ottawa

Mental Health Centre in 2011 in response to two student suicides that generated high public

reaction and requests for youth mental health awareness by parents, teachers, and school

board officials. The program was designed to consist of open and informal conversations

with youth on mental wellness and mental health problems, along with a short facility tour

to demystify mental illness and treatment. It involved presentations by a neuroscientist who

showed brain scans of various subjects, both healthy and depressed, conveying the

connection between brain function and moods and behaviors; a psychologist, who

impressed on students that mental health is parallel to physical health, described various

types of mental illness, and explained how crucial it is for youth to reach out to a trusted

adult when they or their friends need help; and an addiction counselor, who spoke of

alcohol and drug use and treatments. It also included testimonials of young adults living

with mental illness, who shared their personal stories of recovery, as well as a

demonstration by a social worker of some coping techniques that help to reduce stress and

foster positive health behavior. To date, more than 14,000 students have participated. While

the program has received very positive responses among students and teachers, it has not

been scientifically evaluated until now.

In this study, the educational program constituted the independent variable, while

knowledge, stigma, and help-seeking intentions formed the dependent variables. Gender

and age were collected in this study as demographic data and to understand the potential

impact of age and gender on attitudes.

Research Questions

RQ1—Quantitative: Can a multifaceted mental health literacy program affect

mental health knowledge?

Null Hypothesis 1: There is no difference in mental health knowledge

between students who participated in the mental health literacy

program and students who did not receive the program.

Alternative Hypothesis 1: There is a difference in mental health knowledge

between students who took the mental health literacy program and

students who did not partake in the program.

RQ2—Quantitative: Can a multifaceted mental health literacy program affect

stigma?

Null Hypothesis 2: There is no difference in stigma between students who

received the mental health literacy program and students who did

not participate in the program.

Alternative Hypothesis 2: There is a difference in stigma between students

who received the mental health literacy program and students who

did not participate in the program.

RQ3—Quantitative: Can a mental health literacy program affect help-seeking

intentions among youth?

Null Hypothesis 3: There is no difference in help-seeking intentions

between youth who participated in the mental health program and

students who did not participate in the program.

Alternative Hypothesis 3: There is a difference in help-seeking intentions

between youth who participated in the mental health literacy

program and students who did not participate in the program.

Theoretical Framework

The health belief model (HBM), as modified by Rosenstock (1974), constituted the

theoretical framework for this study. The HBM was established as a theoretical framework

with constructs that could influence population-based health promotion. The premise is

that a person’s beliefs concerning a health problem will determine how he or she will

assess the perceived benefits and susceptibility to an illness and whether he or she will

engage in proactive healthy behavior. The model is based on five core perceptions:

susceptibility to developing or having a problem, severity, benefits, barriers, and general

health motivation (Rosenstock, 1988). For example, a person may make a decision to seek

out medical help for a problem or to participate in an exercise program to reduce the risk

of heart disease. In sum, a person thinks of changing a negative behavior by assessing his

or her susceptibility to and the seriousness of illness, as well as evaluating the potential

benefits of the decision in relation to what is required in action (see Appendix A). Because

HBM is a population-based health promotion model, its value is in helping to promote

information and knowledge that will encourage people to consider existing health

behaviors that can be harmful or damaging to their health and take necessary action. The

model has been applied extensively in relation to physical health (Wright et al. 2012), and

a growing body of evidence supports its usefulness and validity in relation to mental health

(Henshaw & Freedman-Doan, 2009). Future testing of the HBM model may elucidate how

adolescents perceive benefits in seeking help, how they perceive barriers to seeking help,

and how these variables can influence help-seeking intentions (O’Connor, Martin, Weeks

& Ong, 2014).

Mental illness is an increasingly important societal health issue, one that requires

concerted intervention. In its report on the Global Burden of Disease Study 2010, the

World Health Organization (WHO) identified mental, neurological, and substance use

disorders as representing the most significant proportion of disease burdens. Ratnasingham

et al. (2012) concluded in a study on public health that the “burden of mental illness and

addictions in Ontario is more than 1.5 times that of all cancers, and more than seven times

that of all infectious diseases” (p. 6). Governments and health organizations are working

together to enhance literacy concerning mental health in order to reduce stigma and

encourage more people to seek help early (WHO, 2010). According to HBM theory, once

individuals learn about mental health and understand signs of mental illness, they will seek

help to deal with mental health problems. However, human behavior is not simply

governed by rational thinking and information; a number of factors are involved. With

respect to mental illness, Corrigan et al. (2012) reported that stigma not only is a treatment

barrier, but also can influence treatment adherence. In the spirit of the HBM model,

lessening the effect of stigma for mental illness could lead individuals to recognize the

need for help and seek treatment without feeling ostracized, isolated, or ashamed; thus,

with less stigma, help-seeking intentions could increase.

The HBM model serves as an excellent framework for population-based health

promotion efforts concerning mental illness among youth that help to challenge existing

beliefs and perceptions about those with mental illness. This model emphasizes the

potential to foster mental health literacy and encourage help-seeking behavior. According

to Jones et al. (2013), the HBM has been shown to be very effective in terms of disease

prevention, treatment adherence, and health benefits. This model acts as a guide to

measuring health beliefs, stigma, and help-seeking in students who receive a mental health

literacy intervention compared to those who do not.

Nature of the Study

This study was a randomized controlled trial that examined whether the program

design of a 3-hour mental health literacy program was effective in affecting mental health

knowledge, lessening stigma, and encouraging help-seeking intentions. This randomized

trial employed a posttest-only control design (Campbell & Stanley, 1963; Marczyk,

DeMatteo &Festinger, 2010). Three scales were used. The first scale, the Mental Health

Knowledge Scale (MAKS), measured mental health knowledge; the second, the Reported

and Intended Behaviour Scale (RIBS), assessed stigma; and the third, the General-

Helpseeking Questionnaire (GHSQ), predicted whether students would be encouraged to

seek help when encountering a mental health problem.

Using t tests, the independent variable of a mental health literacy program was

tested to determine whether there was an impact on knowledge, stigma, and help-seeking

intentions following the participation of students in the program. The first variable tested

the effect of mental health literacy (program vs. treatment as usual) on knowledge; the

second variable tested the effect of the program on stigma; and the third variable tested

whether the literacy program had an effect in encouraging students to seek help should

they present with a mental health problem. Gender and age data were also collected for

background information.

Definitions of Key Terms

The following terms are used throughout this dissertation.

Mental Illness

Mental illness is a brain disease that has a biological base like other medical

illnesses and impairs an individual’s emotions, thought processes, perception, behavior,

and daily functioning. It also affects an individual’s sense of self, others, and the

environment (Malla, Joober &Garcia, 2015).

Mental Health

Mental health is “knowledge and beliefs about mental disorders which aid their

recognition, management or prevention” (Jorm et al., 1997, p. 182).

Mental Health Literacy

Wei et al. (2013) described mental health literacy as encompassing knowledge and

skills that address the biological, psychological, and social aspects of mental health to

increase understanding of mental health and mental disorders, reduce stigma, help

recognize and prevent mental disorders, and facilitate help-seeking behaviors in youth

along the pathway to mental health care (p. 110).

Stigma

Stigma is defined as involving cues that elicit stereotypes and knowledge structures

that the general public learns about a marked social group (Corrigan, 2004). Commonly

held stereotypes about people with mental illness involve notions of violence,

incompetence, and blame (Corrigan, 2004, p. 615). Stigma has two dimensions: public

stigma and self-stigma. Public stigma involves attitudes of fear and anger that members of

the public have concerning people with mental illness and that result in prejudice, social

distance, and loss of opportunity (Corrigan & Rao, 2012). Self-stigma occurs when

individuals with mental illness internalize the public’s negative attitudes toward mental

illness and begin to manifest behaviors that support the negative perceptions (Corrigan,

Watson & Barr, 2006).

Help-seeking

Help-seeking is defined as an adaptive coping process that is an attempt to obtain

external assistance to deal with a mental health concern (Rickwood & Thomas, 2012).

Using the definitions for its components in the Oxford Dictionary, it may be described as

an attempt to find (“Seek,” 2017) assistance to improve a situation or problem (“Help,”

2017). It is also understood as seeking assistance from professionals who have legitimate

and recognized professional roles in providing relevant advice, support, and/or treatment

(Rickwood & Thomas, 2012).

Assumptions

A major assumption in the study was that all students wanted to participate in the

mental health literacy program. Students were randomly assigned to either control or

experimental groups and were subjected to differential dropout rates. A second assumption

was that scales normally tested on adults are equally effective in measuring knowledge,

stigma, and help-seeking intentions among the college student population.

Delimitations

In research, the objective is to establish cause and effect by investigating an

intervention and its effect on a targeted population. While causality cannot always be

proven, posttest-only randomized experimental design is recognized as one of the best

designs for testing cause-effect relationships (Trochim, 2006). Mental health literacy can

have an impact on people of all ages; however, this study was limited to college students in

light of the challenge of conducting research with vulnerable populations such as

adolescents. For this reason, high school students were excluded from the research study.

This study involved students at Algonquin College, the largest college in Eastern Ontario.

This research study was offered only in English and not in French, which impacted its

potential generalization.

The full effects of an educational intervention cannot fully be measured following

the intervention but require a longitudinal research approach. Behavioral change would

need to be measured over a longer timeframe to effectively assess the impact of the

educational intervention. For that reason, this study gauged help-seeking intentions among

youth, and not help-seeking behavior (Eisenberg et al., 2012; Pham et al., 2014). During

that program timeframe, students did not have time to process or reflect on information

presented, or to consolidate the information and translate it into an attitudinal or

behavioural change (Chisholm et al., 2016; Mcluckie et al., 2014).

Stigma is a complex construct that encompasses a level of complexity in

measurement. The scales proposed in this study measured stigma as a global concept but

did not examine specific facets of stigma that deal with the perceptions of dangerousness

and unpredictability that contribute to stigmatizing attitudes toward people with mental

illness (Corrigan & Rao, 2012). Concepts of self-stigma and public stigma were not

measured in this study.

Limitations

Social desirability is a threat to validity that must always be considered when

dealing with youth populations whose members may want to please researchers or their

teachers in generating favorable responses to questions of stigma and how they would treat

someone with a mental illness (Chisholm et al., 2016). To minimize issues related to social

desirability, instructions were presented in simple language, stating that there were no

perfect answers in the survey and that participants should respond according to what they

believed. The validated questionnaires were also tested for social desirability and were

structured to elicit guided responses from participants. To minimize threats of social

desirability, questionnaires were filled out onsite within a designated period of time.

It is probable that participants in this study were subjected to history and social

threats. It was impossible to control the learning setting prior to the data collection phase;

students could have received information about mental health literacy through another

class, a special outing, or an article in the newspaper that would have rendered a history

threat occurring in a natural setting. There was also the possibility of a social threat, given

that one group of students participated in the program as the experimental group while

other students were randomly selected to participate in the survey as the control group.

This study potentially involved some interaction effect where the intervention and some

other variable interacted without my knowledge during the data collection period.

Although an interaction effect has bearing on external validity, generalization of findings

on the effect of an educational mental health literacy intervention on stigma and

helpseeking behaviors was recognized.

Attention span also constituted an important limitation, given that students

completed the survey following the program without time for full reflection on the

experience and information presented (McCambridge, Witton & Elbourne, 2014). This

study focused on measuring the attitudes of college students on mental health and cannot

be generalized to students from other populations or age groups. Milin et al. (2016) found

important differences between higher grade and lower grade students in high schools, and

differences have also been described between high school and college students (Chen,

Romero &Carver, 2015). Socioeconomic and cultural factors may have exercised an

influence on attitudes toward mental illness and willingness to seek help (Ungar et al.,

2013; Yu et al., 2015), but they were not tested in this current study.

Significance

This study offered the potential of serving as a mental health literacy model that

can change stigmatizing attitudes toward people with mental illness and at the same time

create a social context where students do not feel stigmatized in seeking help. Breaking

down stigma and encouraging early intervention for students to seek help if they

experience mental health problems do lead to better recovery outcomes, and healthy

trajectories. This educational mental health literacy program acts as an impetus for

informed dialogue, understanding, and support among youth in their social networks. By

interacting with students of other schools in the region, the program served to demonstrate

how mental illness affects many individuals and their families and does not discriminate

by social status, income, or geographical location.

Summary

Mental health literacy, stigma, and help-seeking behaviors are important constructs

that need to be better understood prior to understanding how these concepts are interrelated

in order to encourage proactive health behavior and generate positive attitudinal change

toward individuals with mental illness. Emerging research is now confirming the role of

mental health literacy in fostering better understanding of mental illness, its causes, and

how stigma can isolate and prevent young people from getting help for a mental health

problem. Being subjected to prejudice and fear can affect individuals’ life trajectories and

limit opportunities for self-development and fulfillment. Knowledge, literacy, and a

positive environment can have a profound impact in encouraging people to seek help.

Chapter 2: Literature Review

Mental illness and addictions have been identified as the second leading global

burden of disease, surpassing all other chronic diseases (WHO, 2014). The rising cost of

mental illness amounts to more than $52 billion annually in Canada, where mental illness

results in more than 500,000 people not working (Cohen & Peachey, 2014). Chan,

Batterham, Christensen, and Galletly (2014) found that the diagnosis of mental illness led

people to feel excluded, devalued, and discriminated against. Many experienced impaired

social functioning as a result of their disorder, as well as unemployment and substance

abuse (Purcell et al., 2011). Delay in seeking treatment for mental health disorders is a

worldwide phenomenon (Thornicroft, 2012; ten Have, de Graaf, van Dorsselaer &

Beekman, 2013). Globally, less than one-third of people with a mental illness receive

treatment. Thornicroft (2012) reported that 52% to 74% of individuals with a mental

disorder in Europe and the United States do not seek treatment. Untreated mental illness

can become severe and treatment resistant and can lead to secondary psychiatric disorders

(deGirolamo, Dagani, Purcell, Cocchi & McGorry, 2012).

The prevalence statistics are no better for youth. Worldwide, mental illness affects

10-20% of children and youth (Kieling et al., 2011). Purcell et al. (2011) highlighted in the

National Comorbidity Survey Replication that 75% of people with a mental disorder had

the onset of their illness in adolescence. Insel and Fenton (2005) called this phenomenon

the “chronic diseases of the young.” Less than 1 in 4 Australians aged 16-24 who had been

diagnosed with a mental disorder accessed any treatment (Reavley & Jorm, 2011). The

reasons why individuals have avoided or delayed seeking help for mental health problems

have been the focus of many studies.

Stigma plays a significant role in deterring help-seeking behavior and reinforcing

negative perceptions of people with mental illness. Adolescents are not immune to stigma,

and many have experienced rejection and discrimination from their peers and social

networks (Beardslee, Chien, & Bell, 2011; Saporito, Ryan, & Teachman, 2011).

Adolescents with a psychiatric disorder were troubled about how their peers would react to

their diagnosis and whether it would affect their standing in the peer network (Beardslee et

al., 2011; Crosnoe & McNeely, 2008; Wisdom, Clarke, & Greene, 2006). Corrigan (2012,

2006) also reported that many individuals were unwilling or afraid to seek help, as this

would entail acknowledging the presence of a mental health problem, which would be

negatively seen by family members and peers.

Mental health has become an important societal issue. There have been an

abundance of studies on the causes and manifestations of mental illness in adolescence and

during adulthood. Searches were conducted in the Google Scholar, PsycINFO, and

PsycARTICLES databases between 2007 and 2017 using the following word associations:

youth and mental health literacy, adolescence and mental illness, and mental health and

adolescence. These searches yielded more than 460 peer-reviewed journal articles.

Additional searches included the combinations stigma, mental illness, and adolescence;

stigma and mental health literacy; help-seeking behavior and stigma, self-efficacy and

mental illness; health belief model and mental illness; and attitudes and help-seeking

intentions. This search generated more than 385 peer-reviewed journal articles. Seminal

articles by renowned mental health researchers such as Kutcher, Chisholm, Corrigan, Jorm

& Reavely were also selected. Of the 945 original articles, 244 were retained for review.

Articles were limited to the relationship between stigma, mental illness, and mental health

literacy. Longitudinal studies on stigma and mental illness in adults were excluded from

the review, along with studies on the range of mental illnesses such as depression or

schizophrenia among youth.

This literature review addresses why the onset of mental health illness occurs in

adolescence, the barriers to seeking help, and the factors that contribute to the development

of stigma in youth. The impact of stigma on help-seeking intentions is explored, as is how

mental health literacy can play a determining role in fostering knowledge and

understanding of mental illness while breaking down stigma and encouraging help-seeking

intentions.

Mental Illness and Adolescence: A Critical Development Phase

Adolescence is a time of significant biological, psychological, and social change,

with critical transformation in brain structure and function. Early signs of mental illness

manifest as adolescents are shaping their identities, establishing social relationships with

peers, and seeking social acceptance (Schulenberg et al., 2004; Spear, 2013; Viner et al.,

2012). Changes in hormonal levels have resulted in adolescents feeling unsure of

themselves and vulnerable to negative peer influences such as the consumption of alcohol

and substance use (Haglund, 2007; Spear, 2013). Neuroscientists have indicated that the

adolescent brain undergoes significant maturation during this stage, and the hippocampus

is still growing when youth are exposed to new life stressors. Lupien et al. (2009) showed

that the amygdala, which controls fear responses, activates the hypothalamus-

pituitaryadrenal axis (HPA) and stress responses. Vulnerability to new stressors

profoundly impacts the adolescent brain and increases the levels of glucocorticoids

compared to those in the adult brain (Lupien et al., 2009).

Haglund, Nestadt, Cooper, Southwick & Charney (2007) argued that stress during

adolescence is a contributing factor in the development of mental health disorders. They

found that continued exposure to social stress and early adverse events exert a considerable

effect on a person’s physical health, and by age 20, can trigger anxiety episodes and

subsequent depression. Viner et al. (2012) highlighted that biological and psychological

changes in adolescence resulted in many college and university students feeling displaced,

stressed, and isolated. Stress from transitioning from adolescence to collegiate or

university life was seen as the most common and significant risk factor for a mental health

problem (Grosbas et al., 2007; Viner et al., 2012; Sawatzy et al., 2012). Researchers found

that those who had higher resistance to peer pressure had a better time dealing with their

emotions than adolescents who had lower resistance to peer pressure. Low resistance to

peer pressure has resulted in many youth experimenting with alcohol and drugs in order to

fit in and conform to peer pressure (Griffiths, 2013; Spear, 2013; Haglund et al., 2009;

Jorm & Wright, 2008; Grosbas et al., 2007; Purcell et al., 2015; Sawatzy et al., 2012). The

Royal College of Psychiatrists in the UK (2011) reported that more than 29% of students

were having mental health problems causing high levels of psychological distress.

Adolescence is a critical developmental period for brain maturation and identity

development. The transition from adolescence to adulthood, and peer pressure have been

noted as risk factors in the development of a mental illness. With the onset of mental

illness often occurring in adolescence, it is essential to understand the factors that

encourage or deter help-seeking behavior in youth.

Seeking Help for a Mental Illness

Help-seeking is defined as a process of making use of personal and social

relationships, formal (school teachers, counselors), and informal (parents), to seek help in

dealing with a problem (Rickwood, Wilson & Ciarrochi, 2005). There are many factors

that can exert influence on help-seeking behavior. The severity and type of a mental health

problem may strongly influence help-seeking behavior. Two national epidemiology studies

seem to indicate differences in which illnesses people will actually seek help in addressing.

Studies in the United States and Australia have served to indicate the severity and type of

illness as the foundational basis for help-seeking. Mackenzie, Reynolds, Cairney, Streiner,

&Sareen (2012) reported that individuals primarily sought help for panic disorder and

depression but also found that help-seeking rates were higher if comorbid depression and

anxiety or depression and substance use were present. Help-seeking rates for panic

disorder (45.3%) and dysthymia (44.5%) were the highest among adults, particularly

middle-aged adults. There was no reported change in rates for panic disorders throughout

the lifespan. The lowest rate of help-seeking for a mental disorder was for specific phobias

(7.8%), which refer to fear or avoidance of objects or situations. With respect to gender,

more women than men sought help for anxiety disorders, specifically in two age brackets,

20-44 and 65+ (Mackenzie et al., 2012). A study in Australia revealed an imbalance ratio

for those seeking help versus those who met the diagnosis criteria, a phenomenon noted in

many other studies. More than 11.95% of the adult population sought help for mental

health problems in a given year, whereas more than 34.9% met the criteria for a mental

disorder (Burgess et al., 2009; Drapalski et al., 2008). These statistics clearly show that

panic disorder and dysthymia are the two predominant disorders that impel people to seek

treatment for a mental illness (Beardslee, et al., 2011; deGirolamo, Dagani, Purcell, Cocchi

& McGorry, 2012; Mackenzie & Sareen, 2012; Wang et al., 2007). The statistics also

frame the question of why help-seeking percentages are so low when the need is high.

Why Do Many Affected by Mental Illness Not Seek Help?

Global statistics signal that many individuals do not feel compelled to seek help.

According to a WHO study, it can take a person suffering a mental illness several years

before seeking treatment. The median for seeking help ranged from 3 years to 30 years for

anxiety disorders in various countries; specifically, 1 to 14 years for mood disorders and 6

to 18 years for substance use (Wang et al., 2007). In a U.S. national comorbidity study,

44.8% of people diagnosed with a mental disorder did not seek help, and 57% of people

with a mild disorder reported a low perceived need to seek help (Mojtabai et al., 2011). A

low perceived need is defined as having symptoms that do not appear to cause

psychological or social impairment that would impact a person’s life. Those with a

moderate disorder reported a low perceived need for help (39.3%), compared to 25.9% of

those with a severe disorder (Mojtabai et al., 2011). The situation is no different for

adolescents. More than three-quarters of students surveyed in a university study did not

pursue help for their mental health symptoms (Andrade et al., 2014). It has been reported

that youth with high suicidal ideation have the lowest intentions to seek help versus youth

who exhibited low suicidal ideation (Czyz, Horwitz, Eisenberg, Kramer & King, 2013;

Klimes-Dougan, Klingbeil & Meller, 2013). High suicidal ideation affects an adolescent’s

cognition and impedes the help-seeking process (Klimes-Dougan et al., 2013). A belief in

self-reliance and the ability to handle one’s own problems are identified as some of the

most important barriers to help-seeking (Griffiths, Crisp, Jorm & Christensen, 2011; Prins

et al., 2010; Rickwood, Wilson & Ciarrochi, 2005). This trend is associated with a

subjective evaluation of mental health symptoms and is often defined and understood as

help negation.

Help negation manifests in refusal or avoidance in relation to seeking help as

symptoms of a mental health problem increase (Calear, Batterham & Christensen, 2014;

Wilson & Deane, 2010; Yakunina, Rogers, Waehler & Werth, 2010; Yoshioka, Reavley,

MacKinnon & Jorm, 2014). Students with mental health issues may report that their need

for care is not urgent (Eisenberg et al., 2012). They may minimize the severity of their

symptoms, stating that emotional distress is to be expected when attending a college or

university. Many have acknowledged the need for help but reported that they preferred

handling the issue on their own (Eisenberg et al., 2012 ; Reavley & Jorm, 2014). Thus, a

high percentage of people with a mental health problem do not seek help or delay seeking

help. The rates of help-seeking are low among students and those who exhibit minor or

moderate symptoms of mental illness. There is an important need to identify the barriers

that prevent those from seeking help prior to looking at strategies that can foster

helpseeking intentions.

There continues to be much debate among researchers about the barriers that

undermine help-seeking behavior and to explain how the adolescent population responds

to the need for help. Several studies appear to indicate that although adolescents display

positive attitudes about mental health and have low stigma toward people with mental

illness, they still choose not to seek help (Bidle, Donovan, Sharp, & Gunnell, 2007,

Eisenberg et al., 2012; Reavley & Jorm, 2014). However, students of this age may have

difficulty in recognizing the symptoms of a mental health problem, may be uncertain as to

how to obtain help, and may be too embarrassed to confide in others (Reavley & Jorm,

2014). Students have acknowledged not knowing what to do when they experience their

first episode of a mental health problem in university or college (Beardslee et al., 2011;

Reavley &Jorm, 2014; Wilson, Bushnell and Caputi, 2011). Some students have also

reported that their sense of autonomy would be violated if they sought help (Wilson et al.,

2011). It has been suggested that students may see mental health treatment as similar to

nutritious diet and exercise. They recognize that it is important, yet they do not necessarily

want to adopt those healthy behaviors (Wilson et al., 2011). Awareness of a mental health

issue and where to seek help remains an important barrier to help-seeking for adolescents

experiencing a mental health problem during the transition to college and university life.

The subjective evaluation of their mental health symptoms also contributes as a barrier.

Many students question the severity of their symptoms and rationalize why mental health

care services should not pursued on or off campus (Laidlaw, McLellan, & Ozakinci, 2015).

Another mitigating factor that curtails help-seeking behavior is the belief that treatment

options are ineffective or not helpful. More than 16% of university students indicated that

they would not talk to anyone if they experienced a mental health problem based on

negative accounts of other students who sought help (Beardslee et al., 2011). Many

students believed that taking medications would be ineffective, would make them feel

different, and would isolate them from others (Beardslee et al., 2011; Dubow et al., 1990;

Wilson et al., 2011). These attitudes may be explained by a lack of understanding of

medications and their properties and the effects of stigma (Beardslee et al., 2011).

The health care model has also been identified as obstructing help-seeking behavior

among youth. Pottick, Warner, Vander, Stoep & Knight (2014) stated that current mental

health services do not make a distinction between adult and youth needs in the delivery of

mental health services. They found that mental health services for adults were designed for

serious and persistent mental illnesses, and appropriate and age-related services were not

available to meet the needs of youth who might be struggling with emotional and

behavioral problems, precursor symptoms of mental illness (Hoagwood, Burns, Kiser,

Ringeisen, & Schoenwald, 2001; Laidlaw et al., 2015; Kazdin & Rabbit, 2013). The

clinical profile of youth does not often correspond to the designated criteria for service,

and consequently, the expertise of staff is not matched to the clinical needs of children and

youth. Children and youth require clinical services that reflect their developmental needs

and an understanding of the difficulties inherent in the transition from adolescence to early

adulthood (Laidlaw et al., 2015). Pottick et al. (2014) argued that care approaches should

be modeled differently for youth. Sukhera, Fisman, & Davidson (2015) also highlighted

gaps in the continuity of care where youth have difficulty accessing services in the adult

mental health system once they have transitioned to adulthood. They feel a sense of

disconnectedness. While they are no longer children, they are not quite adults. Young

adults are at different developmental stages than older adults and may not experience the

same types of challenges or life stressors such as work, having a mortgage, or raising

children (Spear, 2013). Mental health services need to be age appropriate and tailored to

specific needs. Consequently, transitional mental health services remain a significant gap

in meeting the needs of emerging adults (Bates & Birchwood, 2013; Pottick et al., 2014;

Sukhera, Fisman, & Davidson, 2015; Singh, 2009).

Culture also plays a role in whether adolescents decide to seek help. Guo et al.

(2015) found that ethnic minority youth do not seek help despite a higher need for mental

health treatment compared to European Americans. In a global WHO study, Pescosolido et

al. (2013) argued that cultural perceptions of mental illness have shaped how many

cultures react and respond to mental illness and their attitudes toward help-seeking and

treatment. Many studies have highlighted how adolescents from ethnic groups such as

Mexican, Vietnamese, Chinese, and Latino Americans view mental illness and how their

cultures influence their attitudes and beliefs about mental illness and the need for treatment

(Caplan & Cordero, 2015; Elkington et al., 2013; Chen, Romero, & Karver, 2015; Guo,

Nguyen, Weiss, Ngo & Lau, 2015; Hirai, Vernon, Popan, & Clum, 2015). Researchers

Guo et al. (2015) also found that ethnic groups such as Vietnamese place greater value on

group interest and harmony than on individual concerns. There is an implicit expectation

of restraint in the expression of emotions, where negative-valence emotions are not

encouraged or expressed. For example, many Vietnamese refugees experienced high levels

of trauma during the political crisis and displacement in the early 1980s, yet these issues

are not openly discussed or referred to. Guo et al. (2015) highlighted that help-seeking was

lower among Vietnamese compared to American youth. In addition, family obligations had

a greater impact on decisions to seek help for Vietnamese youth versus American youth.

Youth will often try to convince themselves that their emotional state is not as important as

the interests of the family. For many youth, it is more important not to burden the family

than to seek help for mental health problems (Friedlmeier, Corapci, & Cole, 2011; Louie,

Oh & Lau, 2013).

The reality is different in cultures where independence, individual self-interest,

autonomy and expression are recognized and valued within society such as the United

States and Canada. Emotional expression is considered an important value in

selfactualization and adolescents are encouraged to seek mental health care. Individual

interests often take precedent over family or community expectations (Friedlmeier,

Corapci, & Cole, 2011; Louie et al., 2013). Acculturation and enculturation are two

concepts that impact the influence of culture on adolescents. Acculturation was found not

to have any effect on stigma or help-seeking behavior. However, the study did show that

higher rates of enculturation were associated in not seeking cultural and religious treatment

modalities or no treatment at all (Hirai et al., 2015). Culture is a critical variable in

encouraging or discouraging help-seeking behavior. It also needs to be understood within

the phenomena of acculturation and enculturation, adding a level of complexity to the issue

of help-seeking behavior and receiving treatment.

Many of the factors and barriers described above have resulted in a decline of

positive youth attitudes towards mental health services during the past 40 years.

Mackenzie, Erickson, Deane, & Wright (2014)’s meta analysis found that help-seeking

attitudes have become more negative since 1968. Several researchers (Reavley & Jorm,

2011; Yap et al., 2013) have clearly attributed the effects of stigma to negative youth

attitudes. These studies underline the need to understand the relationship between stigma

and help-seeking behavior in mental illness.

Stigma and Mental Illness

Stigma of mental illness needs to be understood within a historical context. Stigma

is a term born during the Roman Empire and subsequently shaped by many theorists over

the decades. Goffman (1963) first characterized the phenomenon as a “spoiled identity”.

The term implied that a person is publically discredited and rejected by peers in the

community. That person is designated “out of the group”, someone who doesn’t belong

and who loses social status in the community (Link & Phelan 2001). The cause of mental

illness has been the subject of much debate. For decades, the causes of mental illness were

entrenched in the belief that individuals with mental illness had certain personality traits

that could explain their behavior (Schomerus et al., 2012). A person with mental illness

was seen as weak, unstable and deemed not deemed in the sense of a physical illness

(Corrigan & Shapiro, 2010). Community leaders or influencers assisted in reinforcing this

phenomenon by attributing negative characteristics to individuals who did not conform to

their sense of societal standards (Corrigan, Larson & Rusch, 2009). Among the illnesses,

mental illness has the lowest level of public acceptance (Mojtabai et al., 2011).

Perceptions of individuals with mental illness are rooted in a lack of understanding of

mental illness, giving rise to the concept of stigma.

In recent decades, stigma has also been associated with the belief that mentally ill

people are violent and unpredictable (Corrigan, Morris, Michaels, Rafacz & Rusch, 2012).

This view was also supported by some psychiatrists such as Torrey (2011) who declared

that the lack of treatment caused mentally ill people to be violent, a perception often

propagated in the media with reports of mentally ill individuals killing innocent members

of the community. Vivid images of these stories have been extensively profiled in the

media and served to reinforce the perception of dangerousness in individuals with mental

illness, particularly those with schizophrenia or an untreated mental illness (Corrigan et al.,

2009; Jorm & Reavley, 2014). Although medical understanding of mental illness has

evolved, negative perceptions of the mentally ill have led to generalizations and nurturing

of public stigmatizing attitudes. There appears to be no significant gender or age difference

in stigmatizing attitudes, nor influenced by education, employment and ethnicity (Jorm &

Wright, 2012a; Jorm & Wright, 2008; Livingston & Boyd, 2010). The most common

stigmatizing attitude is towards individuals with schizophrenia in comparison to depression

or anxiety (Reavley & Jorm, 2011). Stigma has shown to be the most important barrier to

help-seeking behavior surpassing physical, financial or psychological barriers (Kim &

Zane, 2015). This phenomenon has led the Surgeon

General of the Department of Health and Human Services (USDHHS) to declare stigma as

“the most formidable obstacle to future progress in the arena of mental illness and health”

(Elkington et al., 2013, p. 291).

Researchers (Clement et al. 2015; Corrigan, 2005, 2009, 2012; Link and Phelan,

2001) expounded concepts of stigma, describing the effects of social stigma on individual

attitudes and behaviors but also how stigma affects the person living with mental illness.

Link and Phelan (2001) advanced a social-psychological process where influential

individuals in the community labeled an individual as having negative traits and casting

them in isolation, and resulting in social stigma. This stigmatization process resulted in

labeling and stereotyping of individuals with important and negative consequences on their

lives (Clement et al., 2015; Corrigan 2009; Griffiths et al., 2004; Watson & Barr, 2006).

Individuals seeking treatment perceive the cultural stereotypes of mental illness as unwanted

characteristics and internalize these perceptions about themselves. This social-psychological

process impacts how they feel about their identity, deters help-seeking behavior and

ultimately affects their recovery from mental illness. Many individuals hide their thoughts,

behaviors and symptoms in fear that people would stereotype them if they knew of the

existence of a mental illness (Clement et al., 2015; Corrigan 2009; Griffiths et al., 2004;

Watson & Barr, 2006). These researchers characterized stigma differently. Clement et al.

(2015) and Yap & Jorm (2013) argued that stigma is a multidimensional construct

generating four types of stigmatizing attitudes reinforcing self-stigma and two propagating

public stigma. The first type involves the question of anticipated stigma where the

individual with a mental illness perceives and expects to be treated unfairly. In experienced

stigma, an individual actually has the experience of being perceived and treated unfairly.

This type of stigma was found negatively correlated with quality of life and personal

mastery (Depla, DeGraaf, Weeghel, & Heeren, 2005; Markowitz, 1998). The third type

internalized stigma builds on the concept of self-stigma and causes the individual to

believe the stigmatized view of themselves. A high level of internalized stigma was found

to increase depressive symptoms and lower self-esteem (Livingston & Boyd, 2010; Quinn

et al., 2014;). Stigma also generated a positive correlation to depressive symptoms and

anxiety (Mickelson & Williams, 2008; Werner, Aviv & Barak, 2008). Fourthly, perceived

stigma involves people’s general perceptions of individuals with mental illness as weak

and potentially dangerous, which are by definition stigmatizing. The fifth type is

associated with stigma endorsement where people display stigmatizing attitudes and

behaviors towards those with mental illness. The last type refers to treatment stigma, the

stigma specifically related to seeking or receiving treatment. Individuals with mental

illness are often torn with the decision to receive treatment and whether to tell their family

and friends about their illness and their treatment. Corrigan and Rao (2012) have found

that individuals experience sequential phases of self-stigma from awareness, agreement to

application and harm. Once an individual is diagnosed with a mental illness, the individual

becomes aware of the public stigma of their illness (awareness) and moves to accept the

public view (agreement), begins to apply the stereotypes unto themselves (application).

The last stage involves (harm) to oneself where self-esteem is deflated and the person

manifests low efficacy (Corrigan, Watson & Barr, 2006; Corrigan & Rao, 2012;

Livingston and Boyd, 2010). The cycle revolves around more episodes of self-

discrimination to the point where they isolate themselves from others, choose poor health

behaviors over healthy choices and consequently experience low self-worth (Corrigan &

Rao, 2012). They will also be less inclined to pursue employment opportunities and accept

a lower quality of life due to their devalued sense of self (Bathje & Pryor, 2011). Life

goals are often sidelined and not pursued as the influence of stigma shapes their

assessment of capacities and future hopes (Corrigan & Rao, 2012).

Stigma plays out a little differently for youth than for adults. Youth can experience

the same types of stigma identified above, however the manifestations of stigma are more

explicit among adolescents (Elkington et al., 2013; Yoshioka et al., 2014). With the onset

of mental illness occurring during adolescence, stigma has the power to alter the

development of a healthy identity, the level of acceptance among peers and disrupt a

positive transitional period from childhood to adolescence (Rappaport & Chubinsky,

2000). Youth with mental illness have a fear of rejection, feel socially disconnected or

“less than” others, and discriminated upon by their friends and family, peer and teachers

(Elkington et al., 2013; Moses, 2009, 2010a; Yoshioka et al., 2014). Many youth will

reinforce the notion of self-stigma by denying the existence of a mental health problem;

avoid telling others of their diagnosis and withdrawing from their peers (Elkington et al.,

2013; Moses, 2009, 2010a, Yoshioka et al., 2014). They will also internalized stigma and

believe that their peers have stigmatizing attitudes about them (Busby et al., 2015; Chen et

al., 2015; Elkington et al., 2013). Internalized and perceived stigmas are embedded within

their social relationships as they engage in risky sexual behavior, self harm and low self

esteem. Rusch et al. (2014) and Elkington et al. (2013) contend that ‘labeled’ youth

attribute the stigma of mental illness to their sexual identity, seeing themselves as

undesirable, having little or no choice in choosing their partners or believing that they were

undeserving of positive relationships. Consequently, many youth find themselves in unsafe

sexual relationships in order to avoid rejection and desertion. Youth with mental illness

have recounted experiences of rejection and discrimination in sexual relationships due to

their illness and stigma than youth without a mental disorder.

The veil of stigma is pervasive and systematically wields influence over the course

of a person’s life. Stigma is no longer seen as a minor obstacle but has evolved into a

complex and critical societal issue. It has the capacity to shape attitudes, beliefs and

judgments about those who are healthy and contributing to society, and those who have a

mental illness and consequently a burden to society (Elkington et al., 2013; Jorm &

Wright, 2008; Moses, 2009, 2010a; Yoshioka et al., 2014;). Yap, Reavley and Jorm (2014)

attributed stigmatizing attitudes among youth as the direct cause for low help-seeking

intentions and reinforcing perceptions that help is not very beneficial. Other researchers

demonstrated the link between stigma, attitudes, and help-seeking behavior (Corrigan et

al., 2004; Gary, 2005;Thornicroft, 2008; Schomerus and Angermeyer, 2008). In a review

of more than 144 studies, which included 90,189 participants, Clement et al. (2015) found

a small to moderate negative effect of stigma on help-seeking behavior which has

prevented many individuals from getting mental health treatment. Negative attitudes,

stigma, and shame act as important barriers to seek psychological support (Reynders,

Kerkhof, Molenberghs & Audenhove, 2014). Efforts to lower stigma and increase public

acceptance of mental illness are needed to change stigmatizing attitudes and end the

vicious cycle of self-stigma that prevent youth from getting treatment and reaching their

full potential (Corrigan & Rao, 2012). In an effort to increase the acceptance of mental

illness and encourage help-seeking behavior in youth, an understanding of a behavioral

theory of youth attitudes and mental illness is a valuable starting point.

Health Belief Model, Mental Illness, and Help-Seeking Behavior

The health belief model adapted from Rosenstock (1974) was established as a

theoretical framework based on five constructs that could influence and predict health

behavior and population-based health promotion. The premise is that a person’s beliefs of

a health problem will determine how they assess the perceived severity and susceptibility

to an illness. They will evaluate the perceived health risks, barriers, and benefits and

determine the possibility of taking action towards a healthy behavior. Cues to action may

be internal such as symptom manifestation to external, such as going to a clinic.

Selfefficacy was added as an additional construct in 1988 to reflect a person’s confidence

and ability to undertake an action and change health behavior (Rosenstock, Strecher &

Becker, 1988).

The constructs in the health beliefs model helps to gauge the probability a person

will seek help for a mental illness. In the health belief model, the first two constructs are

where an individual evaluates their perceived susceptibility and severity of developing a

health problem such as mental illness. Under this scenario, a person considers all the

factors, which could make them vulnerable to developing a mental illness including

biological and psychosocial factors, and evaluates the threat that mental illness can happen

to them. Neuroscientific research on the biological underpinnings of mental illness has

generated a better understanding of mental illness as a medical and chronic disease,

particularly for depression and schizophrenia (Angermeyer, Holzinger, Carta &

Schomerus, 2011). An individual will assess psychosocial factors that may have bearing on

their health such at family history, genetics, presence of early-life adverse events, coping

mechanisms in relation to stress and life challenges, relationships and financial concerns

(Jones et al., 2013). The person will evaluate the perceived severity of the mental health

problem. Severity is normally determined by the perception of medical consequences such

as death and social consequences such as family life and social relationships. Level of

psychological distress and functional impairment are generally the principal criteria

influencing the perception of the severity of the problem and whether the resolution of the

problem warrants professional help (Kim & Zane, 2015). Corrigan, Druss and Perlick

(2014) found that self-stigma and public stigma exert a strong influence on an individual’s

perception of their psychological distress and can hinder decisionmaking for seeking care.

They argue that individuals minimize their symptoms of psychological distress to avoid the

contempt or disapproval of other people or are embarrassed and experience shame as a

result of stigma. Social exclusion is an omnipresent concern.

The issue of perceived susceptibility is also associated with mental health literacy

and problem recognition of a mental health problem; particularly if individuals do not

recognize or believe they have a mental health problem (Arria et al., 2011; Henshaw &

Freedman-Doan, 2009; Mcluckie et al., 2014; Perry et al., 2014). Lack of knowledge of

mental health was reported by youth as a barrier to help-seeking (Gulliver et al., 2010).

Eisenberg et al. (2012) found in their study that many college students do not seek help

because they may deny the existence of a mental health problem, are unaware of their level

of distress, or believe the problem will eventually resolve itself. Eisenberg et al. (2012) and

Jorm (2012) argued that poor problem recognition may explain low rates of help-seeking

behavior. Compounded to this issue is the fact that many individuals do not know if their

mental health symptoms are treatable or that treatment is urgent or needed (Goldney,

Fisher, Wilson, & Cheok, 2002). Another construct in the theory is for the individual to

assess the perceived benefits of help-seeking. If a youth has a positive attitude towards

help-seeking and treatment, they would be more apt to making the decision to seek help

versus adopting a negative attitude towards treatment (Digiuni, Jones & Camic, 2013;

Yoshioka et al., 2014). Treatment credibility implies that youth believe that treatment can

be helpful and effective. Under the model, the youth will determine a course of action

based on their evaluation of the perceived susceptibility and severity of having a mental

illness, and belief that seeking treatment will help them return to their regular emotional

state (Kim & Zane, 2015).

Treatment adherence is also attributed to stigma and acts as a perceived barrier

where the adolescent believes that seeking treatment can affect their social status within

their peer network. Cues to action may trigger an adolescent’s decision whether to seek

help or not. The cues may relate to the severity of the symptoms (internal cue) such as

psychological or cognitive impairment or experiencing anxiety (Kim & Zane, 2015).

Should they be afraid or shamed to go to a clinic or hospital for help (external cue), the

probability of co-opting the decision to seek help will be high (Kazdin & Rabbit, 2013;

Laidlaw, McLellan & Ozakinci, 2015). The last construct in the health belief model is

selfefficacy, which may very well be the final step in their evaluation to seek help. Once a

youth recognizes the need for treatment and believes they have the capacity to get better,

they will be more apt to seek treatment for their mental health problem. If their selfefficacy

is low, chances of making the decision to seek help will be negligible and they could deny

the existence of a mental health issue (Eisenberg et al., 2012; Sawatzky et al., 2012).

This health belief model is a simple yet effective theoretical framework that can

shed light on how a person can assess their symptoms of mental illness and how values and

attitudes are manifested in behaviors that support or deter help-seeking intentions. A closer

look at stigma reduction models will facilitate the discussion of what mental health literacy

model can best reduce stigma and encourage help-seeking intentions.

Stigma Reduction Approaches

Since 2000, the WHO in collaboration with national governments across the globe

issued several studies illustrating the pervasiveness of stigma in society and identifying the

mechanisms to address stigma and stigmatizing attitudes (Thornicroft et al., 2015).

Corrigan, Druss and Perlick (2014) contend that reducing stigma is vital to increasing help-

seeking intentions in individuals and engaging in treatment. Stigma reduction has been at

the forefront of many campaigns that have attempted to dispel the negative perceptions and

prejudices of mentally ill individual as weak, dangerous and unpredictable (Corrigan et al.,

2012; Thornicroft et al., 2015). Many researchers have called for the need for coordinated

and continued efforts to reduce stigma and improve on the lives of people suffering from

mental illness (Pescosolido, Medina, Martin & Long, 2013; Thornicroft et al., 2015).

Approaches to stigma reduction have generally been conducted as community at large or

school programs. Some programs address stigma as an general issue while others target

specific forms of stigma separately: self-stigma for those living with the illness (Mittal,

Sullivan, Chekuri, Allee & Corrigan, 2012) and public stigma, the stigmatizing and

discriminatory attitudes individuals in society have towards people with mental illness

(Thornicroft et al., 2015; Corrigan et al., 2012).

Reducing self-stigma within individuals living with a mental illness can be a

challenging behavioral and social issue. Many studies have targeted high-risk groups such

as young adults attending college or university who experience their first bouts of

psychological problems. A person with mental illness can internalize the stereotype, suffer

low self-esteem and undervalue their abilities and capabilities (Corrigan & Shapiro, 2010;

Corrigan, Larson & Rusch, 2009). Other researchers argue that self-stigma is not an

inescapable curse (Corrigan & Rao, 2012). They recommend structured programs or peer

support that would enhance personal empowerment in order to reduce self-stigma

(Corrigan & Rao, 2012). Mittal et al., (2012) found that psychoeducation alone or in a

combination with cognitive restructuring were very effective in decreasing self-stigma.

Outcomes included higher coping skills and improvements in self-esteem, and helpseeking

behavior. The authors believe that these strategies could also be effective with victims of

natural disasters or life traumatic events.

In dealing with public stigma, Corrigan et al. (2012); Corrigan and Rao (2012) and

Corrigan and Shapiro (2010) have categorized three predominant strategies that strive to

challenge stigmatizing attitudes. Corrigan et al. (2012) labeled them protest, education and

contact. Protest implies an organized action where individuals want to discredit the public

stigma imposed on people living with mental illness. This approach has taken the form of

public awareness and anti-stigma campaigns by groups such as the National Alliance on

Mental Illness in the US and Canada, Time to Change in the UK and Beyond Blue in

Australia. They have been recognized as the most noted and effective campaigns to reduce

public stigma (Beldie et al., 2012; Pescosolido et al., 2013; Schomerus et al., 2012;

Thornicroft et al., 2015; Thornicroft et al., 2012). The second approach consists of

educational strategies aim to generate awareness of mental illness and boost mental health

literacy (Chisholm et al., 2012; Mcluckie, Kutchner, Wei & Weaver, 2014; Mendenhall &

Frauenholtz, 2015; Skre, et al., 2013; Wei, Kutcher, Hines & Mackay, 2014; Wei, Kutcher

and Szumilas, 2011). Studies have demonstrated that an increase in mental health literacy

is correlated with a reduction of stigma. It also reduces social exclusion of people living

with mental illness and can encourage help-seeking behavior. The third strategy involves

contact with people who live with a mental illness. It may take the form of direct contact

with people with a mental illness present at an organized event or indirect contact, where a

video or vignette is shown on a personal story of someone with mental illness.

Notwithstanding the low number of research trials on the effectiveness of contact,

researchers have found that contact with people living with a mental illness generated

positive changes in attitudes and reduced discrimination towards people living a mental

illness (Beldie et al., 2012; Corrigan et al., 2010; Corrigan & Rao, 2012; Thornicroft et al.,

2015).

The researchers highlighted the caveat that social contact was more effective in the

short term but low on long term outcomes (Thornicroft et al., 2015). Corrigan et al. (2012)

found differences in how adults and youth reacted to programs aimed at reducing stigma.

They found that adults responded more effectively to contact with people with lived

experience while youth responded more effectively to educational methods (Thornicroft et

al., 2015). Other reviews found inconclusive results whether education or contact-based

programming was the best method to achieve stigma reduction (Reavley & Jorm, 2014;

Schomerus et al., 2012).

Reducing self and public stigma in mental health remains important goals in

encouraging youth and adults to seek help for mental health problems. In understanding

stigma as a complex social construct, several strategies are needed at the personal,

organizational and societal level to change people’s perceptions of those living with mental

illness, and to encourage those who are suffering to seek help without shame. Fostering

understanding of mental illness through mental health literacy programs has been found to

be very effective among the youth (Chisholm, Patterson, Torgerson, Turner and

Birchwood, 2012; Mendenhall & Frauenholtz, 2015; Mcluckie et al., 2014; Skre et al.,

2013; Wei et al., 2011). Mental health literacy has taken the form of educational programs

in schools and in communities that have demonstrated important shifts in attitudes and

behaviors towards people living with mental illness and encouraging those with mental

health programs to seek help.

Mental Health Literacy

Jorm (1997) wanted to create public knowledge of mental illness in the same

manner the public learns of chronic disease. He made a clear distinction between mental

health literacy and mental health intervention. Mental health literacy is characterized as the

“knowledge and beliefs about mental disorders which aid their recognition, management

or prevention” (Jorm, Wright & Morgan, 2007, p. 182). Wei et al., (2013) further extended

the definition to embody knowledge and skills that examines the biological, psychological

and social aspects of mental disorders in addition to instilling help-seeking behavior in

youth and enhances their understanding of the pathways to mental health care (Wei et al.,

2013). Jorm et al. (1997) categorized four types of interventions to improve mental health

literacy: public information and community campaigns; campaigns targeted to youth

population; school-based interventions (help-seeking and mental health knowledge), and

mental health crisis intervention training. This review will focus on school-based

interventions to improve mental health literacy among the youth population.

School-based interventions better known as educational mental health literacy

programs developed rapidly over the past two decades in Australia, United States, UK and

Canada to reach a greater number of youth (Chisholm et al., 2016; Chisholm et al., 2012;

Mcluckie et al., 2014; Mendenhall & Frauenholtz, 2015; Skre et al., 2013; Wei et al.,

2011). The principle objective was to reduce stigma and encourage youth to seek early

intervention of their mental health problems (Kauer et al., 2012). However, the state of

evidence on the effectiveness of mental health literacy interventions continues to remain in

infancy with respect to demonstrating knowledge enhancement, fostering attitude change,

or help-seeking behavior in youth (Kutcher et al., 2013; Pinto-Foltz et al., 2011; Wei et al.,

2013; Yamaguchi, Mino and Udding, 2011). Schachter et al. (2008) argued that poor

research methodology; design and unreliable data prevented any significant body of

evidence in mental health literacy and minimized the level of effectiveness of mental

health literacy programs. With greater awareness of mental health on a societal level, there

has been a recent surge of interest by researchers around the globe dedicated to resolving

this quandary in youth mental health research.

One of the most extensive, systematic review on the effectiveness of mental health

literacy programs was conducted by Wei et al. (2013) and included the participation of

more than 13,798 high school and 3,845 post-secondary students. The review highlighted a

number of programs that have been evaluated as randomized control trials to quasi and

controlled-before and after studies. To date, eight randomized control trials have been

conducted in North America (Esters et al., 1998; Kelly and Jorm, 2007; Kutcher et al.,

2013; Pinto-Foltz, Logsdon and Myers, 2011; Wei et al., 2013; Yamaguchi, Mino and

Udding, 2011), one in Norway (Skre et al., 2013) and two in the UK (Chisholm et al.,

2016). Educational programs were designed in two streams: programs that addressed

mental health and the range of mental illnesses and programs focused on specific disorders

such as depression, anxiety and schizophrenia (Wei et al., 2013). The structure of the

programs also varied. Some programs incorporated mental health curriculum in existing

health promotion programs such as Beyondblue and MindMatters, (Kelly, Jorm & Wright,

2007) or offered as workshops or courses such as HeadStrong (Perry et al., 2014). Several

programs were tailored for stigma reduction and attitudinal change towards people with

lived experience (Naylor et al., 2009; Pinfold et al., 2005; Yoshioka et al., 2014) while

others were focused on encouraging positive attitudes towards help-seeking (Chan,

Batterham, Christensen & Galletly, 2014; Taylor-Rodgers & Batterham, 2014). Some

other programs were presented as community-based interventions such as In Our Own

Voice in the United States (Pinto-Foltz, Logsdon and Myers, 2011). The duration of

programs ranged from 40 minute educational sessions (Spagnolo, Murphy & Librera,

2008); 3 hour lectures and videos on depression, diagnosis to treatment (Swartz et al.

2010) to longer programs that include on average 6 weekly sessions (Pejovic-

Milovancevic et al., 2009; Watson et al., 2004). Some researchers evaluated the factors or

program components that measured the effectiveness of improving mental health literacy.

Several programs have been recognized for increasing knowledge and understanding of

mental illness and in some cases, encouraged youth to seek help should they experience a

mental health program.

BeyondBlue is a 50-school mental health literacy study in Australia (Sawyers et al.,

2010). It is the first and most successful mental health literacy program established in

2007. It was structured as in class curriculum that included 30 sessions progressing from

Grades 8 to 10 and focused on the development of resiliency skills. Findings revealed

small changes in youth attitudes and help-seeking behaviour for mental health problems,

yet did not decrease depression rates for youth. SchoolSpace was a feasibility trial of a

mental health literacy program targeted to 7 secondary school with students aged 12-13

years old in the UK with an experimental condition where students received information

on mental illness and contact with students with lived experience, and an active control

condition where the students received information but no contact with someone with lived

experience (Chisholm, Patterson, Torgerson, Turner & Birchwood, 2012). The program

was of 4-hour duration. The study was finally conducted in 2014-2015 with the results

published in 2016. They found mental health knowledge increased but they found that

intergroup contact in addition to education did not reduce stigmatizing attitudes. Our Own

Voice was a 1-hour intervention for 10 weeks among adolescent girls 13-17 years old in

two U.S. high schools. The program is structured on the storytelling approach, video

presentation and discussion covering signs and symptoms of mental illness, personal

experiences, information on the range of mental illnesses and potential treatments. Mental

health literacy did not immediately improve following the program; however, noted

changed were recorded at 4 and 8 weeks post intervention. While literacy increased,

stigma of mental illness remained (Pinto-Foltz, Logsdon & Myers, 2011). Mindwise was a

mental health literacy information campaign inspired by the Australian Beyondblue

Campaign and targeted to university students and to staff as a secondary audience to

improve mental health literacy, encourage help-seeking behavior and decrease

psychological distress. The Mindwise was a cluster-randomized trial on a number of

campuses. Messages were delivered to students in nine paired campuses in course unit

guides with brochures, campus website, twitter, emails to students and campus special

events on mental health literacy for a two year period. Findings were not significant and

marked low improvement in mental health literacy, and help-seeking behavior (Reavley et

al., 2014).

Mental health for everyone, is a 3 day school program targeted to more than 1070

adolescents, aged 13-15 years old in three Norwegian schools. The objective was to improve

knowledge of the signs and symptoms of mental illness, reduce prejudiced attitudes about

people with mental illness and educate them on where to seek help (Skre et al., 2013). The

program consisted of videos, student tasks that focused on self-awareness and identity,

wellness and mental health problems. The study found significant increases in knowledge

and recognition of mental illness in the intervention group in comparison to the control

group. There was a small change in youth who had prejudiced beliefs about mental health

problems. Interestingly, the researchers found a correlation between prejudiced beliefs and

knowing where to seek help (Skre et al., 2013). The higher the prejudiced views, the lower

chances of seeking help. Yap et al., (2011) assessed youth skills in a first aid mental health

literacy program using vignettes through a telephone survey with a 2-year follow up. They

interviewed more than 3,746 Australian youth ranging from 12 to 25 years old. They

evaluated youth’s attitudes of people with mental illness on three beliefs and whether these

beliefs were related to help-seeking behavior. The three beliefs included: i) believing

whether a person was weak and not sick, ii) social distance (desire to maintain distance from

the mentally ill person) and iii) whether the person believed the mentally ill person was

dangerous and/or unpredictable. They found that youth attitudes were linked to their

intentions of seeking help should they have a mental health problem as characterized in the

vignettes. The higher the belief the person was weak, the lower the intention to seek help,

while a belief in seeing the mentally ill as more dangerous or unpredictable increased the

likelihood of seeking help (Yap et al., 2011).

The majority of mental health literacy programs generated only minor gains in

students’ attitudes or knowledge or help-seeking behavior (Wei et al., 2013). It is

important to recognize that most of the educational interventions evaluated occurred

between 1983 and 2009, with more than 11 studies during 2008-2009. Wei et al. (2013)’s

study supports other researchers’ findings that existing educational programs have not

significantly changed current attitudes of mental illness, whether they are explicit or

implicit (Mackenzie et al., 2014; Brohan et al., 2014;Wei et al., 2013 and Skre et al.,

2013). Chisholm et al. (2012) found that school interventions were based on several

intervention methods with little comparability. Yamagucci, Mino and Uddin (2011)

examined the effects of educational interventions on more than 34 studies. They evaluated

whether an educational intervention, face to face contact with a person with lived

experience or video-based contact improve mental literacy awareness and reduced stigma.

They found that different educational strategies using direct or indirect contact with

persons with lived experience, and presentations by mental health professionals did

generate important changes in literacy and stigma. Specifically, 18 of 23 studies reported

significant improvements in mental literacy knowledge while 27 of 34 studies yielded

significant changes in attitudes towards people with mental illness. However, the studies

did not measure long-term changes or help-seeking intentions. In another substantive

review, Wei, Kutcher and Szumilas (2011) concluded that no educational program

addressed the beliefs and dispelled myths of the dangerousness of people with mental

illness, provided a balanced perspective on the biological and psychosocial causes of

mental illness, and included a forum of interaction between youth and people with lived

experience of mental illness. Such a combined program may be more efficacious in

meeting the objectives of mental health literacy and stigma reduction. In the current

review, there appears to be no multi-component program that combines information about

mental illness, contact with people of lived experience in addition to ways youth can seek

help.

Summary

In conclusion, the literature has described the social and psychological impact

mental health, and stigma can have on youth and their development, and the role and

power stigma plays in fostering negative misperceptions and beliefs of people with mental

illness. Stigma has resulted in many people feeling isolated and alienated, not seeking help,

and consequently not pursuing educational or professional aspirations. Governments

around the globe and stakeholder groups have promoted efforts to correct the

misperceptions many people have in regards to individuals living with a mental illness, and

to improve inclusion within their communities. Public stigma and internalized stigma are

not only experienced in adulthood, but is omnipresent in adolescence as youth develop

their identities and social networks. While the nature and content structure of mental health

literacy programs have varied significantly in schools and countries around the globe,

researchers have concurred that mental health literacy is a valuable tool in reducing stigma,

helping change people’s attitudes on the mentally ill, and fostering better understanding of

the need to seek help. The body of evidence on the effectiveness of mental health literacy

programs is growing and will remain important until a full-fledge program model can

replicate consistent results demonstrating overall effectiveness of mental health literacy

program in reducing stigma, and encouraging young people to seek help should they

experience a mental health problem.

The purpose of this study is to evaluate a multifold educational mental health

program that aims to affect mental health knowledge, stigma about mental illness and

promote help-seeking intentions in young people. The evaluation will determine whether

the combination of awareness and understanding of the biological and psychosocial causes

of mental illness, interaction with people with lived experience, and coping strategies in a

presentation is effective at affecting stigma and encouraging help-seeking intentions. In the

next Chapter, a description of the study design will be described in addition to the selection

of students as participants and the process for the quantitative study.

Chapter 3: Research Method

Introduction

This quantitative study, a randomized controlled trial, examined whether a mental

health literacy program can foster mental health knowledge, lessen the influence of stigma,

and encourage help-seeking intentions among college students. The onset of mental illness

has often been identified as occurring during adolescence. Many youth experience stigma

in relation to mental illness, which prevents them from seeking help. Mental health literacy

presents an opportunity to diminish the influence of stigma in fostering misperceptions of

people with mental illness and discouraging students from seeking help should they

experience a mental health problem (Chan et al., 2014; Elkington et al., 2013; Yap,

Reavley & Jorm, 2013; Yap, Reavley & Jorm, 2011; Yoshioka et al., 2014). Wei et al.

(2011) argued that an effective mental health literacy program should include an

explanation of biological and psychosocial factors that contribute to the development of

mental illness, should dispel myths, and should include an interactive component so that

individuals can hear personal stories of people living with mental illness and how they

sought help. The independent variable (IV) for the study was the mental health literacy

program, and the dependent variables (DV) were knowledge, stigma, and help-seeking

intentions.

This chapter consists of the research design, approach, and rationale of the study. It

also describes the setting and study design, including sample size and instruments used to

measure the three identified dependent variables.

The research questions and associated hypotheses were as follows:

RQ1—Quantitative: Can a multifaceted mental health literacy program affect

mental health knowledge?

Null hypothesis: There is no difference in mental health knowledge between

students who participated in the mental health literacy program and

students who did not receive the program.

Alternative hypothesis: There is a difference in mental health knowledge

between students who took the mental health knowledge program

and students who did not partake in the program.

RQ2—Quantitative: Can a multifaceted mental health literacy program affect

stigma?

Null hypothesis: There is no difference in stigma between students who

received the mental health literacy program and students who did

not participate in the program.

Alternative hypothesis: There is a difference in stigma between students

who received the mental health literacy program and students who

did not participate in the program.

RQ3—Quantitative: Can a mental health literacy program affect help-seeking

intentions among youth?

Null hypothesis: There is no difference in help-seeking intentions between

youth who participated in the mental health program and students

who did not participate in the program.

Alternative hypothesis: There is a difference in help-seeking intentions

between youth who participated in the mental health program and

students who did not participate in the program.

Nature of Study

This study was a randomized controlled trial experimental study with a posttestonly

control design. A posttest-only control design was chosen as the primary research method

rather than adopting the traditional pre- and posttest control research design. A posttest-

only control group design is considered a strong experimental research design and was

selected over a pretest and posttest control group design based on several factors

(Campbell & Stanley, 1963; Marczyk, DeMatteo & Festinger, 2010). This type of design

also minimizes effects of maturation and interaction (Campbell & Stanley, 1963; Trochim,

1980). This design is also effective against single-group, multiple-group, or social

interaction threats that are found in other experimental designs (Marczyk, DeMatteo, &

Festinger, 2010). The objective of the posttest-only control only design was to measure a

cause-to-effect relation, which this research design enabled effectively. A pretest is often

used when researchers are trying to determine compatibility of groups; however, Trochim

(1980) argued that groups in a posttest-only control design are considered equivalent from

a probability standpoint. The study involved an experimental group of college students

who accepted an invitation to participate in the Is It Just Me? program and completed the

survey following the program and a control group who completed the survey prior to

participating in the Is It Just Me? program (control group) in April 2017.

About the Program Is It Just Me?

In the Is It Just Me? Program, young clinicians delivered a 2-hour presentation in

an interactive and open conversation with youth on mental illness and mental wellness.

The presenters included a psychologist, social worker, addiction counselor, neuroscientist,

and person with lived experience of mental illness. Segments of the program addressed

how the brain functions; what is known about mental illnesses such as depression, anxiety,

substance use, eating disorders, psychosis, and comorbidities; coping strategies; and the

personal story of a young person who lives with mental illness. A Q & A session is

offered. Is It Just Me? has been offered to Algonquin College and local high schools for

the past 6 years and has generated strong interest among students and teachers. The

program was developed as a result of two high-profile youth suicides, in which the victims

were the daughter of a local NHL hockey coach and the son of a municipal councilor.

Schools and parents expressed the need to educate adolescents on mental health and

mental illness. More than 14,000 students have participated in the Is It Just Me? program

since 2011.

Research Design and Approach

This research study evaluated whether a multifold mental health literacy program

fostered knowledge and resulted in less stigma in addition to encouraging help-seeking

intentions among students. The evaluation determined whether the combination of the

biological and psychosocial causes of mental illness, interaction with people with lived

experience of mental illness, and information on coping strategies, as delivered in a 2-hour

session, was effective in increasing knowledge, reducing stigma, and encouraging

helpseeking intentions.

Sampling Strategy

The sampling strategy for this study was non random sampling of students from

programs whose faculty expressed an interest in the Is It Just Me? program. Probability

sampling was not feasible among the college population due to the nature of the program

and the fact that it needed to be offered in a classroom setting. There was no ability to

randomly select college students to participate in the study. Faculty from child and youth

counseling and police foundations programs were interested in having the program as a

complement to their curriculum on mental health. Certain dates were selected in April

2017 before end-of-term exams. Random assignment was used to randomize college

students to the experimental group (Group A), whose members participated in the Is It Just

Me? program and completed the survey following their attendance of the program, and the

control group (Group B), whose members completed the survey before participating in the

program. The inclusion criteria applied to all registered students at Algonquin College.

The only exclusion criterion was inability to understand English.

Recruitment Procedures

The program and survey were conducted from April 6 to April 10, 2017. All

professors wanted to ensure that all of their students had access to the program, which

constituted one of the conditions of the Research Ethics Board. Students received a random

ID number and an information letter and consent form as they entered their classroom.

They had the opportunity to read the information letter and decide whether they wanted to

participate in the survey. Students were also told that they could stop at any time during

the survey if they were feeling uncomfortable. They were also informed that they could

speak to the team of clinicians in the program following the program as an informal

debriefing activity. Once students had made their decision to accept or not accept the

invitation to participate in the survey, they turned the consent form over, and I collected

the forms. Students with odd numbers were placed in the control group, which constituted

Group B, and were provided a specific link to the survey. Students with even numbers

were placed in the experimental group (Group A) and completed the survey at the end of

the program; these students were given a different survey link.

Sample Size

The desired sample size for this study was 102 students: 51 in Group A, the

experimental group, and 51 students in Group B. GPower was used for measuring the

difference between two independent means (two groups) with an alpha of 0.05, an effect

size of 0.05, and a power of 0.80. For this study, the required sample size was 51 for each

group, for a total of 102.

Data Collection Instruments

Three existing scales were used for the dissertation study. The first scale used was

the Mental Health Knowledge Scale (MAKS), which was developed by Evans-Lacko et al.

(2010) to measure mental health literacy. Mental health literacy is often characterized as

knowledge of mental illnesses and an understanding of their symptoms and treatments, as

well as how to seek help (Wei et al, 2013). Studies have demonstrated that an increase in

mental health literacy is correlated with a reduction of stigma (Mcluckie, Kutcher, Wei, &

Weaver, 2014). The MAKS is the first psychometrically tested scale to measure

knowledge of mental health applicable to a population base. MAKS measures 6 areas of

mental health knowledge (help-seeking, recognition, support, employment, treatment, and

recovery) and 6 items on knowledge of mental illness conditions (Evans-Lacko et al.,

2010). This scale involves measuring the responses to 12 items rated on an ordinal scale (1

to 5). Items rated strongly agree are set at 5, whereas 1 point is linked to strongly disagree

and 3 is rated as neutral. The survey took approximately 1 minute and 23 seconds to

complete. The internal reliability has a Cronbach’s alpha (a) of 0.71, and the test-retest

reliability is rated as moderate to substantial (Evans-Lacko et al., 2010). This scale has

been tested in the 25 to 45 adult age categories during the course of three studies. The

authors argued that the MAKS scale (knowledge) can measure how knowledge can lead to

changes in attitudes and behaviors (Evans-Lacko et al., 2010).

A total score for the MAKS is created by averaging Items 1 through 6, with Item 6

reverse scored so that the correct response is associated with a higher score. Participants

answered on a 5-point Likert scale and indicated whether they agreed strongly (5) or

disagreed strongly (1) with each of the questions, with “don’t know” coded as neutral (3).

Higher scores indicated greater mental health knowledge.

For purposes of this study, the MAKS scale was modified to minimize a ceiling

effect and included an additional question, “Do you think clinicians/researchers know the

causes of mental illness?” with answer options ranging from agree strongly (5) to disagree

strongly (1) and “don’t know” coded as neutral (3).

The modified scale score therefore included 7 items averaged to compute a total

score, with higher scores indicating great mental health knowledge. Further, participants

were also asked whether they considered a list of 6 conditions as a type of mental illness

(depression, stress, schizophrenia, bipolar disorder [manic depression], drug addiction, and

grief). Likert scale answers ranged from agree strongly (5) to disagree strongly (1), with

“don’t know” coded as neutral (3). Higher scores indicated greater mental health

knowledge, and Items 8 and 12 were reverse scored and are presented separately from total

scores. The modified scale results are shown separately from the main findings to maintain

the integrity of the scale used for this study and to respect the protocol relating to this scale

(Appendix D).

The second scale used was the Reported and Intended Behaviour Scale (RIBS),

which measures stigma-related behavior (Evans-Lacko et al., 2011). Researchers have

argued that behaviors are at the core of discrimination. This scale was used to assess a

person’s actual behavior and future behavior toward people with mental illness using

hypothetical vignettes (Evans-Lacko et al., 2011; Thornicroft et al., 2007). The RIBS

(2011) was built on an original scale by Star (1952) called The Star Social Distance Scale,

which measured people’s attitudes of social distance toward people with mental illness.

The RIBS scale was used to measure intended stigma-related behavior and to evaluate the

effectiveness of an educational intervention aimed at reducing stigma about mental illness

(Evans-Lacko et al., 2011). There were eight items in RIBS measuring intended behavior.

The scale evaluated reported and intended behaviors toward an individual with a mental

illness in four contexts: (a) living with, (b) working with, (c) living nearby, and (d)

continuing a relationship with someone who has a mental health problem. The first four

items measured reported behavior using yes/no options, and the last four items measured

intended behavior using a 5-point ordinal scale ranging from strongly agree (5) to strongly

disagree (1), with “don’t know” in the middle with a score of 3. Overall test-retest

reliability was 0.75. The sample for the three studies conducted in the development of the

scale was 495 adults. On average, it took 1 minute and 1 second to complete the online

questionnaire. The overall internal consistency-based Cronbach’s alpha (a) was 0.85

(Evans-Lacko et al., 2011). The scale has been population-based and can be applied to the

general population. Another advantage is the feasibility of adding this scale to an existing

survey without significant additional response time for respondents (Evans-Lacko et al.,

2011). The total score for the RIBS was computed by adding Items 5 through 8.

Participants answered using a 5-point Likert scale and indicated whether they agreed

strongly (5) or disagreed strongly (1) with each of the questions, with “don’t know” coded

as neutral (3). Higher scores indicated reduced mental health stigma and a greater

likelihood of willingness to live with or nearby, work with, or continue a relationship with

someone with a mental health problem.

The third scale was the General Help-seeking Questionnaire (GHSQ; Wilson et al.,

2005), which assessed a student’s future help-seeking intentions from different sources and

for different problems. This questionnaire explored whom youth and young adults would

consult when dealing with two problem-type issues: (a) having suicidal ideation and (b)

experiencing personal-emotional problems. As one scale, the questionnaire generated a

Cronbach’s alpha a = .83 and test-retest reliability, assessed over a 3-week period, of .88

(Wilson et al., 2005). Wilson et al. (2005) also tested the properties of the questionnaire as

two separate scales (one scale measuring decision making with suicidal ideation and one

scale measuring personal emotional problems). In this study, for the first type (suicidal

ideation), the Cronbach’s alpha was a = .83, with a test-retest reliability over a 3-week

period of .88, and for the second type (personal-emotional problems), Cronbach’s alpha

was α = .70, with a test-retest reliability assessed over a 3-week period of .86 (Wilson et

al., 2005). One of the two questions in the questionnaire was “If you were having a

personal or emotional problem, how likely is it that you would seek help from the

following people?” Each question followed a Likert rating scale, and students were asked

to rank how they would respond from 1 (extremely unlikely) to 7 (extremely likely) for

each help option. The 10 help options included intimate partner (e.g., girlfriend, boyfriend,

etc.), friend, parent, family member, doctor, and “no one.” This questionnaire’s format has

been recognized for its flexibility and introspective quality in capturing future helpseeking

intentions for specific problems and is an important tool in mental health promotion and

early intervention among adolescents (Wilson et al., 2005).

Participants were asked to indicate whether they were extremely unlikely (1) or

extremely likely (7) to seek help from someone, such as an intimate partner (e.g., girlfriend,

boyfriend), unrelated friend, parent, or phone helpline, among other sources. Higher scores

indicated greater likelihood of help-seeking intentions from a greater number of persons.

The GHSQ scale produced a total score (sum of 18 items) and two subscale scores (sum of

9 items each), one for personal/emotional problems and another for suicidal thoughts.

Data Analysis

The data was analyzed using the statistical software package SAS (2013), the

Statistical Analysis System, a fourth generation programming language used in social

sciences research. t Tests were the chosen data analysis method, as it is known to be

effective in analyzing the effect of the outcome variable, the mental health literacy

program. t Tests are as effective as one-way Analysis (ANOVA) and regression analysis

and research has found that these three data analysis methods generated the same type of

results (Trochim, 2006). Age and gender were collected in the survey, but random

assignment equalized effects that age and gender had on the outcome variable. They were

reported as valuable demographic information. With respect to the predictor/variable of

knowledge, if the hypothesis was rejected, there would be a difference of mental health

literacy between those who participated in the program versus students from schools who

did not participate in the program. With the predictor/variable of stigma, there would be an

effect on stigma between students who receive the mental health literacy program versus

students who did not participate in the program. The third predictor/variable will determine

whether a mental health literacy program has a statistically significant effect on help-

seeking intentions among youth. Independent samples, 2 tailed t tests were conducted to

compare group means on the MAKS total scale scores with α set at .05.

The Pearson product-moment correlation coefficient and the Spearman rank-order

correlation coefficient were used to explore the strength of the association between stigma

and help-seeking behaviors.

Protection of Participants’ Rights

All participants signed informed consent prior to the beginning of the survey. The

information letter stipulated that students had the right to participate, refuse or withdraw

from the study at any time. No additional communication was conducted with those who

wish to withdraw. To protect participant confidentiality, no identifying information was

collected and all questionnaires received a random ID number. No individuals were

identified in any reporting of the study findings. The data and information obtained were

stored electronically on a password-protected computer. The author was the only one with

access to the data from completed surveys. Once the student completed the online

selfadministered survey, this protocol signified the participant’s consent and

acknowledgement of the study.

Ethical Considerations

No data collection process was initiated until approval was obtained by the

Research Ethics Board of the Royal Ottawa Mental Health Centre in addition to the

Research Ethics Board of Algonquin College for a study among their student population.

A Walden University’s Institutional Review Board (IRB) was also received for data

analysis of secondary data, which had been authorized by the Royal Ottawa Mental Health

Centre and Algonquin College. Each student had the right to participate or withdraw from

the study as indicated on the informed consent form provided to the student. Each student

was informed about resources available should they experience any level of stress as a

result of participating in the program and/or completing the self-administered

questionnaire (survey). In analyzing all the potential ethical considerations, the study did

not appear to put students in any significant risk and helped them gain better understanding

on how mental health literacy can reduce stigma and help those with mental health

problems get the help they need and deserve. Hence the risk/benefit ratio was excellent.

Threats to Study Validity

Many threats can affect the validity of a study, which vary according to research

design. Creswell (2009) argued that internal validity matters in studies that look at a causal

relationship between independent variable and dependent variables. The objective in a

posttest-only control design is to measure outcomes, whether any observable change can

be attributed to the intervention. In non-random sampling, students agreed to participate in

the program and complete the survey before or after the program. Consequently, no testing

or instrumentation threats were present (Creswell, 2009). There was very little opportunity

for design contamination where students in the experimental group could compare notes

about study expectations with students in the control group. One disadvantage of this

design is the fact that a researcher cannot fully measure changes in attitudes or behaviors

between the groups within classroom and school clusters (Corrigan, 2000). Social threats

can surface since human interaction is the basis of research activity, however, if

experimental group and control group are distinct and chosen in different schools, the

probability of social bias is well guarded (Social Research Methods, 2015).

Frankfurt-Nachmias & Nachmias (2008) cautioned that if a study is effective at

controlling internal validity in causation type experimental studies, then the question of

generalization becomes an issue since it affects external validity. External validity in this

study was not be comprised given that students will be in a natural setting similar to their

classroom. Self-report questionnaires have the potential to affect validity; however, all

questionnaires have shown good reliability and validity (Grotle, Garratt, Krogstad &

Stuge, 2012) reducing this concern.

Delimitations

This study was limited to college students and did not include high school students

in light of their designation as a vulnerable population in research for a student

dissertation. This study involved the only English speaking college in Ottawa and no other

community college. This research study was offered in English and not in French, which

could impact the generalization of the study. Evaluating students following a 2-hour

program did not fully evaluate student attitude or behavior but rather gave an indication of

student attitudes with respect to mental illness, and how stigma can influence their current

perceptions of mental illness and their decision to seek help should they experience a

mental health problem. Behavioral change would need to be measured over a longer

timeframe to determine the impact of the educational intervention (Eisenberg et al., 2012;

Pham, Hawley McWhirter & Murray, 2014). For that reason, this study gauged

helpseeking intentions among students, and not help-seeking behavior. During that 2-hour

timeframe, students did not have the time to process or reflect on information presented,

nor at another level, consolidate the information and translate that into an attitudinal or

behavioral change (Chisholm et al., 2016; Milin et al., 2016; Mcluckie et al., 2014).

Information on mental wellness was presented as part of the mental health literacy

program; however, the study did not explore the retention of knowledge of positive and

good mental health (Milin et al., 2016).

Stigma is also a complex construct that involves a level of complexity in

measurement. The scales proposed in this study cover key elements of stigma but did not

examine in totality the perceptions of dangerousness and unpredictability that contribute to

stigmatizing attitudes towards people with mental illness (Corrigan & Rao, 2012).

Measuring impact two hours following the educational intervention did not determine the

real impact of the intervention without a larger and longer trial. Generalization of results

were also limited to the college level surveyed, and can’t necessarily be generalized to

students in the provincial college system, or high school system (Chisholm et al., 2016;

Mackenzie et al., 2015). Geographical data was not analyzed to explore whether there are

differences between youth in urban and rural areas and whether it may influence attitudes

towards mental illness and willingness to seek help (Ungar et al., 2013; Yu et al., 2015).

Limitations

Studies have shown that social desirability can influence participants (Evans-Lacko

et al., 2011; Thornicroft, 2007). Both the MASK and RIBS scales may have had the

potential to create social desirability where participants, students respond in a manner that

will please the researchers. It is sometimes difficult to predict how students will respond

and anticipate how much social desirability can affect the quality of the response

(Henderson et al., 2012). However, it has been noted that if the scale is completed online,

social desirability can decrease. While the MASK scale can assess stigma and knowledge,

it becomes more effective when combined with an instrument such as RIBS that measures

attitudes or behaviors (Evans-Lacko et al., 2011). Social desirability was also a noted

limitation of RIBS yet the authors could not determine the extent of the ceiling effect

(Evans-Lacko et al., 2011). The ceiling effect was potentially a factor that needs to be

considered in the MASK scale. In recent pilots, the high response rates and answers of

college students highlighted the potential issue of the ceiling effects. In the two surveys,

students’ rates were considered very high lending the hypothesis that the baseline of

responses that could be generated was likely due to the ceiling effect.

Another limitation was the potential interpretation of the reported behavior for each

individual in a brief evaluation period of 5 minutes. While a self-administered

questionnaire can elicit quick responses, it can also lead to misinterpretation of behavior on

the part of a respondent, something a face-to-face interview could eliminate (Henderson et

al., 2012). Furthermore, the effects of attention were not being controlled in this study.

Attention is a key factor in research participation and it is difficult to effectively control

the effects or magnitude under the conditions of this study (McCambridge,Witton, &

Elbourne, 2013).

Using 2-tailed t tests, this study had strong generalizability of findings shaping the

foundation of understanding of the key elements in a mental health literacy program and its

potential in resulting in less stigma and encouraging help-seeking intentions among youth.

Summary

This study examined whether a mental health literacy program given to college

students helped change myths and misperceptions of mental illness, and lessen the

influence of stigma. The study considered whether fostering mental health knowledge

encouraged students to seek help should they ever be faced with a mental health problem.

Students in the experimental and control group both completed self-reported

questionnaires. For the experimental group, the questionnaire followed the presentation.

For the control group, the questionnaire was given to students prior to their participation in

the mental health literacy program. Using t tests, this study analyzed the impact a mental

health literacy program can have on students’ knowledge of mental health, whether it

addresses stigma, and encourages help-seeking intentions should they experience a mental

health problem.

Chapter 4: Results

In this chapter, I describe the results of the data collection effort among college

students participating in the Is It Just Me? program. A randomized trial, with a posttestonly

control group design, was used to determine whether this multicomponent mental health

literacy program increased mental health knowledge, reduced mental health stigma, and

encouraged help-seeking intentions among college students. Specifically, one research

question focused on mental health knowledge, another focused on stigma, and the third

focused on help-seeking intentions among youth.

Data Cleaning

Analyses were conducted using SAS software (version 9.4). Data screening and

cleaning techniques were conducted as recommended by Tabachinck and Fidell (2006; 5th

ed.). Outcome measures were assessed for normality, including skewness and kurtosis,

influential observations (outliers), and equality of variances. To identify unusual or highly

influential data points, Cook’s distance (Cook’s D) statistic, leverage (Hat) statistic, and

bubble plots examining residuals, Cook’s D, and leverage were explored. Observations,

which had a Cook’s distance value exceeding 4/n, where n is the number of observations,

were considered to be potential outliers. For purposes of this study, a Cook’s distance

cutoff of 0.04 was used (4/94 = 0.04). However, as indicated by Tabachinck and Fidell, a

Cook’s D cutoff score of 1.00 is sometimes used to indicate whether a value may be an

outlier. For purposes of this study, the more conservative approach using a cutoff of 0.04

was used and examined in conjunction with the other exploratory analyses. Leverage

statistic values exceeding 0.20 were also considered in need of more detailed data

screening investigation and a comparison using multiple sources of information (e.g.,

Cook’s D value, etc.) in order to determine whether outlying scores may influence the

analyses. Skewness and kurtosis values of zero indicate a normal distribution and values

that diverge from zero indicate departure from normality. All observations were

independent. The amount of missing data was minimal (< 5%) for each outcome measure

and therefore considered missing at random. All participants answered more than half of

each of the scale items used in the computation of total scale scores; as such, all

participants were retained in analyses (Appendix B).

Total scores for measures were computed by taking the mean of the scale items.

Where participants had missing data on one or more items used in the computation of the

total scale score, a total score was calculated by taking the prorated mean of answered

items and is noted below. To explore whether there were differences between the treatment

and control conditions on total scores of the Mental Health Knowledge Schedule (MAKS),

Reported and Intended Behaviour Scale (RIBS), and General Help-Seeking Questionnaire

(GHSQ), two-tailed independent samples t tests were conducted with α set at .05. Included

in the t test analyses was test of equality of variances, and when violated, the Satterthwaite

correction was reported and noted in the relevant tables; otherwise, estimates using pooled

variances were reported.

Results

Out of a potential sampling base of 130 students, 115 students signed consent

forms following random assignment. Overall, 94 students participated, 46 students in the

experimental group and 48 in the control group. The program was offered to 3 different

classes during one week in April 2017. In the first class, 11 students in the experimental

condition did not complete the survey due to a shortage of time, and they did not submit

later that day. In the second class, 4 students (two in the experimental condition and two in

the control condition) signed the consent forms but did not complete the survey. In the

third class, 2 students in the experimental class signed the consent form but did not

complete the survey. Students may have decided not to pursue the survey, given they had

the right to decide at any stage of the process, as outlined on the information sheet.

Table 1

Participant Characteristics by Experimental (Is It Just Me?) Condition (n = 46) and

Control Condition (n = 48)

Is It Just Me? Control

n (%) n (%) Df χ2 p

Age 3 4.70 0.195

18 years 25 (54.3) 18 (37.5)

19 years 7 (15.2) 5 (10.4)

20 years 5 (10.9) 9 (18.8)

≥ 21 years 8 (17.4) 15 (31.3)

Missing 1 (2.2) 1 (2.1)

Sex 1 1.85 0.174

Males 18 (39.1) 25 (52.1)

Female

Other

28 (60.9) 0

(0.0)

22 (45.8) 1

(2.1)

Note. Percentages may exceed 100% due to rounding. Missing and other categories were

excluded from chi-square analyses due to small cell sizes.

As shown in Table 1, the experimental condition had a higher proportion of

younger participants (18 and 19 years) compared to the control condition, which had a

higher proportion of older participants (20 and ≥ 21 years); however, there were no

significant differences between groups (p = .195). The experimental condition had a higher

proportion of females (60.9%) and a smaller proportion of males (39.1%) compared to the

control condition (45.8% and 52.1%, respectively); however, there were no significant

differences between the treatment arms (p = .174). Missing and other categories were

excluded from analyses due to small cell sizes.

Research Question 1: Mental Health Knowledge

Mental health knowledge was assessed using the Mental Health Knowledge

Schedule (MAKS). A total score for the MAKS was created by averaging Items 1 through

6, with Item 6 reverse scored so that the correct response was associated with a higher

score. Only one participant failed to answer a MAKS item required for the computation of

the total scale score. As such, only one MAKS item had 1.1% of missing data. The total

scale score was computed by taking the average of answered items (i.e., prorated). The

distributions of the MAKS total score approximated normal (see Appendix B), with small

deviations from zero for skewness (-0.81) and kurtosis (0.60). Two observations exceeded

the recommended Cook’s D cutoff of 0.04, and one could be considered an influential

outlier in the control group. The highest Cook’s D value observed was 0.11, and this

observation had the lowest original MAKS total score of 2.33. This observation was

considered an influential outlier. The next lowest original MAKS total score was 2.67,

with an associated Cook’s D value of .07. The remaining scores fell below the cutoff

value. There was minimal variation in leverage scores (range: 0.0208 to 0.0217), and no

observation exceeded the cutoff of 0.20. In preliminary testing of MAKS among college

students, there was noted concern of a potential ceiling effect among the experimental and

control conditions demonstrating good knowledge. Questions were added to the MAKS

questionnaire. While these items were unvalidated and contravened the protocol of the

MAKS scale, it was hoped that these additions would curb the ceiling effect of the scale.

However, the analysis showed no difference with the added questions compared to the

original scale. For the purpose of this study, the descriptive analysis of the supplementary

questions is found in Appendix C. Analyses examining the original MAKS total scale

score without the additional items created for purposes of this study were solely conducted

for comparison purposes. A sensitivity analysis assessed the robustness of the results by

examining how study results could change through the application of different methods of

handling data.

Table 2

Assessment of Mental Health (MH) Knowledge Using Original Version of the Mental Health

Knowledge Schedule (MAKS): Independent Samples t Tests

M (SD) M (SD) Df T p

MH Knowledge -- -- --

Original total score 24.46 (2.42) 23.47 (3.33) 85.86a -1.65 0.103

As shown in Table 2, there were no significant differences in mental health

knowledge between the experimental and control conditions on the original MAKS scale

(p = .103) Although participants in the experimental condition reported higher mental

health knowledge compared to the control condition on the original MAKS scale

(experimental: M = 4.08, SD = 0.40; control: M = 3.91, SD = 0.55), this difference was not

significant (p =.103).

Research Question 2: Mental Health Stigma

Mental health stigma was assessed using the Reported and Intended Behaviour

Scale (RIBS). The total score for the RIBS was computed by summing Items 5 through 8.

Is It Just Me? Control

Missing data were observed on one of the scale items not used in the calculation of the

RIBS total score; thus, one question had 1.1% of missing data, while the remaining items

had 0% missing. All participants answered all of the four items used in the computation of

the RIBS total score, and so all participants were retained in analyses. Distributions were

negatively skewed, indicating a large buildup of high overall total scores. Values of

skewness (-1.86) and kurtosis (4.21) indicated a departure from normality. In total, four

observations exceeded the 0.04 cutoff for Cook’s D, and the remaining observations had

Cook’s D values < 0.04 (see Appendix B). More specifically, the control condition

appeared to have two outliers (i.e., extreme scores) with total RIBS scores < 10. These

observations had Cook’s D values of 0.14 and 0.19, both of which exceeded the

recommended cutoff of 0.04. Additionally, these observations were considered to be of

considerable distance from the remaining observations (see Appendix B, figures of Cook’s

D for RIBS total scale score).

There was greater than a 0.09 (Cook’s D) unit separation between these

observations and the majority (see Appendix B). Given the potential for these observations

to impact analyses, further exploratory analyses were conducted and demonstrated that

these observations also had high residual and leverage values compared to the other

observations (see Appendix B). As in the preliminary analyses for the other total scale

scores, there was minimal variation in leverage values (range: 0.0208 to 0.0217).

Sensitivity analyses were conducted with the two primary influential outliers removed

from analysis and then rerun with the outliers included. Additionally, a square root

transformation of the RIBS total score was computed as a means to examine whether a

statistical adjustment could correct some of the nonnormality. The square root

transformation did not substantially improve the lack of normality. A log transformation

was then conducted but also did not substantially improve the distribution and produced

comparable results (see Table 3). As such, primary analyses were conducted using

untransformed data with α set at .05.

Table 3

Assessment of Mental Health (MH) Stigma Using the Reported and Intended Behaviour

Scale (RIBS): Independent Samples t Tests

M (SD) M (SD) df t P

MH stigma -- -- -- -- --

Total score with outliers 18.30 (2.21) 17.02 (3.78) 76.38a -2.02 0.047*

Square root MH stigma 4.27 (0.27) 4.09 (0.53) 70.66a -2.06 0.043*

Log MH stigma 2.90 (0.13) 2.80 (0.31) 64.05a -2.07 0.043*

Total score no outliers 18.30 (2.21) 17.54 (2.86) 90 -1.43 0.157

As shown in Table 3, using the untransformed data with outliers, there were

significant differences between the experimental and control conditions on mental health

stigma (p = .047). Participants in the experimental condition had higher total scores (M =

18.30, SD = 2.21) compared to the control condition (M = 17.02, SD = 3.78), thus

indicating that participants in the experimental condition had reduced mental health stigma

including greater willingness to live with or nearby, work with, or continue a relationship

with someone with a mental illness. Sensitivity analyses were conducted to compare

Is It Just Me? Control

results using the untransformed data but with the exclusion of two outliers identified in the

control condition (RIBS total scores < 10). With the exclusion of the outliers, there were

no significant differences between the control and experimental conditions on mental

health stigma (p = .157). However, the experimental condition had higher total scores,

indicating reduced mental health stigma (M = 18.30, SD = 2.21) compared to the control

condition (M = 17.54, SD = 2.86).

Given that the two total RIBS scores < 10 are representative of actual observations

and the results of the analyses using the square root and log transformations mirrored those

of the untransformed data, it would be reasonable to interpret the results of the analyses

with the two extreme scores included. However, it should be noted that their removal had

moderate impact on the mean RIBS total score for the control condition (Δ 0.52), which

impacted the significance of the findings.

Research Question 3: General Help-seeking Intentions

General help-seeking intentions were assessed using the General Help-Seeking

Behaviour Questionnaire (GHSQ). Participants were asked to rate how likely they were to

seek help from different people for a personal or emotional problem (10 items) and if they

were experiencing suicidal thoughts (10 items) on a 7-point Likert scale. Missing data

were considered minimal, and therefore mean substitution on the outcome measure was

performed for cases with missing data. All participants were retained in analyses because

more than 50% of the scale items were answered by each participant. One question had 4

missing responses (4.3%), two questions had 2.1% missing, and five questions had 1.1%

missing. For participants with missing data, the average of answered items was taken (i.e.,

prorated mean scale scores). This was the same technique used to handle missing data on

the MAKS (previously reported). The distribution for total GHSQ scores approximated

normal as indicated by the minor deviations from zero for skewness (-0.45) and kurtosis

(0.27; see Appendix x). The maximum Cook’s D and leverage values were 0.07 and 0.02,

respectively. As in the exploratory analyses for the other total scale scores, there was

minimal variation in leverage values (range: 0.0208 to 0.0217). While there was some

evidence of possible outliers, as indicated by the scores that exceeded the recommended

Cook’s D cutoff of 0.04; the measure of influence, which demonstrated that no scores

exceeded the cutoff of 0.20, and visual aids such as histograms and box plots (see

Appendix B) did not indicate that the potential outliers were of considerable distance from

the remaining observations. There was less than a 0.04 (Cook’s D) unit separation between

these observations and the majority (see Appendix B).

The overall total score for the GHSQ personal/emotional subscale approximated

normal as demonstrated by the skewness and kurtosis values of -0.37 and 0.34,

respectively (see Appendix B). The maximum Cook’s D and leverage values were 0.08

and 0.02, respectively, which were comparable to that for the distribution of the total

GHSQ scale score. Statistical visual aids indicated that the distribution of GHSQ

personal/emotional subscale scores approximated normal for the control condition;

however, histograms and boxplots indicated that there was evidence of some negative

skew for the experimental condition. As a precautionary measure, square root and then log

transformations of the total score were compared. Neither substantially improved the total

scale distributions, and produced comparable results (see Table 4). As such, untransformed

data were used in the primary analyses for this subscale with α set at .05. The overall total

score for the GHSQ suicidal thoughts subscale roughly approximated normal, as

demonstrated by the skewness and kurtosis values of -0.28 and 0.05, respectively (see

Appendix B). The maximum Cook’s D and leverage values were 0.05 and 0.02,

respectively, which was comparable to that for the distribution of the total GHSQ scale

score and the GHSQ personal/emotional subscale score. Statistical visual aids indicated

that the distribution of GHSQ suicidal subscale scores approximated normal for the control

condition; however, histograms and boxplots indicated that there was evidence of some

negative skew for the experimental condition. As a precautionary measure, square root and

then log transformations of the total score were compared; they produced comparable

results (see Table 4). As such, untransformed data were used in the primary analyses for

this subscale with α set at .05.

Table 4

Assessment of General Help-seeking Behaviors Using the General Help-Seeking

Questionnaire (GHSQ): Independent Samples t Tests and Descriptive Statistics for Overall

(Total) Help-seeking Behaviors, and Help-seeking for a Personal/Emotional Problem or

Suicidal Thoughts

M (SD) M (SD) df T P

Help-seeking -- -- --

Total score 3.80 (1.08) 4.28 (1.14) 92 2.07 0.041*

Personal/emotional problems 3.92 (1.03) 4.25 (1.20) 92 1.41 0.161

Suicidal thoughts 3.68 (1.25) 4.31 (1.25) 92 2.44 0.017*

Subscale transformations

Is It Just

Me?

Control

Square root personal/emotional problems 1.96 (0.29) 2.04 (0.30) 92 1.31 0.194

Log personal/emotional problems 1.32 (0.35) 1.40 (0.31) 92 1.23 0.222

Square root suicidal thoughts 1.89 (0.36) 2.05 (0.32) 92 2.39 0.019*

Log suicidal thoughts 1.23 (0.44) 1.41 (0.33) 92 2.33 0.022*

*p < .05.

As shown in Table 4, there were significant differences between the experimental

condition and control condition for total help-seeking behaviours (p = .041) and for

helpseeking if experiencing suicidal thoughts (p = .017). The control condition had

significantly higher scores for both total help-seeking behaviours and for the suicidal

thoughts subscale, indicating a greater likelihood to seek help from someone overall and if

experiencing suicidal thoughts. There was a nonsignificant difference between the

experimental and control conditions for help-seeking if having a personal/emotional

problem (p = 0.161). The control condition had a higher total score for the

personal/emotional subscale, indicating a greater likelihood to seek help from someone if

having a personal or emotional problem; however, this was non significant.

Summary

Compared to the control condition, students in the Is It Just Me? Program

experimental condition reported less stigma and lower help-seeking intentions but no

difference in mental health knowledge. Knowledge and attitudes about help-seeking were

high in both the experimental and control condition, which may signal the presence of a

ceiling effect in the primary scales used. This constellation will be looked at in greater

detail in Chapter 5.

Chapter 5: Discussion, Conclusions, and Recommendations

Discussion

Is It Just Me?, a mental health literacy program, was evaluated to determine its

impact on mental health knowledge, stigma, and help-seeking intentions should students

experience a mental health problem. More than 14,000 high school and college students

have attended the program. The program was well received by students and teachers yet

never scientifically evaluated. A scientific evaluation of this program would help

determine its impact with respect to mental health literacy and its association to

knowledge, stigma reduction, and help-seeking intentions. It could also contribute to the

growing body of evidence on educational interventions in mental health literacy. This

chapter contains a discussion of the results of the study and their relationship to the current

literature on mental health literacy. Recommendations are advanced to support future

research in this important and growing field.

Findings of the study showed that the Is It Just Me? mental health literacy program

had minimal impact on knowledge; however, less mental health stigma and lower

helpseeking intentions were found in the experimental condition compared to the control

condition. Notwithstanding these mixed results, enhancing knowledge, breaking down

mental health stigma, and encouraging help-seeking intentions help to promote good

mental health among college students. Wei et al. (2015) argued that mental health literacy

is an important strategy that generates awareness, facilitates early identification of risk

factors associated with mental illness, exerts a positive influence on stigma, and

encourages help-seeking behaviour. Milin et al. (2016) also inferred that increases in

knowledge about mental health and disorders could ensure effective early interventions

and use of services, but also ultimately improve mental health outcomes.

In this chapter, I provide an evaluation of the findings of this randomized trial of

the Is It Just Me? program and consider recommendations to build the body of knowledge

in the field of mental health literacy for college and high school students.

Impact of Is It Just Me? on Mental Health Knowledge

Knowledge is a key construct of a mental health literacy program. The Is It Just

Me? program did not generate significant differences in knowledge between the

experimental and control conditions. In the current study, both the experimental and

control conditions demonstrated good mental health awareness while not presenting any

significant statistical difference. Friedrich et al. (2013) found similar findings, with no

significant improvements in mental health knowledge of medical students following an

educational intervention; however, improvements were seen in lowering stigmatizing

attitudes toward people with mental illness. The current findings may be attributed to a

ceiling effect: Mental health knowledge was already very high before starting the Is It Just

Me? program, and hence the program could not have been expected to raise mental health

knowledge significantly. Milin and colleagues (2016) and Sebbens, Hassmen, Crisp, and

Wensley (2016) also found a potential ceiling effect in their mental health literacy studies.

There are several explanations for a ceiling effect. First, a ceiling effect may be due

to the lack of validated scales used for mental health knowledge and literacy (Wei et al.,

2015). Wei et al. (2015) examined measures of mental health literacy in 401 studies that

evaluated knowledge, stigma, and help-seeking and identified significant gaps in the

psychometric properties of these scales, especially for youth. No scales were found to

concisely measure general knowledge and stigma associated with mental illness in youth

and young adults (Wei et al., 2015). In a meta-analysis of scales, MAKS and RIBS scales,

used in the current study, were found to be the most comprehensive in the field and have

been used in a number of studies evaluating mental health knowledge and stigma levels

(Chisholm et al., 2016; Li, Thornicroft, & Huang, 2014). It is important to mention that the

scales were not validated with adolescent and young adult populations, which may affect

the baseline in attitudes. In one of the most significant randomized trials on mental health

literacy in the youth population, Milin et al. (2016) did not use any standardized measures

as they found that no validated standardized tools existed to measure mental health

knowledge and stigma constructs in their study. They developed their questionnaire based

on the curriculum content they were evaluating. Hence, the lack of well-validated

questionnaires is a well-known problem in the field.

A second reason for a ceiling effect in Canada could be the success of mental

health awareness campaigns on college campuses and of national campaigns in the past

couple of years. One such campaign in Canada is Bell Let’s Talk, a public outreach

campaign that has garnered substantial awareness and support over the past 5 years (Milin

et al., 2016). Although past studies may have reported that mental health literacy

knowledge was lacking among students, research by Mackenzie et al. (2014) and

Yamagucci et al. (2011) has indicated that students have higher mental health literacy

awareness and as a result has indicated important ceiling effects in knowledge scales

(Friedrich et al., 2013; Milin et al., 2016). The fact that more students have been more

likely to experience mental health issues themselves may also contribute to the higher

scores (Milin et al., 2016). With higher awareness levels in students resulting from public

education campaigns, future research could consider validating new scales that could more

accurately measure the effect of knowledge on stigma and help-seeking intentions. It could

also be argued that if students receive a perfect knowledge score for important mental

health concepts, then perhaps that components of mental health literacy has been achieved,

and efforts could focus on stigma and help-seeking exclusively. At the time of this writing,

no study had been found that could help to explain this phenomenon.

Stigma

Compared to the control condition, participants in the experimental condition

following the Is It Just Me? program reported less stigma and a greater willingness to live

with or nearby, work with, or continue a relationship with someone with a mental illness

following the program. These findings were similar to the Milin et al. (2016) educational

intervention mental health literacy study that evaluated the effect of a mental health

literacy curriculum on knowledge. Milin et al. (2016) found a reduction in stigma and

improved knowledge among high school students who participated in their curriculum.

The majority of the students in the Is It Just Me? study (63% of the experimental condition

and 56% of the control condition) reported currently living with or having lived with a

person with a mental health concern. This is even higher than national statistics showing

that mental illness will affect 1 in every 3 Canadians sometime in their lifetime (Statistics

Canada, 2012). Two large studies by Hunt and Eisenberg (2010) clearly illustrated how

common mental health issues are among U.S. college students. One in three

undergraduates acknowledged depressive thoughts while 1 in 10 reported having suicidal

ideation and 17% of students met the DSM-IV criteria for depression (Hunt & Eisenber,

2010). Clement et al. (2012) particularly highlighted that adolescents who had more

contact with people with lived experience of mental illness had lower stigmatising attitudes

toward people with mental illness than students who did not receive the educational

intervention. These experiences may explain a high level of knowledge about mental

health.

Even though the Is It Just Me? program did not seem to affect knowledge, there

was evidence that it may have affected stigma. The finding that college students who

participate in an educational program have less stigma than those students who do not

attend, is particularly encouraging, in that the last national antistigma campaign found that

half of the 2,000 respondents were uncomfortable or would feel somewhat uncomfortable

socializing with a person with mental illness (Stuart et al., 2014). Previous research by

Lyndon et al. (2016), Griffiths et al. (2014), and Corrigan et al. (2012) reported that

adolescents mirrored the attitudes of many adults who believed that people were

responsible for their mental illness in comparison to those who had cancer or heart disease.

These adolescents viewed their peers as responsible for their mental illness. In a college

student perception study, Lyndon et al. (2016) found that a high percentage of students

who knew someone with mental illness also preferred to have some level of social distance

from people with mental illness, qualified as a moderate level of stigma. While the

evidence on short-term educational interventions may be limited (Yamaguchi et al. 2013),

the current study may indicate that short mental health literacy programs and contact with

people with lived experience can have some impact on stigma.

In the next section, I look specifically at help-seeking intentions and whether the

mental health literacy program had any bearing on encouraging help-seeking intentions

among college students.

Help-Seeking Intentions

Those in the control condition showed higher help-seeking intentions compared to

those in the experimental condition who participated in the mental health literacy program.

The score included two questions on help-seeking intentions, the first on personal or

emotional problems and the second on help-seeking intentions for suicidal thoughts.

Compared to the experimental condition, the control condition showed higher response in

their intention to seek help from partners or close friends for a personal or emotional

problem. For a separate question, students in the control condition also responded at a

higher rate to indicate that they would seek the help of close friends, but not family

members, should they experience suicidal thoughts. Seeking the help of close friends when

experiencing suicidal thoughts has been noted in other educational intervention studies

where researchers found a marked difference between seeking help from friends and

seeking help from family members (Chen et al., 2015; Chisholm et al., 2016; Deanne,

Ciarrochi and Richwood & Gulliver et al., 2010; Eisenberg et al., 2012).

Why would help-seeking be increased in the control group? As discussed in the

previous section, approximately 60% of students in both groups indicated that they knew

or lived with someone with a mental illness. Personal experience with mental illness may

be one factor explaining high scores to seek help for a mental health problem. Reynders et

al. (2015) and Calear et al. (2014) highlighted that many students reported seeking help

from “no one” for personal-emotional and suicidal problems. Many have acknowledged

the need for help but have reported that they preferred handling the issue on their own.

Reavley and Jorm (2014) and Eisenberg, Speer & Hunt (2012) further elucidated that

students believed that their problem would get better with time or categorized their

symptoms as normal stress in college. However, the control and experimental conditions

had similar numbers of people who lived with someone who had a mental health problem,

so this cannot explain why the control group reported higher help-seeking intentions.

Despite randomizing participants to groups, health seek intentions may have been different

at baseline. Although randomization is the gold standard and controls for bias, differences

between control and experimental conditions in baseline variables can happen by chance

and this is not an uncommon occurrence in randomized trials. In a posttest control only

study design no measurement is taken pre-program in the intervention condition. Baseline

differences are not expected given randomization, but it cannot be tested if this happened

by chance.

Notwithstanding these potential explanations, it remains surprising that the

experimental condition’s response levels were not higher than those of the control

condition, particularly in light of the presentation of the public speaker with lived

experience who shared her personal story with mental illness, described her suicide

attempts, and strongly encouraged students to seek help if they experienced a mental health

problem. This observation is supported by the findings of Chisholm et al. (2016) and

Corrigan et al. (2012), which indicated that intergroup contact added to educational

teaching on mental illness did not appear to add any significant value to the educational

method of mental health literacy nor for intentions to seek help. More research is needed to

determine why this might be the case.

Another factor to take into account is that the study measured intentions to seek

help but not actual help-seeking behavior. Actual help-seeking behaviors can only be

measured if the participants are followed over time, which was not in the purview of this

study. It may be that the Is It Just Me? program was better at changing actual help-seeking

rather than help-seeking intentions. However, help-seeking intentions are recognized as

important precursors to actually seeking help. Reynders et al. (2015) contended that if a

person displays a positive attitude toward the intention of getting help, the person’s

intention is strong enough to initiate behavior in getting help. Behavioral researchers Ajzen

and Fishbein (2005) argued that intentions are actual precursors/antecedents of behavior.

Skre et al. (2013), Bathje and Pryor (2011), and Olsson and Kennedy (2010) revealed

strong correlations between positive attitudes, help-seeking intentions, and contacting a

professional service for help.

Stigma and mental health knowledge are theoretically related to help-seeking

intentions. Calear et al. (2014), in an extensive study with 1,274 Australian young adults,

contended that high suicide literacy and low stigma were directly linked to higher

helpseeking intentions. Calear et al. (2014) also highlighted the fact that students who

experience suicidal ideation have predominantly negative attitudes about seeking help and

consequently lower intentions to actually seek help. These studies underscore the need for

further investigation in exploring the role and effect of a mental health literacy program on

suicide ideation and negative attitudes resulting from stigma and how this could impact

help-seeking.

The Is It Just Me? study did not allow any specific evaluation of whether

individuals exhibited minor or moderate symptoms of mental illness. It is therefore not

possible to determine any conclusion on students' frame of mind or any antecedents of

mental health symptoms as they completed the survey. A post follow up and longitudinal

study with the college student population could certain provide valuable data on the

correlation of attitudes to help-seeking intentions and, more importantly, how intentions

can be translated into help-seeking behaviors should students experience a mental health

problem or suicidal ideation. Higher help-seeking intentions among the control condition

appear to indicate that the Is It Just Me? program did not translate an effect on stigma into

help-seeking intentions among those in the experimental condition, who were exposed to

suicide ideation literacy and testimony of a person with lived experience.

Several researchers have noted that stigma is an influential factor in fostering

negative attitudes toward seeking help while at the same time lowering intentions of

seeking help (Eisenberg et al., 2009; Elkington et al., 2012; Evans-Lacko et al., 2012

Golberstein et al., 2009; Yoshioka et al., 2014). Based on this existing body of literature, a

correlation analysis was explored to measure the relationship between stigma and

helpseeking intentions. However, following analysis of the Pearson product moment

correlation coefficient, the correlation was nonsignificant (rp -0.12). Thus, changes in

stigma are not associated with changes in help-seeking intentions. Given the complexity of

stigma and its many dimensions (Eisenberg et al., 2009; Golberstein et al., 2009), more

research is needed to discern the dimensions and their relationship to help-seeking. In

retrospect, the RIBS stigma scale measured general stigma, which characterizes perceived

public stigma and not specifically personal stigma. To date, Eisenberg et al. (2009) have

conducted the only study to consider perceived stigma and personal stigma in relation to

help-seeking. They found that personal stigma was significantly correlated with a lower

willingness to seek help and that perceived stigma was not significantly correlated with

help-seeking (Eisenberg et al., 2009). Yak et al. (2013) suggested that future research

could explore the various dimensions of stigma in relation to different sources of help and

effectively measure its relational impact. This type of research could help to support

targeted efforts to impact self-stigma and encourage higher help-seeking intentions.

Furthermore, the findings in the Is It Just Me? study may be accounted for by the

large buildup of scores on the higher ends of the distributions of the measures used in

analyses. The reduced variability in the distribution of scores may be responsible for the

small correlation. Cautious interpretation of these correlation results is recommended, and

future work with more sensitive measures may yield an association between stigma and

help-seeking.

In the end, short educational interventions such as this program still have an

important role to play in addressing stigma, which impacts attitudes towards people with

mental illness and can help foster help-seeking among students.

The health beliefs model was the theoretical framework that guided this research

study and the next section will highlight possible understanding of the constructs that

influence attitudes and health behavior.

Health Beliefs Model

The health belief model is a model that predicts how likely a person will perform a

health behaviour such as treatment seeking for a mental health illness. The health beliefs

model predicts that the readiness of someone to act is driven by analyzing whether the

benefits outweigh the barriers to action. To do so, a person assesses the probability,

severity and susceptibility to the illness and their own self-efficacy (See Appendix A for

health belief model). The Is It Just Me? program addressed many of these health beliefs

including probability and severity of the illness. For example, the current study found that

students were able to describe the types of mental illness appropriately and estimated the

perceived severity of a mental illness correctly. With respect to analyzing barriers and

benefits of dealing with a mental health problem, college students identified key sources

they would seek in talking about their problem with significant members i.e. partners and

friends. While the sample size was small in comparison to the two current and relevant

studies in the field (Milin et al. 2016 and Chisholm et al. 2016), the high percentage of

scores and responses are very positive. The current study also measured health behaviour

by assessing the intention to seek help for an emotional or personal problem or for suicidal

ideation.

While the current findings are largely in line with the health behavior model, the

study was not designed to test the model. Many aspects of the model were not assessed

such as susceptibility to developing a mental illness, or cues to action. These would clearly

be an area of interest for future research. Furthermore, concepts that were not included in

the health behavior model, such as stigma, are still expected to exert an influence on an

individual’s perception of their psychological distress, and hinder help-seeking behaviour.

In sum, the health belief model was a valuable theoretical framework that provided

a good theoretical approach in understanding how knowledge and stigma can impact

helpseeking intentions and how this model can be used to promote good health behavior,

in other words, help-seeking behavior for a mental health problem.

Limitations

Despite a number of strengths, the current study has a few delimitations,

limitations, and assumptions. As delimitation, this research study was a short-term

educational intervention in mental health literacy that measured the impact on knowledge,

stigma and help-seeking intentions among the college student population in Ottawa. The

findings cannot be generalized or representative of the entire college study population but

rather presented a perspective on current attitudes of students on mental health in one

primary college. Socio-economic and cultural factors may have exercised an influence on

attitudes towards mental illness and willingness to seek help (Reynders et al., 2015; Ungar

et al., 2013; Yu et al., 2015) but were not tested in this current study. Age of participants

may also be a limiting factor. Milin et al. (2016) and Chen, Romero and Carver (2015)

found differences in knowledge and stigma between higher grade and lower grade students

in high schools. There may be important differences between college and high school

students, which would be useful to evaluate in the future. The ceiling effect noted in the

mental health knowledge scale may be associated with the age factor.

There were also some limitations in the study that must be noted. First, social

desirability is an important threat to validity, therefore, the professor nor the investigator

was aware who signed or didn’t sign consent forms, thereby limiting the need to answer

questions in a socially, desirable way. This message was communicated to students before

they were asked to sign the consent forms. Social threats were also minimized due to

random assignment as students walked into class.

Students’ mental health literacy levels may be higher than expected due to

students’ learning in other classes, from experience in knowing or living with someone

with mental illness. The potential of ceiling effects in the knowledge scales cannot be

overlooked. It may have had an impact on measuring any significance resulting from the

mental health literacy program. With the relatively high levels of awareness among

students, future research could focus on evaluating a younger student population to assess

whether their mental health knowledge scores are comparable to college students, and

evaluate the presence and depth of ceiling effects.

The short duration of the study was another limitation. The program is generally

presented in a 3-hour presentation at the Mental Health Centre but in order to

accommodate class schedule and time, the content of the presentation was limited to 2

hours. Students may not have had adequate time to absorb or reflect on the information, or

discussions held during the program before being asked to complete the survey. The short

duration of the program could be addressed by conducting a more intensive and longer

intervention among the college student population. Potential social desirability and lack of

generalization of findings could also be corrected by designing a multi-site study involving

a number of colleges in the province, or in the country could also help validate findings

and ensure generalization of the results of college students. Furthermore, the short time

frame of the study was a limitation. Clearly studies are needed that measure the long-term

impact of the Is It Just Me? program over time and on actual help-seeking behaviors rather

than intentions. Using pre and post baseline measures in future research could help

quantify changes in knowledge, stigma, and help-seeking intentions.

Recommendations

This research study has generated interest in assessing the potential long-term

impact of a short educational intervention among college students’ attitudes and

helpseeking intentions. Conducting a longitudinal study could help qualify the impact this

program may have on attitudinal change and help-seeking behavior. This may be designed

as a yearly evaluation at the beginning of the students’ first college semester with

subsequent measurements the following year. This is particularly important when

measuring a complex and multifaceted construct such as stigma and looking at the

association with help-seeking. While that relationship of knowledge and stigma on

helpseeking intentions has been established in the literature, the relationship of suicide

ideation literacy and actual help-seeking behavior should be further investigated. Suicide

prevention remains an important goal, and where the risk of suicide remains a significant

issue among the student population (Skre et al., 2013; Calear et al., 2014). The program

can also be implemented across the programs at the college, thus enabling a more robust

evaluation and large sample size of its effects on knowledge, stigma reduction and

helpseeking.

As there are very few scales that address positive or good mental health, it would

be valuable to measure the ability to foster, or take care of one’s mental health, a key

outcome of mental health literacy. Future research can serve to build evidenced-based

practices that can be incorporated into existing educational venues that will embed

curriculum to enhance knowledge, address stigma and foster not only help-seeking

intentions but also effective coping skills that can decrease risk factors in the development

of a mental illness. It is also hoped that in future research, there will be new validated

scales that can help prevent ceiling effects in studies, and more adequately measure the

effects of a mental health literacy program on knowledge, stigma reduction and

helpseeking intentions among the youth and young adult population.

Significance

The Is It Just Me? mental health literacy program has shown that stigma can be

addressed in an educational intervention, which can have a positive effect on attitudes

towards individuals with mental illness. While the program did not have an impact on

knowledge among the students, the noted significant difference in stigma among attendees

and non-attendees could have a positive influence in attitudes as students prepare to enter

the workforce and encounter people with lived experience in their future line of work.

Educating students could help in fostering understanding and empathy in their interactions

with vulnerable populations such as people living with mental illness.

While not a dimension evaluated in the program, many college professors

expressed interest in hosting more Is It Just Me? presentations as an annual component of

their program curriculum. Recognizing the importance of integrating mental health literacy

within existing curriculum is a positive step in promoting good mental health and positive

help-seeking intentions among the student population.

Conclusion

Mental health literacy, stigma reduction, and help-seeking behavior have become

important societal goals in fostering healthy individuals and healthy communities.

Statistics Canada (2012) have confirmed that 1 out of 3 Canadians will experience a

mental health problem during their lifetime with symptoms of a mental illness manifesting

during adolescence. There is a critical role in implementing mental health literacy

programs to help younger generations such as college students learn about their mental

health, better understand the risk factors that lead to the development of mental illnesses

and foster positive attitudes in seeking help should they experience a mental health

problem. Furthermore, mental health literacy can also help foster positive coping

mechanisms, and educate students among the effects of poor coping mechanisms (Chen,

Romero & Carver 2015; Chisholm et al., 2016; Milin et al., 2016). Educating future

generations of health and community service providers could help change stigmatizing

attitudes towards people with mental illness.

We know from research that knowledge and stigma reduction are interrelated

constructs, which impact and influence each other (Chisholm et al., 2016; Milin et al.,

2016; Wei et al., 2015). A person’s life trajectory can be negatively influenced by stigma

and they may experience fewer opportunities for self-development and self-fulfillment

than others (Chisholm et al., 2016). Consequently, there is critical value in promoting

mental health literacy in order to foster proactive health behavior and support positive

attitudes towards individuals who are afflicted with mental illness. If students can

experience little or no stigma in getting help early for a mental health problem, as a

society, we will be successful in caring for all members of the community.

This research study confirms that those who attended the Is It Just Me? mental

health literacy program demonstrated less stigma towards people with mental illness than

college students who did not attend the program. Stigma can exert a damaging influence in

attitude development and formation, and can negatively impact the attitudes of students

towards people with mental illness. Addressing stigma among a group of college students

could help them become more supportive towards those living with mental illness as they

enter the workforce. Stigma reduction is an important societal goal and mental health

literacy programs such as Is It Just Me? may contribute to students having a better

understanding and acceptance of those individuals living with mental illness, and an

awareness of their own attitudes and beliefs about mental illness and help-seeking.

Reducing Stigma and Encouraging Help Seeking Intentions Through a Mental Health Literacy Program

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