Does mental health literacy influence on help-seeking be- havior in medical students?

*) Corresponding author: azimatul.karimah@fk.unair.ac.id Introduction: Medical students are experiencing uncertainty in finding the appropriate help for their mental health problems. When they finally decide to seek help, some of them are already in a mental crisis. The suitable indicator for early identification of mental disorder is mental health literacy. Mental health literacy also functions as a tool to decrease stigma towards people with mental illness and to improve help-seeking behavior. The purpose of this study is to determine the influence of mental health literacy to help-seeking behavior and to describe mental health literacy and help-seeking behavior of the medical students. Methods: The study design was observational analytical. Participants filled demographic data and answered questionnaire via an online file sharing platform. The questionnaires used in this study were Mental Health Literacy Scale (MHLS) and Attitudes Toward Seeking Professional Psychological Help Short Form (ATSPPH-SF). The influence of mental health literacy to helpseeking behavior was analyzed using logistic regression analysis. Results: The respondents were 60 medical students. No differences of literacy and attitude were found across the admission years. Overall, the students had good literacy and attitude. Students showed lower scores in the MHLS attributes containing ideas about self-treatments, confidentiality, social distance, and reliance on self. Being literate in the total score of MHLS did not influence on having a good attitude in ATSPPH-SF (p=0.303). Only by being literate in attitudes that promote recognition and help-seeking, the students showed a good attitude in ATSPPH-SF (p-value=0.027). Conclusion: There was no influence on mental health literacy to help-seeking behavior.


Introduction
Mental health problems in medical students may have a significant impact on their life. It could affects their ability to study in long hours, ability to well socialize, and ability to achieve good performance at school. In contrast with general population of the same age, medical students have higher rates of burnout along with depression. This higher prevalence is likely due to the excessive workload given to the students. 1,2 The declining of students' academic performance can be a definitive sign of students having mental health disorders. 2,3 Medical students are experiencing uncertainty in finding the appropriate help for their mental health problems. When they finally decide to seek help, some of them are already in a mental crisis state. 4,5 The main reason students avoid getting help is the stigma. Another point is shame and embarrassment in admitting weakness. Mental health stigma may lead to a fear that having mental health problems will affect their future career and job offers. Concern regarding confidentiality violation also hinders students for seeking help. 4 The suitable indicator for early identification of mental disorder is mental health literacy. Mental health literacy also functions as a tool to decrease stigma towards people with mental illness and to improve help-seeking behavior. The purpose of this study is to determine the influence of mental health literacy to help-seeking behavior and to describe mental health literacy and help-seeking behavior of medical students.

Methods
This study was cross-sectional. Study population were medical students at Faculty of Medicine Universitas Airlangga batch 2015-2017. The sampling method was non-probability sampling, with the specific method of quota sampling. Subjects included in this study would be selected from the first 20 respondents of each batch.  8 The questionnaire has six attributes measuring 1) the competence to recognize particular disorders, 2) knowledge of how to find information about mental health, 3) knowledge of risk factors and causes, 4) knowledge of oneself's treatments, 5) knowledge on the accessibility of professional help, and 6) attitudes that promote recognition and appropriate help-seeking. It consists of 35 questions with 4-point and 5-point Likert scale. The reversed scores are in item number 10, 12, 15, and 20-28. The final result was obtained by totalling all numbers. The maximum grade is 160 and the minimum grade is 3.8 For MHLS the condition of literate was those who answered 'likely' and 'very likely', 'helpful and 'very helpful', 'agree' and 'strongly agree', together with 'probably willing' and 'definitely willing'.

Help-Seeking Behavior
The assessement of help-seeking behavior was completed by ATSPPH-SF Scale. This one-factor instrument was developed by Fischer and Farina.9 It consists of ten questions with 4-point Likert scale. The reversed scores applied to numbers 2, 4, 8, 9, and 10. The total score was obtained by combining all items. The possible range of scores varies from 0 to 30.10 For ATSPPH-SF the requisite for literate was those who answered 'partly agree' and 'agree' All data analyzed using IBM SPSS Statistics ver. 23. The distribution of good literacy and attitude was presented using crosstabulation, and the significance of the difference between batch was analyzed by Kruskal-Wallis Test. The distribution of literate and illiterate responses for each items in the questionnaire was described by frequency tables. Analysis by logistic regression was utilized to search for the effect of total scores of mental health literacy to help-seeking behavior, as well as the impact of mental health literacy attributes to help-seeking behavior.

Results
The total of 176 responses was acquired from three academic years: 2015, 2016, and 2017 with 115, 24, and 37 medical students respectively. The respondents were planned to be 60 people, 20 from each batch. Three people were excluded from the sample because of double answers in number 16-35, and they could not be contacted to confirm the answers. The mean age of the respondents was 20.33 years old ± 1.244 years.

Good Scores Distribution Based on Admission Years
Students from all admission years were showing good literacy in attributes 1-4, where 60, 51, 51, and 54 students, respectively, reached the required scores for each section (Table 1). On the other hand, none of the participant had score>12, which ruled them out as literate in attribute 5. More than half of the students (56.7%) showed of having a good attitude towards seeking professional help as measured in ATSPPH-SF. There was no significant differences (p>0.05) on MHLS attributes and ATSPPH scores between the students in each admission years.

Influence Of Mental Health Literacy Attributes to Help-Seeking Behavior
As shown in Table 2, there were no correlation of being literate in attribute 2 "knowledge of how to find information about mental health" (p=0.428), attribute 3 "knowledge of risk factors and causes" (p=0.996), and attribute 4 "information on self-treatments" (p=0.263) of MHSL with having a good attitude in ATSPPH-SF.
There was an influence in being literate in attribute 6 "attitudes that promote recognition and appropriate help-seeking" (p=0.027) with having a good attitude in ATSPPH-SF. The explanation on why there was no significant difference between several grades was because all of the participants were chosen from the same faculty and only diverse in admission years. Since the age of the respondents was varied from 18 to 24 years old, they can be classified into the same age group, which according to the theory proposed by Arnett 11 was called emerging adulthood. Emerging adulthood is a period with a focus on age 18-25 years old, where young people in this age group had left the dependency of adolescence but had not yet enrolled in the eternal responsibilities of adulthood. A research on knowledge and beliefs about mental health problems conducted in Australian households with five age groups from 18 to 70+ years revealed that the age differences happened primarily between the oldest age group and all other ages. The finding of this research, regarding the appropriate discipline major of the respondents, has similar characteristic to the other two conducted among university students in Britain and Switzerland. Education background can be a very important factor in establishing good mental health literacy and changing prejudice. Faculty affiliation of medicine and psychology, courses on the subject of psychology and psychiatry, in addition to experience with mental disorder by interest and work as well as one own's experience, have a positive influence in recognising mental illness symptoms. 12,13 Modules learned by this research participants are very likely affecting their literacy for choosing the correct options in the questionnaires. In attribute 5, the students indicated strong agreement to mental health professional revealing their discretion to help others support them better. Given the age of the participants, we suggest this might be because the students were just step out of their adolescence years. Emerging adults still rely on their parents for source of comfort and support, although they also obtain certain degree of autonomy in their house. 11 Providing treatment during adolescence years involve a triad of patient-doctor-parent. Since parents are responsible for starting and funding the care, they may have their own expectations on the course and goal of the treatment. We propose that the participants were still holding on to those norm in their early years of leaving their teenagehood behind. It is possible the breeching of confidentiality done in non life-threating situation is thought to parallel the dynamics from their adolescence years.
More than half of the students had score >15 which categorise them as having a good atitude towards seeking psychological professional help. Attitudes towards help-seeking behavior is a reliable predictor of a person's inclination to seek mental health treatment when encountered with personal problems. 14 However, students showed poor attitude in several numbers which can be grouped as statements about reliance on self. It is an internalised stigma about seeking professional help: viewing it as the last resort, belief that one can handle one's own problems, and thoughts that problems can be settled on their own. 15,16,17 The participants as an emerging adults gradually believe they should be able to handle their own problems and they need to have autonomy and independence even so their desire will become a barrier to seek help. 18 Another possible explanation for the delay on help-seeking is the consideration of the risk and benefit of a treatment before they attain it. People may decide to wait and see if the symptoms can be relieved without treatment or may try to solve it by themself through reading selfhelp books for instance. The wish to rely on themselves to solve the problems contributes to the long postponement between the onset of sickness and the initial care with mental health professional. 15 The current research found no influence from mental health literacy to help-seeking behavior. However, the previous research had a contrary result where respondents who had higher level of mental health literacy were more likely to have positive views toward seeking professional psychological help. 19 Many factors inhibiting and facilitating the conversion of cognitive intention into actual behavior of seeking help. The major barrier is negative attitudes and beliefs related to seeking professional help. In the other hand, positive attitudes and mental health literacy encourages the help-seeking intention into becoming definite help-seeking behavior. 20 Only one out of six components of mental health literacy had an influence to the attitudes toward seeking professional psychological help. Rickwood et al. proposed a four-staged help-seeking behavior framework. 20 The process begins with being aware of the symptoms and consider having problems that may have need of intervention. Secondly, those awareness and appraisal must be expressed into words that can be understood by others and comfortably used by the person. Thirdly, the sources of help must be available and accessible. Lastly, the person must be able and willing to disclose their condition to the source of help. The ability to identify feature of disorders and factors that increased the risk of developing disorders are assessed in attribute 1 and 3. Both components have an impact to the help-seeking process that can be explained by the first stage of help-seeking behavior model. The individuals that are aware of the symptoms and risk factors of the disorders will be able to make an assessement for the requirement of a treatment. The assessement of having the knowledge on where to access information about mental health and professionals treatment, along with having the capacity to do so are contained within attribute 2 and 5. The help-seeking behavior model of stage three identified those factors as the resources that should be available if an individual are to reach out for mental health services. In attribute 4 where the knowledge of self management recommendation by mental health professional is evaluated, the statements can be explained by the first and second stage of help-seeking behavior model. The individuals are becoming aware and evaluating the problem they have and then expressing the need for a help from mental health professional. Attribute 6 was the only component of the literacy scale that had influence on the attitude towards professional help. The probable reason is because the majority of the statements in attribute 6 and ATSPPH-SF are similarly can be organised into stage 1, 2 and 4 of the help-seeking behavior framework. The individuals were aware of problems or conflicts within themselves and realise the need for treatment from mental health professional. Furthermore, they are willing to talk about their inner state to the source of help in order to resolve their emotional crises. 20,21,22 This study was limited on the medical students within three batch in preclinical setting, thus this study is not a representation of all the medical students' mental health literacy and help-seeking behavior. We assumed that literacy and attitude regarding mental illness issues in clinical settings could be different from the preclinical one that need further studies in that area, as well as studies on the medical students compared to non medical students. This study also cannot provide the comparison of mental health literacy and help-seeking behavior between female and male students because of the dominated of female students who were third times more than the male samples. Another limitation of this research is the lack of questionnaire capacity to measure actual help-seeking behavior in the past and the future. This research only measured the factor predicted to modifiy intention of seeking help into concrete behavior.

Conclusion
The students generally have a good mental health literacy and good attitudes toward professional help-seeking. The students still show distrust in regard to confidentiality from mental health professional in non life-threatening situation, false self-treatment technique, and unwillingness to engage in activities with people with mental illness. There is low positive correlation between mental health literacy and help-seeking behavior. Three out of six attributes of mental health literacy has positive correlation to the attitudes toward seeking professional psyhological help.