Help Seeking Measures in Mental Health

 

 

He lp -s -se e e king me mea a sur ure e s in ment me nta al hea he a lth: a ra p id revi vie ew

Deb ra Ri Debr Ric c kwoo wood d Kerry Thomas Sa ll lly yB Brra d for fo rd

kere ed b y the the Sa x Ins Insti titut tute e A n Evidence Check review b ro ker for beyondblue   August 2012

 

 

 Thi  This s rap id rreview eview was brokered brokered by tthe he S Sax ax Ins Insti titu tute. te.  Thi  This s repo rt wa was s prepared by Debra Debra Ri Ric c kwoo d, K Kerr erry y Thomas and S Sally ally Brad for ford. d. Augu Au gus st 2012 ©The Sax Sa x Institute 2013  Thi  This s work is c opyright opyright.. No pa rt may be repr reprod od uced uce d b y any pr proc oc ess excep t in in ac c ordanc e with the the p rovisions of the C opyr opyright ight A ct 196 1968 8. Enquiries reg reg a rding this this rrep ep ort may b e direc direc ted to: Knowledg e Exc hange Pr Knowledg Program ogram  The  The S Sax ax Institut titute e Level 2, 10 Quay Street Haymarket NSW 2000 PO Box K6 K617 17 Ha Hayma ymark rke e t NS NSW W 124 1240 0 Austra Austra lia  T:  T: +61 2 951 951459 45950 F: +61 2 95145951 Email:: knowledge.e Email knowledg e.ex xc hange @sa xinsti titut tute.o e.orrg.au g.a u Suggest ugg ested ed C itation: itation: Rickwood D, Thomas K, Bradford S. (Review of help-seeking measures in mental health: an Evidence Check   rapid review brokered by the Sax Institute (http://www.saxinstitute.org.au) for beyondblue , 2012.

Disc Disc laimer:  T  Thi his s Evidence Check   review was produced using the Evidence Check  methodology in response to specific questions from the commissioning agency. It is not necessarily a comprehensive review of all literature relating to the topic area. It was current at the time of production (but not necessarily at the time of publication). It is reproduced for general information and third parties rely upon it at their own risk.

 

 

 

 

C ONTENTS EXEC UTIVE SUMMAR MMARY ........................................................ ................................................................................................................... ......................................................................... ..............6  1 Background............................. Bac kground........................................................................................ ................................................................................................................ .....................................................8  2 Introduc roducttion .......................................................... ..................................................................................................................... ................................................................................... ........................9  History of help-s help -see eeki king ng a s a c onc on c ept ep t .................. ......................... ............... ................ ............... ............... ............... ............... ................ ............... ............... ................ ........10 10  Dimensions of help-seeking .......................................................................................................................10 .......................................................................................................................10  Aims of the review .......................................................................................................................................11 .......................................................................................................................................11  3 Met Methodolo hodology........ gy.................................................................. ..................................................................................................................... ....................................................................... ............13  Se a rch rc h strateg trate g y ........................................................ ............................ ....................................................... ....................................................... ........................................................ ..............................13  4 Nat Nature ure Of Of The Evidence Evidenc e ....................................................................................................................... .......................................................................................................................15  O rigin rigin of the evidenc evid enc e ............... ....................... ................ ............... ............... ............... ............... ................ ............... ............... ................ ............... ............... ................ ............... ............ .....15 15  Study sa mple c ha harac rac teristics teristics............... ....................... ................ ............... ............... ................ ............... ............... ............... ............... ................ ............... ............... ................ .......... ..16 16  Study design ................................................................................................................................................. .................................................................................................................................................18 18  5 Help-seeking Help- seeking definit definitions ................................................................................................................... ...................................................................................................................... ...21  Sta tand nda a rdised mea me a sures ..................................................... ......................... ....................................................... ....................................................... .............................................. ..................22 22  Non-st No n-sta a nd nda a rdised rdised mea sures............... ....................... ............... ............... ................ ............... ............... ................ ............... ............... ............... ............... ................ ............... ........... ....23 23  Help-seeking in the National Survey of Mental Health and Wellbeing .............................................. 24  Elements of help-seeking ........................................................................................................................... ...........................................................................................................................25 25  6 C onclusions onc lusions.......................................................... ..................................................................................................................... ................................................................................. ......................28  C ommon ommo n elements e lements of help-s help -see eeki king ng de defini finitions tions and meas mea sures in Australia/ Australia/ New Zea land ........ ............ ....28  7 Rec ecomme ommenda ndattions........................................................ ................................................................................................................... ....................................................................... ............30  Proposed definition .....................................................................................................................................30 .....................................................................................................................................30  Impleme Imp lementa ntation tion is issues................................................... sues.............................................................................. ....................................................... ................................................... .......................32  References eferenc es .................................................................................................................................... ................................................................................................................................................ ............34 

 

 

 

 

EXECUTIV EXECU IVE E SUMM MMA ARY beyondblue c o mmiss mmissione d this lit litera erature ture revie review w to ide ntify and synthesis ynthesise key resou resource rces s that tha t de define fine the term ‘help-s ‘he lp-see eeki king ng beha b ehaviour’ viour’ in the c ontext of mental healt hea lth h and an d well we llbe being. ing. There is currently no agreed and commonly used definition of help-seeking, and the purpose of the review is to support recommendations for development of a standardised definition of helpseeking behaviour be haviour appli ap plic c ab le to the Austr Australian alian mental health he alth context c ontext.. A database search revealed a very high level of research activity in the field, and restriction to the terms ‘help’, ‘seek’ and ‘mental’ was required to generate a manageable review. This ge generate nerated d 316 a rtic rticles les,, which wer we re sys systematica tema tica ll lly y reviewe reviewed. d. Almos A lmostt half the pub lic lic a tions tions ori originated ginated fr from om the USA, USA, b ut sec sec ond most most c ommon we re Austr Austra a lia lia n publi pub lic c ations, ations, which c ompri omp ris sed 15 15% %. Publica tions range d b a c k tto o 1971, 1971, but there has ha s been be en a sur urge ge in interes interestt since since 2005.  T  The he review review confi c onfirrmed that there there is no c ommonly ommonly rrefer eferrred to defi de fini niti tion on of help-s help-seeki eeking, ng, and tha tha t most articles did not explicitly define the term but took its definition to be self-evident. Nevert Neve rtheless heless,, in the mental menta l health hea lth c ontext, help-seeking has ha s be been en c ha harac rac teris terised primarily primarily a s a n a daptiv da ptive e c op oping ing respo respons nse e to mental menta l health problems that that c omprises a sea earrc h for as a ssis istanc tanc e from from externall so urce s. externa

 There here were no p sychometri ychometric all ally y sound sound meas mea sures ures of help-seeki help-seeking ng that were were routin routinely ely us used ed in the the literatur literature. e. M ost studies studies develop deve loped ed their own mea sur ures. es. The most commonly co mmonly used used standa tand a rdised rdised meas mea sures were the Attitude Attitudes s Towa ow a rd See Seeki king ng Professiona Professionall Psycho Psycho logic a l Help Help Sca le1,  which measures attitudes, and the General Help-Seeking Questionnaire Questionnaire 2, which  whic h meas mea sures intentions intention s to seek future help and past help-seeking experiences.  T  Ther here e were were few element elements s of help-s help-seeki eeking ng that that were were c ommon ac ros oss s all definiti definitions ons and populati po pulation on sub-groups, ub-groups, and a nd no pa tt tterns erns were evident whereby parti p artic c ular el elements ements were c ommon to spec pe c ific ific population sub-groups. The most common element was a focus on formal help-seeking sources, rather than informal sourc sources, es, although studie studies s did not as a ssess a c ommon set of o f profes profe ssional iona l sources―ea eac ch s study tudy addres ad dress sed an idiosyncratic idiosyncratic range of formal formal sour sourc c es es.. Similarly, the studies considered help-seeking for a range of mental health problems and no c onsis onsistent termi terminolog nolog y was app li lied ed.. The most c ommon ommo n mental healt hea lth h problem prob lem inves investigate tigated d wa s de depress pression, followed by use use of gene g enerric terms suc uch h as mental menta l health hea lth problem, prob lem, psyc psycholo hologic gic a l distres dist ress s, o orr emotiona l problem. p roblem. On the basis of the results of the review, it is evident that a simple definition of help-seeking is much needed, along with development of psychometrically valid measures. It is recommended that help-seeking help-seeking be defined as:

In the the mental healt health h c ont ontex ex t, help-se ek ing is an adaptive c oping proc ess th that at is the att attemp emp t to obtain ex ternal assist assistanc anc e to de al wit with h a me ntal ntal healt health h c onc ern.  T  To o enabl enab le c onsis onsistency and the the ab abil ilit ity y to c ompare stu tudy dy res esul ults ts, res esea earrc hers hers need to be enc ouraged ourage d to c onsider onsider and make explic explic it tthe he foll fo llowing owing elements: elements: ocess ess (and respective timeframe timeframe)) refers to the part of the process that is of interest: 1.  Proc whetherr the foc us is on a general whethe ge neral orientation or attitude attitudes s towa rd obtaining ob taining as a ssis istanc tanc e; future behavioural intentions; or observable behaviour (either in the past or prospectively in the future)

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nce e is the sourc e and type type o 2.  Assistanc  off as a ssis istanc tanc e that is soug sought. ht. Source of as a ssis istanc tanc e needs nee ds to c learl lea rly y distinguis distinguish: h: a.   professional health service providers with a specified role in delivery of mental health care (formal) b.  service providers and professionals that do not have a specified role in delivery of mental health care (semi-formal) c .  inform informa a l soc soc ial supports supp orts (informal) (informal) d.  self-help elf-he lp resourc resources es (s (self-he elf-help) lp) 3.  Concern refers to the type of mental health problem for which help is being sought. This needs to be clearly defined and made explicit. Finally, to develop a psychometrically sound measure of help-seeking that could be commonly applied across a range of studies and that clearly addresses each of the elements referred to above, a research project needs to be undertaken. This would provide clear examples of valid and reliable ways to operationalise help-seeking. In the meantime, using the general definition presented here and encouraging researchers to consider the major conceptual elements described above will begin to provide a guide to standardised outcome measurement, program de develop velop ment, resource resource a ll lloc oc a tion and a nd a ssis istt s stakeho takeholders lders to c ommunica ommunic a te in this this relation to this c ritica itica l health ca re pr p roc es ess s.

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1 Bac kgr kground ound beyondblue,  a lea ding Aus A ustr tra a li lia a n nationa l s stakeho takeholder lder in menta mentall healt hea lth, h, has co mmis mmissioned ione d this literature literature review review on o n the topic of help-s he lp-see eeki king ng beha b ehaviour viour.. The aim a im of the review review is to identif ide ntify y and synthesi ynthesis se key resourc resources es tha tha t define de fine the term ‘help-s ‘help -see eeki king ng b eha viour’ viour’ in the c ontex onte xt of mental me ntal healt hea lth h and wellbe wellbeing ing to make recommendations reco mmendations for development of a standa rdised dised defin de finit ition ion of help-seeking help-s eeking behaviour be haviour app li lic c a ble to the Austr Australian alian mental menta l health context c ontext.. A standa rdised dised evidenc e-inform e-informed ed defin de finit ition ion of o f help-seekin help-seeking g behaviour be haviour in in mental hea lth lth has ha s n not ot be been en d evelope eve lope d fo r tthe he Austr Austra a lian c ontex onte xt, nor internationa internationall lly. y. This review will inform an import impo rta a nt be benc nc hmarking hmarking initiative initiative aiming to develop de velop a c onsensus onsensus umbrella umbrella d efinition efinition of help-s help -see eeki king ng be beha haviour, viour, with po potential tential tailored app a ppli lic c a ti tion on to p riority iority po popula pulation tion sub-g sub-groups. roups. The c onsensus onsensus definition needs to have operational value to be able to guide program development, resource a lloc lloc a ti tion, on, stand standa a rdised dised outcome outc ome measurement, measurement, and a nd a ssis istt s stakeholders takeholders to to c ommunic ommunic ate.  T  The he a udience for thi this s review eview is pri primar maril ily y the the senior enior polic polic y makers makers and pr p rogram mana gers withi within n beyondblue , but it may be dis diss seminated eminate d more mo re broadly broa dly ac ross ross the Austra Austra lia lia n mental menta l healt hea lth h sec sec tor in the medium med ium to to longe lo ngerr tterm. erm.  T  The he major major questi questions ons the the revi review ew add res ess ses are: 1.  How has ha s help-seeking help-seeking behaviour be haviour been defined d efined in the mental health contex c ontext? t? 2.  Which elements e lements for defini de finitions tions of help-s he lp-see eeki king ng beha b eha viours viours in menta mentall health are c ommon ommo n a c ross ross a ll definitions definitions and po popula pulation tion sub-g sub-groups? roups? Likewis Likewise, e, whic h elements for definitions definitions of help-s he lp-see eeki king ng beha b eha viours viours a re spe spec c ifi ific c for popula po pulation tion sub-g sub-groups roups or interventions interventions (help type)? Ev Evide idenc nce e related relate d to these these quest q uestions ions is used used to add a dd ress ress the main ma in aim of the review, which whic h is to: 3.  Provide an evidence-informed expert recommendation, applicable to the Australian setting, on the feas fea sibility ibility a nd (if cons co nsidered idered fea sible) the potential po tential content c ontent for a universa universa l op operational erational defini d efiniti tion on of hel he lp-seeking p-seeking be haviour in in the mental health he alth c ontext. ontext.

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2 Introduc ucttio ion n Mental health is a major health priority area for Australia. The 2007 National Survey of Mental Healt Hea lth h and a nd Wellbeing Wellbe ing found that almos a lmostt half (45.5 (45.5% %) of Aus A ustr tra a lia lia ns a ge ged d 16 to to 85 experience experienc e a mentall illnes menta illness s at some sta sta ge in their lives lives,, with abo a bout ut one in five five exper expe riencing ienc ing mental menta l illness illness in any a ny given year yea r3. This rate increases to one in four for those aged 16 to 2 24 44,  and adolescence and young adulth a dulthoo ood d a re a c kn knowled owledged ged as critica critica l llife ife stage stages s for mental mental hea lth. lth. Despite the high high pr p revalenc eva lence e of o f mental illnes illness s, most most people peo ple do d o not no t ac c ess profes profe ssional iona l hea lth lth care for mental health problems. It might be expected that the high prevalence of mental disorder should be matched by a high level of service use and associated help-seeking behaviour; but rather there is a marked mismatch between the prevalence of disorder and the levell of profe leve p rofes ssiona l help-seeking. help-see king. Figure Figure 1 sho shows ws the ext e xtent ent of o f this misma mismatc tch. h. It plots the the pe perce rcentag ntage e of Aus A ustr tra a li lia a ns exper expe riencing ienc ing mental disorde disorderr within within a 12-month 12-month period and a nd the relative proportion of those with disorder who sought professional help. help .4  At all ages there is a much muc h higher prevalenc e than tha n there is servic ervic e use, although the mismatc h is greates grea testt where the prevalenc e is highes highest—for t—for thos those e ag ed 16 16–24 –24—a —and nd d ec rea eas ses with with age. ag e. In the 16–24 16–24 year age a ge group, for males, there were 23% who reported mental disorder, but only 13% of these young men had sought professional help (about 3% overall); for the females in this age group, 31% experienced mental disorder and 30% of these young women had sought professional help (a (abo bout ut 10% 10% overall ove rall). ). 

Ma les Pr Prevalenc evalence e M a les Servi ervic c e Use

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Fema emales les Preva Prevalenc lence e

30

Females Fema les Se rvic vice e Us Use e

25   e   g   a    t 20   n   e 15   c   r   e    P 10 5 0 16-24

25-34

35-44 35-44

  45-54

55-64 65-74

75+

Age group group Figure 1. Prevalence of 12-month mental disorder and relative proportion who had sought professional help, by gender and age group C onseq onsequentl uently, y, a foc fo c us on unde rstanding a nd enc e ncouraging ouraging help-seekin help-seeking g b ehavi eha viour, our, partic partic ularly ularly for young young peo p eople, ple, has emerged a nd bec b ec ome a growing priori priority ty for res resea earrc h, polic polic y and pr p rog ogrra m initiatives. For example, a major aim of beyondblue  is raising awareness and improving mental hea lth literac literac y tto o improve help-s help -see eeki king ng beha b eha viour; viour; similarly imilarly a pri p rimary mary function func tion of the headspa hea dspac ce National Youth Mental Health Foundation is to increase young people’s help-seeking behaviour for mental healt hea lth h pr p rob oblems lems.5 

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History of help-s His help-see ee kin kingg as a c onc ep t Despite the ra ra pidly pid ly expanding expa nding resea resea rc h and intervention intervention foc us on help-s he lp-see eeki king, ng, there is no agreed definition of the term. At face value, its definition is self-evident. Using the Oxford Dictionary it can be defined as an ‘attempt to find’ (seek) ‘assistance to improve a situation or problem’ (help). Within Wit hin the health hea lth researc research h conte c ontex xt, the the term origina originates tes from from the med ica ic a l soc soc iology iolog y literature literature examining illnes illness s be beha haviour viour.. ‘Illness ‘Illness be beha haviour viour’’ is a term that was wa s introd introd uc uced ed by David Da vid Mec Me c hanic ha nic in 1962 19626  to refer to human health behaviour, incorporating the way people monitor their bodies, de define fine and a nd interpret their their symptoms, ymptoms, take preventiv p reventive e or o r remedial remedia l ac tion, or util utilis ise e the hea he a lth c a re syste sys tem m7. The study of illness behaviour developed in response to recognition that people do not c onsult onsult healt hea lth h c a re profes profe ssionals iona ls whenever whene ver they experienc experienc e symp symp toms. toms. As far ba b a c k as 197 1976, 6, it it was reported that people consult a doctor for only about one in 10 medically significant symptoms they experienc e8.  Ill Illness ness be beha haviour viour includes includ es the the many ma ny fac tors that determine d etermine how peop pe ople le respo respond nd to healt hea lth hs sym ymptoms ptoms and use healt hea lth h c are. A further rationale for studying illness behaviour is that the nature of health conditions has c ha hange nged d over o ver time, time, par pa rticularl ticula rly y during during the last last half of the 20th century. Prior to that, acute and infec tious tious disea disea ses were the most prevalent; suc such h dis d isea ea ses had symptoms that were we re ea sily ily recognised, were seen as a problem that was appropriate to be taken to the doctor, and the symptoms ymptoms were expec ted to be b e c ured ured or alleviated alleviated b y med medica ica l tr trea eatm tmen entt9. Around 19 1976 76,, c chr hronic onic illness illness, disa disa bilities bilities,, mental dis d isorde orders rs a nd living problems prob lems be bega gan n to b e rec ognis og nised ed a s the ma major jor 10 health concerns for primary care .  Suc Such h c ondit ond itions ions ha have ve symptoms symptoms tha thatt ar a re not no t eas ea sily recognised and often have a gradual onset; they can be difficult to identify and interpret as something ome thing approp ap proprriate for fo r medic med ica a l a ttention. ttention. For For these these healt hea lth h co nditions, nditions, tthe he dec de c is ision ion to consul c onsultt a health hea lth professional iona l iis s les less s influenc influenc ed by the na natur ture e of the illnes illness s itself than tha n by b y a voluntary help11 seeking process. process.   Early models of illness behaviour were put forward by Mechanic Mechanic 6,  S Suc uc hman hma n12,  Aday and Andersen13,  and o others thers. See eeki king ng help was wa s c onc ep eptualis tualised ed a s one p a rt of the ill illness ness be beha haviour viour proc ess. However, Howe ver, even though tho ugh it c ompri omp ris ses part pa rt of the illness illness be beha haviour viour proc ess, help-seeking is a lso c onc ep eptuali tualis sed as a dynamic proces proc ess s it its self. O ne of o f the ear ea rlies iestt definiti definitions ons of help-seekin help-seeking g wa s provide provided d b y David Mec M ec hanic, hanic , who saw it as an adaptive form of coping. Later, help-seeking was defined as the behaviour of actively seeking help from other people. people .14  It was deemed to be about communicating with others to obtain a ssistanc istanc e in terms terms of unders und erstand tanding, ing, ad vice, vice , information, information, treatment, and a nd g gene eneral ral supp supp ort in in respo res pons nse e to a problem prob lem or distr distress essing experience. experienc e. As suc suc h, it it was a form of ac a c tive and problemprob lemfoc us used ed c op oping, ing, whic whic h reli relied ed on ex e xter ternal nal as a ssis istanc tanc e from other people. peo ple.

D imens imensions ions of he lp-s p-se e eking Help can be sought from a wide range of external sources, including people who occupy different roles and who vary in terms of their relationship with the person seeking help. Two main ty types pes of help-seekin help-seeking g have ha ve been be en deli d elinea neated ted―formal and informal:  

•

Formal help-see help-see king is assistance from professionals who have a legitimate and recognised professional role in providing relevant advice, support and/or treatment. Formal help-s he lp-see eeki king ng is its itself divers d iverse a nd includes includ es a wide range of profes profe ssions. ions. T These hese include spe pec c ialist ialist and ge generalis neralistt health ca c a re providers, providers, but also also non-hea no n-hea lth lth professiona professionals ls,, suc uch h as a s teac tea c hers, hers, c clergy, lergy, communi co mmunity ty and youth work wo rkers ers.. The term ‘treatment-s ‘trea tment-see eeki king’ ng’

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INTRODUC TION

has recently begun to be used to delineate seeking help from specific health treatment providers provide rs a nd seeking help from from ge neric support suppo rt a nd c ommunity servic ervic es  

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Informal help-see help-see king is assistance from informal social networks, such as friends and family. It comprises sources of help that have a personal, and not a professional, relationship relations hip with the help-seeker.

 self-help lp has emerged as an area of attention. This has occurred because of the Most recently, self-he rapidly growing opportunities to use computer mediated communication technologies to support mental health. health.15  Help-seeking can now include assistance from sources that do not comprise communication with an actual person. Sophisticated and dynamic help-seeking options are increasingly available through online and computer-mediated processes. Such op tions make an a n interpe interpers rsona l compo co mponent nent less less c riti itic c a l iin n the help-seeking proc ess. help,, which can be categorised in  T  Ther here e are, therefor therefore, e, mul multi tiple ple―and expanding ―sourc es of help different ways wa ys,, including formal, informal informal and a nd self-help. problem. Within Help can be sought for any type of health problem. Within the mental menta l health hea lth field field,, this c o mprises mprises a very wide range of potential issues. Mental health problems and mental disorders span many divers diver se c onditions onditions,, and a nd a lso c ompris omprise both bo th emerging emerging and mi mild ld c onditions onditions without without spe spec c ific ific diagnoses as well as very specific categories of illness diagnosed according to agreed criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)   or Interna International tional Class C lassifi ific c a ti tion on of Disea Dis ea ses (ICD) (IC D).. nce e s  T  The he type of assistanc  sought ought is als also o broad broa d and c an include a lm lmost ost anythin anything g that tha t entails ac tively tively seeki ee king ng as a ssistanc istanc e to ad a d dress a p roblem or o r situation. Assis istanc tanc e c a n include: include : iinformation, nformation, understanding, unders tanding, ge neral suppo suppo rt, advi ad vic c e, general g eneral or spe spec c ific ific trea treatm tment ent in res respo pons nse e to a pa rtic tic ul ular ar 14 problem or set of problems. problems.   T The type o f a ssistance sought c an, therefore, therefore, range range from from entir entirely non-specific (help) in the form of some type of adaptive coping, to engagement of social support, upp ort, through through to a n ac a c tion that is very spec pe c ifi ific c in terms terms of servic service e use from from a spe pec c ific ific servic ervic e provider, provide r, suc uch h as see eeki king ng a p resc resc ription from from a g eneral ene ral prac titioner titioner (GP). timeframe.. It has been conceptualised as not being simply the act Help-seeki Help-see king ng oc o c c ur urs s within within a timeframe of responding to symptoms by accessing a source of health care, but rather as a complex proc es ess s that take plac e over o ver a per pe riod of o f ti time. me. Fina Finall lly, y, bec a us use e help-s he lp-see eeki king ng is a proc ess, it is is not just just ac tual observ o bserva a ble b eha viour, suc uch h as as spe pec c ific ific a c ts of servi servic c e use. use. Potential Potentia l dimensions dimensions of the proc ess c a n vary from from ac a c tual beha be haviour viour to intenti onsdifferent to to beha b eha ve thr throug ough hltoproc more gene ral orientations orientations to beha be have ve ctudes, ertain ways waintentions ys.. The The pa p ain rts rtsc ertain of theways beha b eha vioura viour a essgeneral include dispo dispos sitions, itions, beliefs, beliefs , in atti a ttitudes, intentions and behaviours.

 A ims of the the re revie vie w  T  The he term term help-s help-seeki eeking, ng, while while widely widely used, used, is not clearly clearly defined defined a nd ther there e is no cur c urrrent c onsens onsensus us o n its de finitio finitio n or its meas mea surement. uremen t. The a im of this p a p er is to review a nd a dd ress ress this is iss sue ue.. It is evident evide nt tha thatt measurement measurement of o f help-seeking req requir uires, es, a t a minimum, minimum, co ns nsidera ideration tion of a number of elements, which whic h ca c a n be summa summa ri ris sed a s: 1.  Proc Process ess – spe spec c ifi ific c pa rt of the the beha be haviour vioura a l proc ess (attitude, intention, intention, beha be haviour viour)) 2.  Source ourc e – source ourc e of of a as ssis istanc tanc e (formal, informa informa l, s self-help) elf-help) 3.  Pr Prob oblem lem – type type of mental hea lt lth h problem 4.  Ass Assis istanc tanc e – type of o f assis istanc tanc e, from generic to spec ific ific

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INTRODUC TION

5.   Tim imefr efra a me – temporal temporal c onstr onstraint aints s.  T  The he aim of this this stu tudy dy is is to revi review ew the the c urr urrent state of the the lit liter eratur ature e to determi determine ne how help-s help-seeki eeking ng has been conceptualised and measured. It will determine whether there is any consensus in the way the concept has been operationalised in the literature, and how the five elements outlined ab ove have be en ad dress dressed.

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METHODOLOGY

3 Methodology A systematic review of the literature was undertaken by reviewing studies that met the selection c riteria iteria desi d esigne gned d to gene g enerate rate the relevant literatur literature e on o n see seeki king ng help he lp for mental health hea lth problems prob lems..

 Se  Sea a rc h strate strate g y Initially, a broa d search Initially, sea rch strateg strategy y was wa s implemented c over ove ring a all ll studies published published in Englis English h pr p rior to the sea searrc h da te of 13 J une 2012 2012.. The following EB EBSC O da tabases tab ases were sea searrc hed: Ac a demi de mic c Sea rch C omplete, omp lete, C INAHL Plus Plus,, MEDLINE MEDLINE,, Ps Psyc ycINF INFO O. Initial Init ial sea sea rc hes using relevant terms yi yielde elde d a huge number numbe r of art a rtic icles les.. F For or example: examp le:  

Requesting Requesti ng ‘help* ‘he lp*’’ a nd ‘s ‘ see eek* k*’’ in the titl title e and a nd ‘mental* ‘ mental*’’ or o r ‘emotional’ or ‘ps ‘p sychologic ycho logical’ al’ in subjec t terms, terms, resulted resulted in 424,90 424,902 2 art a rtic icles les

 

Requesting ‘help*’ and ‘seek*’ in the title and ‘emotional’ or ‘psychological’ in subject te terms rms,, resulted in 124,331 124,331 a rticles rtic les

 

Requesting ‘help*’ and ‘seek*’ in the title and ‘emotional’ or ‘psychological’ in subject terms term s and ‘mental*’ ‘me ntal*’ to NOT NO T be in the sear sea rc h result resulted ed in 109,0 109,034 34 artic articles les

 

Req eques uesti ting ng ‘help* ‘ help*’’ a nd ‘ seek*’ in tit title le and a nd ‘emotional’ ‘ emotional’ or o r ‘psycho ‘psychologic logical’ al’ to be in the the title title (ratherr ttha (rathe han ns sub ubjec jec t terms) terms) resulted resulted in 36,86 36,865 5 articles article s.

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 T  Thes hese e sea searrc hes reveal the the huge amoun a mountt of int interes erestt in in the the area o off help-s help-seeki eeking ng withi within n tthe he mental mental healt hea lth h field; field; however, how ever, the the output o utput from from these these sear ea rc hes was wa s unmanag ea eable ble for fo r a review. A more managea mana gea ble search strateg trategy y was shown shown to be us usin ing g the terms terms ‘help*’ a nd ’s ’seek*’ eek*’ in the the tit title le and a nd ‘mental* ‘menta l*’’ in the subjec t term, term, which whic h result resulted ed in 939 939 artic artic les les.. When the sea earch rch wa w a s limit limited ed to art a rtic icles les that were report repo rted ed in Englis English, h, were peer-r pe er-reviewe eviewed, d, were we re rela related ted to only human be beha haviour, viour, a nd d uplica uplic a te ME M EDLINE DLINE results results were removed remove d from C INAHL, 48 480 0 artic artic les remained. remained .  T  Thes hese e resul results ts were were exported exported to Endnote, Endnote, and 84 fur furth ther er dupli duplic c ates were were removed, removed, res resul ulti ting ng in in 396 396 a rt rtic icles les.. Seve Seventeen nteen of o f these these art a rtic icles les were review art a rticle icles s, and seven eve n were propo p ropos sed models mod els of help-seeking, which whic h were removed remove d to a subfolder, ubfo lder, resul resulting ting in 372 372 a rtic rticles les.. A review of o f titles titles a nd a bstrac bstrac ts revealed revea led that tha t tthere here were we re 62 non-relevant non-releva nt artic artic les les,, which included inc luded seeki ee king ng help for fo r job hunting, asylum seeking, grieving, and for medical problems such as irritable bowel syndrome, tinnitus,, premenstrua tinnitus premenstruall syndrome, yndro me, a and nd HIV/ AIDS.   T  The he final final resul esultt yi yielded elded 310 relevant elevant art articles icles.. These hese were were supplemented upplemented by a sea earrc h of th the e C oc hrane da d a tab a se, using using the sa sa me sea sea rch terms. terms. This yielde yielde d 64 a rtic rticles les,, of which whic h one wa w as relevant, after dupli dup lic c a te articles from the previous sea rch and a nd art a rtic icles les not releva relevant nt were removed. Finally, a search of PubMed, available through CareSearch, as well as a search of majorr a ge majo genc ncy y rep reports orts (i. (i.e. e. Worl Wo rld d Hea lth O rganization, Austra Austra lia lia n Institute titute of Health Hea lth a nd Welfare) Welfa re) was wa s c ond uc ucted ted,, resul resulting ting in 148 1488 8 artic artic les les.. These were limited limited to human, huma n, cli c linica nica l trial, trial, metameta a naly na lys sis, is, randomis rand omised ed c ontrol trial, trial, sys systematic tema tic review review a nd review, result resulting ing in 257 artic articles les,, of o f whic h 23 231 1 were not relevant to mental menta l health hea lth help-seeking. Of O f the 26 relevant eleva nt artic artic les les,, 13 13 had a lrea lrea dy been identified in the previous searches, seven were review articles and one was a proposed model mod el of o f help-seeking. This resulted resulted in an a n add a dd iti itiona ona l five five a rtic rticles les.. It should should b e noted no ted that this sea rch strateg strategy y was highly targeted targe ted a nd, therefore, therefo re, not exhaustiv exhaustive. e. It did not pr p rod oduce uce all the relevant relevant a rti tic c les on help-s he lp-seekin eeking g withi within n the mental hea he a lth lth c ontext ontext.. In fac t, 16,17,18 many semina seminall artic articles les were not c a ptured by b y the the sea sea rch (i.e. (i.e. ). However, a preliminary

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investigation of the articles that were produced showed that the help-seeking measures that were used in the well-known seminal articles that were not captured had been picked up. C onseq onsequentl uently, y, the the search stra tra tegy is argued to be b e effec tively tively co compr mprehens ehensiv ive e for fo r the the a im of determining the ways that help-seeking has been conceptualised and measured within the mental health field. The fina final c combined ombined search of of relevant eleva nt articles ic les yielded yielded 316 artic icles. les. Each of these articles was read by one of the authors and its details entered into a spreadsheet. There were 25 different c harac ter teris isti tic c s of studies studies c onsidered onsidered a nd rec orded. orded . A random rando m sa sa mple of 15% 15% of the ar a rtic tic les was rechecked bythe another author.

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METHODOLOGY

4 Na Nattur ure e of the Evide videnc nce e A brief brief summar summary y of the general g eneral c harac teris teristi tic c s of the evi e vide denc nce e generated g enerated by the review review search searc h is provided provide d below b elow.. This includes inc ludes the the ori o rigin gin of the evide nc nce, e, the ma main in cha rac teris teristic tic s of the study study populations, and the types of designs of the studies.

O rig in of the evidenc e C ount ountr ry of of origin It is evident from Figure 2 that most of the pub lic lic a tions originate from the US USA, followe followed d by Australia. Almost half (45%) of the p ub ublica lica tions were from the USA; 15% 15% from Au Aust stralia ralia;; 8 8% % from the UK; 6% from Ca C a na nad da ; 4% from the Netherlands; and 3% from New Zea land. land . A diverse diverse range rang e of o f other countr co untries ies made up the remaining 18% of the pub lic lic a tions, tions, but there were fewer fe wer than 2% of a rt rticles icles from from any a ny part pa rtic icular ular countr co untry. y.  T  Ther here e were were 58 58 public public ations that that were were from from Australia or New Zealand. Zealand .

Figure 2. Country of origin of publication

 Yea ear r of pu publ bliicat catiion  Y  T  The he yea yearr in whic whic h the the articles articles were were publis published is is presented in Figure 3. This shows the large growth in interest interest in the help-seeking area. a rea. Publications generated by the database sea earrc h went ba c k to 1971 1971,, and a major sur surge ge in interest is eviden evid entt from 2005. 2005. A simila imila r pattern pa ttern was evident for the Australian/New Zealand a rt rtic icles, les, the first first of whic h was wa s pu published blished in 1974, 1974, and half were published after 2005.

Figure igure 3. Year of publica public ation  ion 

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NA NAT TURE OF THE EVIDENC EVIDENC E

 Study sa samp mp le c ha hara racc te teris ristic tic s Age Ag e of of pa par rtic icipa ipant nts Ag e group g roup o f the pa p a rtic rticipa ipants nts in the review studies is p resen resented ted in Figure Figure 4. This sho hows ws tha thatt just just over half the studies (51%) were of general adult populations, aged 18 years and over. The next most c ommon ommo n were studies studies of ea e a rl rly y adult ad ults s a ge ged d 18–25 18–25 (14 (14% %), followed by teena tee nage gers rs a ge ged d 12– 18/9 (12%), parents of children and adolescents (8%), and middle-aged adults (4%). There were very few studies studie s o f children c hildren (2%) or o r adults ad ults a ge ged d over o ver 65 years yea rs (2%). In the Austr Austra a lia lia n and a nd New Ne w Zea Zea land studies (Fi (Figure gure 5), there there wa s a much muc h greater grea ter prop prop ortion of articles focussed on teenagers and youth (40%), and none on children or older adults.

Figure 4. Age group group of study part pa rticipa ic ipant nts 

Figure 5. Age group of of study pa partic icipa ipant nts (Aust/ NZ) 

Gende ender r of par partic icipa ipant nts Mo st s studies tudies had a n equivalent eq uivalent number of male ma le and a nd female fe male p a rtic rticipa ipants nts (56% (56%), as show shown n Figure Figure 6. Otherwi Othe rwis se, the studies had either a major majo rity (14 (14% %) or o r were predo p redominantly minantly (9% (9%) o orr c comp ompletely letely (8%) female sample groups. There were 4%, 1% and 7% where the sample was mostly, predomina pred ominantl ntly y or completely co mpletely ma ma le, respe respec c tively. tively. A relativ rela tively ely simi similar lar patter pa ttern n was wa s evident evide nt for par pa rticipa nts in the Austra Austra lian/ New Zea Zea land studies (F (Figure igure 7), a lt lthoug hough h there was wa s a higher proporti prop ortion on of of s studies tudies with with more female fema le pa rtic rticipa ipants nts..

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NA NAT TURE OF THE EVIDENC EVIDENC E

Figure 6. Gender ender of study pa par rticipa ic ipant nts

Figure 7. Gender ender of study pa part rtic icipa ipant nts (Aust/ (Aust/ NZ)

Reg egiona ionall se setting of par partic icipa ipant nts s   T  The he regional sett settin ing g of st study udy pa rti tic c ipants is pres presented ented in Figur Figure e 8. Thi his ss shows hows that that over o ver half half the studies (54% (54%) were we re of o f urban urba n or o r iinner nner urba urba n pop p op ulations. ulations. T The he next most most c ommon ommo n were we re studies studies where the setting setting was wa s not spe spec c ifi ified ed (1 (18% 8%), followed by studies studies tha thatt ra ra nged nge d a c ross urban, regiona regio nall a nd rura l s settings ettings (16 (16% %). There There were w ere 6% of studies in eac ea c h of o f regiona regio nall and a nd rur rura al s settings ettings,, a and nd only one study that was specifically of participants from a remote setting. For the Australian and New Zealand studies (Figure 9), there were more where the setting was not spe c ified (28%), and a nd relatively rela tively fewer fewe r that tha t were of o f urban urba n or inner urb urb a n only on ly (44% (44%). The here re were 12% that were regiona regio nall or rural, rural, but no studies studies of pa p a rticip rticipa a nts spe pec c ific ific a lly lly in in remo remote te loc a tions. tions.

Figure 8. Regiona egionall sett setting of study part pa rticipa ic ipant nts

Figure 9. 9. Reg egiona ionall setting of study part partic icipa ipant nts (A (Aust ust/ NZ)

Type of par partic icipa ipant nt sample  T  The he type type of stu study dy participants participants is presented presented in in Figure 10. This 10. This shows that most of the studies were of ge general neral c ommunity-ba ommunity-ba sed sa mples (41% (41%). The The nex ne xt most most co c o mmon wa s studies of c ollege/ ollege / univers university students (20% (20%), followed followe d by mental me ntal hea he a lth servi servic c e po popula pulation tion groups group s ((12 12% %).  T  Ther here e were 10 10% of stu studies dies ba bas sed on o n sc sc hool stu students dents.. About Abo ut 8% of stu studies dies were were of gener ge neral al health health

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NA NAT TURE OF THE EVIDENC EVIDENC E

or community c ommunity servic ervic es populations, pop ulations, a nd 6% were of o f very spe pec c ific ific types of community c ommunity groups group s. A very sma small ll numbe r of studies studie s we were re of samples samp les from inpa tient servic services es and p ris riso ns (1.6% (1.6% ea c h). In the Australian and New Zealand Studies (Figure 11), 11), a similar proportion was of the general c ommunity (42 (42% %), but more were we re sc sc hool hoo l s student tudent p op ulation groups g roups (23% (23%).

Figure 10. Type of study participants

Figure 11. Type of study participants (Aust/NZ)

C ultural bac bac kgroun kground d of par partic icipa ipant nts  T  The he c ultu ulturral bac ba c kground ground of the the pa parrti tic c ipants was gener gene rally ally not spec ified; ified; thi this s was the the c ase for a lmost lmost half ha lf the studies studies (47% (47%). For those those studies studies where c ultur ultura a l bac ba c kground of o f pa rticipa nts wa was s spe pec c ific ific a lly lly noted, note d, the majori majo rity ty were of gene g eneral ral US USA po pulation pula tion groups (23 (23% %), follo follo wed by Africa n Ameri Ame ric c a n sa sa mples (15% (15%), reflecti reflec ting ng that tha t most studies origina originated ted in the USA. USA. O verall, there there wa was a wide range ra nge of o f cultura cultura l ba bac c kgrounds studied; tudied ; investigating investigating the help-seeking beha viour of pa rt rtic icular ular Cult C ulturally urally a nd Linguistica Linguistica ll lly y Divers Diverse e (C ALD) groups group s is is of c onside onsiderra ble interes interest, t, p a rti rtic c ularly in the US USA. For the Australian Australian and a nd New Ne w Zea land studies, a large la rge prop ortion did not no t spe pec c ify the c cult ultur ura al ba c kground (65% (65%). There were 14% 14% that were of gene g enerra l New Zea Zea land c ultural ultural bac ba c kground and a nd 13% 13% that were of g general eneral Austr Austra li lian an or Ca C a uca sian ba b a c kground. kground. An important aspect related to cultural background that was evident, however, was the sources of help he lp that were provided provide d as a s op tions in various studies. Although diffi d iffic c ult to qua ntify ntify bec a us use e of of the lack of specific information on cultural background, the different sources of help tended to vary according to the nature of the population groups being studied. For example, ‘prayer’ a pp ppea earred to be included more more often o ften as a source source of help within within the the US studies c ompa red with with the Australian and New Zealand studies. Traditional healers were included as a source of help in studies that included population po pulation groups for whom suc such h roles a re an im impo porrtant, and often for fo rmal, source ourc e of suppor suppo rt.

 Study d e sig n  T  The he studies tudies were ex examin amined ed for their their sample sample siz ize, e, type type of design, design, level level of evidenc evidenc e and th the e conceptual frameworks that were applied.

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NA NAT TURE OF THE EVIDENC EVIDENC E

Sample size  T  Ther here e was a large large range in sa sa mple mple siz ize e amongst amongst the the studies tudies.. T The he small smalles estt s sample ample size ize was n=10 from a qua q ualit lita a tiv tive e study study c ompri omp ris sing interviews interviews with parents pa rents who ha d sought help he lp for c hil hildren dren with 19 ea rl rly y signs of mental menta l disorde disorderr in Ca na nada da ; the largest largest was a na tion-wide tion-wide e pidemiologica pidemiologic a l s study tudy―  20 the C ana dian C ommunity ommunity Hea Healt lth h Sur Survey vey―with n=123,543. 123,543.   Sa mple si size ze of the Austr Austra li lia a n and a nd Ne w Zea Zea land studies ra ra nged nge d from n=16 from a study of that investigate inves tigated d ba b a rriers to help-seeking for menta mentall health conc c onc erns a nd ex e xplor plo red the role o off p sycho yc holog logic ica a l minded minde d ness us using ing semi-str semi-struc uc tured interviews with 16 16 a du dults lts in a South South Aus A ustr tra a lian rur rura a l centre c entre21  to a study of o f n=96 966 622  randomly rand omly selec ted sec onda ond a ry sc hool hoo l students tude nts from ac ross ross New Zealand who participated in the Youth2000 Health and Wellbeing Survey.

Type of design In terms of overa o verall ll study design, d esign, the majori majo rity ty o f studie studies s we were re cros cro ss-s -sec ec tional tiona l designs. This wa was s followed by qualitative studies. There were few longitudinal or prospective studies.  studies.   Tab able le 1 shows the the perce p ercentage ntage of studies studies that that used used ea eac c h type type of d es esign. ign.

Table 1. Percentage of studies by type of design Type of design

All studies

Aust/NZ studies

Cross sectional

73

69

Qualitative

14

17

Longitudinal

6

7

Intervention

3

5

Prospective

4

2

Level of evidence Overwhelmingly, the level of evidence produced by the studies according to NHMRC criteria 23 was very low (Table 2). 2). The vast majority were descriptive studies of population groups with no c ompa omp a ri ris sons. There wer we re only o nly two rando ra ndo mised c ontrolled tria tria ls (RC (RC T). 24

O ne of o f the RCT RC Ts wa was s Austr Austra a li lia a n , a  and nd c ompri omp ris ses a randomis rand omised ed c ontrolled tria tria l of 1094 1094 pe pers rsons randomly rand omly selec selec ted from the c ommunity who sc reened po pos sitive itive for depress de pressive symptoms. symptoms. Partic Parti c ipants were were mailed eit e ither her an evidenc e-ba sed c onsumer onsumer guide guide to trea treatm tments ents for depres de press sion or, as a c ontrol, a general ge neral broc hure hure o on n dep ress ression. Outc O utcome omes s were the rated us usefulnes efulness s of the informa inform a tion provided , cha nges nge s in a tti ttitude tudes s to depress de pression trea trea tments, tments, ac tions taken to reduc e d ep ress ression, and a nd c ha hang nges es in depre de pres ssive sympto symptoms ms,, anxi an xiety ety sympto symptoms ms a nd d is isa a b ility. ility. The results results showed that the pa rti tic c ipants rated the evidenc e-ba sed c onsumer onsumer guide a s more more useful useful than than the c ontrol broc hure, hure, a and nd that tha t attitude attitudes s to so so me tr trea ea tments c ha hange nged. d. Improvements in in s symptoms ymptoms a nd d isa isa bility bility did not differ d iffer signific ignific a ntl ntly y betwee be tween n interventions interventions..  T  The he other RC T stud tud y25 examined ba rriers to see seeki king ng mental menta l health hea lth c a re rep reported orted by b y individua individuals ls in a rura l iimpo mpoveri veris shed po popula pulation. tion. There were we re 646 646 ra ndomly ndo mly selec ted a dults sc reened for depression, anxiety, and alcohol abuse. Respondents who screened positive were randomly assigned to: no intervention, an educational intervention alone, or the educational intervention in the presence of a significant other. Virtually all respondents said they would seek mental health c are if they thought mental mental hea lt lth h serv service ices s would help he lp them. Res Respo pondents ndents who received rec eived the

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NA NAT TURE OF THE EVIDENC EVIDENC E

ed educ uc a tional tiona l interv intervention ention end orsed orsed several evera l barr ba rriers iers a t signifi signific c a ntl ntly y low lower er ra ra tes in the the foll fo llow ow-up -up than prior to the intervention. intervention.

Table 2. Percentage of studies by level of evidence NHMRC Level of evidence

All studies

Aust/NZ studies

II III.II

Randomised controlled study Comparative study: non-randomised

0.6 1.7

1.7 1.7

III.III

Comparative study: non-control

7.6

7.6

IV

Case study: non-comparative

90.2

87.9

C onc oncep epttual frame amewor work Fina Finall lly, y, the studies studies were ex e xa mined for fo r the conc c onc ep eptual tual fra fra mework mewo rks s they applied ap plied.. Overwhelm Ove rwhelming, ing, the studies studies were de sc riptive iptive and a nd app a ppli lied ed no c onc ep eptual tual fra fra mework mewo rk (81% (81%). The most c o mmon conceptual framework used was the Theory of Planned Behaviour/Reasoned Action 26 (TPB) (4%).  T  Ther here e were were ab out 3% that that us used ed Andersen Andersen and Ada y’ y’s s27  service ervic e util u tilis isa a tion framew fra mework, ork, 1.3% 1.3% that tha t 14 applied one of the stages of help-seeking models models ,  and just over 1% that used the Network 28 Episode pisode Mod el. el.  Another 10% 10% us used ed a range ang e of o f other conc co ncep eptual tual framewo framewo rks, eac ea c h of which whic h was unique uni que to the study study and not a spec pe c ifi ific c help-seekin help-seeking g mod el. Similar patterns were evident for the Australian and New Zealand studies, although there was a slight light preferenc p reference e for fo r tthe he Theo Theory ry of Planned Planne d Beha viour/ viour/ Reasoned Ac tion (7%). This foc us on the TPB is impo imporrtant to note bec ause the theory prop proposes oses that ac a c tual beha viour viour is is a rational dec d ec ision that is made according to intentions to behave in a particular way, and that intentions are in turn determined by attitudes, as well as subjective norms and perceived behavioural control (which can also have a direct effect on behaviour). This conceptual framework supports a focus on the three different processes―attitudes, intentions and behaviour. It is important to note, however, that the strength strength of a ssoc iations between betwe en a tti ttitudes, tudes, intentions intentions a nd beha b eha viour is typica typic a lly lly wea weak k29,  pa rt rtic icularl ularly y for the rela relations tionship hip betwee be tween n intention intention and b eha viour, a nd in the study of helpseeking for mental health problems compared with other health-related issues. issues.30 

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5 Helplp-s seeking de deffini inittions  T  The he review eview revealed that that many differen differentt definit definitions ions have been ap appli plied ed in the the mental mental health health c ontex onte xt and there is no c ommonly refe referrenc ed single defini de finition tion that is routinely routinely referred referred to. to . O verall, a lmost lmost half the studies studies provided no c lear lea r de defini finiti tion on o off what wha t they they meant mea nt by help-seeking help-seeking (46% (46 %). Ma ny studies studies provided minimal minimal definit d efinitions, ions, suc uch h as a s ‘visiti ‘visiting ng a do doc c tor’, ‘utilis ‘utilisa tion of c a re’, ‘seek ad vic vic e a nd assis istanc tanc e’ and ‘willin ‘willingness gness to seek help’. O ne of o f the most comprehens co mprehensiv ive e a tt ttempts empts to to defin de fine e help-s he lp-see eek king c omes from from a World World Hea Healt lth h 31 O rganization study study of adolesc ad olescent ent help-see help-seeki king ng , which d efined it as a s:    A ny a c tion or ac tivity c a rrie rrie d out by an ad olesc e nt who wh o pe rc e ives ive s he rself/himself a s

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nee ding pe rsonal, rsonal, psyc psyc holog holog ic al, affec ti tive ve a ssis ssistanc tanc e or health or soc soc ial servic servic es, with with the purpo se of mee ting thi thiss n nee ee d in a p ositive ositive wa y. This This includes seeking help from formal formal  servic  serv ic e s—fo s—forr exa mple, mp le, c linic servic e s, c ounsell oun sellors, ors, p syc holog ists ists,, me dic al staff, trad tra d itional itiona l hea lers, relig relig ious lea lea de rs or youth youth p rog rammes—as rammes—as we ll as informal informal sourc sourc es, whic h includes pe er g roups and friends, family family memb ers or kins kinship hip g roups and/o r other adults adults iin n the c ommunity. ommunity. The The ‘help’ ‘help’ provided mig ht c onsis onsistt of a servic servic e (e .g . a medic al c onsultation, onsultation, clinica clinica l c are, me dic al treatme treatme nt or a c ounsell ounselling session), session), a referral for a  servic  serv ic e p rovid e d e lse lse whe wh e re or for follow follow -up c are or talking t alking to a nothe noth e r p e rson inf informa orma lly about the nee d in question. question. We empha siz ize e a ddressing ddressing the nee d in a  positive  way to disting dist ing uis uish h help-see help-see king be haviour from beha viour ssuc uc h as assoc assoc iati iation on with anti-soc anti-soc ial  pe e rs, or substanc substa nc e use in a g roup setting , whic wh ic h a young you ng pe rson mig m ig ht d e fine a s he lp see king or c op ing , b ut w hic h w ould not b e c onside onsid e red p ositive from a he alth a nd we ll ll-being perspec perspec ti tive. ve. O ther definitions definitions include: includ e:  

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The a c tive tive searc h for resourc resourc es that are releva nt for the resoluti resolution on of that prob lem 32  Help-see king be haviours invol Help-see involve ve a re que st for assis assistanc tanc e from informal supports or  forma lised servic e s for the purpo pu rpo se of re resolving solving e motion, mot ion, be ha havio vioural, ural, or he alth 33  prob  p rob le m s   The decision to seek some form of professional assistance and the choice of a particular he lp sourc e sourc e 34 

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The first firs t sstag tag e ocfommunica the soc ial ti support tto is, is, to sat pany erson, theof recsupp ther ini initiati tiative ve a nd ting ng withproc others othess; ers that that o reque kind sipient, upp ort,taking whethe affec tive, tive, v aluative, aluative, or ins instr trumental umental.. 35 

For the Austra Austra lia lia n and New Zea Zea land studies, over ove r one-thir one -third d of o f the studies studies provided provide d no de defini finition tion of help-seeking (38%). Of those that did, some of the more comprehensive attempts included:  

 A requ re que e st fo r a ssistanc ssistanc e with pro blems ble ms that tha t the individua indiv idua l d oe s not n ot ha ve the pe rsona rsonall resource s to to solve solve on their ow n36 

 

 A n ac tive proc pro c e ss of using a ssistanc ssistanc e from fro m othe r pe op le to solve p roblem rob lem s37 

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The e xtent xtent to w hich individuals individuals util utilis ise e different sourc sourc es of suppo rt for overc oming pe rsonal rsonal 38 difficulties..   difficulties

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 Stan d a rd  Stand rdised ised me a sure suress A minority minority of the studies used used a stand a rdised rdised meas mea sur ure e (31% (31%). The The most co mmonly used used standardised measure was the attitude measure published in 1970 by Fischer and Turner―the Attitudes To ward wa rd See Seeki king ng Profes Profe ssional iona l Psyc Psycholo hologic gic a l H Help elp Sc a le (AT (A TSPPHS) PPHS)39  and its adaptations, including inc luding its sho hort rt form. fo rm. This wa was s us used ed by 17% o f s studie tudies s overall, ove rall, an and d c o mprised mprised 55 55% % of thos tho se tha t used a published standardised measure. Another 10% of studies used some type of published meas mea sure, but these these were we re generally gene rally unique to the study, study, and did not c ompri omp ris se mea sures with repo rted report ed psyc psyc hometr home tric ic p rop erti erties; es; there were 24 different named meas mea sures, ures, only one of whic h was wa s us used ed by more mo re than two studies. C onsequentl onseque ntly, y, the the nex ne xt most most co c o mmon meas mea sure, whic whic h was wa s us used ed by 3% of studies overall, a nd 10% of those those with w ith a standa rdised rdised meas mea sure, was wa s the G eneral ene ral 2,14 Help-Seeking Questionnaire (GHSQ). (GHSQ).   Among the Australian and New Zealand studies, there were 32% that used a standardised measure; half (16%) used the ATSPPHS and the other half used the GHSQ.

Attit itude udes s Towa owar rd See Seeking king Pr Profess ofessiona ionall Psyc sycholo hologic gica al Help Sc ale  T  The he Attit Attitudes udes Towar owa rd Seeki Seeking ng Profes Profess sional Ps Psychologica l Help Sc Sc ale (ATS (ATSPPHS PPHS)39 is made up of 29 items de des signed to as a ssess ge general neral atti a ttitude tudes s towa rd see seeki king ng profess p rofessional iona l psyc psycholo hologic gic a l help for psychologic psycho logic a l prob prob lems a nd iss issues. The full sc a le has four fac fa c tors: tors: rec rec ognit og nition ion of pers p ersona ona l need for psyc psycholog holog ica ic a l help (8 items); items); stigma toleranc tolera nce e as a ssoc iated with psyc psyc holog ica l help (5 items items); ); inter interpe pers rsona l (9 openne opitems). ennes ssItems regarding rega rding one’on s problems prob lems Likert-type (7 items); items); and onfid encfrom e in (0) mental menta l hea lth ltto h disagree professionals are rated a 4-point scalec onfidenc ranging (3) agree. Items include, inc lude, “If I be beli lieved eved I was wa s ha having ving a mental menta l breakdow breakd own, n, my firs first thoug thought ht would be to get professional attention”. Note that a large number of adaptations of the measure have be been en develo d evelope ped, d, and a nd very few studies studies a re fully fully c ompliant omp liant with the original meas mea sure. A brief 1010item item version version has ha s also bee n develope de veloped d 40, but again many researchers adapt the language used in the mea me a sure. With regard With rega rd to the elements e lements of help-s he lp-see eeki king ng identi ide ntified fied in the introduc introduc tion tion a s important to c onside onsider, r, the AT A TSPPHS c overs ove rs the fo ll llowing owing::  

Process – general attitudinal orientation

 

Source ourc e – unspec ifi ified ed profes profe ssional iona l sourc sources; es; wording in items vari va ries, es, inc including luding ‘psy ‘ psyc c hiatris hiatrist’, ‘p ‘ps sychologis ycho logist’, t’, ‘c ounsell ounselling’, ing’, a nd ‘pr ‘p rofessional ofessional help’ he lp’

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•

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Problem – unspe unspec c ifi ified ed psyc psyc holog ic ica a l problems prob lems;; items items use several differ d ifferent ent terms to refer to psychological problems including: ‘mental breakdown’, ‘worried or upset for a long ti time’, me’, ‘pe ‘ perrsonal ona l and emotional pr p rob oblems lems’, a nd ‘ emotional emotiona l difficult difficulties ies’’

 

Assis Ass ista tanc nce e – not spe spec c ifi ified ed

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   Tim imefr eframe ame – not not spec if ifiied.

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General Help-Seeking Questionnaire  T  The he Gener Ge neral al Help-S Help-Seeking eeking Questionn Questionnair aire e was wa s developed in Aus Australia tralia (GHSQ (GHSQ ).2,14 It as a sse sses future help-seeking intentions intentions a nd rec ent and a nd pa p a st help-see help-seeki king ng exper expe rienc es. O ften the intentions intentions measure is referred to as the General Help-Seeking Questionnaire and the past help-seeking experiences as the Actual Help-Seeking Questionnaire (AHSQ). Intentions are measured by listing a number of potential help sources and asking participants to Intentions are indicate how likely it is that they would seek help from that source for a specified problem on a 7po point int sc a le ra ra nging from (1) (1) extremely unlikely  to   to seek help to (7) extremely likely to seek help.

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Note that the specific sources of help listed, the future time-period specified and the type of problem can be modified to be appropriate to the particular research objectives. For example, school counselors or internet sources can be made specific sources of help if these are a resea res ea rc h foc us us.. With regard to the important elements of help-seeking, the GHSQ covers the following:  

Process – future behavioural intentions (‘likelihood’ of behaviour)

 

Source – meas mea sur ure e c an be ad ap ted to li lis st spe spec c ific ific sources, inc includi luding ng for fo rmal, inform informal al and a nd self-help

 

Problem – measure can be adapted for different types of problems; it has often been used referring to ‘personal or emotional problems’

 

Assis Ass istanc tanc e – not spe spec c ifi ified ed

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•

•

•

   Tim imefr efra a me – mea meas sure ure ca n be adapted ada pted for differ different ent time time periods. periods.

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Past help-seeking behaviour  behaviour  is operationalised by asking whether professional help has been sought oug ht in in the pa st for a spe spec c ifi ified ed prob lem and, and , if help help has ha s be been en sought, how many ma ny ti times mes it was sought, what specific sources of help were sought, and whether the help obtained was evaluated eva luated a s wort wo rthwhile hwhile on a 5-point sc sc a le indica ting more more or o r les less s helpfulness. Rec ecent ent helphelp-s seeking behaviour behaviour is de determ termined ined b y llis isting ting a numbe r of pote p otential ntial help sourc sources es and asking whether or not help has been sought from each of the sources during a specified period of ti time me for a spe pec c if ified ied p rob oblem. lem. Note that the spec ific ific sources of he help lp lis listed, the time per pe riod specified and the type of problem can be modified to be appropriate to the particular research objectives.  T  To o provide provide ad dit ditional ional desc desc ript iptiv ive e in infor formati mation on and to ens e nsur ure e th that at par pa rticipa ticipa nt nts s are are res esponding ponding in the ap propriate way, wa y, pa rti tic c ipants are as a sked to br b riefly iefly elabor elabo rate o n the nature nature of o f the problem for which help was sought. Participants can also indicate that they have had a problem, but have sought help fr from om no one. With regard With rega rd to the elements e lements of help-s he lp-see eeki king ng identi ide ntified fied in the introduc introduc tion tion a s important to c onside onsider, r, the AHSQ AHSQ ha has s the following c ha harac rac teris teristi tic c s:  

•

Pr Proc oc es ess s – recent rece nt and pa st behavi beha viour our

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Source – formal, needs to be specified, and measure can be adapted to list specific sources, including informal and self-help

 

Problem – needs to be specified, and measure can be adapted for different types of problems; it has often been used referring to ‘personal or emotional problems’

 

Assis Ass istanc tanc e – not spe spec c ifi ified ed

•

•

   Tim imefr eframe ame – needs to be spec if ified, ied, and measur measure e ca n be ad ap apted ted for dif d iffer ferent ent tim time e

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periods.

No n-sttand a rdis Non-s dise e d mea sur ure es O ver half the studies studies (52% (52%) de veloped velop ed self-report elf-repo rt ques que stionnaire-ba tionnaire-b a sed ques que stions spe pec c ific ific a lly lly for the study. Another Ano ther 11% 11% de develop veloped ed interview interview quest q uestions ions spe spec c ific ific a lly lly for the study; a further further 4% developed de veloped foc us group questions questions related to help-s he lp-seeking; eeking; and 2% us used ed behaviour be havioural al indica indic a tors tors from a database. Among the Australian and New Zealand studies, a similar proportion (48%) used

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self-report questionnaire-based questions developed specifically for the study. Another 12% used interview questions specific to the study, and 9% developed focus group questions. Items related to attitudes toward seeking particular types of formal help generally used a 4-point response scale from strong ly d isag ree  to  strong ly ag ree  to deter de termi mine ne the direc direc tion tion a nd strength trength of the evalua e valuation tion of that sourc source e of o f help. Very often ofte n multiple multiple sourc sources es of help were we re inves investigate tigated. d. Studies investigating investigating ac a c tual beha be haviour viour of see seeki king ng pa p a rtic rticular ular sources ourc es of help generally ge nerally us used ed a dichotomous  yes/no respons nse e form fo rma a t. Either Either one pa p a rticular ticula r s sourc ource e of o f help wa was s of interest interest or  ye s/no   respo several evera l different sourc sources es of help were we re invest investiga igated. ted.  The remainder of o f the the stu tudies dies used used interv nterviewiew-ty type pe questi questions ons that determi determined ned either either a general evaluation of a source of help or whether that particular type of help had been sought in the past. More in-depth information related to unique help-seeking experiences was revealed by these studies tudie s.

He Hellp-see king in the N a ti tiona onall Sur urve ve y of Me M e nt nta a l He Hea a lth a nd W el elllbe in ingg  T  The he measur measures es of help-s help-seeki eeking ng us used ed in the the National National Sur urvey vey of Mental Hea ealt lth h and Wellbei Wellbeing ng (NSMHWB) (NS MHWB) are wort wo rth h spe spec c ial mention bec b ec a us use e these result results s a re freq frequently uently used to show show the low level of help-seeking for mental health problems among Australians (i.e. Figure 1). Note, however that these mea sures were not no t used used in any of o f the reviewed studies. Many different types of detailed questions were used in the NSMHWB, but with regard to the important elements of help-seeking, the questions generally consider the following:  

Process Proc ess – pa st beha viour

 

Source: ourc e: o  friends or family o  telephone c ounsell ounselling ing o  the internet o  do doc c tors or profess p rofessionals iona ls:: −  gene generral prac ti titi tioner oner −  psychologist −   p syc ychia hiatr tris istt −  menta mentall healt hea lth h nurse nurse −  other mental health professional −  other specialist doctor −  othe otherr health professiona professionall who provide ge general neral servi servic c es including soc ial workers workers, oc c upa tional thera thera pists pists or couns co unsellors ellors −  c omplementa omp lementary ry or alternative therap therap is istt

 

Problem – ‘menta ‘ mentall problems proble ms suc uch h as a s stress tress,, anxiety, de pression, or depe de pende ndenc nc e on o n drugs or alc alc ohol’

 

Assista Assis tanc nc e: o  informa inform a tion abo a bout ut mental illness illness,, it its s trea trea tment and a vailable vaila ble servic servic es o  medicine medic ine or tab lets o  psyc psy c hotherapy hothera py – discussion ab out c a us uses es tha thatt s stem tem from from the p pa a st o  cognitive behaviour therapy—learning how to change your thoughts, behaviours

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•

•

•

o 

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and emotions c ounselling ounselling – help to talk ta lk thr throug ough h your problems

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o  o  o  o  o 

 

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help to sort out hous ho using ing or o r mone money y problems prob lems help to improve your ab il ility ity to wo rk, rk, or to us use e your time time in other o ther ways wa ys help to improve improve your abil ab ility ity to look loo k after yourself yourself or your home help to meet people for support or company other – specify

 T  Tim imefr eframe–mos ame–mostt questi questions ons wer we re framed framed as ‘In the the pa pas st 12 months months’, ’, but some asked asked a bo bout ut lifeti lifetime me (‘e ver’). ver’).

Ele me Ele ment ntss of help-see help-see king Proc ess O verall, most most studies studies used a meas mea sure of p a st beha be haviour viour (48 (48% %). Next most most common c ommon were measures of attitudes toward help-seeking (44%). There were 12% of studies that measured orientation, 12% 12% that meas mea sured intentions, intentions, and 8% that mea sur ured ed c urr urrent ent behavio be haviour. ur. Almost a quarter of the studies (22%) measured more than one dimension, most often both attitude and pa st behaviour. be haviour. Among the Australian and New Zealand studies, there were more that used measures of attitudes (51% (51 %) a and nd 39 39% % foc us uss sed on pa st beha be haviour. viour. Intentions Intentions were a ls lso o more c ommonly ommo nly studied (33% (33%). A similar proportion examined orientation (10%), and very few measured current behaviour (4%).  J ust ust over one-t o ne-thi hirrd (35 (35%) measur measured ed more more than than one dimens dimension, ion, most most c ommonly ommonly attitu attitudes des a nd some other dimens d imension. ion. A small proport propo rtion ion of o f the studies studies (abo ut 10% 10%) used used vignettes to ex e xa mine hypothetic a l helpanticipate seeking attitudes or intentions. Vignettes allow people to  what they would do if  they   they were ex e xpe perriencing ienc ing the sympto symptoms ms de des sc ri ribe bed d in the vignette. Suc Suc h meas mea sures a re useful useful in studies studies of non-clinical populations to attempt to determine what people who are not experiencing symptoms would do if they were to experience symptoms. Vignettes have been used more often in the Australian and New Zealand studies (about 20% of studies), possibly because the vignettes a re often o ften bas ba sed on J orm’s work on mental healt hea lth h liter literac ac y41, which  whic h origina originated ted in Austra Austra lia lia a nd is often incorporated inc orporated as a predicti predic tive ve fac fa c tor in in s studies tudies of help-seeking. help-seeking.

Sour ourc c e of of help  T  The he majorit majority y of studies tudies wer were e of formal formal help-seeking eeking b ehaviour (66 (66% %) a nd a fur furth ther er 32 32% were were of both formal and informal; only 2% were of informal help-seeking only. A similar pattern was evident for the Australian and New Zealand studies. No studies generated by this review were direc tly tly rrela elated ted to self-help; studies studies with suc uch h a foc fo c us wo would uld be more mo re lik likely ely tto o be b e ge nerated nerate d by by different sea sea rch terms (i.e. spe spec c ifi ific c a ll lly y ‘self-help’ ‘self-help’). ). Examining sources of help in more detail revealed that a wide range of sources of help were investigate inves tigated d a nd rarely ra rely were ex e xa c tl tly y the sa sa me sourc sources es of help e xa mined over o ver severa severall s studies. tudies. The c ommon ommo n terms terms us used ed were:  

Informal – most studies studies refe referr rred ed to friend and a nd fa mily, mily, but als a lso o inc luded pa rents, mother, father, fa ther, peer, pe er, part pa rtner, ner, rela relativ tive, e, sibling, sibling, neighbour, neighbo ur, c olleague ollea gue,, s soc oc ial network netwo rk,, lla a y suppo up porrt, c lose lose fr friend iends s

 

Formal  – many studies Formal  studies used the generic ge neric term mental health hea lth profes profe ssional, iona l, a nd a ls lso o c ommon were w ere the spec ifi ific c terms terms of c ounselor, psychologist psycho logist a nd p sychiatri yc hiatris st. Other terms terms included: o  c linica linica l psyc psycholog hologis ist, t, soc ial work wo rker, er, therap therapis istt

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•

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o  o 

o  o  o 

o  o  o  o 

G P, family family doc do c tor, fa fa mi mily ly phys physician, d oc tor tor,, nurs nurse, pae p ae diatric diatric ian school counselor, guidance officer, teacher, school staff, school supports, school psyc psy c holog is istt a c a de demic mic a dvisor, dvisor, univers university ity c ounselor, student a dvisor, dvisor, profess professor or help-lines,, phone help-lines pho ne help, internet resource resources s, web site clergy, minister, traditional healer, faith healer, spiritual support, religious leader, folk hea ler, prayer, priest/ priest/min minis ister/ ter/rra bb i, spiri spiritual tual hea he a ler, chur c hurc c h member, memb er, religious religious counselor, chaplain work supports, manager herba lis herbali st, ac upunc tur turis istt coach, youth worker, police mentall hea lt menta lth h service service,, professional iona l psyc psyc hologic holo gica a l help, healt hea lth h servi servic c es c entre, c ommunity mental menta l hea lt lth h servi servic c e, psyc psyc hiatric hiatric o utpatient utpa tient c linic, linic, prima prima ry hea lth lth ca re, soc ial agenc ag enc ies ies,, s supp upport ort group group , sc sc hool hoo l hea lth servic ervic e, famil fa mily y couns co unselli elling ng s servi ervic c e, ac c ident and a nd emergency, emergenc y, psychiatri psychiatric c hospital, hospital, inpa inpati tient ent unit unit,, outpa tients tients..

It is important to ac knowledge knowled ge that tha t the the distinction distinction be tween form fo rma a l a nd informal sourc sources es of help varies depending on the population group and context under consideration. For example, a traditional healer could be a critical source of formal health care in a traditional indigenous population group, but not so in a study of a mainstream urban ‘western’ population. The great diversity divers ity of hea he a lth c a re provide providers rs, other types of servi servic c e provi p rovide ders rs a nd d ifferent ifferent types of profes profe ssionals iona ls means mea ns that the terms terms ‘fo ‘form rma a l’ or ‘profe ‘profes ssional’ iona l’ need to be explained. explaine d. In the the mental menta l health hea lth c ontext, it c a n be useful to to dis d isti tinguis nguish h betwee be tween n formal service service p roviders that have ha ve a clearly identified and specific professional mental health care role, such as a psychologist, and other profes profe ssionals iona ls who might have a semi-formal role in the help-seeking proc ess, s suc uch h as as a teacher.

Problem For types of mental health issue, about half the studies listed more than one type of mental hea lth problem a s ttheir heir foc us us;; this c ompri omp ris sed 46 46% % of the total to tal studie studies s a nd 57 57% % of the Aus A ustr tra a lia lia n a nd New Zea Zea land studies. studies. Those that lis listed ted only o nly one prob lem type, type, most often ofte n us used ed a gene g eneri ric c term suc h as ‘mental ‘menta l health problem’. prob lem’. There There were a small number of studies studies tha thatt foc us uss sed on a very spe pec c ific ific mental hea lt lth h problem prob lem or menta mentall disorde disorderr (s (suc h as ADHD, eating dis d isorde order, r, schizophrenia).  T  Tab able le 3 shows the the percentage of studies tudies that that foc us used ed on differ different ent types types of mental mental health health prob lems. lems. Overwhelm Ove rwhelmingly, ingly, de depress pression was wa s the mental hea lth lth problem prob lem tha tha t was most most commonly co mmonly studied. tudied . Studies Studies us using ing generi ge neric c terms terms of ‘mental ‘ mental hea lth prob lem’ or o r ‘p ‘pers ersona ona l or emotional emotiona l prob lem’ or o r ‘psyc ‘psyc holog ic ica a l or emotional emotiona l distr distress ess’, c ompri omp ris sed 35 35% % of studies studies overall, and 23 23% % of the Austra Austra lia lia n and a nd New Ne w Zea Zea land studies. Anxiety Anxiety was the the mos mo st co mmonly studied spe pec c ific ific mental health problem after depression. Suicide-related issues were a focus on 10% of studies overall, and slightly more of the Australian a nd New Zea land studies (16% (16%). M o re serious serious menta menta l iillnes llness s, suc suc h as a s p syc ycho hos sis a nd schizop sc hizophrenia hrenia,, as well as use use of o f the term ‘mental ‘me ntal illness illness’’ were w ere foc fo c i in a minority minority of studies. studies. S Simi imilarly larly,, a alc lcoho oholl and o ther drug use use wa w a s in the minority – however, this can be attributed to use of the specific search term ‘mental’.

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Table 3. Percentage of all studies and Aust/NZ studies by type of mental health issue Mental health issue

All studies

Aust/NZ studies

Depression

30

40

Mental health problem

19

10

Anxiety

17

21

Personal/emotional problem

15

10

Suicidal ideation/suicide/self-harm ideation/suicide/self-harm

10

16

Psychosis/schizophrenia Psychosis/schizophreni a

8

5

Alcohol or other drug use

7

5

Psychological/emotionall distress Psychological/emotiona

6

3

Mental illness

5

5

Typ ype e of of assistanc nce e  T  The he spec ific ific type type of assistance sought or provided provided was very very rarel arely y made ex expli plic c it. it. It wa s not specified what form of assistance was specifically sought in terms of issues such as information, a dvic e, therapy, therap y, ge general neral supp supp ort, etc . In pa rticula rticular, r, the ques que stionna tionna ire-b ire-ba a sed studies did not no t dril drilll down to this level of detail. Qualitative studies were more likely to investigate the type of a ssistanc istanc e that tha t was soug sought ht or rec rec eived, eived , although althoug h these these were we re not rigo rigorous rously ly des de sc ribed ibe d or or categorised.

Timeframe In the vast majority of studies the timeframe was either not specified in the measure or not made c lear lea r in in the study methodolo method ology; gy; this was wa s tthe he c a se for fo r 7 70% 0% of a ll studies and 76 76% % of the A Aus ustr tra a lia lia n a nd New Ne w Zea Zea land studies. J us ustt over 1% of a ll studies had a one week wee k timeframe; timeframe; 3% of a ll studies and of the Australian and New Zealand studies had a one month timeframe; 5% of all studies and of the Austr Austra a lian and a nd New Ne w Zea Zea land studies had a 2–6 month timeframe timeframe;; there there were we re 16% 16% of a ll studies and 12% of the Australian and New Zealand studies that had a 12-month time frame; 3% of all studies and of the Australian and New Zealand studies had around a 2-year time frame; and 3% of all the studies, but no Australian and New Zealand studies had a lifetime timeframe.

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6 C onc onclu lus sions Overall, the main conclusions to be drawn from this review are that no clear definition of helpseeking has been applied within this literature area and there are no commonly applied, wellde develop veloped ed meas mea sures in us use. This is de des spite a very large number numbe r of publica p ublica tions in the the a area rea a nd ra pidly growing interes interestt in the the field. field. C onseque onsequentl ntly, y, the the development de velopment of a workab workab le de finit finition ion a and nd some a greed gree d and a nd psychometri psycho metric c a ll lly y sound mea me a sures is long overdue. o verdue. Even though a consensus definition is lacking, a common component evident in help-seeking de defini finitions tions or implicit implicit in in their a pp li lic c a tion, is is that help-seeking is a n ac tive tive and a nd ada a da ptive proc ess of attempting to cope with problems or symptoms by using external resources for assistance. The lac k of co ns nsensus ensus c omes ome s a bout bo ut through through wide variation in how how the differ d ifferent ent elements of suc suc h a broad broa d definition definition ar a re op operati erationa onali lis sed ed:: the foc us of the pr p roc es ess sv va a ries from from hypo hypotheti thetic c a l attitudes attitudes to spe spec c ifi ific c pa st beha vi viour; our; the the types of problems or symptoms symptoms are wide-r wide -rang anging ing and a nd c a n include very ver y spe spec c ific ific mental healt hea lth h pr p rob oblems lems/ diag noses noses or generic generic terms terms for psyc psyc hologic al or o r emotional distress; and there are many potential external sources of help. Elements that are very poorly op erationa lis lised inc lude timeframe timeframe,, which is often not no t clea rly rly spe spec c ified ified or very very imprec imprecis ise e (i.e. ‘ever’); and the type type of a ssistanc e sought, whic whic h is gener gene rally not not as a sc erta erta ined, proba bly bec ause there ar a re so many potential po tential forms of a ssis istanc tanc e and a nd they have ha ve not bee b een n sys systema tematica tica lly lly c a tegori tego ris sed (information, supp ort, therapy, therap y, etc .).

C ommon e leme nt ntss of help-s help-see ee ki king ng d efini efinittions a nd mea me a sur ure e s in in A us ustr tra a lia/N e w Ze Ze a la nd For the the studies studies that originated in Austr Austra a li lia a a nd New Ne w Zea Zea land spe pec c ific ific a lly, lly, there there wa s littl little e c onsis onsistenc y iin n ap plica plic a tion of defini de finitions tions or measures measures of help-s he lp-see eeki king. ng. Some Some of the more c ommon ommo n characteristics were: Definition Definit ion of o f help-s he lp-see eeki king: ng:  

•

No clear definition of help-seeking evident, but an implicit or explicit understanding that help-seeking was an active process of using the resources of other people to deal with problems.

Population groups studied:  

While almost half the studies focused on general adult populations, a substantial proportion (40%) were of teenagers or youth; there were no studies of older adults and very few of of c chil hildren dren

 

Mo st studies c ompri omp ris sed eq equivalent uivalent numbers of males ma les a nd females, fe males, or had a higher proporrti propo tion on of females fe males

 

 T  The he majorit majority y of studies tudies were were of urba urban n pop ul ulation ation gr groups oups,, alt although hough often the the regional setting was wa s not c learl lea rly ys stated tated ; tthere here wer we re no studies of peo p eople ple in remo remote te areas a reas

 

Mo st studies studies were of o f gener gene ra l communi co mmunity ty po popula pulations tions (non-c linica linica l group group s), but the next next most common co mmon pa p a rticipa ticip a nt type type was wa s high sc sc hool hoo l s students, tudents, followed followe d by university university students

 

C ultur ultural al b ac kground kground was wa s gener gene rally not spe spec c ified; ified; where it was, the the study study pop p op ul ula a tion tion group wa w a s us usua uall lly y described a s mostly mostly C a uc uca a sian or o r Austr Austra a lia lia n.

•

•

•

•

•

Study d esigns:  

•

Mo st s studies tudies were c ross ross-s -sec ec tional, tiona l, questionna questionna ir ire-b e-ba a sed de des sc riptive studies studies

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HELP-SEEKING HELP-SEE KING DEFINIT DEFINITIO IONS NS

 

•

 

•

Few applied a clear conceptual framework, being largely descriptive  T  The he mos mostt c ommon c onc eptual framework framework was the the Theory of Planned Planned Behaviour Behaviour..

Me a sur ures es of help-s help -see eeki king: ng:  

Few studies used a standardised measure and most developed a measure for the specific study

 

Where a stand a rdised rdised meas mea sure was wa s us used ed,, it was either the ATS ATSPPHS or the G HSQ HSQ

 

Mo st studies studies focus foc used ed on a tti ttitude tudes s towa rd see seeki king ng pa p a rtic rticular ular type types s of suppo rt us using ing an an pa st beha be haviour viour was also also a strong trong foc us us,, usua usuall lly y using using a respo respons nse e sca le format of o f whether whethe r help had been be en sought sought or not

 

All studies studies foc us used ed on formal help-s help -see eeki king, ng, usually exa exa mining mining mental hea he a lth professionals iona ls,, GPs, psychologists and psychiatrists; informal supports of friends and families were often included in the list of potential sources, but were not the primary focus

 

 The main mental mental health health pr p roblem of o f inter interes estt was wa s depress depression, foll followed by gener g eneric ic terms terms indica indic a ting ting ps p sycholog yc holog ica l or emotional emotiona l problems prob lems or distr distress ess; anxiety was the the nex ne xt most most common mental health problem indicated, and almost 20% of studied included suicidal ideation as an issue

 

 The type type of as ass sistance sought sought or obtained was rarely arely spec ified. ified.

•

•

•

•

•

•

Most studies did not specify or report a timeframe; where timeframes were evident, this was usually over the past 12 months.

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7 Rec omme ommenda ndattions An agreed definition of help-seeking within the mental health context is much needed and long overdue. To take the field forward and be able to compare the findings of studies over time and a c ross different different population po pulation groups, groups, there there need ne eds s to be an ag reed understanding understanding of o f what is being be ing measured. This would guide program development, resource allocation, standardised outcome measurement, and assist stakeholders to communicate.

Prop op osed d e fi fini nittion Pr While c hallenging, due to the broad While broa d nature nature o f the pr p roc es ess s of help-s he lp-seeking eeking and divers diversity ity in how it has been bee n inves investi tiga gated ted to da te, it is feas fea sible to develop d evelop a univer univers sa l oper ope rational defini d efiniti tion on b ec a us use e most studies have a similar imilar underlying underlying implicit defini de finiti tion. on. However, Howe ver, a universa universa l definition definition ne need eds s to incorporate the diverse aspects of the help-seeking process of interest to specific research and practice applications. A definition that enables consistency and comparability, but also allows a foc us on specif spec ific ic aims a nd a spec pe c ts of help-s he lp-seekin eeking, g, will will grea greatl tly y ad advantag vantage e the field. A proposed general definition is as follows:

In the the mental healt health h c ont ontex ex t, help-se ek ing is an adaptive c oping proc ess th that at is the att attemp emp t to obtain ex ternal assist assistanc anc e to de al wit with h a me ntal ntal healt health h c onc ern.  T  Thi his s de fini finiti tion on is mad mad e up of thr three main elements elements, a nd eac h of thes these e needs to be ex expli plic c itly itly c onside onsidered red in help-s help -see eeki king ng mea sur ures: es: 1.  Proc ess (and respective timeframe) refers to the part of the behavioural process that is of interest―whether the focus is on a general orientation or attitude toward obtaining a ssistanc istanc e, future future be ha haviour vioura a l intentions, intentions, or obs ob servable ervab le beha be haviour viour  (either in the past or prospec tiv tively ely in the the future). It is essential essential that tha t s studies tudies are explicit abo a bout ut which whic h pa rt of the process they are focused on, which can be one of the following components:  components:  a.  G eneral or o rientation ientation or o r attitu attitude de towar towa rd ob obtaini taining ng a ssis istanc tanc e b.  Fut Futur ure e b eha vioura vioura l iintention ntention c .  O bs bserv ervab ab le b ehaviour―either in in the p a st or pros p rospe pec c tively tively in the the future.

 see king   in the Note that attitude, or general orientation, is not truly a measure of help- see sense of an active coping attempt. However, because attitudes have been such a large foc us in the the literature, literature, it is not poss p ossible ible to ex e xc lude a ttitudinal ttitudinal app a pp roac roa c hes from from conceptualising a measure. Attitudes are relevant as part of a general orientation or prop ensity ensity to to seek help, rather rathe r than c ompri omp ris sing ac a c tual help-seeking itself. The ex e xpe pec c ted proc ess is that atti a ttitude tudes s would wo uld predic pred ictt intentions intentions,, which would wo uld predic t beha viour, c o ns nsis istent tent with the Theo Theo ry o f Planned Plan ned Behaviour. Beha viour. It is essentia essentiall that future resea resea rch fully investigate inves tigate the str streng ength th of relationships relationships between betwe en ori o rienta entation/ tion/a a ttitude ttitudes s, intentions, intentions, a nd actual behaviour to determine the usefulness of each part of the process for unders unde rstand ing beha viour a nd avenues a venues for effe effec c tive tive intervention. intervention.  

•

Timeframe – a c ourse of Timeframe – of a ac c ti tion on takes ta kes plac e within within a par pa rtic tic ul ula a r ttim imeframe, eframe, and this this needs need s to be clearly specified. The better defined the timeframe, the better respondents are able to provide a reliable and valid response. Timeframes can be retrospective or prospec tiv tive. e. Ma ny studies ha have ve examined a 12 12-month -month pe perriod, iod , but ti timeframes meframes need nee d to be able to vary to suit the purposes of different research aims.

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2.  Assist Assistance anc e –  refers to the c harac ha rac teris teristi tic c s of the as a ssis istanc tanc e that tha t is sought, oug ht, inc including luding the source ourc e and a nd the form (or type) of o f assis assistanc tanc e.  

•

Source of as a ssis istanc tanc e var va ries a c c ording to the level of profes profe ssional iona l expert expe rtis ise e and a nd relationship with the person seeking help, as well as the origin of the resource (i.e. online). Sources need to be clearly specified. Then, because there are so many potential single sources ourc es of as a ssis istanc tanc e, it is us useful eful to be a ble to agg a ggrega regate te related sources ourc es into ca c a tegor tego ries of ‘formal’, ‘ formal’, ‘semi-forma ‘semi-forma l’, ‘informal’ o orr ‘self-help’ ‘self-help’ resourc resources. es. Suc uch h class c lassific ific a tions a re not no t absolute, however, and will vary depending on cultural context and other factors. C onsequentl onseque ntly, y, it it is is preferable prefera ble for fo r sources ourc es of help to be b e spec ific ific a lly lly and individua individua lly lly lis listed ted;; classification of the sources should then be carefully considered and choice of category explained . U Us seful general gene ral clas cla ssifi ific c a ti tions ons for the mental hea lth lth field include: include : a.  Professional iona l healt hea lth h servi servic c e providers p roviders with a spec ified ified role in deli de livery very of mental hea lt lth h c a re (formal) – i.e. psyc psychiatri hiatris st, psyc psycholog holog is ist, t, GP, mental menta l healt hea lth h nurs nurse b.  Servic ervic e providers p roviders a nd profes p rofess sionals iona ls that do not have ha ve a spe pec c ified ified role in de deli livery very of mental healt hea lth h c a re (s (semi-for emi-formal) mal) – i.e. teac tea c her, work work supervi supervis sor, ac a demi de mic c a dvisor, dvisor, youth youth wor wo rker, ker, c coa oa c h c .  Informal soc soc ial supp supp orts (informal) (informal) – i.e. friend friend,, pa rtner, rtner, parent pa rent d.  Self-help resources esource s (s (self-help) – i.e. unguided unguide d web site use. use.

 

•

Type of a ssis istanc tanc e refers to the form fo rm of a c tual supp support ort that is sought, oug ht, suc suc h as as psyc psy c hoeduc hoe duc a tion, refe referr rra a l, supp ortive ortive c ounselling, ounselling, therapy, therap y, etc. etc . This element eleme nt has not be been en well we ll de develop veloped ed to da d a te in the literatur literature e a nd it is is not c urr urrently ently po pos ssible to identify ide ntify relevant dimensions. However, it would be helpful for research to begin to explore the actual forms of help that are sought to start to develop relevant categories of types of assistance. Researrc h from Resea from the soc soc ial supp supp ort field provide provides s some guida g uidanc nce. e. For For exa exa mple, soc soc ial 31 support upp ort has bee n c ategori ateg oris sed into into the following following four categ c ategori orie e s : 

− 

Ins Instr trumental umental support supp ort – financ ial a ssis istanc tanc e, tra tra ns nspo port rt

− 

Informational support – health-related information, referral information

− 

Affiliative support – peer support

− 

Emotional support – support for emotional wellbeing.

A further category for the mental health context could be type of treatment or health service provision:

−   Trea eatm tment ent – type type of trea treatm tment ent or therapy. therapy. It iis s likely likely that much muc h of the time peop pe op le s see eeki king ng help he lp may not know ex e xa c tly tly what type o f a ssistanc istanc e they are a re see seeki king ng  – they just want to alleviate their distress or symptoms by wha tever teve r means mea ns.. This help-s help -see eeking king element eleme nt is c urrently urrently unexplored unexplo red in the litera literature, ture, however, and it may be – particularly as people’s mental health literacy increases ― that that they do know what it is that they are looking for, or have a preference for a particular type of assistance. 3.  Concern refers to the type of o f mental menta l healt hea lth h problem p roblem for fo r whic whic h help is being sought. oug ht. This needs nee ds to be c learl lea rly y defined, defined , part pa rtic icularl ularly y use of o f generi gene ric c term terms s suc uch h as ‘mental ‘me ntal health hea lth problem’, ‘emotiona ‘ emotionall problem’ or ‘ps ‘p sychologic ycho logical al d is istr tres ess s’. It woul wo uld d be helpful for the the field to examine help-seeking separately for different types of mental health problems and mental disorders, rather than grouping a wide range of problems together, which makes it diffic diffic ult to c ompa omp a re betwee be tween n studies studies a nd over o ver different different types of mental menta l healt hea lth h iss issues. If

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more general terms are used, these need to be clearly defined for those responding to q uestionnair uestionna ires es as well as those using using the results results in prac tic tice. e. Figure 12 outlines a framework for the decisions that need to be made when conceptualising help-seeking and a nd determin d etermining ing a wa w a y to meas mea sure it. it. Resea Researche rchers rs, evaluators evalua tors,, program progra m planners planne rs and policy makers need to be very clear and explicit about what part of the help-seeking proc ess they are interested interested in, over what timefra timefra me, from what wha t sourc sources es of as a ssis istanc tanc e, and a nd for fo r which whic h mental hea lth prob lems. lems. Note that tha t Type o off as a ssis istanc tanc e is fade fa ded d out o ut sli slightly ghtly bec a us use e this element is c urr urrently the leas lea st well investigate investigated d a nd a ble to b e mea sured.

Influences luences

Help-seeking

Pro c e ss  Timef Pro mefrra me

Source

Orientation

Pa Past st// next 4 wee ks

Formal

Intention

Past/next 12 months

Semi-formal

 Type

Instrumental

Information

Concern General distress/ concern

Specific symptom types (i.e. depression)

Behaviour

Ever

Informal

Self-help

Affiliative

Emotional

Outc Out c omes  Treatment

Figure 12. Help-seeking measurement framework

Imp Implle me mentation ntation issues issues  T  To o implement implement the the proposed univer univers sal definit definition ion and the the framework framework shown in in Figur Figure e 12, 12, a number of iss issues need to be b e a dd ddres ress sed ed.. The main ma in barr ba rrier ier to to a c hieving consi c onsis stenc y in this this field is the many ma ny diverse contexts in which help-seeking is of interest. Many investigations are interested in a very spe pec c ific ific ap plic plic ation, which has ha s lled ed to wide variab variab il ilit ity y in sources ource s of help, he lp, timefr timefra a mes and type types s of mental health problems. This means that we cannot easily compare service needs or gaps for different age groups, identify common predictive factors, or evaluate the impact of different interv interventions entions.. A c onsis onsistent tent measur measurement ement app a pprroa c h is needed need ed to be b e a ble to c ompa re the result results s of differ different ent des d esc c riptive iptive a nd interventi intervention on studies tudies and poli po lic cy a app pprroa c hes. hes.

 T  To o monstr move rforward, forw resea ear c h needs to Tbe undertaken undert to to devel d tevelop oper ope rational mea meas sur ures es that th at have de demonst a tedard, relia reliares bility bilit y rand validity. hese meas meaaken sures must mus be op versa vers a tile, tile, ho howeve wever, r, so that they c an be a da pted pte d to the differ diffe rent c ontexts of interest. interest. No single, single, simple simple ques que stionnair tionna ire e or o r mea mea sure is

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go going ing to be b e able a ble to be us used ed routinely routinely in in all resea research, rch, intervention intervention or policy polic y context co ntexts s. How Howeve ever, r, resea esearrc h c ould develop d evelop a seri eries es of standa standa rdised dised measures measures that that c ould b e used in many c ontexts ontexts. In the interim, however, the first step is to use the definition and framework proposed here to support a more consistent approach to defining and measuring help-seeking. This will ensure that a ll the releva relevant nt help-see help-seeki king ng elements ele ments a re consi c onside dered red and a nd c learl lea rly y described . This will enable ena ble resea res ea rc hers, hers, evaluators eva luators,, poli po lic c y ma ma kers a nd program p rogram providers p roviders to be tter unders unde rstand the helpseeking needs of different population groups and compare different approaches to improving help-seeking help-s eeking behaviour be haviour in in the c rit itica ica l area of mental hea lth. lth.

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