Social barriers as a challenge in seeking mental health among Saudi Arabians.

BACKGROUND: To extend our knowledge of social barriers in relation to mental health, the present study was conducted to investigate the impact of social barriers on mental health help-seeking among Saudi Arabians aged 18 years and above.
MATERIALS AND METHODS: This cross-sectional study was carried out on 1632 participants in 2018 during the months of October and November. The participants completed self-administered online surveys about the demographic characteristics, social barriers, and knowledge and attitudes about mental health.
RESULTS: The majority of the participants agreed that social barriers could prevent them from seeking mental health help. Stigma was chosen as the most common social barrier among the participants (76.3%), followed by culture (61.5%) and negative perceptions (56.2%).
CONCLUSION: Social barriers are a challenge in seeking mental health. Increasing public awareness of available services and resources as well as developing programs to fight stigmatization should be initiated to create more positive attitudes toward people with mental illness and promote holistic well-being. Copyright:

Introduction

Mental disorders, mental illness, or psychiatric disorders are considered one of the numerous issues affecting the global population. Mental disorders account for more than 300 million cases worldwide.[1] Mental disorders are the second leading cause of disability among individuals.[2] A recent study by the Institute for Health Metrics and Evaluation was conducted to estimate the global prevalence of mental disorders and substance use together. There is a wide range of mental disorders with different symptoms such as mood disorders, anxiety disorders, eating disorders, personality disorders, and psychotic disorders. Mood disorders include major depression, dysthymia, bipolar disorder, substance-induced mood disorder, and mood disorder related to another health condition.[3] Depression is a frequent and severe mental disorder; according to the WHO, it is the leading cause of disability worldwide.[4] Although depression often requires long-term treatment, usually it remains undiagnosed and untreated.[5] Globally, the proportion of depressive disorder in 2015 is estimated to be 4.4%, with a high prevalence rate among females (5.1%) than males (3.6%).[6] In Saudi Arabia, the prevalence of depressive disorders is 4.5%.[4] A cross-sectional study was conducted to assess the prevalence of depression in three primary care centers in Riyadh, Saudi Arabia. The sample was 477 people, 66.2% females, 77.4% married, and about 20% illiteracy. Patients who showed symptoms of depression were 49.9%, 31% mild, 13.4% moderate, 4.4% mild-severe, and 1.0% severe. The results were related to gender and the level of education.[7] Furthermore, another cross-sectional depression was conducted in four primary health-care centers (PHCs) in Al Khobar, Saudi Arabia. A sample of 850 males and females were interviewed. The results of the study showed that the prevalence of moderate-to-severe depression among PHC clients was approximately 16%.[8] Although the studies have shown that early diagnosis has several benefits in reducing the costs by 80% and depression by 30%–50%, patients do not attend their appointments or sessions.[7] Anxiety, stress, and overthinking are natural feelings that may occur at any time during a person's lifespan, but anxiety disorder is a medical condition that needs treatment.[9] Anxiety disorder is characterized by excessive and persistent fear, worry, and thinking a lot about ordinary everyday situations.[10] Eating disorders are psychological disorders that cause severe disturbances to an individual's eating behaviors and can lead to severe and fatal illnesses, including obsessions with food, body weight, and shape.[11] There are three types of eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder.[11] In Saudi Arabia, a study held at Taif University showed a high prevalence of eating disorders among females. 35.4% (per 1200) of the students were classified as at risk for eating disorders.[12] Moreover, a study was conducted in Dammam city revealed that 29.4% of 670 preparatory-year Saudi female students at the Imam Abdulrahman Bin Faisal University were at a high level of concern for eating disorders, 45.5% were at risk of having problematic feeding behaviors, 60.7% demonstrated high-risk feeding behavior attitudes, and 11.5% classified as underweight that required referral to a psychologist.[12] Mental illness is affected by a variety of factors. Both stigma and discrimination are the most critical barriers for mentally ill individuals to overcome in the community.[13] An online survey directed toward young adults aged 18–25 years from the general UK population was conducted to investigate barriers that prevent or delay young adults from seeking any support for emotional or mental health difficulty. About 35% of the respondents have difficulties in emotional or mental health, but they did not seek any help because of stigmatizing beliefs, difficulty identifying or expressing concerns, a preference for self-reliance, and difficulty accessing help.[14] In addition, 81% of the participants have identified “feeling embarrassed or ashamed” to be the most stigma barrier that may prevent them from seeking help.[15] Moreover, several studies showed that stigma prevents patients from seeking help, adhering to treatment, and being an active community member.[13] Besides stigma and discrimination as a challenge in getting mental health help, the community's perception is another factor. Individuals could stand back from getting treatment for mental illness because of poor community perceptions, which negatively affects the prognoses of disease because they tend to push back medical treatment until the disease becomes hard to reverse.[16] The cultural factor in the society bears a great responsibility in the extent of people's awareness of a specific issue such as mental illness and how patients communicate their symptoms and feelings.[13] The individual is affected by the prevailing social perception of mental illness and sometimes found himself forced to consider it even at the expense of his health and psychological well-being.[17] Culturally surrounded beliefs and misconceptions cause stigma, discrimination, and isolation not only for people with a mental disease but also for their families and caregivers.[13] Mental illness is affected by how family and friends adapt to the patient and other psychosocial aspects.[18] Many psychosocial problems can arise from mental illness, and it can negatively influence the quality of life of members surrounding the patient and decrease social interaction between the patient and family members.[13] Furthermore, family and friends act as the first persons of contact with the ill person, which holds an emphasis on the importance of the ability of these persons to be acceptable and understanding.[17] As the concept of mental health expands, more and more areas are falling under the understanding of its complex nature, and one of these areas is demographic factors. Demographic factors are features of a population that can be conveyed statistically, such as age, gender, educational level, marital status, family size, and occupation. Considering the holistic nature of mental health, demographic factors ought to have a significant relation to that inclusive nature.[18] For example, a study conducted in Iran showed that the majority of people who showed signs of poor mental health were female, the most impacted age group were 20–30 years, and most were married, unemployed, and did not have any academic education.[19] Around the globe, mental health services gained interest and improvements, yet it is still considered lacking in some aspects.[20] Saudi Arabia gained knowledge and began to pay more attention to mental health.[2] A wide range of services are available all around the Gulf countries; for instance, establishments in the capital city Riyadh alone include 16 government and 11 private hospitals, 9 clinics, 43 rehabilitation centers, and 10 associations and committees with qualified psychologists and psychiatrists.[21] Overall, most of the studies in Saudi Arabia have been conducted regarding mental health services or specific mental disorders or specific populations and age groups. While most research in Saudi Arabia is directed toward the prevalence of mental health in Saudi Arabia, little is known about the effect of social barriers on mental health help-seeking. Therefore, the present study was conducted to investigate the impact of social barriers on mental health help-seeking among Saudi Arabians aged 18 years and above.

Materials and Methods

The study was a descriptive cross-sectional study conducted using an online survey to investigate the impact of social barriers in help-seeking regarding mental disorders among the Saudi population aged 18 years and above. The questionnaire was developed by adapting some questions from MIND (Mental Health Association), 2014, and other questions were established by the researchers.[22] All questions were developed after revising them by experts in the Public Health Department at the College of Applied Medical Sciences at King Saud University. A pilot study was conducted before officially publishing the survey from October 28 to October 31, 2018, on 16 participants. Based on the pilot's results, modifications were made to be more appropriate to the target population. Some questions were altered, and one was added to the second section of the survey. The research instrument consisted of three sections. The first section of the survey was developed to measure the knowledge and attitudes regarding mental health. The second section was developed to measure social barriers. The last section of the survey consisted of demographic questions. The study population involved all Saudi citizens, both males and females, aged 18 years and above in all regions of Saudi Arabia. All members of the population who met the inclusion criteria were accepted to be part of the study sample. The survey was conducted from October to November 2018 through self-administered online surveys. The data were collected after the study was approved by the Institutional Review Boards of King Saud University. All data collected were statistically analyzed using the Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp). to calculate frequencies and relations between the variables of the study. The frequencies and percentages of participants were all analyzed. Descriptive statistics were used to determine the means and standard deviations of all variables. Quantitative data were analyzed using the Pearson correlation coefficient to determine the relationship between the variables. Descriptive and inferential statistical data analyses were applied in the study, with P < 0.05 considered statistically significant. Ethical approval was obtained from the Ethics Committee Review Board of the College of Applied Medical Science of King Saud University, Riyadh, Saudi Arabia (CAMS 009–3940) before the beginning of the study. The participation in the study was voluntary. Participants were fully informed about the research and were required to agree on a consent form before answering the survey questions. All collected data were kept strictly confidential.

Results

A total of 1632 participants (286 males and 1346 females) completed an online survey to answer questions related to demographic data and measuring knowledge, attitudes, and behaviors in relation to mental health. The majority of the participants were in the age range of 18–28 years (51.8%), whereas 22.9% were aged 29–39 years and 25.3% were 40 years or older. A total of 51.6% of the participants were single and 42.4% were married, whereas 72.6% of the participants had a university or postgraduate degree and 24.4% had completed a high school diploma or equivalent degree [Table 1 for more details].The prevalence rate of mental illness among the participants was based on either if the participants are diagnosed by a professional or themselves diagnosed. Over half of the study participants do not have mental illness, whereas a smaller segment of the sample indicated to have mental illness. The majority of the participants recognized depression, obsessive–compulsive disorder, and schizophrenia as mental health conditions. Most of the participants were agreed to the statements, “It is possible for anyone to develop a mental illness” and “social barriers can prevent me from help-seeking when faced with a mental issue” [Table 2 for descriptive statistics].

Table 1

Sociodemographic characteristics of participants

Variables	Frequency (%)
Age
18-28	845 (51.8)
29-39	374 (22.9)
40-50	291 (17.8)
51-61	115 (7.0)
62+	7 (0.4)
Total	1632 (100.0)
Gender
Male	286 (17.5)
Female	1346 (82.5)
Total	1632 (100.0)
Nationality
Saudi	1571 (96.3)
Non-Saudi	61 (3.7)
Total	1632 (100.0)
Region
Middle	1133 (69.4)
Eastern	141 (8.6)
Western	218 (13.4)
Northern	45 (2.8)
Southern	95 (5.8)
Total	1632 (100.0)
Marital status
Never married	842 (51.6)
Married	692 (42.4)
Widowed	18 (1.1)
Divorced	63 (3.9)
Polygynous	2 (0.1)
Married to a polygynous	10 (0.6)
Unable to get divorce	5 (0.3)
Total	1632 (100.0)
Educational level
Less than high school diploma	50 (3.1)
High school diploma or equivalent degree	398 (24.4)
Bachelor’s degree	1021 (62.6)
Higher education	163 (10.0)
Total	1632 (100.0)

Table 2

Knowledge and attitudes

Statements	1 Strongly disagree (%)	2 Disagree (%)	3 Neutral (%)	4 Agree (%)	5 Strongly agree (%)
“People with mental illness are generally violent and dangerous”	17.1	44.4	23.6	13.6	1.3
“It is possible for anyone to develop a mental illness”	1.3	3.9	8.7	55.8	30.3
“People with mental illness are a burden to society”	35.2	37.4	17	9	1.3
“People with mental illness should not be given any responsibility”	27.6	49.5	16.4	5.3	1.2
“I would not want to live next door to someone who is mentally ill”	16.7	29.8	30.6	18.9	3.9
“Social barriers can prevent me from help-seeking when faced with a mental issue”	2.2	6.6	12.3	50.3	28.6

Participants identified stigma as a significant social barrier to seeking mental health care, followed by culture and negative perceptions. A Pearson correlation (r) test was used to specify how two variables vary together, the social barriers and demographic data. A significant positive correlation was found between age and social barriers as the P level was defined at P ≤ 0.05. Respondents who were in the age range of 18–39 years and 62 + have identified stigma to be a major social barrier that influences mental health care seeking. On the other hand, respondents who were in the age range of 40–61 years have identified culture to be a major social barrier that influences mental health care seeking. Responses given by the participants in this study showed a significant positive correlation (P < 0.05) between gender and social barriers. Furthermore, a significant positive correlation was found between the region and social barriers as P < 0.05. Respondents from the middle region have identified culture as a significant barrier to seeking mental health care, whereas respondents from eastern, southern, and western regions have identified stigma as a significant barrier to seeking mental health care. On the other hand, respondents from the northern region have identified a negative perception, a significant barrier to seeking mental health care. A significant positive correlation was found between marital status and social barrier as P < 0.05. Stigma was the most commonly reported social barrier for seeking mental health care by single and divorced participants. A significant positive correlation was found between educational level and social barrier as P < 0.05. Respondents with high school diploma or less have identified negative perceptions to be a major social barrier that impacts mental health help-seeking, whereas respondents with bachelor's degree and higher education have identified stigma to be a major social barrier that impacts mental health help-seeking. The results of the study indicated a significant positive correlation between participants who are diagnosed by a professional and the likelihood of visiting a general practitioner for help as P < 0.05. Furthermore, a significant positive correlation was found between participants who are diagnosed by professional and social barriers as P < 0.05. Participants who are diagnosed by a professional have identified culture to be a significant barrier to seeking mental health care. A significant positive correlation was found between people who do not have any mental illness and social barriers as P < 0.05. Participants who do not have any mental illness have identified culture, a significant barrier to seeking mental health care. A significant positive correlation is found between people who think that they have symptoms for mental illness and social barriers as P < 0.05. Participants who think that they have symptoms for mental illness have identified stigma to be a significant barrier to seeking mental health care.

Discussion

Social barriers could be considered a key factor that prevents or delays individuals to seeking help for a mental health illness; thus, the present study aimed to examine the impact of social barriers on mental health help-seeking among the Saudi population aged 18 years and above. The major findings of this study showed that social barriers affecting seeking help for a mental health illness vary among the participants. Specifically, stigma, culture, and negative perceptions were reported by most of the participants as barriers to seeking mental health help. However, stigma was recognized by most of the participants as a potential barrier to seeking help for a mental health illness. This result concurs with previous research, indicating that 35% of the British young adult respondents have difficulties in emotional or mental health, but they did not seek any help because of stigmatizing beliefs.[15] The major findings of this study showed that 44.4% of the respondents disagreed with the statement, “people with mental illness are generally violent and dangerous,” which is consistent with a previous study, indicating that 44.9% of the participants disagreed with the statement, “most people believe that someone with a previous mental illness is dangerous.”[23] The participants of the study recognized the high prices of psychiatric care as a social barrier to mental health care; this has also been found in a previous study in the UK.[15]

In the Attitudes to Mental Illness 2014 Research Report in England, 53% of 1736 participants with mental illness reported to experience stigma and discrimination, which is consistent with our results as 39.5%.[24] In the same report, 43% believed that mental health stigma and discrimination did not improve, which contradicts with our results as 64.6% of the sample of the study believed it decreased.[24] The major findings of this study showed a significant positive correlation between gender and social barriers. Males have identified culture (72.0%) to be the most common social barrier that impacts mental health help-seeking, followed by stigma (70.1%) and then negative perceptions (62.3%). However, females have identified the same social barriers but in a different order. The most frequent social barrier was stigma (67.7%), followed by culture (60.3%) and negative perceptions (59.7%). Identification of the social barriers in different components in the current study was significantly associated with several participants' characteristics. The findings presented in this study highlighted how demographic characteristics of the sample can be related to the social barriers that delay or prevent individuals to seeking mental health care. The study not only identified key social barriers to seeking mental health care but also how these barriers are influenced by many factors. Mental health care of the population can be enhanced through the recognition of social barriers as well as to recognize that barriers differ based on sociodemographic characteristics.[6] Social barriers could be a significant factor to impede appropriate mental health-care seeking including stigma, culture, and negative perceptions. Considering the mental health, patients' views and perspectives may serve as a backbone for future mental health-care improvements. The study results suggest that new health education initiatives are needed to increase recognition of mental illness in conjunction with the efforts currently underway to reduce social barriers, especially stigma and culture.

Study limitations

The current study includes several limitations. The variables of interest were measured by self-report and therefore subject to bias, underreporting, and over-reporting. Another limitation was the design of the study, which was based on quantitative correlational design. Correlation does not imply causation, and there is no way to determine or prove causation from a correlational study. The variables interact with each other, and correlation design does not determine how they react. However, the findings of this study could help promote the improvement of mental health care. The results reported in this study have illuminated some of the important issues related to Saudi mental health, particularly concerning their mental health help-seeking behaviors. On the other side, the findings have also raised some serious concerns regarding prevention and intervention strategies for population with mental health illness. Future research should investigate stigma, culture, and negative perceptions about mental health and their effect on help-seeking behaviors in population. The findings of this study should be considered in the design of comparative studies on population in other countries in the Middle East to identify whether these populations have social barriers and related factors that are similar to the ones identified in the current study. Perhaps, a qualitative study targeting the Saudi population would provide more detailed information about why and how social barriers influence mental health help-seeking behaviors.

Conclusion

The study was conducted to measure the impact of social barriers on mental health help-seeking among the Saudi population aged 18 years and above. Most of the participants did not suffer from any mental illness, at the ages between 18 and 28 years, not married, and women. The most frequently chosen mental illness was obsessive–compulsive disorder. Social stigma was chosen from most of the participants as the most frequent factor preventing help-seeking for a mental issue compared to other social factors. This study was a first step in looking at the Saudi population's mental health in relation to help-seeking behaviors. It is hoped that the findings from this study will be a springboard for future research and contribute greater insight into the association between social barriers and mental health help-seeking behaviors in the Saudi population. Health education professionals should collaborate with governmental, nongovernmental, and nonprofit agencies to better understand the issues of mental health and work collaboratively to reduce the challenges.

Financial support and sponsorship

The author extends her appreciation to the Deanship of Scientific Research at King Saud University for funding this work.

Conflicts of interest

There are no conflicts of interest.