Barriers to mental healthcare seeking among individuals attending primary healthcare centers in Riyadh, Saudi Arabia

Abstract

BACKGROUND:

Mental health conditions remain a major global public health concern. Despite national efforts to integrate mental health services into primary healthcare (PH) in Saudi Arabia, its utilization remains limited. Understanding stigma-related and nonstigma-related barriers is essential to improving access and informing service development.

MATERIALS AND METHODS:

A cross-sectional survey was conducted between April and August 2025 among Saudi adults attending PH centers (PHCs) in Riyadh. Participants were recruited through convenience sampling; data was collected using a validated self-administered questionnaire in Arabic. Barriers to Access to Care Evaluation (BACE-III) scale was used to measure stigma and nonstigma barriers. Initial analysis included descriptive statistics; t-tests and ANOVA were used to compare the mean stigma and nonstigma domain scores, and multiple linear regression was performed to determine predictors of perceived barriers. Reliability of the BACE-III in this sample was high (Cronbach’s α = 0.956).

RESULTS:

A total of 416 participants were surveyed. Younger age, lower educational level, and student status were associated with significantly higher stigma and nonstigma barrier scores (P < 0.001). Awareness of the availability of mental health services in PHCs was strongly associated with lower perceived barriers (P < 0.001). No significant differences based on gender, health insurance status, or prior experience with mental health services were observed. Regression analyses showed that age and awareness independently predicted perceived barriers.

CONCLUSION:

Stigma-related and nonstigma-related barriers continue to impede utilization of mental health services in PH settings. Increasing public awareness, affirming the assurance of confidentiality, and implementing community-level antistigma initiatives may improve equitable access and support the goals of the Saudi Vision 2030 health transformation.

Introduction

Mental health plays a vital role in an individual’s overall well-being, influencing emotional balance, interpersonal connections, and the ability to function effectively daily. Worldwide, conditions such as depression, anxiety, and substance use disorders impact on nearly one in eight people and are major contributors to disability, with considerable social and economic consequences.[1,2] In Saudi Arabia, approximately one-third of the population is likely to have a mental health disorder at some stage in their life. Although there have been nationwide initiatives to embed mental healthcare in primary healthcare (PH), the uptake of the service remains low, particularly in such fast-growing metropolitan areas as Riyadh where rapid population increases place additional demands on health systems.[3,4]

Barriers to care are multifactorial. In the Saudi context, cultural norms and reliance on family or self-help strategies discourage professional help-seeking,[5] while limited mental health literacy contributes to delays in recognizing symptoms and accessing appropriate treatment.[6] Social stigma further deters individuals owing to fears of judgment or discrimination.[7] Structural challenges, including shortages of trained professionals, long waiting times, and financial constraints, compound the issues of access. In Riyadh, urbanization and uneven resource distribution further exacerbate these disparities in service utilization.[8,9]

Primary Healthcare Centers (PHCs) serves as the main entry point for most mental health concerns in Saudi Arabia, where family physicians play a central role in early identification, counseling, and referral. Understanding the barriers that determine whether an individual seeks help in PH settings is therefore essential. To examine these challenges, the present study utilized the validated Barriers to Access to Care Evaluation (BACE-III) scale to assess attitudinal, cultural, and structural factors influencing help-seeking behaviors of Saudi adults attending PHCs in Riyadh.[10] Recent Saudi research using the BACE-III on medical students has also demonstrated numerous stigma-related and attitudinal barriers to seeking mental healthcare, underscoring the relevance of this tool in the local context.[11] The aim of the findings is to inform culturally sensitive interventions that would reduce stigma, enhance awareness, and strengthen the integration of mental health services within PHCs in line with Saudi Vision 2030 objectives.

Materials and Methods

A quantitative, cross-sectional design was employed between April and August 2025 to investigate barriers to primary mental healthcare utilization in Riyadh, Saudi Arabia. Saudi nationals living in Riyadh were approached using convenience sampling, primarily through PHCs, where the questionnaire was completed by PH attendees. Criteria for inclusion comprised Saudi adults and adolescents who have no history of severe mental illness and not currently being seen in primary mental healthcare. From this pool of eligible participants, individuals were excluded if they were non-Saudi residents, had a known diagnosis of severe mental illness, were already in the care of mental health services, or resided outside Riyadh. Ethical approval was obtained from the Institutional Review Board of King Saud Medical City vide Letter No. H1RI-02-Mar25-10 dated 10/03/2025, and written informed consent was taken from all participants in the study.

Data collection was conducted using a structured, self-administered questionnaire adapted from the validated Arabic version of the BACE-III scale, with permission from the INDIGO Network.[12] Paper-based questionnaire was provided to eligible participants during their visit to participating PHCs in Riyadh, where trained staff explained the purpose of the study. This approach ensured that the sample represented individuals actively attending PH services. The questionnaire gathered demographic information (age, gender, education, employment status, health insurance, and area of residence), and questions assessing participants’ awareness of and prior experience with primary mental health services. The BACE-III consists of 30 items in three domains: 12 stigma-related barriers, 10 attitudinal barriers, and 8 instrumental or practical barriers.

For each BACE-III item, three scoring metrics were calculated: (1) the mean score, (2) the proportion of participants who reported the barrier to any degree (responses 1, 2, or 3; “any barrier”), and (3) the proportion reporting it as a major barrier (response 3; “major barrier”). The stigma subscale score was computed as the mean of the 12 stigma-related items (items 3, 5, 8, 9, 12, 14, 17, 19, 21, 24, 26, and 28). Nonstigma scores were calculated as the mean of the remaining attitudinal and instrumental items. These domain-specific means (stigma and nonstigma) were used in subsequent comparative and regression analyses. A pilot test conducted among PHC attendees confirmed the clarity and cultural appropriateness of the questionnaire. All items were mandatory to ensure complete data, and responses were stored in a password-protected, anonymized database to maintain participant confidentiality.

The sample size was calculated using the single-sample proportion formula (n = Z² × P × [1 − P]/e²), with P set at 0.5, Z at 1.96, and e at 0.05, yielding a minimum required sample of 384 participants. After accounting for an anticipated 5% nonresponse rate (384 ÷ 0.95 = 405), the final target sample size was set at 405 individuals.[13]

Data analysis conducted using SPSS version 29.0 (IBM Corporation, Armonk, NY: USA). Descriptive statistics included means and standard deviations for continuous variables, and frequencies and percentages for categorical variables. For BACE-III items, “any barrier” was defined as a response of ≥1 (“a little,” “quite a lot,” or “a lot”), whereas a “major barrier” was defined as a response of 3 (“a lot”). Domain-specific scores were calculated according to the BACE-III structure, which includes a stigma-related subscale (12 items) and a nonstigma subscale comprising attitudinal and instrumental barriers (18 items). Mean stigma and nonstigma domain scores were used for comparative analyses. Group differences were examined using independent samples t-tests for two-category variables and one-way ANOVA for comparisons of more than two groups. Multiple linear regression analyses were conducted separately for stigma and nonstigma subscale scores to identify independent predictors of perceived barriers, as the BACE-III is not designed to generate a single total score. Statistical significance was set at P < 0.05. Internal consistency of the BACE-III was assessed using Cronbach’s alpha, which demonstrated excellent reliability in this sample (α = 0.956).

Results

A total of 460 individuals completed the questionnaire, yielding a response rate of 97.5% (460/472). Of these, 416 met the eligibility criteria and were included in the final analysis. Table 1 summarizes the sociodemographic characteristics of the study population. More than two-thirds of participants were aged 18–40 years (n = 283; 68%), and females slightly outnumbered males (54.3% vs. 45.7%). Over half held a Bachelor’s degree (n = 231; 55.5%), while 28.8% (n = 120) had done postgraduate studies. The largest proportion resided in northern Riyadh (n = 138; 33.2%), followed by eastern Riyadh (n = 96; 23.1%). In terms of employment, civilian government employees represented the largest group (n = 171; 41.1%), followed by private-sector employees (n = 82; 19.7%). Approximately 62% of participants had no health insurance (n = 259), and the vast majority (90.1%; n = 375) had no prior experience with primary mental healthcare services. More than half the respondents (57.9%) were unaware that mental health services were offered at PHCs, while 42.1% knew of these services.

Table 1.

Demographic characteristics of persons attending primary healthcare centers, Riyadh, Saudi Arabia, 2025 (n=416)

Variables/Categories	N (%)
Gender
Male	190 (45.7)
Female	226 (54.3)
Age (years)
Under 18	25 (6.0)
18–40	283 (68.0)
Older than 40	108 (26.0)
Educational level
Elementary	2 (0.5)
Intermediate	8 (1.9)
High school	55 (13.2)
University	231 (55.5)
Postgraduate	120 (28.8)
Residence in Riyadh
East Riyadh	96 (23.1)
West Riyadh	71 (17.1)
Central Riyadh	55 (13.2)
North Riyadh	138 (33.2)
South Riyadh	56 (13.5)
Employment status
Student	66 (15.9)
Government employee (Civilian)	171 (41.1)
Government employee (Military)	47 (11.3)
Employee in the private sector	82 (19.7)
Unemployed	33 (7.9)
Retired	17 (4.1)
Do you have health insurance?
Yes	157 (37.7)
No	259 (62.3)
Do you have prior experience with mental healthcare services in primary care centers?
Yes	41 (9.9)
No	375 (90.1)
Did you know that mental healthcare services are provided at primary care centers?
Yes	175 (42.1)
No	241 (57.9)

Table 2 presents the descriptive statistics for the 30 items of BACE-III. The most frequently reported barriers included a preference for handling problems privately (mean = 2.00; 94% reporting any barrier; 33.4% reporting a major barrier), belief that the problem would improve on its own (mean = 1.75; 87.5% any; 25% major), unease with the discussion of personal emotions or thoughts (mean = 1.59; 81% any; 23.1% major), concerns about side effects of treatment (mean = 1.64; 79.8% any; 28.6% major), preference for alternative or traditional support (mean = 1.59; 79.3% any; 25.7% major), and anxiety about having mental health information recorded in medical files (mean = 1.63; 77.2% any; 28.6% major). The least frequently endorsed barriers were being too unwell to seek help (mean = 0.75; 43.5% any; 7% major), having had previous negative experiences with mental healthcare (mean = 0.76; 42.3% any; 8.9% major), difficulties with transportation (mean = 0.93; 52.2% any; 7% major), concerns related to childcare (mean = 0.95; 33.4% any; 11.1% major), and fear of involuntary hospital admission (mean = 0.96; 51.2% any; 10.6% major).

Table 2.

Mean scores and prevalence of reported barriers to accessing primary mental healthcare services among persons attending primary healthcare centers, Riyadh, Saudi Arabia, 2025 (n=416)

BACE-III Item description	Mean±SD	Percentage reporting any barrier (≥1)	Percentage reporting a major barrier (=3)	Stigma related barriers (Yes/No)	Nonstigma related barriers (Yes/No)
1. Not being sure where to go to get mental healthcare	1.43±0.996	77.6	14.9	No	Yes
2. Wanting to solve the problem on my own	2.00±0.886	94	33.4	No	Yes
3. Worried that I might be seen as weak for having a mental health problem	1.22±1.055	66.6	13.5	Yes	No
4. Fear of being admitted to a hospital against my will	0.96±1.070	51.2	10.6	No	Yes
5. The worry that it might harm my chances when applying for jobs	1.36±1.207	53.8	21.2	Yes	No
6. There are problems with transportation or travel to arrive on time	0.93±1.011	52.2	7	No	Yes
7. My belief that the problem will improve on its own	1.75±0.970	87.5	25	No	Yes
8. Worrying about what my family might think, say, do, or feel toward me	1.38±1.029	74.8	15.9	Yes	No
9. Feeling embarrassed or ashamed	1.14±1.047	63.7	12.3	Yes	No
10. I prefer to receive alternative forms of care	1.59±1.083	79.3	25.7	No	Yes
11. Inability to afford the financial costs	1.26±1.105	65.4	16.6	No	Yes
12. Worrying that I might be seen as “crazy”	0.99±1.055	54.1	10.3	Yes	No
13. My belief that mental healthcare probably won’t help me	1.16±1.014	65.9	10.3	No	Yes
14. Worrying that I might be seen as a bad parent	1.14±1.183	45.4	16.1	Yes	No
15. Specialists from my own racial or cultural group are not available	0.97±1.000	56.7	8.2	No	Yes
16. Being too ill to the extent that I am unable to seek help	0.75±0.981	43.5	7	No	Yes
17. Worrying that people I know will find out about me	1.18±1.060	65.4	13.9	Yes	No
18. I don’t like talking about my feelings, emotions, or thoughts	1.59±1.042	81	23.1	No	Yes
19. Worrying that people might not take me seriously if they find out I have been receiving mental healthcare	1.28±1.086	67.5	16.3	Yes	No
20. Concerns about available treatments (for example: side effects of medications)	1.64±1.099	79.8	28.6	No	Yes
21. Not wanting the mental health issue to appear in my medical records	1.63±1.125	77.2	28.6	Yes	No
22. Having previously had bad experiences with mental healthcare	0.76±1.020	42.3	8.9	No	Yes
23. I prefer to get help from family and friends	1.43±1.030	78.4	19	No	Yes
24. Worrying that my children might be taken into care	0.95±1.143	33.4	11.1	Yes	No
25. My belief that I didn’t have a problem	1.42±1.079	73.6	19.5	No	Yes
26. Worrying about what my friends might think, say, or do toward me	1.19±1.050	65.9	13.2	Yes	No
27. Difficulty taking time off from work	1.25±1.131	63.9	18.3	No	Yes
28. Worrying about what people at work might think, say, or do toward me	1.43±1.177	58.9	22.1	Yes	No
29. Problems occurring with childcare when I receive mental healthcare	1.06±1.128	38.9	11.1	No	Yes
30. I have no one to help me access mental healthcare	1.06±1.101	56.5	14.2	No	Yes

SD: Standard deviation, BACE: Barriers to Access to Care Evaluation

Mean stigma and nonstigma barrier scores varied significantly across demographic and awareness-related factors [Table 3]. Participants younger than 18 years reported the highest levels of perceived barriers, with mean stigma (2.07 ± 0.56) and nonstigma (1.94 ± 0.41) scores that were significantly higher than those of participants aged 18–40 years and older (P < 0.001). Educational level demonstrated a similar trend, as individuals with intermediate or elementary education showed notably higher stigma and nonstigma scores compared to graduate and postgraduate groups (P < 0.001). Students also exhibited elevated perceived barriers across both domains relative to employed and unemployed participants (P ≤ 0.001). Awareness of mental health services within PHCs was strongly associated with lower barrier scores; participants who were aware of available services reported lower stigma (1.03 ± 0.81) and nonstigma (1.07 ± 0.56) scores compared with those who were unaware of the services (1.44 ± 0.86 and 1.44 ± 0.59, respectively; P < 0.001). No statistically significant differences were observed by gender, health insurance status, or prior experience with mental health services (P > 0.05).

Table 3.

Association between stigma and nonstigma barriers and seeking mental healthcare among persons attending primary healthcare centers, Riyadh, Saudi Arabia, 2025 (n=416)

Variables	Stigma score Mean±SD	P-value	Nonstigma score Mean±SD	P-value
Gender
Male	1.26±0.795	0.880	1.25±0.554	0.252
Female	1.27±0.915		1.32±0.645
Age (years)
Under 18	2.07±0.556	<0.001*	1.94±0.405	<0.001*
18–40	1.18±0.821		1.21±0.557
>40	1.29±0.928		1.33±0.671
Educational level
Elementary	1.64±0.346	<0.001*	1.60±0.146	<0.001*
Intermediate	2.40±0.423		2.14±0.522
High school	1.63±0.923		1.55±0.596
University	1.24±0.840		1.30±0.591
Postgraduate	1.06±0.795		1.08±0.549
Employment status
Student	1.57±0.819	0.001*	1.55±0.573	<0.001*
Government employee (civilian)	1.08±0.831		1.14±0.588
Government employee (military)	1.36±0.768		1.27±0.552
Employee in the private sector	1.32±0.869		1.34±0.588
Unemployed	1.20±0.965		1.29±0.659
Retired	1.57±0.942		1.52±0.654
Health insurance status
Yes	1.17±0.870	0.081	1.24±0.606	0.233
No	1.32±0.852		1.31±0.604
Do you have prior experience with mental healthcare services in primary care centers?
Yes	1.18±0.950	0.505	1.12±0.663	0.070
No	1.27±0.852		1.30±0.597
Did you know that mental healthcare services are provided at primary care centers?
Yes	1.03±0.814	<0.001**	1.07±0.557	<0.001*
No	1.44±0.855		1.44±0.593

**P < 0.05 considered statistically significant. **P < 0.001 considered highly statistically significant. SD: Standard deviation

Multiple linear regression analyses were conducted separately for the stigma and nonstigma BACE-III domains [Table 4]. Age and awareness of PH mental health services emerged as significant predictors in both models. Compared with participants younger than 18 years, those aged 18–40 years demonstrated significantly lower stigma (B = −0.426, 95% confidence interval [CI]: −0.826 to −0.025, P = 0.037) and nonstigma scores (B = −0.402, 95% CI: −0.754 to −0.051, P = 0.025). Similarly, participants aged more than 40 years reported lower stigma (B = −0.422, 95% CI: −0.841 to −0.003, P = 0.049) and nonstigma scores (B = −0.388, 95% CI: −0.728 to −0.048, P = 0.030). Awareness of the availability of mental health services within PH was also a strong negative predictor of perceived barriers. Participants who were aware of the services reported significantly lower stigma (B = −0.301, 95% CI: −0.446 to −0.156, P < 0.001) and non-stigma scores (B = −0.289, 95% CI: −0.428 to −0.150, P < 0.001). No statistically significant associations were found for gender, educational level, employment status, health insurance status, or prior experience with mental healthcare services in either domain (P > 0.05).

Table 4.

Predictors of stigma and nonstigma Barriers to accessing mental healthcare services among persons attending primary healthcare centers, Riyadh, Saudi Arabia, 2025 (n=416)

Variables	Stigma score ß (95% CI)	P-value	Nonstigma score ß (95% CI)	P-value
Female gender	0.057 (−0.081 to 0.195)	0.421	0.044 (−0.067 to 0.155)	0.432
Age
18–40	−0.426 (−0.826 to −0.025)	0.037	−0.402 (−0.754 to −0.051)	0.025
>40	−0.422 (−0.841 to −0.003)	0.049	−0.388 (−0.728 to −0.048)	0.030
Educational level
Intermediate	0.563 (−0.506 to 1.631)	0.301	0.512 (−0.478 to 1.503)	0.304
High school	0.005 (−0.973 to 0.982)	0.992	0.018 (−0.915 to 0.951)	0.968
University	−0.139 (−1.109 to 0.832)	0.779	−0.122 (−1.033 to 0.788)	0.890
Postgraduate	−0.248 (−1.228 to 0.731)	0.618	−0.196 (−1.104 to 0.711)	0.668
Employment status
Student	0.180 (−0.136 to 0.496)	0.264	0.172 (−0.118 to 0.462)	0.245
Civilian government employee	0.084 (−0.187 to 0.355)	0.541	0.078 (−0.158 to 0.315)	0.512
Military employee	0.240 (−0.087 to 0.567)	0.150	0.231 (−0.075 to 0.537)	0.137
Private employee	0.297 (−0.006 to 0.601)	0.055	0.281 (−0.009 to 0.571)	0.060
Retired	0.221 (−0.191 to 0.632)	0.292	0.214 (−0.172 to 0.601)	0.274
Health insurance (yes)	−0.127 (−0.287 to 0.034)	0.122	−0.118 (−0.271 to 0.035)	0.128
Prior PHC mental health experience (yes)	0.019 (−0.214 to 0.253)	0.871	0.011 (−0.201 to 0.224)	0.915
Awareness of PHC mental health services (yes)	−0.301 (−0.446 to −0.156)	<0.001*	−0.289 (−0.428 to −0.150)	<0.001*

*Significant at P<0.05. Reference categories: male, <18 years, Elementary education, unemployed, “No” for last three variables. PHC: Primary Health Centre, CI: Confidence interval

Discussion

This study identified substantial stigma-related and nonstigma-related barriers to mental health service utilization by adults attending PHCs in Riyadh. Stigma-related factors such as embarrassment, fear of being labeled, and concerns about social judgment were prominent and in line with broader regional patterns. Nonstigma barriers, including self-reliance, expectations of natural improvement, and unease with any discussion of personal emotional concerns, also contributed to reduced help-seeking. Younger age, lower educational attainment, and lack of awareness of services available were consistently associated with higher perceived barriers, underscoring the need for targeted interventions. Although mental health disorders remain a major global public health concern, gaps in help-seeking behaviors are still evident in many populations. In Saudi Arabia, despite the integration of mental health into PH, utilization remains limited.[14] Cultural norms, stigma, low awareness, and structural challenges remain significant obstacles.[15] This study examined barriers to accessing primary mental health services in Riyadh, with the aim of informing culturally tailored strategies that enhance access, reduce stigmas, and boost early intervention.

Notably, the most prevalent barrier reported was the preference to manage problems independently (94% of any barrier and 33% of major barriers). This finding is consistent with international studies where self-reliance is frequently reported as a major obstacle to the utilization of mental health services. Previous international research has identified studies in which “wanting to handle the problem on one’s own” was one of the most common attitudinal barriers across cultural contexts.[16] Similarly, Australian research shows that individuals are often reluctant to seek help until problems escalate, which reflects cultural ideals of autonomy and resilience.[17] In Saudi Arabia, this tendency is reinforced by cultural values that emphasize self-control and reliance on personal or family resources before seeking professional advice and help.[18]

Belief in the natural improvement of problems emerged as another common obstacle, reflecting an optimistic bias that has been reported in Middle Eastern populations. For instance, Altuwairqi et al., similarly found that many individuals expect mental health symptoms to resolve spontaneously, contributing to delays in seeking treatment.[19] Such beliefs may reflect limited awareness of the chronic and relapsing nature of many mental health conditions, as well as cultural tendencies to normalize psychological distress as part of everyday life challenges.

Concerns regarding available treatments, particularly the fear of the side effects of medication and anxiety about having mental health diagnoses recorded in medical records, also emerged as frequently reported barriers. These findings accord with those of González de León et al., who reported fears of overmedication, dependency, and mistrust of pharmacological interventions as commonly cited barriers.[20] In Saudi Arabia, Al-Shareef et al., reported patients’ reluctance to take psychiatric medications, citing cultural narratives of harm, which reinforce medication-related barriers.[21]

The fear of documentation of mental health information in medical records has also been reported in Gulf and Arab countries, where concerns about confidentiality, social standing, and potential consequences for employment or marriage are significant barriers to accessing mental health services.[22] This finding aligns with Al-Hashemi et al., whose stigma framework illustrates how perceived and enacted stigma directly deter help-seeking.[23]

Furthermore, stigma-related barriers in PH were evident, with embarrassment, the worry of being labeled “crazy,” and concerns about social or familial judgment featuring prominently. Approximately two-thirds of participants expressed worry about perception by their family, while 63.7% reported embarrassment as a barrier. These results are in accord with international research showing that stigmatization is among the most widespread barriers to mental healthcare.[24] In the Saudi context, stigma is particularly tied to family and community dynamics, underscoring the influence of collectivist values. Similarly, studies from nearby Gulf countries, such as the UAE, have documented elevated stigma levels, where family honor and reputation impact decisions to seek psychiatric services in PH settings.[25]

Interestingly, despite strong stigma themes, structural barriers such as transportation difficulties and childcare responsibilities were less commonly endorsed. This contrasts with Western studies, particularly in the USA, where logistical barriers, including financial costs and access to care – often ranked higher.[26] This difference suggests that in Riyadh, cultural and attitudinal barriers weighed more heavily than practical or instrumental barriers, especially since many have insurance cover for health services or have free access as Saudi nationals.

Moreover, subgroup analysis showed significant demographic differences in barriers to primary mental healthcare. Younger participants (<18 years) reported the highest barrier scores, consistent with global research showing that adolescents are more stigmatized, have limited mental health knowledge, and often depend on family approval to seek help.[27] Education also influenced barriers; individuals with lower levels of education reported higher scores. Shim et al., found that awareness campaigns among university students reduced attitudinal barriers.[28] This supports evidence that higher education improves awareness, reduces stigma, and encourages positive behaviors.

However, in the regression analysis, education level and employment status were not statistically significant after adjusting for other factors, indicating that the association between these variables and perceived barriers may be indirectly influenced, primarily through awareness and mental health literacy. Awareness emerged as a strong predictor of lower barrier scores, highlighting the critical role of illiteracy as an obstacle. Importantly, more than half of the respondents (57.9%) were unaware of the presence of mental health services in PHCs.

This study has several strengths, including the use of a validated Arabic version of the BACE-III scale, a relatively large sample size, and a focus on PH attendees, a population directly impacted by national mental health integration efforts. However, the study also has limitations. Convenience sampling limits generalizability, and reliance on self-reported data could introduce recall and social desirability biases. The cross-sectional design prevents causal inference. In addition, the study was conducted in one region only of Saudi Arabia, which may not fully represent other regions with different sociodemographic characteristics.

From a clinical perspective, the study’s findings have several important implications for practice and policy. The BACE-III scale provided a structured framework for examining stigma-related and non-stigma-related barriers that influence help-seeking behaviors in PH settings. Understanding which barriers are most pertinent to younger individuals, those with lower education, and those unaware of existing services can guide the development of targeted interventions intended to increase awareness, reduce stigmatization, and improve the accessibility and acceptability of mental health services in primary care. As the first large-scale BACE-3 study conducted in Riyadh, the present findings provide valuable insights for shaping public health policies and improving clinical practice of mental health in community settings. Differentiating between stigma-related and non-stigma-related barriers would enable the development of more targeted interventions, such as school-based literacy programs, confidentiality safeguards in electronic medical records, and digital awareness campaigns that address misconceptions about psychiatric treatment and medication. These interventions should also emphasize culturally sensitive communication and patient education, particularly within family-centered societies where stigma and self-reliance are considerable.

Conclusion

This study highlights both stigma-related and nonstigma-related barriers to utilizing primary mental healthcare services in Riyadh. Cultural tendencies toward self-reliance, expectations of natural recovery, apprehension about treatment, and concerns regarding confidentiality were among the most frequently cited obstacles. Younger age, lower educational attainment, and student status were associated with higher barrier scores, whereas greater awareness of available services predicted fewer perceived barriers. Although integration of mental healthcare into PH settings in Saudi Arabia has increased, the degree of implementation and accessibility remains variable across regions. Collectively, these findings emphasize the need to reduce both stigma-related and structural barriers by improving public awareness, strengthening confidentiality, and promoting routine mental health screening within PH practice. School-and university-based initiatives, together with community-based stigma-reduction programs, may help normalize help-seeking behaviors and support prompt intervention. These strategies accord with the goals of Saudi Vision 2030, which emphasize the improvement of the quality of life, reduction of health disparities, and advancement of comprehensive, community-based mental healthcare, to support Saudi Arabia’s ongoing transformation toward a healthier and more resilient society.

Future work should include longitudinal assessments to track changes in perceived barriers to mental healthcare over time and evaluate targeted interventions designed to reduce stigma and enhance awareness. Incorporating mental health education into PH outreach activities and community programs may promote timely identification of symptoms and increase help-seeking behaviors. Further research is also needed to examine provider-level and system-level barriers, such as workload, training, referral pathways, and organizational capacity to ensure a comprehensive, sustainable approach to improving mental health service utilization in PHC settings in Saudi Arabia.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.