Abstract
Background
Despite the high prevalence and burden of mental health problems among young people, studies have suggested that they infrequently seek professional help. Understanding the barriers to help-seeking is an important step towards facilitating early access to mental health services and improving psychological wellbeing.
Aim
To investigate why young adults may choose not to seek any support for an emotional or mental health difficulty.
Design and setting
A cross-sectional online survey of young adults aged 18–25 from the general UK population.
Method
The survey consisted of an anonymous questionnaire that measured psychological distress, help-seeking preferences, and barriers to accessing help, which included the Barriers to Access to Care Evaluation (BACE) scale and an open-ended question to explore reasons for not seeking help in the past. Qualitative feedback was analysed using thematic analysis.
Results
Overall, 35% of participants (n = 45) who reported having an emotional or mental health difficulty did not seek any formal or informal help. The thematic analysis revealed that stigmatising beliefs, difficulty identifying or expressing concerns, a preference for self-reliance, and difficulty accessing help were prominent barrier themes among responders.
Conclusion
Young adults experiencing psychological distress may struggle to access help from others. Stigma and negative perceptions surrounding mental health and help-seeking may explain why young people are reluctant to approach others for help. Improving public awareness of the services and resources that are available, as well as screening for psychological distress in primary care services, may be necessary to improve mental wellbeing among young adults.
Keywords: health services accessibility, help-seeking behaviour, mental health, primary health care, young adults
INTRODUCTION
One in four adults in England will experience a mental health problem at any one time1 and it is estimated that 75% of all lifetime mental health difficulties emerge by the age of 25 years.2 Poor mental health can cause significant disability, and for young people it is associated with an increased risk of antisocial behaviour, substance misuse, unemployment, and suicide.3–5
Seeking help is considered to be an important step towards accessing appropriate mental health support and improving quality of life. In recent years, improving public wellbeing and access to mental health services has become a key agenda in government policies, campaigns, and programmes.5–8 Despite a conscious move towards improving public awareness and reducing the stigma that surrounds mental health, evidence suggests that young people are less likely to seek help from others, particularly professional help from GPs.9–12
Barriers to help-seeking can include difficulties in accessing support, concerns about confidentiality and trust, a preference for informal sources of help, and stigma.13,14 Although existing studies, including those outside of the UK, have focused on mental health help-seeking among adolescents,10,15 university students,16–18 or adults of all ages,13,19 few have reported on the barriers experienced by young adults aged 18–25 years from the UK general population. This age group is an important cohort to study, as it is typically associated with a separation from parents and a transition into adulthood when important decisions regarding education, career, and intimate relationships are made.20
This study sought to include participants from the wider population, extending beyond those in education, as has been done in previous studies of this kind.21 The aims of this study were to explore the barriers in accessing mental health support among young adults aged 18–25 years from the general UK population.
METHOD
Study population and participants
Participants were recruited from a community sample of young adults aged 18–25 years living in the UK. To recruit individuals who may be reluctant to engage in primary care services, posters detailing the study and an e-mail with a direct weblink to the study were sent to various community and educational settings. Organisations who agreed to advertise the study on their premises or website included a community library, four UK-based community colleges, and two third-sector charities working with young people. Online networks such as ‘The Student Room’ and social media were also used to promote the study. Convenience and snowball sampling techniques were used during recruitment. All participants were required to provide informed consent and volunteered to participate in the study.
Study design
This study formed part of a larger project exploring help-seeking among young adults. A cross-sectional online survey was developed and data collection took part between January and March 2015.
How this fits in.
Mental health problems are prevalent among young people and are associated with adverse effects. There is a concern, however, that young people infrequently seek help. Barriers to accessing mental health support include difficulties in identifying and communicating distress, stigmatising beliefs, shame, a preference for self-reliance, and anticipation that help will be difficult to access. These findings have relevance to GPs and healthcare professionals in reducing barriers to care and improving accessibility to mental health services.
Focus group
A mixed-sex focus group held with six volunteers (aged 18–25 years) from a charity organisation (Kids Company) was used to explore help-seeking. The findings were used to inform the content of the questionnaires developed to measure help-seeking behaviour. A further focus group (n = 4) was used to pilot the survey and minor amendments were made to improve the face validity of the survey.
Measurements
The survey consisted of a series of questionnaires that measured psychological distress, help-seeking behaviour, and barriers to seeking help. A history of help-seeking was assessed by asking participants who reported having ‘an emotional or mental health difficulty’ whether they had ever sought help (formal or informal) for their difficulties. Participants who indicated that they did not seek help were presented with the following open-ended question: ‘In your own words, please describe why you chose not to ask for help for your emotional or mental health needs, there is no right or wrong answer.’ All participants were presented with the 30-item Barriers to Access to Care Evaluation (BACE) scale,22 which was used to assess barriers to seeking professional help in the future. The BACE consists of a 12-item stigma scale, and attitudinal and instrumental barrier items.
Data analysis
Statistical analysis was conducted using IBM SPSS for Windows (version 22). An χ2 analysis with Fisher’s exact test and odds ratio (OR) was performed on categorical data. The internal consistency of the BACE was determined using Cronbach’s α. Qualitative feedback was coded using an inductive approach and a thematic analysis was performed using guidelines from Braun and Clarke.23 The reliability of the extracted themes was assessed by a second researcher.
RESULTS
Sample characteristics
In total, 203 participants responded to the online survey and 19% dropped out before completion. The demographic characteristics of the sample can be seen in Table 1. A total of 91 (48%) participants disclosed a current emotional or mental health difficulty and 123 (65%) reported a lifetime difficulty. Depression (n = 91), anxiety (n = 71), and self-harm (n = 60) were the most prevalent difficulties self-reported in the sample. Lifetime prevalence rates were significantly higher among female (74%) participants than males (26%), p = 0.032 (OR 1.92, 95% confidence interval [CI] = 1.02 to 3.62).
Table 1.
Demographic characteristics of participants (n = 203)
| Demographic variables | Male % (n ) | Female % (n) |
|---|---|---|
| Sex | 31 (62) | 69 (141) |
|
| ||
| Age, years | ||
| 18–19 | 12.4 (25) | 29.7 (60) |
| 20–21 | 5.0 (10) | 17.3 (35) |
| 22–23 | 8.4 (17) | 12.4 (25) |
| 24–25 | 5.0 (10) | 9.9 (20) |
| Mean (SD) | 20.6 (2.39), range 18–25 | |
|
| ||
| Relationship status | ||
| Single | 21.2 (43) | 46.8 (95) |
| Other | 9.4 (19) | 22.7 (46) |
|
| ||
| Ethnicity | ||
| White British | 11.8 (24) | 42.9 (87) |
| Black/black British | 5.4 (11) | 3.9 (8) |
| Asian/Asian British | 5.9 (12) | 10.8 (22) |
| Mixed | 3.4 (7) | 3.4 (7) |
| Other ethnic background | 3.9 (8) | 8.4 (17) |
|
| ||
| Religion | ||
| No religion | 14.3 (29) | 32.5 (66) |
| Christian | 7.4 (15) | 24.1 (49) |
| Muslim | 5.4 (11) | 6.9 (14) |
| Other | 3.4 (7) | 5.9 (12) |
|
| ||
| Employment statusa | ||
| Unemployed | 4.1 (11) | 2.3 (6) |
| Student | 14.1 (37) | 34.2 (90) |
| Part-time work | 5.3 (14) | 14.4 (38) |
| Full-time work | 6.4 (17) | 6.8 (18) |
| Other (volunteer/unable to work) | 2.0 (5) | 10.3 (27) |
|
| ||
| Self-reported current mental health problem | ||
| Yes | 10.0 (19) | 37.9 (72) |
| No | 21.1 (40) | 31.1 (59) |
| OR (95% CI), P-value | 2.57 (1.35 to 4.90) P= 0.003 | |
|
| ||
| Self-reported lifetime mental health problem | ||
| Yes | 16.8 (32) | 47.9 (91) |
| No | 14.2 (27) | 21.1 (40) |
| OR (95% CI), P-value | 1.92 (1.02 to 3.62) P= 0.032 | |
Total exceeds 203, as options were not mutually exclusive.
Anticipated barriers to accessing professional help in the future: results from the BACE scale
The BACE scale was completed by 169 participants. The scores on the BACE were normally distributed across males (skew = 0.17) and females (skew = −0.18). Results from an independent t-test showed that females scored significantly higher on the overall BACE scale (mean 36.5, SD = 14.3, n = 113) than males (mean 30.5, SD = 16.7, n = 56), where t (167) = −2.46, P = 0.015.
The internal consistency of the 12-item ‘treatment stigma’ subscale was shown to have good reliability (α = 0.95) and the overall scale had a Cronbach’s α of 0.93.
The percentage of all participants reporting the degree to which each barrier item would ‘stop, delay, or discourage’ them from seeking professional help is presented in Tables 2–4. Each barrier was ranked according to the items being rated as a ‘major barrier’.
Table 2.
Percentage, frequencies, and mean scores on treatment stigma subscale of the BACE
| Stigma-related barrier items | Reporting item as a barrier to any degree % (n ) | Reporting item as a major barrier % (n ) | Total (N) | Mean (SD) |
|---|---|---|---|---|
| Feeing embarrassed or ashamed | 81.4 (144) | 31.1 (55) | 177 | 1.70 (1.10) |
| Concern that it might harm my chances when applying for jobs | 77.4 (137) | 24.3 (43) | 177 | 1.53 (1.09) |
| Concern that I might be seen as weak for having a mental health problem | 75.1 (133) | 22.0 (39) | 177 | 1.45 (1.09) |
| Concern about what my family might think, say, do, or feel | 75.7 (134) | 22.0 (39) | 177 | 1.42 (1.09) |
| Not wanting a mental health problem to be on my medical records | 71.1 (123) | 21.4 (37) | 173 | 1.42 (1.21) |
| Concern that I might be seen as ‘crazy’ | 66.7 (118) | 19.8 (35) | 177 | 1.28 (1.13) |
| Concern that people I know might find out | 73.4 (127) | 18.5 (32) | 173 | 1.36 (1.07) |
| Concern that people might not take me seriously if they found out I was having professional care | 77.5 (134) | 17.9 (31) | 173 | 1.40 (1.03) |
| Concern about what people at work might think, say, or do | 72.8 (126) | 15.6 (27) | 173 | 1.34 (1.04) |
| Concern about what my friends might think, say, or do | 67.6 (173) | 13.9 (24) | 173 | 1.21 (1.05) |
BACE = Barriers to Access to Care Evaluation scale. Note: stigma-related barrier items 14 and 24 not applicable to participants and excluded from the analysis.
Table 3.
Percentage, frequencies, and mean score on attitudinal barrier items of the BACE
| Attitudinal barrier items | Reporting item as a barrier to any degree % (n ) | Reporting item as a major barrier % (n ) | Total (N) | Mean (SD) |
|---|---|---|---|---|
| Dislike of talking about my feelings, emotions, or thoughts | 84.4 (146) | 35.8 (62) | 173 | 1.77 (1.10) |
| Concerns about the treatments available (for example, medication side effects) | 75.9 (132) | 27.6 (48) | 174 | 1.53 (1.14) |
| Wanting to solve the problem on my own | 85.3 (151) | 24.3 (43) | 177 | 1.68 (1.00) |
| Thinking that professional care would not help | 75.7 (134) | 24.3 (43) | 177 | 1.48 (1.11) |
| Fear of being put in hospital against my will | 68.4 (121) | 23.2 (41) | 177 | 1.36 (1.54) |
| Thinking the problem would get better by itself | 77.4 (137) | 18.1 (32) | 177 | 1.46 (1.03) |
| Having had previous bad experiences with professional care for mental health | 75.9 (132) | 16.7 (29) | 174 | 1.01 (1.15) |
| Thinking I did not have a problem | 71.8 (125) | 14.4 (25) | 174 | 1.28 (1.03) |
| Preferring to get help from family or friends | 54.1 (93) | 9.3 (16) | 172 | 0.86 (0.98) |
| Preferring to get alternative forms of care | 27.1 (48) | 4.0 (7) | 177 | 0.40 (0.75) |
BACE = Barriers to Access to Care Evaluation scale.
Table 4.
Percentage, frequencies, and mean score on instrumental barrier items of the BACE
| Instrumental barrier items | Reporting item as a barrier to any degree % (n) | Reporting item as a major barrier % (n ) | Total (N) | Mean (SD) |
|---|---|---|---|---|
| Not being able to afford the financial costs | 66.7 (118) | 26.6 (47) | 177 | 1.47 (1.21) |
| Being too unwell to ask for help | 61.3 (106) | 16.2 (28) | 173 | 1.11 (1.10) |
| Difficulty taking time off work | 64.7 (112) | 14.5 (25) | 173 | 1.20 (1.08) |
| Unsure where to get professional care | 67.8 (120) | 13.0 (23) | 177 | 1.20 (1.03) |
| Problems with transport/travel to appointments | 57.1 (101) | 12.4 (22) | 177 | 1.06 (1.08) |
| Having no one who could help me get professional care | 63.8 (111) | 10.3 (18) | 174 | 1.06 (1.00) |
| Unavailability of professionals from my own ethnic or cultural group | 22.6 (40) | 2.3 (4) | 177 | 0.33 (0.69) |
BACE = Barriers to Access to Care Evaluation scale. Note: instrumental barrier item 29 not applicable to participants and excluded from the analysis.
Over two-thirds of participants anticipated that each stigma item would serve as a barrier to some degree if they were to seek help in the future. The most highly-rated stigma barrier was ‘feeling embarrassed or ashamed’, with 81% (n = 144) of participants anticipating that this would prevent or delay them from seeking professional help.
The most commonly-anticipated attitudinal barrier was ‘dislike of talking about my feelings, emotions, or thoughts’, whereby 84% (n = 146) of participants anticipated that this would serve as a barrier to some degree and 36% (n = 62) thought that it would act as a major barrier to them seeking professional help in the future.
The most commonly-rated instrumental barrier was ‘not being able to afford the financial costs’ involved in seeking professional help, with 67% (n = 118) of participants anticipating that this would serve as a barrier to some degree and 27% (n = 47) thinking that it would act as a major barrier to help-seeking.
Barriers to seeking help for an emotional or mental health difficulty
A total of 123 (65%; 32 males, 91 females) participants self-disclosed a lifetime emotional or mental health difficulty, and, of these, 45 participants (35%; 17 males, 28 females) reported that they did not seek any help. Of these participants, 38 (84%) provided qualitative feedback detailing reasons why they did not seek help. The themes that emerged in the data are reported below.
Stigmatising beliefs
Public and self-stigmatising beliefs around mental health and help-seeking emerged as a prominent barrier theme in the data. Some of the participants reported that help-seeking was ‘pathetic’ or ‘weak’. Others expressed concerns about what family, friends, or professionals would think if they were to seek help or receive a mental health diagnosis:
‘There is a negative stigma attached to any mental illness, as soon as you say that you’ve got one, people judge you and start thinking of you differently. It is something that people are too afraid and shy to talk about …’
‘Being actively labelled with a mental or emotional disability is hard to get rid of once it’s official. People might think less of you if they think you might be a bit crazy …’
‘I was afraid of what people might have thought of me.’
Perceiving problem as not serious enough
Reasons for not seeking help were also related to the perception that other people had more serious difficulties:
‘I did not feel I was doing terribly compared to others …’
‘I don’t feel like I’m bad enough to ask for help when there’s many more people with much more serious problems than me.’
Reliance on self
Participants often reported that they chose not to seek help because they preferred to resolve their own difficulties:
‘I am independent and I mostly tend to think I can deal with my emotions and that I don’t need help.’
‘I felt I could get over it by myself and there was no need to include other people …’
Difficulty accessing help
There was a dominant barrier theme related to the belief that help was unavailable, ineffective, or difficult to access:
‘… I feel that others didn’t have the time to help me.’
Perceived difficulties in accessing effective help related to the belief that friends or family had limited awareness of mental health and therefore would not be able to offer sufficient help:
‘Don’t think they’d understand how nervous I feel sometimes.’
‘Not many people are fully aware and educated on mental illnesses. This causes them to say insensitive things such as: “get over it”, “can’t you feel happy?”’
Others drew connections between underfunded services and limitations in professional resources:
‘There’s very little they [the GP] can do considering how underfunded mental health services are in the NHS.’
One responder commented that they did not discuss their concerns with a GP because they thought they would:
‘… be fobbed off with medication.’
Difficulties in accessing help were also associated with a lack of awareness of mental health services. One young person believed that their only means of accessing support was through private services, which they could not afford.
Fear of negative outcome
Fear of a negative outcome as a result of seeking help also emerged as a key theme in the results. Responders anticipated that if they spoke about their difficulties it could cause their family or others to ‘worry’, become ‘upset’, or they themselves would feel like a ‘burden’.
Negative outcomes were also related to the fear that seeking help would worsen their problem:
‘Just thinking about having a mental illness can make you feel terrible, so talking about it to another person would make you feel worse.’
Difficulty identifying or expressing concerns
Difficulties with identifying symptoms or communicating concerns to others were also cited as reasons for not seeking help. Participants believed that they were unable to speak about, or were too afraid to speak about their mental health difficulties:
‘Not understanding and being able to coherently explain my issues, not being physically able to talk about issues due to crying whenever topic comes up … ’
‘I didn’t realise I had a problem … The only reason this was resolved was I had to go to the doctors because I still wasn’t menstruating at 17.’
DISCUSSION
Summary
This study found that 35% of participants who reported having a mental health or emotional difficulty did not seek any formal or informal help. The results indicate that barriers to accessing mental health care can emerge at any stage in the help-seeking process, ranging from difficulties in recognising one’s own symptoms, to concerns about the availability of help. The results from the BACE identified that ‘dislike of talking about my feelings, emotions, or thoughts’ was the most highly reported reason for delaying or not seeking professional help in the future, followed by embarrassment and shame associated with mental health help-seeking. These barriers were also consistent with the themes that emerged in the qualitative data. Additional barriers that were cited as reasons for not previously seeking help included a perception that problems were not serious, a preference for self-reliance, difficulties in communicating symptoms, and fears about the outcome of seeking help.
Strengths and limitations
This study has provided some rich qualitative and quantitative information that contributes to the understanding of why young adults from the UK may choose not to seek help for their mental health problems. Although the small sample size may impose some limitations on the quantitative results, efforts were made to recruit participants who are ‘hard to reach’ and the study was successful in recruiting participants from minority ethnic groups, who are often under-represented in mental health services24 and research.25 Although there was a higher than expected percentage of participants experiencing psychological distress than in the general population,1 these young people are nonetheless those who are most likely to require access to mental health services. Therefore, their participation in the study, as well as input from participants from black and minority ethnic groups, provided some essential information about barriers to care.
Several limitations to the study should be considered when reviewing the results. These include a potential selection bias in the use of convenience and snowball sampling techniques, as well as the use of an online survey for data collection, which excluded any individuals without internet access. The limited sample size and under-representation of males in the sample may also limit the generalisability of the findings to the wider population of young people. A further limitation was imposed by the use of the BACE scale. As the scale was used to measure anticipated barriers to help-seeking, conclusions regarding the extent that these barriers would hinder or prevent actual help-seeking behaviour should be drawn with caution.
Comparison with existing literature
Approximately one-third of participants did not seek any help, which suggests a higher rate of help-seeking than observed in previous UK-based studies of young adults.9,11 Nonetheless, the present findings add to the existing evidence that stigma and embarrassment surrounding mental health remains a prominent obstacle to help-seeking.13,14,18
Although some of the responders expressed a preference for self-reliance, which is consistent with the idea that young people want to assume increased responsibility for their own health concerns,10 other participants acknowledged that they required support, but faced instrumental barriers. A lack of accessibility of services has previously been identified as a prominent barrier to help-seeking for those living in rural settings.14 In the present study, however, some of the participants believed that, because of financial restraints on the NHS, help would be unavailable. While this highlights the impact of service restraints on young adults’ reluctance to seek professional help, it may also reflect a lack of awareness of the availability of other mental health services such as third-sector charities. Furthermore, the present findings add to the existing evidence that young people may not consider GPs to be a potential source of support for their psychological distress,21,26 and highlights the importance of GPs in providing a safe environment to facilitate discussions about potential mental health concerns.27
Implications for research and practice
The present findings indicate that interventions are required to improve young adults’ mental health literacy and knowledge of local services. Possible strategies can include providing information about statutory and non-statutory services in a wide range of settings such as GP practices, libraries, job centres, and educational establishments.
These findings also have practical implications for the training of GPs and primary care workers. To improve the detection of psychological distress, it is important that primary care practitioners are skilled in assessing mental health difficulties in their standard practice and that this is achieved in a safe, non-judgemental therapeutic relationship, with the understanding that young people may not be forthcoming about their difficulties. Practitioners may also facilitate help-seeking by providing information about the availability of local support groups and third-sector services. Providing self-help materials may also benefit young adults who prefer to resolve their issues independently.
In the present study, stigma was highlighted as a key barrier to seeking help. This indicates a need for policymakers to continue developing anti-stigma and anti-discrimination campaigns. It is equally important for GPs and other healthcare professionals to ensure that services are delivered in an environment that is compassionate, non-judgemental, and de-stigmatising.
Taking into account that males were under-represented in this study, further research is required to investigate help-seeking behaviour among males. This is particularly important given that the literature has shown that males are less likely to seek help9,28 and that they may experience different types of barriers compared with females.
Finally, this study raises the question regarding how GPs perceive their role in assessing for mental health among young people. Given that help-seeking can be perceived as a relational process, gaining perspectives from GPs would provide insight into the potential barriers that healthcare providers face in this complex process.
Acknowledgments
We would like to thank Joerg Schulz, Dr Keith Sullivan, and staff at the University of Hertfordshire, Doctorate in Clinical Psychology, for their assistance and advice that was kindly offered at various stages of this project. We are also very grateful to all the young adults who participated in the study.
Funding
This study was supported by the University of Hertfordshire, Life and Medical Sciences.
Ethical approval
Approval was obtained from the University of Hertfordshire, Health and Human Sciences Ethics Committee and Delegated Authority (ECDA) (LMS/PG/UH/00298).
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
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