URC

Barriers to Seeking Help for Mental Health Issues in Women Ages 22 64

Olivia Means
Mary Armstrong*
Kathleen Moore*
University of South Florida

Abstract

The 2010 Patient Protection and Affordable Care Act (ACA) was designed to make more comprehensive health care services available and affordable. However, if barriers other than affordability exist and are not addressed, the newly available services will continue to be under-utilized. Using a theoretical framework of help-seeking behavior, the two research questions are: (a) To what extent do barriers other than affordability exist in women accessing mental health care services? and (b) To what extent do the identified barriers affect help-seeking behavior? For this pilot study we surveyed women, who ranged in age (22-64), employment status, type of health insurance, and mental health diagnosis. We identified clear barriers such as homelessness and stigma, which increased delay in and desire to seek help for mental health issues. Our findings support "housing-first" initiatives, programs in the work place for early detection and prevention, and co-locating mental health and physical primary care services.

Introduction

Health Care Reform

Health care reform has become increasingly important with the proposal and passing of the 2010 Patient Protection and Affordable Care Act (ACA, Public Law 111-148). The recent Supreme Court decision upheld the Act, making it a requirement by law for citizens to purchase health insurance (Mears & Cohen, 2012). When the law is in full effect (estimated to occur in 2014), it is anticipated that around 32 million Americans who are currently uninsured will have access to health care services, including mental health services ("Overview," 2010).       

The expansion of behavioral health services is vital, considering that "almost a quarter of currently uninsured adults indicate that they have experienced either serious psychological distress or substance abuse or dependence (or both) in the past year …" (Garfield, Lave & Donohue, 2012, 1082). The updated provisions of ACA have firm specifications for insurance company policies and the packages they offer ("People with disabilities," 2012). One unanswered question is that while ACA provides a means for approximately 32 million people to have access to health services, will affordability ensure the utilization of such services, especially in regards to services for mental health issues?

Help-Seeking Behavior

Before a person considers seeking professional help, he or she must first recognize that there is a problem. In certain areas of health care there are mechanical devices and metrics commonly used to delineate normal from unusual (e.g., a thermometer to detect a fever). In the area of mental health it is far more complicated to determine whether a feeling is from an isolated incident or the beginning of a steady decline in one's mental stability (Kadushin, 1958).

One model of help-seeking behavior outlines the process in four steps: (a) identify problem as behavioral issue, (b) tell friends and family, (c) decide to seek professional help and choose a facility, and (d) choose a practitioner (Kadushin, 1958). Another model of help-seeking behavior breaks down the process into two stages. The first stage is the time between recognition of symptoms to first contact with a professional and the second stage is the time between first speaking with a professional and beginning a planned treatment program (Lin, Inui, Kleinman, & Womack, 1982). In summary, the process of help seeking involves three basic entities: (a) a person in need, (b) a source of help, and (c) a need for help (Nadler 1991).

Despite having recognized the need to seek help for a mental health issue, there are many factors that influence a woman's decision to conceal or reveal her situation, such as sociocultural characteristics (Lin, Inui, Kleinman, & Womack, 1982), ethnicity (Cooper, et al., 2003), gender (Horwitz, 1977; Mackenzie, Gekoski & Knox, 2007; McMullen & Gross, 1983), age (Fischer, Winer, & Abramowitz, 1983; Mackenzie, Gekoski & Knox, 2007), religious affiliation (Ayalon & Young, 2005; Moreira-Almeida, Neto & Koenig, 2006), previous experience with health care professionals (Diala, Muntaner, Walrath, Nickerson, LaVeist & Leaf, 2001), stigma and fear (Angermeyer, Beck, Dietrich & Holzinger, 2004, 160; Corrigan, 2004 ). Previous research studies in addressing the barriers to seeking help for mental health issues recognize such demographic variables that have a substantial effect on one's ability to utilize health care. However, earlier studies were conducted when a majority of Americans were uninsured or their insurance program did not adequately cover mental health treatment. In addition, few studies have focused on women, because they do utilize more services than men (Bertakis, Azari, Helms, Callahan & Robbins, 2000; McMullen & Gross, 1983).

The purpose of this study was to identify if significant barriers for women accessing mental health care exist outside of those being attended to under ACA (i.e., affordability). Once we determined the barriers, we examined how significant those barriers were in preventing women from gaining care. If we can successfully identify which barriers pose the greatest threat to women seeking help, we can implement programs and initiatives addressing the needs of this population.

Methods

Sample

The study population consisted of women between the ages of 22 and 64. The sample group was determined by the need to have a pool of adult women who had health insurance, either from Medicaid or private insurance, but were not yet eligible for Medicare. We recruited participants from two approved locations: Mental Health Care, Inc. (MHC) facility called "The Shop" and the College of Behavioral and Community Sciences at the University of South Florida. The Shop is a drop-in center where homeless individuals receive support services. It was chosen as a site where the people served have moderate to low access to care for identified mental health needs. The USF sample was used as a representation of women with fairly high access to care and a more unknown mental health status. The sample size was determined by running a power analysis using SPSS SamplePower2. To compare two groups at alpha= .05, with 80 percent power we are able to detect large effects with 25 cases per group.

Measurement Tool

A 26-question survey was developed to assess how women view their ability to access services for mental health issues. The survey asked the women to list any mental health issues diagnosed, their experienced mental health symptoms over the past year, incidents of hiding symptoms, perceptions of mental health issues in their community, and willingness to seek help from a professional and/or from friends and family. A three-item measure was constructed to understand how the respondents felt about people with mental illnesses and the Duke University Religion Index (internal consistency Cronbach's alpha = 0.78 -0.91) was used to see how important one's religious views impacted help-seeking behavior (Koenig & Bussing, 2010). The final question was taken from the General Help-Seeking Questionnaire – Vignette Version (Wilson, Deane, & Ciarrochi, 2005a, b) and used as a measure of help-seeking intentions, mental and physical health literacy, and perceived need for help (Wilson, Deane, & Ciarrochi, 2005a).

Results

Table 1 (see Appendix) summarizes the demographic characteristics of the 58 women surveyed at the two locations. There were no significant differences in survey responses within demographic variation, and so comparisons were made based on location. The women at The Shop reported having significantly more diagnosed mental health issues; the most common issues were schizophrenia, bipolar disorder, PTSD, depression, and anxiety. These women also showed a higher frequency of experiencing major psychological distress in the form of mood swings, delusions, and/or hallucinations. The higher frequency of mental health diagnosis among women at The Shop was not surprising, considering it is a service operated by a licensed mental health care facility. Although many of the women surveyed at USF were not diagnosed with a mental illness, they had experienced mental health-related distress. There were no significant differences between the women at The Shop and the women at USF in their incidence of masking symptoms and self-management. Although women at The Shop felt forced to handle their problems on their own due to external factors such as their homelessness and lack of employment, the women at USF were inclined to handle their problems at first and, if things got worse, then seek additional help.

A 3-item measure was developed on a Likert scale to score respondents personal feelings toward people with mental illnesses (Cronbach's alpha reliability of 0.818). Possible totals ranged from 3 to 15, with a higher score reflecting a more positive attitude towards those with mental health issues. The average score of women at The Shop was 8.82 and that of women at USF was 7.07. Both scores represent a moderate view of people with mental illness.

A 2-item measure of community attitudes was constructed on a Likert scale to see how respondents felt people with mental health issues were viewed within their respective communities (Cronbach's alpha reliability of 0.728). Possible totals ranged from 2 to 10 and there were no significant differences between average scores by location. The middle range averages indicated that, while respondents would tell their family and friends about their mental health issues, there was still a feeling that they would be judged or seen as weak for having such problems. There was no clear impact of religion on help-seeking behavior or attitude towards mental illness.

The General Help-Seeking Questionnaire-Vignette Version (Jane) asked participants about their help-seeking intentions including how they would identify Jane's problem, and how they would seek help when feeling like Jane (Wilson, Deane, & Ciarrochi, 2005b). 86 percent of participants recognized Jane's problem as a mental health issue. Across locations, the women were more likely to seek help from a Doctor/GP, followed by an intimate partner, and then a mental health professional given Jane's description (anxiety). Although the women were likely to seek help from an intimate partner, as the family relation grew more distant the intention to seek help from that source also decreased. Seeking help from a religious leader or minister was also very unlikely.

Discussion

Between the women at The Shop and at USF there was a shared practice of handling their mental health issues on their own. This finding strengthens the argument that accessibility does not guarantee utilization considering that a majority of women across both sample locations had some form of health insurance.

The most significant help-seeking barrier to the women at The Shop was homelessness. Being homeless, and therefore having little or no social support, money, or access to other basic resources, took precedence over getting help for mental health problems. Because their homelessness was a problem they could not easily disguise, many felt no need to hide their mental health issues. As one woman stated, "Everyone can tell I have issues." Another woman from The Shop said that even if she had the money to get her medication she would spend it in other ways because she did not get the immediate satisfaction from trying to better her mental health problems like she did when spending money on other needs.

An unexpected barrier that came out within The Shop was the misunderstanding of mental health services. When asked about the high prevalence of medication as treatment, many felt that medication was not over-prescribed because they could not afford their medication. However, having too many prescriptions and not being able to get prescriptions are very different issues. When asked about their access to mental health services, some women felt that The Shop was adequate because it offered benefits like using a phone and doing laundry. Very rarely was there mention of speaking with a counselor or physician even though these services are accessible at The Shop.

Stigma appeared to be the most significant help-seeking barrier for the women surveyed at USF. Although the majority had access to and would seek help, they still held many reservations about sharing their feelings of mental health distress. A majority of women at USF also said that they would handle their problems on their own until they got "bad enough" to seek help; however, usually as severity increases, so does the cost of treatment.

From the general help-seeking questionnaire-vignette most respondents were able to recognize Jane's symptoms as anxiety or some form of a mental health issue. However, they felt she only needed to seek help because she was having trouble breathing. Even after acknowledging her mental health problem, the respondents only felt she needed help because of the physical problem. Not surprisingly, respondents were more likely to seek help from a doctor or general practitioner (instead of a mental health professional) if they were feeling like Jane, even when the problem was identified as a mental health issue.

These findings support the need to co-locate physical and mental health services for timely assessment and treatment. In addition, the findings strengthen "housing-first" programs for homeless individuals, which first address housing needs and then incorporate other needed services. There is also need for support services in the workplace for early detection and prevention. In conclusion, the study highlights that even when mental health care services are affordable, they may be underutilized due to other barriers. These additional barriers must be attended to when trying to improve health status for everyone.

In interpreting our results, some limitations should be considered. Although the sample size within each group was adequate to detect large effects, the nature of the sites surveyed limit our ability to generalize the findings to the larger community.

References

Angermeyer, M. C., Beck, M., Dietrich, S., & Holzinger, A. (2004). The stigma of mental illness: Patients' anticipations and experiences. International Journal of Social Psychiatry50(2), 153-162. doi: 10.1177/0020764004043115

Ayalon, L., & Young, M. A. (2005). Racial group differences in help-seeking behaviors. The Journal of Social Psychology145(4), 391-404. Retrieved from http://dx.doi.org/10.3200/SOCP.145.4.391-404

Bertakis, K. D., Azari, R., Helms, L. J., Callahan, E. J., & Robbins, J. A. (2000). Gender differences in the utilization of health care services. The Journal of FamilyPractice49(2), 147-152.

Cooper, L. A., Gonzales, J. J., Gallo, J. J., Rost, K. M., Meredith, L. S., Rubenstein, L. V., Wang, N., & Ford, D. E. (2003). The acceptability of treatment for depression among African-American, Hispanic, and White primary care patients. Medical Care,41(4), 479-89. Retrieved from http://www.jstor.org/stable/3767760

Corrigan, P. (2004). How stigma interferes with mental health care. AmericanPsychologist59(7), 614-625. doi: 10.1037/0003-066X.59.7.614

Diala, C. C., Muntaner, C., Walrath, C., Nickerson, K., LaVeist, T., & Leaf, P. (2001). Racial/ethnic differences in attitudes toward seeking professional mental health services. American Journal of Public Health91(5), 805-807.

Fischer, E. H., Winer, D., & Abramowitz, S. I. (1983). Seeking professional help for psychological problems. In A. Nadler, J. D. Fisher, & B.M DePaulo (Eds.), New directions in helping: Vol. 3. Applied perspectives on help-seeking  and receiving. New York, NY: Academic Press. 

Garfield, R. L., Lave, J. R., & Donohue, J. M. (2012). Health reform and the scope of benefits for mental health and substance use disorder services. Psychiatric Services61(11), 1081-1086. Retrieved from http://ps.psychiatryonline.org/

Horwitz, A. (1977). The pathways into psychiatric treatment: Some differences between men and women. Journal of Health and Social Behavior,18(2), 169-178. Retrieved from http://www.jstor.org/stable/2955380

Kadushin, C. (1958). Individual decisions to undertake psychotherapy. Administrative Science Quarterly,3(3), 379-411. Retrieved from http://www.jstor.org/stable/2390718

Koenig, H. G., & Bussing, A. (2010). The Duke University Religion Index(DUREL): A five-item measure for use in epidemological studies. Religions1(1), 78-85. doi: 10.3390/rel1010078

Lin, K., Inui, T. S., Kleinman, A. M., & Womack, W. M. (1982). Sociocultural determinants of the help-seeking behavior of patients with mental illness. The Journal of Nervous and Mental Disease170(2), 78-85.

Mackenzie, C. S., Gekoski, W. L., & Knox, V. J. (2007). Age, gender, and the underutilization of mental health services: The influence of help-seeking attitudes. Aging and Mental Health10(6), 574-582. doi: 10.1080/13607860600641200

McMullen, P.A., & Gross, A.E. (1983). Sex differences, sex roles, and health-related help-seeking. In B. M. DePaulo, A. Nadler & J. D. Fisher (Eds.), New directions in helping: Vol 2. Help-seeking . New York,NY : Academic Press.

Mears, B., & Cohen, T. (2012, June 28). Emotions high after Supreme Court upholds health care law. Retrieved from http://articles.cnn.com/2012-06-28/politics/politics_supreme-court-health-ruling_1_individual-mandate-health-insurance-health-care?_s=PM:POLITICS

Moreira-Almeida, A., Neto, F. L., & Koenig, H. G. (2006). Religiousness and mental health: A review. Journal of Psychiatry28(3), 242-250.

Nadler, A. (1991). Help-seeking behavior: Psychological costs and instrumental benefits. In M.S. Clark (Ed.), Prosocial behavior (pp. 290-311). Newbury Park, CA: Society for Personality and Social Psychology, Inc.

(2010). Overview of the affordable care act: What are the implications for behavioral health?. SAMHSA News,18(3), 15. Retrieved from http://www.samhsa.gov/samhsanewsletter/Volume_18_Number_3/MayJune2010.pdf

U.S. Department of Health & Human Services (n.d.), People with disabilities and the Affordable Care Act. (2012, July 18). Retrieved from http://www.healthcare.gov/news/factsheets/2011/08/people-with-disabilities.html

Wilson, C. J., Deane, F. P., & Ciarrochi, F. (2005a). Measuring help-seeking intentions: Properties of the General Help-Seeking Questionnaire. Canadian Journal of Counselling / Revue canadienne de counseling, 39(1), 15-28. Retrieved from cjc-rcc.ucalgary.ca/cjc/index.php/rcc/article/download/265/588

Wilson, C. J., Deane, F. P., & Ciarrochi, F. (2005b). General help-seeking questionnaire – vignette version (ghsq-v). (n.d.). Retrieved from http://www.uow.edu.au/gsm/staff/UOW028294.html

Appendix

Table 1      

Sample Characteristics

Characteristics

The Shop

USF

 

(N=28)

(N=30)

Race/Ethnicity

 

 

  Caucasian, White

14

18

  African American, Black

11

4

  Hispanic

2

5

  Asian, Pacific Islander

0

1

  American Indian

1

0

  Other

0

2

Age

 

 

  22-29

4

12

  30-39

6

5

  40-49

14

1

  50-59

3

6

  60-64

1

6

Level of Education

 

 

  less than high school

5

0

  some high school

10

0

  some college

9

5

  college degree

4

11

  master's degree

0

5

  doctoral degree

0

9

Religious Affiliation

 

 

  Christian

19

12

  Catholic

4

6

  Jewish

0

2

  Muslim

1

0

  Spiritual, Agnostic

2

4

  Other

2

6

Insurance

 

 

  none

14

3

  public insurance (Medicaid,   Medicare)

11

1     

  private insurance

0

23

  other

3

3

 


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