Ibrahim et al.

BMC Public Health 2019, 19(Suppl

4):544
[Link]

RESEARCH Open
Access
Do depression literacy, mental illness
beliefs and stigma influence mental
health help-seeking attitude? A cross-
sectional study of secondary school
and university students from B40
households in Malaysia
Norhayati Ibrahim1,2*, Noh Amit1,3, Suzana Shahar2,4, Lei-Hum Wee3,5, Rozmi Ismail6, Rozainee
Khairuddin6, Ching Sin Siau1 and Aisyah Mohd Safien1

Abstract
Background: Mental illness rates among young people is high, yet the frequency of help-seeking is
low, especially among those from lower socioeconomic backgrounds. Understanding factors
influencing help-seeking, such as mental illness beliefs, stigma and literacy among B40 individuals is
important, but past studies are sparse. Hence, we aimed to examine the factors associated with
mental help-seeking attitude among students from the B40 income bracket. Differences in beliefs
toward mental illness, stigma and help-seeking attitudes among university and secondary school
students were also investigated.
Methods: University and secondary school students from low-income households (N = 202) were
involved in this cross-sectional study. Participants completed the Depression Literacy Questionnaire
(D-Lit), General Help Seeking Questionnaire (GHSQ), Mental Help Seeking Attitudes Scale (MHSAS),
Self-Stigma of Seeking Help Scale (SSOSH), and Beliefs toward Mental Illness (BMI).
Results: Mental help-seeking attitude had a significant relationship with self-stigma on seeking
help (r = −.258, p < .001), general help-seeking attitude (r = .156, p = .027), and age (r = .187, p <
.001). However, the strongest predictor for mental help-seeking attitude was self-stigma on seeking
help (F (2,199) = 8.207, p < .001 with R2 of .076). University students had better depression
literacy and lower levels of self-stigma and negative beliefs toward mental illness compared
to secondary school students.
Conclusion: Higher self-stigma and younger age were associated with negative mental help-
seeking attitudes among students from low-income households. As self-stigma may be a barrier
to actual mental help-seeking, efforts to reduce self-stigma in this population need to be

* Correspondence: norhayati70@[Link]
1
Health Psychology Program, Faculty of Health Sciences,
Universiti Kebangsaan Malaysia, Kuala Lumpur,
Malaysia
2
Research Centre for Healthy Aging and Wellness, Faculty of Health
Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur,
Malaysia
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons
Attribution 4.0 International License ([Link] which permits unrestricted
use, distribution, and reproduction in any medium, provided you give appropriate credit to the original
Ibrahim et al. BMC Public Health 2019, 19(Suppl
4):544 author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
The Creative Commons Public Domain Dedication waiver ([Link]
applies to the data made available in this article, unless otherwise stated.
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 2 of
4):544

Background mental health which help to aid his or her recognition,

Mental disorders are estimated to affect up to 13.4% of management, and prevention of mental disorders [22].
children and adolescents [1]. However, the treatment Thus, mental health literacy means understanding the
rate is low. For example, a review on the use of psychi- signs and symptoms of psychiatric disorders and the
atric treatment found that only around 33% of students need to refer to a specialist for proper treatment. Many
with mental health problems were treated [2]. This trend people do not receive accurate information about psy-
was also observed among young people who showed chiatric disorders and incorrect or misleading informa-
symptoms of depression and anxiety, of which only 18 tion could deprive them of appropriate medical care
to 24% sought professional help [3]. Those who did seek and proper support [23]. The inadequacy of an
help preferred to obtain assistance from friends and fam-
individual’s mental health literacy may lead to an
ily, rather than a professional [4]. In addition, individuals
unwillingness to seek help, while the former’s
from lower socioeconomic background have a lower rate
improvement has been shown to increase help-seeking
of mental health service utilization [5].
intentions [24]. However, results on mental health
Seeking help for mental health issues is the first step
literacy and help-seeking inten- tions are mixed and
toward assessing the mental state, getting the proper
require further exploration [25].
diagnosis and subsequently undergoing the intervention
Lower socioeconomic status is associated with lower
and management of mental health by professionals.
education level, poor quality of housing, unemployment,
However, the factors influencing mental help-seeking at-
and financial debt, and these factors are linked to the
titudes need to be explored further. Researchers have
increased prevalence of mental illness [26–28]. Past
identified the barriers and listed several factors; a)
research has indicated that individuals with lower socio-
technical problems such as financial burden incurred by
economic status reported increased stigma toward men-
mental health services [6] and difficult access to the care
tal illness [29], and decreased mental health literacy [29]
provider due to transportation or undersized and
and mental help-seeking attitude [30]. However, research
inadequate resources [7, 8]; b) Personal views such as
on mental illness stigma, literacy and help-seeking inten-
the lack of perceived need for treatment [9] or perceived
tions in conjunction with socioeconomic status is sparse.
ineffectiveness of the therapy [2, 10] and c) stigma. In
The Malaysian government has divided household
addition, cultural factors could also influence help-seek-
income into three categories; Top 20% (T20), with a me-
ing intentions. For example, the practice of making a
dian income above RM13,148 [31], Middle 40% (M40)
spiritual diagnosis and treatment among clergy in East
with income ranging from RM3,860 to RM8,319 and
Malaysia could delay medical help-seeking [11].
lastly Bottom 40% (B40) with earnings of RM3,900 a
The stigma on mental illness is a concern for helpers,
month or less [32]. The B40 household group also in-
as well as the patients. Individuals with mental disorders
cludes poor households with monthly income lower than
are often labeled and stigmatized by society due to their
the poverty line income. The B40 group is at a higher
behavior and appearance that are considered to deviate
risk of having poor mental health caused by lower men-
from the norms of society [12]. Stigma refers to an attri-
tal health literacy and negative attitudes toward seeking
bute which society considers as undesirable and which
help compared to those with a higher socio-economic
leads to the exclusion of an individual from society [13].
status. Studies on mental health stigma, literacy, and
Negative stereotypes, prejudice, and discrimination from
attitudes in Malaysia are limited compared to other
society could be internalized and generate feelings of in-
countries [33]. In addition, there may be cultural varia-
competence and low self-esteem within an individual,
tions which necessitate the exploration of these issues in
defined as self-stigma [14]. Studies showed that stigma is
Malaysia [11, 21]. The present exploratory study seeks to
one of the deterring factors for seeking mental help
examine the factors associated with mental help-seeking
in various populations, such as among university stu-
attitude among students from the B40 income bracket in
dents [15, 16], faith communities [17], veterans and
Malaysia. In addition, differences in beliefs toward men-
military personnel [18, 19] and healthcare students
tal illness, mental illness stigma, and mental
and professionals [20]. In addition, mental illness
help-seeking attitudes among university and secondary
stigma in Asian communities has been associated school students were also investigated.
with the idea of ‘losing face’, especially for the family
members of the mentally ill [21]. Methods
The mental health literacy of an individual with mental Study design and participants
health problems is another factor that could predict his This study is a cross-sectional survey carried out among
or her attitudes toward seeking help. Mental health 202 students from low income or B40 households. The
literacy is a facet of the health literacy concept, defined sample comprised 127 secondary school students aged
as an individual’s knowledge and beliefs regarding 13 to 17 years old and 75 university students aged 18 to
25 years old. Participants from secondary school were
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 3 of
4):544

residents of a hostel under a non-government question is stated as “I would not seek help from any-
organization which houses almost 200 poor students one” and is reverse scored. Higher scores on this instru-
from all over Malaysia. University participants were ment indicate better attitudes on general help-seeking.
recruited from one of the universities in the Klang Valley The reliability of GHSQ when tested as a single instru-
of Malaysia. ment is good, with Cronbach’s alpha 0.85 and 0.92 for
test-retest reliability, as assessed over a three-week
Data collection period. GHSQ has been analyzed as two scales, one for
Permission was obtained from the relevant authorities of each problem-type: suicidal problems (Cronbach’s
the sites selected for this study. Participants were alpha = 0.83, test-retest reliability assessed over a three-
approached in their classrooms before the lesson week period = 0.88) and personal-emotional prob- lems
commenced. Those who met the inclusion criterion (Cronbach’s alpha = 0.70, test-retest reliability assessed
(from the B40 population with household income <RM over a three-week period = 0.86). Internal consistency for
3,900 per month) were selected. The participants who the current study was 0.749.
did not meet the B40 criterion were excluded from the
study. Verbal consent from the caregivers of the younger
participants was obtained, whilst the university partici- Mental help seeking attitude scale (MHSAS) [39]
pants verbally gave their consent. All of the participants This questionnaire is developed by Hammer, Parent, and
were then asked to complete the self-rated question- Spiker [39] to assess attitudes toward seeking help from
naires. Ethical approval was obtained from Universiti a mental health professional. It contains nine items and
Kebangsaan Malaysia Research Ethics Committee. uses a 7-point semantic differential scale. In order to
calculate the total score, it is necessary to reverse items
Instruments 2, 5, 6, 8 and 9. Higher scores indicate more favorable
This study used questionnaires which were translated attitudes toward seeking help from mental health profes-
into Malay for the purpose of this study. A demographic sionals. The reliability was good with Cronbach alpha
question sheet obtained information on age, gender, and value of 0.92 [39] and for the current study, the value
family income. was 0.884.

Depression literacy scale [34]

The Depression Literacy Scale or D-Lit was developed Self-stigma of seeking help scale (SSOSH) [40]
by Griffiths et al. [34] to assess mental health literacy The 10-item SSOSH scale has been developed to assess
specific to depression. It consists of 22 items which can self-stigma on seeking help regardless of whether an in-
be answered either “true”, “false” or “don’t know” by dividual has already been diagnosed with a mental illness
the participants. Each correct response receives one or not [40]. It consists of a 5-point Likert scale rated
point and higher scores indicate higher literacy of from “strongly disagree” to “strongly agree”. The
depression in the participants. It has an internal SSOSH obtained good reliability (α = 0.90) and test-retest
consistency of Cronbach’s alpha = 0.77 and 0.74 when reliability (α = 0.72) [40–42]. Items 2, 4, 5, 7, and 9 were
tested among a Bangladesh population and healthcare reverse scored and high scores indicate high levels of self-
professional students in India respectively [35, 36], which stigma on seeking help. The scale’s reliability for the
reflect a good reliability. For the present study, five items current study was Cronbach’s alpha = 0.667.
were deleted leaving only 17 items, to achieve the
accept- able KR20’s value of Cronbach’s alpha = 0.55.
The Cronbach’s alpha value of 0.60 is considered Beliefs toward mental illness (BMI) [43]
accept- able in social sciences [37]. BMI has been developed to measure cross-cultural dif-
ferences in negative beliefs, perceptions and judgments
General help seeking questionnaire (GHSQ) [38] toward mental illness [43]. This scale comprises of 21
GHSQ has been developed to measure intentions to seek questions under three sub-dimensions: gravity, incurabil-
help from different sources and for different problems ity/poor social and interpersonal skills and embarrass-
(personal or emotional problems and suicidal emotion) ment. It uses a 6-point Likert scale and is rated from
[38]. The instrument consists of 10 items repeated twice “completely disagree” to “completely agree”. Higher
for both problems, with a total of 20 questions, scores indicate higher levels of negative belief toward
measured with a 7-point Likert scale ranging from mental illness. The reliability of this instrument was
“extremely unlikely” to “extremely likely” to find help good when tested on American, Japanese, and Korean
from different sources such as intimate partner, friend, women, with Cronbach’s α value of 0.92 [44] and in the
parent, mental health professional and others. One present study was 0.797, indicating good reliability.
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 4 of
4):544

Table 1 Demographic profile of the participants (N = total score of 50; and negative belief toward mental
202) Variable Frequency illness was 58.99 ± 11.91 from a total score of 150.
Percentage Gender Table 3 demonstrated the t-test analysis on the
comparison of mental health literacy with academic
Male 65 32.2
level. There were significant differences between the
Female 137 67.8
three variables, namely Depression Literacy, Self-Stigma
Age of Seeking Help and Negative Belief Toward Mental Ill-
13–15 90 44.6 ness when compared according to their academic level
16–17 35 17.3 whereas help-seeking variables showed no significant
18–20 19 9.4 difference. University students showed a significantly
higher level of depression literacy compared to the
21 and above 58 28.7
secondary school participants. However, an inverse trend
Household income
was observed for Self-stigma of Seeking Help and
< 1000 63 31.2 Negative Belief toward Mental Illness. All participants
1000–3000 117 57.9 showed similar levels in their general help-seeking atti-
3001–3860 22 10.9 tude and mental help-seeking attitude.
As shown in Table 4, Mental Help Seeking Attitude
Data analysis for all participants had a significant positive correlation
This study used the IBM SPSS Statistics for Windows, with General Help Seeking Attitude (r = .156 p = .027)
version 22.0 (IBM Corp., Armonk, N.Y., USA) to and age (r = .187, p < 001) as well as a negative
analyze the data. Descriptive analysis was conducted correlation with Self-stigma of Seeking Help (r =
for the description of the mean and standard −.258, p < 001). This means higher levels of General
deviation of all the variables. The Pearson’s correl- Help Seek- ing Attitude and older age is associated
ation test was used to test the correlation between help- with a higher mental help seeking attitude, while higher
seeking domain, self-stigma, negative belief toward levels of self-stigma among the participants is associated
mental illness and depression literacy with mental help- with the inhibition of help-seeking behavior. From the
seeking. In order to compare all variables based on educa- tional level perspective, a similar trend could be
academic level, t-test analysis was chosen. Lastly, seen in the attitude of secondary school students.
multivariate linear regression was used to test the effect Meanwhile, university students only demonstrated a
of multiple independent variables (self-help seeking significant nega- tive correlation between Mental Help
domain, self-stigma, negative belief, and depression Seeking Attitude with Self-stigma of Seeking Help (r =
literacy) on the dependent variable (mental help-seeking −.305, p < 001). From Table 5, we can see that only Self-
attitude). Stigma of Seek- ing Help predicted Mental Help Seeking
attitude, re- gardless of the academic level (R2 = .066–.093,
Results p < 0.05). (Table 5).
Most of the participants (N = 202; Mean age = 17.03 ±
3.36) in this study were females (67.8%), and from the Discussion
second group of B40 household income which is within The present study found that Self-stigma was the stron-
the range of RM1000-RM3000 (57.9%) (Table 1). gest predictor for mental health help seeking attitude
As shown in Table 2, the mean of depression literacy among teenagers and young adults of low socioeconomic
was 5.01 ± 1.93 out of a total score of 21. For the rest of status. These findings may be related to the Modified
the scales, out of a total score of 140, the mean for Labelling Theory developed by Link et al. [45], where
general help-seeking was 85.26 ± 14.17. The score for people’s self-efficacy is impaired by the label imposed by
mental help-seeking was 48.93 ± 9.10 from a total the public. Internalization of the stigma leads to non-
score of 63; self-stigma of seeking help was 26.18 ± 4.86 adaptive coping strategies such as avoidance.
from a

Table 2 Mean and standard deviation (SD) of the scales

Domain Scales Mean SD
Depression Literacy Depression Literacy (D-Lit) 5.01 1.93
General help seeking General Help Seeking Questionnaire (GHSQ) 85.26 14.1
7
Mental help seeking Mental Help Seeking Attitude Scale (MHSAS) 48.93 9.10
Self-stigma of seeking help Self-Stigma of Seeking Help (SSOSH) 26.18 4.86
Negative belief toward mental illness Belief toward Mental Illness Scale (BMI) 58.99 11.9
1
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 5 of
4):544

Table 3 t-test analysis of education level on the attended psychological counseling and psychotherapy
variables Variables M F t df faced more negative attitudes compared to those who
p Depression Literacy did not undergo such therapy.
In this study, general help-seeking attitude was posi-
Secondary school’s 4.67 .004 −3.22 200 .001
student tively and significantly related to mental help-seeking at-
University’s student 5.56 titude. Higher readiness and likeliness to get help from
General Help Seeking different people, professionals and non-professionals,
Attitude indicates their favorability on seeking help for mental
Secondary school’s 84.72 .816 −.71 200 .482 problems. Previous studies, such as in Horwitz [52]
student showed that people will talk to at least four members of
University’s student 86.13 their social network about their personal concerns be-
Mental Help Seeking fore seeking professional help from the psychiatrist.
Attitude
Meanwhile, the Research of Consortium Study [53] and
Secondary school’s 48.08 7.34 −1.88 186.6 .062 Eisenberg et al. [2] reported that the majority of the
student 1
University’s student 50.39
students who experienced mental health problems get
advice and support from non-professionals, such as fam-
Self-Stigma of Seeking Help
ily members, romantic partner, roommate, or friends.
Secondary school’s 26.96 1.080 3.016 200 .003 This may indicate that seeking help from social support
student
University’s student 24.87
(peers and family) could serve as a stepping stone to re-
ceive appropriate management (mental health profes-
Negative Belief toward Mental
Illness
sional) in the future.
Secondary school’s student .318 5.64 200 .000 The present study found that university students who
62.37 were older had a better mental help-seeking attitude.
University’s student 53.27 Other studies also observed that attitudes toward
seeking help are better in older adults compared to
younger adults [54]. A study on primary and secondary
Self-stigma on seeking help hinders an individual from school students in Scotland reported that the participants
getting treatment for their problems, either through psy- would delay or avoid disclosing their mental health prob-
chiatric management or counselling therapy. Previous lems due to their own perceptions of the symptoms as
studies [46, 47] reported that those with psychological ‘weird’ or ‘rare’ and feared stigmatization from the peers,
concerns hide their problems and avoid treatment to teachers and parents once they opened up [55]. Strong
limit the harmful consequences they may experience parental influence among younger adolescents may be a
from psychological services. One harmful aftereffect is barrier in seeking professional help [56].
the sabotaging of their self-esteem. Seeking professional For educational level, three variables were found to be
psychological help is perceived as a threat to self-esteem significantly different among participants. University
[48], and a sign of weakness and acceptance of failure participants showed significantly better depression liter-
[40]. Those who consider seeking help for mental health acy, and lower levels of self-stigma on seeking help and
problems for the first time are likely to be labeled as a negative belief toward mental illness compared to the
mentally ill patient, and to be discriminated by society secondary school participants. University students may
[49]. Scheff’s (1966, cited in Corrigan) [50] Labelling have better knowledge of depression as they are exposed
Theory asserted that the label “mentally ill” leads society to a broader social network and have more opportunities
to treat the labeled individual abnormally and differently. to learn about mental health. Higher education also
Individuals who get treatment for depression are consid-
ered less emotionally consistent, less interesting and
with lower self-esteem compared to people who get
treatment for physical diseases. An experimental study
by Sibicky and Dovidi [51] found that individuals who

Table 4 Correlations between Mental Help Seeking Attitude with other variables
Variables/Domains All participants Secondary school students University students
p r p r p r
Depression Literacy .372 .063 .307 .091 .487 −.081
General Help Seeking Attitude .027 .156 a
.040 .183 a
.420 .095
Self-Stigma of Seeking Help .000 −.258 .016 −.213 a .008 −.305b
b

Negative Belief toward Mental Illness .166 −.098 .680 −.037 .384 −.102
Age .008 .187 b
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 6 of
4):544
a
Correlation is significant at the 0.05 level (2-tailed)
b
Correlation is significant at the 0.01 level (2-tailed)
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 7 of
4):544

Table 5 Multiple Regression to determine the predictors of Mental Help Seeking Attitude
All participants Secondary school students University students
B SE B β B SE B β B SE B β
General Help Seeking .064 .045 .100 .106 .064 .147
Self-Stigma of Seeking −.439 .131 −.23 −.398 .191 −.185 −.45 .164 −.30
Help R2 5* * 5*
.076 .066 .093
*p < 0.05

means more access to health information and a better Abbreviations

understanding of such information to help them ANOVA: Analysis of Variance; B40: Below 20%; BMI: Beliefs toward
utilize it for the benefit of their mental health state. Mental Illness Scale; D-Lit: Depression Literacy Questionnaire; GHSQ:
General Help Seeking Questionnaire; M20: Middle 20%; MHSAS:
The negative belief and stigma toward mental illness Mental Help Seeking Attitude Scale; RM: Ringgit Malaysia; SPSS:
were more likely to occur among those with lower Statistical Package of Social Sciences; SSOSH: Self-Stigma of Seeking
education [57, 58]. It is interesting to note that Help Scale; T20: Top 20%;
WHO: World Health Organization
although educational level influences these variables
in the present study, it does not affect the mental
Acknowledgements
help seeking attitude of the participants. This may be We would like to thank all the students who participated in this
partly due to the equal availability of mental health research. We are also very thankful to the principals and warden at
services in both settings (i.e. secondary and tertiary Asmara Kasih Yayasan Basmi Kemiskinan for their permission to
collect the data.
education) in Malaysia.
This study has a few limitations. As this is a cross- Funding
sectional study on B40 students from a few educa- tional This study was funded by Research Grant for Grand Challenges of
institutions in the Klang Valley, Malaysia, the the Universiti Kebangsaan Malaysia (DCP-2017-014/3). The funding
body evaluates the proposal, determines the suitability of the study
generalizability of the results should be made with and provides funds for conducting the research. The authors also
caution. In addition, comparisons of the findings of acknowledged the financial assistance for publication received from
this study with other studies should also be inter- the Research University Grant awarded by the Ministry of Health
to the National University of Malaysia specifically for the
preted with caution and need to take into account Consortium of B40 Research (CB40R) under the auspice of B40
differences in methodology and context. Future stud- Grand Challenges (IDE 2018–01).
ies should consider employing the qualitative method
in order to obtain a more in-depth understanding of Availability of data and materials
The datasets used and/or analysed during the current study are
existing results, especially on the differences found available from the corresponding author on reasonable
between secondary school and university students. request.
The intention to utilize mental health services could
also be influenced by other factors not investigated in About this supplement
this research, such as knowledge about the availability This article has been published as part of BMC Public Health
Volume 19 Supplement 4, 2019: Health and Nutritional Issues
of mental health services and other perceived barriers, Among Low Income Population in Malaysia. The full contents of
and these could be further investigated in future stud- the supplement are available online at
ies. Finally, sociocultural aspects, such as religion and [Link]
volume-19-supplement-4.
ethnicity, need to be investigated in future studies as help-
seeking behavior may be different across cultures and in Authors’ contributions
different countries. The idea for research or article- NI, SS. Planning the methods to
generate hypothesis- NI, NA. Responsibility for the organization and
course of the project and the manuscript preparation- NI, AMS.
Responsibility for conducting data collection, organizing and
Conclusion reporting data- NI, AMS. Responsibility for presentation and logical
This study demonstrated that higher self-stigma and explanation of results- NI, AMS. Responsibility for conducting
literature search- AMS. Reworking the final, before submission
younger age were associated with negative mental help-
version of the manuscript for intellectual content, spelling and
seeking attitudes among students from low-income grammar check- NI, WLH, NA, SS, SCS, RI, RK. All of the authors have
households. These findings may serve as a guide for the read and approved the final manuscript.
improvement of psycho-education efforts targeting self-
stigma in all academic settings, especially among younger Ethics approval and consent to participate
All procedures performed in studies involving human participants
students, as they may indirectly enhance the attitude of were in accordance with the ethical standards of Research Ethics
Malaysians toward help-seeking for mental health Committee, National University of Malaysia (UKM) and its later
problems. amendments or comparable ethical standards, and was approved
by the committee with approval number UKM PPI/111/8/JEP/− 2018–
267. Verbal consent from the legal guardians of the younger
participants was obtained while the university participants
verbally gave their consent, as they were already above 18 years
old.
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 8 of
4):544
Consent for publication
Not applicable.
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 9 of
4):544

Psychiatrist. 2013;37:253–60.
Competing interests 16. Eisenberg D, Downs MF, Golberstein F, Zivin K. Stigma and help
The authors declare that they have no competing interests. seeking for mental health among college students. Med Care Res
Rev. 2009;66:522–41.
17. Mantovani N, Pizzolati M, Edge D. Exploring the relationship
between stigma and help-seeking for mental illness in African-
Publisher’s Note descended faith communities in the UK. Health Expect.
Springer Nature remains neutral with regard to jurisdictional claims
2017;20:373–84.
in published maps and institutional affiliations. 18. Ben-Zeev D, Corrigan PW, Britt TW, Langford N. Stigma of mental
illness and service use in the military. J Ment Health.
Author details
1
2012;21:264–73.
Health Psychology Program, Faculty of Health Sciences, Universiti
Kebangsaan Malaysia, Kuala Lumpur, Malaysia. 2Research Centre for
Healthy Aging and Wellness, Faculty of Health Sciences, Universiti
Kebangsaan Malaysia, Kuala Lumpur, Malaysia. 3Centre for
Community Health, Faculty of Health Sciences, Universiti Kebangsaan
Malaysia, Kuala Lumpur, Malaysia. 4Dietetics Program, Faculty of
Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur,
Malaysia. 5Nutrition Sciences Programme, Faculty of Health Sciences,
Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
6
Centre of Human and Societal Well-being, Faculty of Social
Sciences and Humanities, Universiti Kebangsaan Malaysia, Bangi,
Selangor, Malaysia.

Published: 13 June 2019

References
1. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual
research review: a meta-analysis of the worldwide prevalence of
mental disorders in children and adolescents. J Child Psychol
Psychiatr. 2015;56:345–65.
2. Eisenberg D, Hunt J, Speer N, Zivin K. Mental health service
utilization among college students in the United States. J Nerv Ment
Dis. 2011;5:301–8.
3. Gulliver A, Griffiths KM, Christensen H. Perceived barriers and
facilitators to mental health help-seeking in young people: a
systematic review.
BMC Psychiatry. 2010;10:113.
4. Rickwood DJ, Deane FP, Wilson CJ. When and how do young
people seek professional help for mental health problems. Med J
Aust. 2007;187:35–9.
5. Packness A, Waldorff FB, dePont Christensen R, Hastrup LH,
Simonsen E, Vestergaard M, Halling A. Impact of socioeconomic
position and distance on mental health care utilization: a
nationwide Danish follow-up study. Soc Psychiat Psychiatr
Epidemiol. 2017;52:1405–13.
6. Rowan K, McAlpine DD, Blewett LA. Access and cost barriers to
mental health care, by insurance status, 1999–2010. Health Aff.
2013;32:1723–30.
7. Knickman J, Krishnan R, Pincus H. Improving access to effective
care for people with mental health and substance use
disorders. JAMA. 2016;316:1647–8.
8. Chong ST, Mohamad MS, Er AC. The mental health
development in Malaysia: from independence till now.
ASS; 2013.
9. Sareen J, Cox BJ, Afifi TO, Stein MB, Belik SL, Meadows G. Combat
and peacekeeping operations in relation to prevalence of mental
disorders and perceived need for mental health care findings
from a large representative sample of military personnel. Arch
Gen Psychiatry. 2007;64:843–52.
10. Prins M, Meadows G, Bobevski I, Graham A, Verhaak P, Penninx B.
Perceived need for mental health care and barriers to care in the
Netherlands and Australia. Soc Psychiat Psychiatr Epidemiol.
2011;46:1033–44.
11. Shoesmith WD, Borhanuddin AF, Yong Pau Lin P, Abdullah AF,
Nordin N, Giridharan B, Forman D, Fyfe S. Reactions to symptoms
of mental disorder and help seeking in sabah, malaysia. Int J Soc
Psychiatr. 2018;64:49–55.
12. Ismail RF, Abd Wahab H. Persepsi pesakit mental terhadap
stigma masyarakat. Akademika. 2015;85:13–24.
13. Goffman E. Stigma: notes on the management of spoiled
identity, New Jersey, Prentice-Hall; 1963.
14. Corrigan PW, Larson JE, Rusch N. Self-stigma and the “why
try” effect: impact on life goals and evidence based practices.
World Psychiatry. 2009;8:75–81.
15. Lally J, ó Conghaile A, Quigley S, Bainbridge E, McDonald C. Stigma
of mental illness and help-seeking intention in university students.
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 10 of
4):544 2008. p. 61–82.
19. Sharp ML, Fear NT, Rona RJ, Wessely S, Greenberg N, Jones N. 39. Wilson CJ, Deane FP, Ciarrochi JV, Rickwood D. Measuring help
Stigma as a barrier to seeking health care among military seeking intentions: properties of the general help seeking
personnel with mental health problems. Epidemiol Rev. questionnaire.
2015;37:144–62. Can J Couns. 2005;39:15–28.
20. Ross C, Goldner E. Stigma, negative attitudes and
discrimination towards mental illness within the nursing
profession: a review of the literature.
J Psychiatr Ment Health Nurs. 2009;16:558–67.
21. Ng CH. The stigma of mental illness in Asian cultures. Aust
New Zeal J Psychiatr. 1997;31:382–90.
22. Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Raue P, Friedman
SJ, Meyers BS. Perceived stigma as a predictor of treatment
discontinuation in young and older outpatients with depression.
Am J Psychiatry. 2001;158:479–81.
23. Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P.
Mental health literacy: a survey of the public’s ability to
recognize mental disorders and their beliefs about the
effectiveness of treatment. Med J Aust. 1997;166:182–6.
24. Sayarifard A, Ghadirian L. Mental health literacy in Iran: an urgent
need for a remedy. Int J Prev Med. 2013;4:741–3.
25. Kutcher S, Wei Y, Gilberds H, Ubuguyu O, Njau T, Brown A, Sabuni
N, Magimba A, Perkins K. A school mental health literacy
curriculum resource training approach: effects on Tanzanian
teachers’ mental health knowledge, stigma and help-seeking
efficacy. Int J Ment Health Syst. 2016;10:50.
26. Ross SG, Bruggeman B, Maldonado M, Deiling M. Examining
personal, perceived, treatment, and self-stigma in college
students: the role of Parent beliefs and mental health
literacy. J Col Stud Psychother. 2019;16:1–5.
27. Pickett K, Oliver J, Wilkinson R. Income inequality and the
prevalence of mental illness: a preliminary international
analysis. J Epidemiol Community Health. 2006;60:646–7.
28. Stansfeld S, Clark C, Bebbington P, King M, Jenkins R, Hinchliffe S.
Chapter 2: common mental disorders. In: McManus S, Bebbington
P, Jenkins R, Brugha T, editors. Mental health and wellbeing in
England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS
Digital; 2016.
29. Pinto-Meza A, Moneta MV, Alonso J, Angermeyer MC, Bruffaerts R,
De Almeida JM, De Girolamo G, De Graaf R, Florescu S, Masfety VK,
O’Neill S. Social inequalities in mental health: results from the EU
contribution to the world mental health surveys initiative. Soc
Psychiat Psychiatr Epidemiol. 2012;48:173–81.
30. Holman D. Exploring the relationship between social class,
mental illness stigma and mental health literacy using British
national survey data. Health. 2015;19:413–29.
31. Abolfotouh MA, Almutairi AF, Almutairi Z, Salam M, Alhashem A,
Adlan AA, Modayfer O. Attitudes toward mental illness, mentally
ill persons, and help- seeking among the Saudi public and
sociodemographic correlates. Psychol Res Behav Manag.
2019;12:45.
32. Ooi CS: The T20, M40 and B40 income classifications in Malaysia.
2017. [Link]
malaysia. Accessed 6 August 2018.
33. Lidiana R: CIMB: budget 2018 should focus more on B40, M40 &
SMEs. 2017.
[Link]
budget-2018- should-focus-more-b40-m40-smes. Accessed 6
August 2018.
34. Jaladin RAM, Amit N, NAM A. Enhancing mental-health
literacy among cultural minorities in Malaysia. In: Social
Sciences and Interdisciplinary Behavior - Proceedings of the
4th International Congress on Interdisciplinary Behavior and
Social Science, ICIBSOS 2015. Kazan: CRC Press/Balkema;
2016. p. 357–62.
35. Griffiths KM, Christensen H, Jorm AF, Evans K, Groves C. Effect of
web-based depression literacy and cognitive-behavioural therapy
interventions on stigmatising attitudes to depression:
randomised controlled trial.
Br J Psychiatry. 2004;185:342–9.
36. Arafat SMY, Shams SF, Chowdhury HR, Zarin E, Hoque MJ, Abdul
Bari M. Adaptation and validation of the Bangla version of the
depression literacy questionnaire (D-lit Bangla). J Psychiatry.
2017;20:412.
37. Ram D, Chandran S, Gowdappa BH. Suicide and depression
literacy among healthcare profession students in tertiary care
center in South India.
J Mood Disord. 2017;7:149–55.
38. Darusalam G. Kesahan dan kebolehpercayaan dalam kajian
kuantitatif dan kualitatif. Jurnal Institut Perguruan Islam;
Ibrahim et al. BMC Public Health 2019, 19(Suppl Page 11 of
4):544

40. Hammer JH, Parent MC, Spiker DA. Mental help seeking
attitudes scale (MHSAS); development, reliability, validity and
comparison with the ATTSPH-SF and IASMHS-PO. J Couns
Psychol. 2018;65:4–85.
41. Vogel DL, Wade NG, Haake S. Measuring the self-stigma
associated with seeking psychological help. J Couns Psychol.
2006;53:325–37.
42. Sevgi S, Fatih K. The reliability and validity of self stigma of
seeking help scale (SSOSH) in a Turkish sample. J Psychiatr Neurol
Scie. 2013;26:148–56.
43. Pheko MM, Chilisa R, Balogun SK, Kgathi C. Predicting intentions to
seek psychological help among Botswana University students: the
role of stigma and help-seeking attitudes. SAGE Open.
2013;3:1–11.
44. Hirai M, Clum GA. Development, reliability, and validity of the
beliefs toward mental illness scale. J Psychopathol Behav Assess.
2000;22:221–36.
45. Link BG, Cullen FT, Struening EL, Shrout PE, DOhrenwend BP. A
modified labeling theory approach to mental disorders: an
empirical assessment. Am Sociol Rev. 1989;54:400–23.
46. Overbeck AL. Life stress antecedents to application for help at
a mental health center: a clinical study of adaptation. Smith
Coll Stud Soc. 1977;47:192–233.
47. Corrigan PW, Matthews AK. Stigma and disclosure: implications for
coming out of the closet. J Ment Health. 2003;12:235–48.
48. Corrigan P. How stigma interferes with mental health care. Am
Psychol. 2004;59:614–25.
49. Ben-Porath DD. Stigmatization of individuals who receive
psychotherapy: an interaction between help-seeking behavior and
the presence of depression. J Clin Soc Psychol. 2002;21:400–
13.
50. Corrigan PW. On the stigma of mental illness: practical
strategies for research and social change. American
Psychological Association: Washington DC; 2005.
51. Sibicky M, Dovidio JF. Stigma of psychological therapy:
stereotypes, interpersonal reactions, and the self-fulfilling
prophecy. J Couns Psychol. 1986;33:148–54.
52. Horwitz A. Pathways into psychiatric treatment: some differences
between men and women. J Health Soc Behav. 1977;18:169–
78.
53. Drum DJ, Brownson C, Denmark AB, Smith SE. New data on the
nature of suicidal crises in college students: shifting the
paradigm. Prof Psychol Res Pr. 2009;40:213–22.
54. Robb C, Haley W, Becker M, Polivka L, Chwa H. Attitudes towards
mental health care in younger and older adults: similarities and
differences. Ag Ment Health. 2003;7:142–52.
55. MacLean A, Hunt K, Sweeting H. Symptoms of mental health
problems: children’s and adolescents’ understandings and
implications for gender differences in help seeking. Child Soc.
2013;7:161–73.
56. Boulter E, Rickwood DJ. Parents’ experience of seeking help for
children with mental health problems. Adv Ment Health.
2013;11:131–42.
57. Yuan Q, Abdin E, Picco L, Vaingankar JA, Shahwan S, Jeyagurunathan A,
Sagayadevan V, Shafie S, Tay J, Chong SA, Subramaniam M. Attitudes
to mental illness and its demographic correlates among general
population in Singapore. PLoS One. 2016;1:e0167297.
58. Subramaniam M, Abdin E, Picco L, Pang S, Shafie S, Vaingankar JA,
Kwok KW, Verma K, Chong SA. Stigma towards people with mental
disorders and its components - a perspective from multi-ethnic
Singapore. Epidemiol Psychiatr Sci. 2017;26:371–82.