Facilitators and barriers of mental health help-seeking behaviours among adolescents in Oman: a cross-sectional study

Abstract

Objectives

This study aimed to explore and identify facilitators and barriers to help-seeking behaviours among adolescents in Oman, by exploring the relationship between knowledge, attitude, and behaviour towards mental health help-seeking.

Methods

A cross-sectional descriptive study was used and 424 adolescents were recruited to participate in the study. Participants were asked to complete five self-reported questionnaires, including two open-ended questions about the main motivations and barriers to seeking professional help for mental problems.

Results

It was found that those with positive help-seeking attitudes towards mental health were more knowledgeable about mental health, had more positive attitudes towards mental illness, and had higher intention to help seeking. On the contrary, those with higher help-seeker stereotypes had more negative attitudes towards mental illness. Having an adequate support system, being positive and knowledgeable about mental illness, and the reputation of mental health are the main factors facilitating seeking professional help. However, fear, lack of family support, and the time-consuming procedures were the main barriers emerging from the open-ended questions.

Conclusions

This study contributes by identifying facilitating factors as well as barriers in an Arabic context (Oman) to fill the exiting knowledge gap; both need to be considered when planning interventions targeting the younger individuals in this society.

Keywords:

• Adolescents
• help-seeking behaviours
• help-seeker stereotypes
• attitudes to mental illness

Introduction

One out of seven adolescents are diagnosed with mental illness worldwide [1], and mental illness constitutes 16% of the total burden of the disease or injury among children aged 10–19 years worldwide [2]. Half of all mental illnesses emerge at the age of 14, but most cases go unnoticed and untreated [2]. Mental illnesses are linked to many negative outcomes, including poor academic performance, poor relationships with peers; a higher incidence of substance misuse [3], and suicide attempts [4]. These negative outcomes demonstrate the importance of detecting and treating mental illness at an early stage to prevent these negative effects.

An immense body of literature supports the effectiveness of the current approaches in treating adolescents with mental illness [5]. However, in some countries like England, only one-third of the adolescents who need assistance seek professional help [6]. Globally, adolescents have reported reluctance to seek professional help for mental illness and psychological suffering [7].

Several associated factors are linked to the failure of adolescents to seek professional help. These factors include high cost of treatment [8], prolonged waiting time [9], and distrust of both the treatment and mental health care providers [8], as shown in systematic reviews covering findings from different global settings. The level of knowledge about mental illness is another contributory factor. Additionally, parents do not possess sufficient knowledge to seek professional help [8]. Some general practitioners (GPs) also have inadequate knowledge or skills to detect mental illness and cannot, therefore, refer adolescents for specialised mental health support [10]. These factors are related to the knowledge of parents and GPs. However, there is a need to explore the barriers and attitudes to seeking professional mental help from the adolescents’ perspective, as they are essentially responsible for their own health.

According to research [11,12], some adolescents lack sufficient knowledge about where to get help, whom to approach for help, and whether their situation is urgent enough to require immediate professional health care [13,14]. Furthermore, some adolescents are uncomfortable sharing personal information with strangers [15,16] and fear upsetting their families.

Another barrier the social stigma attached to mental illness. Some adolescents perceive mental illness as a sign of weakness and are unwilling to appear weak in front of their peers [17,18]. One major challenge is that some adolescents believe their psychological stress or problem is temporary and will resolve itself after a while [12,15]. As a result, they prefer to depend on themselves to cope with their psychological difficulties without asking for help from others [19,20].

On the other hand, several facilitating factors have been identified in previous studies promoting professional mental help-seeking behaviour in adolescents. These include a positive attitude and frequent encouragement from peers [21,22], a positive relationship and trust with parents [23], and previous positive experience and help-seeking behaviour with mental healthcare services [24,25]. In addition, when some adolescents feel appreciated [13], listened to, and not judged by parents and peers [26], they are more likely to seek help from a professional.

Help-seeking behaviour among adolescents has not been researched extensively in the Arab region, which is a unique context for mental illness. Some Arabs show stigmatising behaviours towards mental illness in general, and to people with mental illness specifically. Some believe that mental illness might be a sign of being possessed by evil spirits or of being a victim of black magic (Sehr) or the evil eye (Hasad) [27]. As a result, some adolescents and their families often seek help from non-professional sources (for example Islamic scholars and Sheikhs) [28].

Only one Omani study was found about professional mental health help-seeking behaviour, and it explored this phenomenon from parents’ perspective [29]. Results showed that parents have a negative attitude regarding psychiatric services, and this hinders their help-seeking behaviour. In general, the Arab community shares Omani parents’ negative attitudes towards psychiatric services [30]. Parents need to explore the professional mental health help-seeking behaviour from the perspective of their children.

Oman is a high-income country located on the south-eastern coast of the Arabian Peninsula in Western Asia and most of its population is young [31]. The Omani government pays special attention to health [32]. However, mental health has not received the same attention as physical health. For example, only one referral psychiatric tertiary hospital is available in Oman [32,33]; and there are only two institutions, Sultan Qaboos University Hospital (SQUH) and Al-Massarah Hospital, that provide mental healthcare to adolescents [34]. Al-Massarah Hospital started serving adolescents recently [34].

A detailed understanding of facilitating factors and barriers to seeking professional help among adolescents is critical to bridging the gap between the high prevalence of mental illness among adolescents and the low utilisation of mental health care services. This study aimed to fill the gap in knowledge about facilitators and barriers to help-seeking behaviours among adolescents in an Arabic context, namely Oman. The main objective of the study was therefore to explore and identify facilitators and barriers to help-seeking behaviours among Omani adolescents by exploring the relationship between their knowledge, attitude, and behaviour towards mental health help-seeking behaviours.

Materials and method

Design

A cross-sectional descriptive study was used.

Sample

A convenience sampling technique was used to recruit adolescents aged between15 and 19; registered in a governmental school; and able to read and understand Arabic. We aimed for school students because education in Oman is compulsory, so schools are the best place to find the eligible targeted sample.

The participant recruitment process was coordinated with the help of the Ministry of Education who provided a list of schools attended by 15–19- year-old students. Only public schools were selected to better reflect the whole population from different socio-economic groups. Slovin’s formula (n = N/(1 + N e²) was used to determine the sample size, where n = number of participants, N = total population and e = margin of error (0.05). The total population of Omani adolescents of this age is 216,747 [35], so n = 216,747/(1 + 216,747 * (0.05)²) = 399 school students were required to participate in the study.

Ethical considerations

Ethical approval was obtained from the Institutional Review Board in the College of Nursing at Sultan Qaboos University (CON/EA/21/2019) and the Omani Ministry of Education (Ref. No. 2819186833). In all phases of the study, the Helsinki Declaration (1989) guided our ethical considerations. The information requirement was met through distribution of a letter prior to collecting the consent. The students were informed that their participation was voluntary, and that they were free to leave at any time without giving a reason. Confidentiality of the data was assured, and the students were not asked to provide any details that could be used to identify them. All the data were deleted at the end of the study.

Data collection

The study was conducted from October 2020 to the end of February 2021. Since Omani schools are gender-segregated, fourteen schools (7 males and 7 females) were randomly selected from the 67 government schools located in Muscat, Batinah, and Sharqiyah; students from grade 9 to 12 were invited to participate in the study. The researchers provided the participants’ parents with a link to the information sheet, consent form, demographic data form, and four self-administered questionnaires. They requested parents to read the information sheet, contact the principal investigator if they had any queries, and if they agreed, to allow their children to complete the survey independently. The link was distributed among one class from each level in the respective schools, to assure equal distribution of the age groups. However, we could not control for the gender distribution as this was dependent on the classes, schools, and the rate of response. Seven hundred school students were invited to take part in the study but only 424 completed the survey, a response rate of 60.4%.

Measures

Participants’ demographics

The researchers developed the survey and it was used to collect general information about the participant’s age, gender, educational level, parents’ level of education, and family income. It also asked for information on the participant’s health, including the current or previous history of mental illness or symptoms among the participants, family members, and friends; and whether the participants were suffering from any chronic illness.

The mental help-seeking attitudes scale (MHSAS)

The MHSAS was developed by Hammer et al., [36] to measure participants’ general feelings about finding support from a mental health provider. The survey has 9-items, each measured on a seven-point semantic differential scale (favourable and unfavourable). The range of possible total scores was 7 to 63, with a higher score indicating a more positive attitude towards seeking help. The original tool was deemed to have good validity and reliability, with Cronbach’s alpha 0.90 [36]; Cronbach’s alpha for this study was 0.94.

Mental help-seeking intention scale (MHSIS)

The MHSIS was developed by Hammer et al. [36] to assess the participant’s intention to seek help from a mental health provider. The questions were on what the participant would do if he/she had a mental health concern, for example: ‘if I had a mental health concern, I would intend to seek help from a mental health professional’. The survey has three items measured on a seven-point Likert scale from 1 (extremely unlikely) to 7 (extremely likely), with possible total scores ranging from 3 to 21. The higher score indicates a greater intention to seek help. The internal reliability of the tool has been well established, with Cronbach’s alpha = 0.94 [36]; Cronbach’s alpha for this study was 0.88.

The help-seeker stereotype scale (HSSS)

The HSSS was developed by Hammer and Vogel [37] to assess participants’ negative stereotypes about people who seek help from a professional mental health provider. The survey has 12-items with responses measured on a seven-point Likert scale from 1 (not at all) to 7 (very much), with a possible total score ranging from 12 to 84. The higher scores indicate a stronger negative stereotype for help seekers. The validity and internal reliability of HSSS have been well established; Cronbach’s alpha was 0.88 [38], and for this study 0.90.

Attitudes and knowledge related to mental illness questionnaires

The surveys were developed by the Chinese Ministry of Health [39] to measure the attitude and general knowledge respectively of the general public to mental illness.

The Attitudes questionnaire has 12-items measured on a five-point Likert scale from 1 (completely disagree) to 5 (completely agree), with a possible total score ranging from 12 to 60; a higher score suggests a more positive attitude towards people with mental illness. The agree/disagree scales were reversed for half of the items. An example of items used is ‘Most people are willing to make friends with people who have suffered from mental illness’. Cronbach’s alpha in this study was 0.734.

The Knowledge questionnaire has 20 items on a nominal scale (Yes/No), with possible total scores ranging from 0 to 20, with a higher score suggesting greater knowledge about mental illness. One point was given for the answer yes for 13 of the items, and one point for no for the remaining items. An example is ‘Mental health is an integral part of health’. The validity and internal reliability of the tool have been well established, with Cronbach’s alpha.73 [40]; Cronbach’s alpha for this study was 0.60.

Facilitators and barriers to professional mental help-seeking behaviours

At the end of the survey, two open-ended questions were provided: (1) ‘From your perspective, please describe the three main facilitating factors for professional mental help-seeking behaviour’; and (2) ‘From your perspective, please describe three main barriers that hinder your professional mental help-seeking behaviour’.

The surveys were available in English or Chinese, and the researchers adhered to the World Health Organization guidelines to translate them into Arabic [41].

Analysis plan

Quantitative data

Data were analysed using the Statistical Package for the Social Sciences version 23 (SPSS Inc., Chicago, IL). Data were initially checked for completeness, and no missing data were found. Descriptive statistics of frequencies and percentages were used to describe the socio-demographic categorical variables and means and standard deviations of the continuous variables. Since the dependent variables were distributed normally, the independent sample t-test and one-way ANOVA were performed to describe mental help-seeking attitudes in relation to participants’ socio-demographic characteristics. Pearson’s correlation was performed to determine the association between knowledge and attitudes related to mental illness, mental help-seeking attitudes, mental help-seeking intention, and help-seeker stereotype. In all the statistical analysis, a p value of <.05 was considered significant.

Information from the open-ended questions

Content analysis, as guided by Hsieh and Shannon [42], was conducted for the last two open-ended questions; each question’s responses were retrieved and analysed separately, i.e. separate analysis for barriers and for facilitators. Two independent researchers read and re-read the answers to the questions to obtain an overall understanding and to generate a sense of the whole. They were then able to identify the meaningful units in the text. These were then coded before the codes were categorised. The categories were then compared and structured into main themes and sub-themes. Statements outlining the facilitating factors were grouped under main themes in the last step. For descriptive analysis, the statements were tabulated to produce frequency of occurrence. The two researchers met to discuss their findings and to resolve any ambiguities. The research team met again and examined the data to agree on the themes, sub-themes, interpretations, and appropriateness, with prolonged discussion to reach a consensus. Although this process consumed some time, it was necessary to guarantee the trustworthiness of the data analysis.

Results

Four hundred and twenty-four responses were received over the study period, from participants with a mean age of 16.74 (SD = 1.012). More than half were male (55.7%) and in 12th grade (53.8%). Most (98.8%) had not been diagnosed with mental illness and did not have a family member (94.3%) or friend (97.2%) diagnosed with mental illness. Table 1 describes the demographic characteristics of the study sample in detail.

Table 1. Participants’ socio-demographic characteristics (N = 424).

Variable	n	%		n	%
Gender			Visiting psychologist
Male	236	55.7	No	381	89.9
Female	188	44.3	Yes	43	10.1
Mother’s level of education			Father’s level of education
Illiterate	57	13.4	Illiterate	49	11.6
Elementary	70	16.5	Elementary	35	8.3
Secondary	146	34.4	Secondary	173	40.8
University	145	34.2	University	167	39.4
Mother’s employment			Father’s employment
Not employed	102	24.1	Not employed	176	41.5
Employed	322	75.9	Employed	248	58.5
Self-report of mental illness			Family member with a mental illness
No	419	98.8	No	400	94.3
Yes	5	1.2	Yes	24	5.7
Monthly family income (OMR)			History of chronic illness
Less than 500	110	25.9	No	403	95.0
500 − 999	137	32.3	Yes	21	5.0
1000–1499	138	32.5	Friend with a mental illness
1500 − 2000	39	9.2	No	412	97.2
	M	SD	Yes	12	2.8
Age	16.7	1.0	–	–	–

Table 2 shows the overall mean value for knowledge about mental illness.2 (SD = 2.9), attitudes related to mental illness 34.2 (SD =7.9), mental health help-seeking attitudes 37.3 (SD = 13.7), mental health help-seeking intention 13.3 (SD = 5.8), and help-seeker stereotype 43.3 (SD = 16.2).

Table 2. Sample characteristics (N = 424).

Scale	Mean	SD	Min–max (range)
Knowledge related to mental illness	12.2	2.9	4–18 (14)
Attitudes related to mental illness	34.2	7.9	12–60 (48)
Mental help-seeking attitudes	37.3	13.7	9–63 (54)
Mental help-seeking intention	13.3	5.8	3–21 (18)
Help-seeker stereotype	43.3	16.2	12–84 (72)

The mean score for the Mental help-seeking attitudes scale was significantly higher among male students (M = 38.9, SD = 13.4) than their female counterparts (M = 35.4; SD = 13.9), p = .009. It was also higher among students who had previously received psychological help (M = 41.5, SD = 12.8); p = .001. Further, the higher Mental help-seeking intention scores were significantly associated with being male (p < .01); having an employed father (p = .003); not having a chronic illness (p = .003) and having a high family income (p < .01), compared to those in other categories. The mean score for the help-seeker stereotype scale was significantly higher among students in 11th grade (M = 46.2, SD = 16.6) compared with their 10th (M = 36.9, SD = 14.7) and 12th (M = 44.9, SD = 16.0) counterparts p < .01. For more detail refer to Table 3.

Table 3. Bivariate analysis to MHSAS; MHSIS; HSSS.

	MHSAS		MHSIS		HSSS
Variable	Mean (SD)	p Value	Mean	p Value	Mean (SD)	p Value
Gender		.009		<.01		.067
Male	38.9 (13.4)		14.2 (5.9)		42.0 (18.0)
Female	35.4 (13.9)		12.2 (5.5)		44.8 (13.4)
Education		.701		.020		<.01
10th	38.3 (14.2)		11.9 (6.0)		36.9 (14.7)
11th	37.4 (12.9)		13.6 (5.7)		46.2 (16.6)
12th	36.9 (13.9)		13.8 (5.7)		44.9 (16.0)
Mother’s level of education		.110		.785		.063
Illiterate	39.2 (12.7)		13.5 (6.2)		39.9 (18.3)
Elementary	33.8 (12.8)		12.7 (5.9)		44.3 (17.0)
Secondary	37.5 (14.1)		13.5 (6.1)		45.8 (17.0)
University	38.1 (14.1)		13.4 (5.4)		41.8 (14.0)
Father’s level of education		.824		.865		.094
Illiterate	38.0 (12.4)		13.6 (6.1)		37.8 (18.2)
Elementary	35.4 (17.3)		12.9 (5.4)		42.8 (18.1)
Secondary	37.3 (13.4)		13.5 (6.0)		45.2 (16.7)
University	37.6 (13.6)		13.1 (5.6)		43.0 (14.2)
Mother’s employment		.125		.659		.161
Not employed	35.5 (15.9)		13.1 (6.5)		41.2 (17.9)
Employed	37.9 (12.9)		13.4 (5.6)		43.9 (15.6)
Father’s employment		.882		.003		.430
Not employed	37.3 (13.6)		12.3(5.2)		43.8 (18.0)
Employed	37.5 (13.9)		14.0 (6.1)		42.6 (13.2)
Self-report of mental illness		.165		.159		.710
No	37.2 (13.7)		13.3 (5.8)		43.3 (16.3)
Yes	45.8 (13.8)		17.0 (5.0)		40.6 (10.6)
Family member with a mental illness		.292		.947		.019
No	37.2 (13.9)		13.3 (5.8)		42.8 (16.0)
Yes	40.2 (10.5)		13.4 (5.7)		50.8 (17.4)
Friend with a mental illness		.034		.294		.557
No	37.1 (13.8)		13.3 (5.8)		43.2 (16.3)
Yes	45.6 (8.3)		15.1 (5.4)		46.0 (14.2)
History of chronic illness		.274		.003		.009
No	37.5 (13.4)		13.5 (5.8)		43.7 (16.1)
Yes	34.1 (19.1)		9.6 (6.1)		34.2 (16.1)
Visiting mental health specialist		.037		.136		.572
No	36.9 (13.7)		13.2 (5.9)		43.4 (16.1)
Yes	41.5 (12.8)		15.4 (5.1)		41.1 (18.1)
Monthly family income (OMR)		.005		<.001		.406
Less than 500	39.2 (14.3)		14.8 (5.9)		42.5 (18.2)
500–999	34.4 (14.8)		12.2 (5.7)		42.2 (15.4)
1000–1499	37.6 (12.4)		12.5 (5.8)		45.1 (14.8)
1500–2000	42.0 (10.1)		16.2 (4.2)		43.0 (17.5)

MHSAS: mental help-seeking attitudes scale; MHSIS: mental help-seeking intention scale; HSSS: help-seeker stereotype scale. Significant at p < 0.05.

There was a significant positive relationship between mental help-seeking attitudes; knowledge related to mental illness (r = 0.299; p < .01); attitudes related to mental illness (r = 0.231; p < .01); and mental help-seeking intention (r = 0.587; p < .01). There was also a significant negative relationship between help-seeker stereotype, and attitudes related to mental illness (r = −0.207; p < .01). That is, when the students have a positive attitude to mental illness, their negative view about mental health professionals is reversed. See Table 4.

Table 4. Correlations between knowledge and attitudes related to mental illness, mental help-seeking attitudes, mental help-seeking intention, and help-seeker stereotype.

Variables	1	2	3	4	5	6
1. Knowledge related to mental illness	1.000	0.023	.299**	.205**	−0.049	0.027
2. Attitudes related to mental illness	0.023	1.000	.231**	.192**	.207**	−0.036
3. Mental help-seeking attitudes	.299**	.231**	1.000	.587**	0.006	−0.002
4. Mental help-seeking intention	.205**	.192**	.587**	1.000	0.086	.104*
5. Help-seeker stereotype	−0.049	.207**	0.006	0.086	1.000	.140**
6. Age	0.027	−0.036	−0.002	.104*	.140**	1.000

*p < .05; **p < .01.

Perceived facilitating factors for seeking professional help

There were a total of 936 responses reflecting perceived facilitating factors and 799 responses reflecting barriers to seeking mental health care. The main motivational factors are grouped into three themes: having an adequate support system (36 answers); being positive and knowledgeable about mental illness (681 answers); and the reputation of the mental health care system (219 answers). See Table 5 for more information.

Table 5. The Theme/subthemes of perceived barriers and facilitator factors of seeking professional mental help.

Facilitators		Barriers
Theme/subthemes	N	Theme/subthemes	N
Having an adequate support system		Feelings of anxiety, shame, and mistrust
Family support	23	Doctors will not solve my problem	110
Friends’ support	13	Stigma of being diagnosed with mental illness	98
Being positive and knowledgeable about mental illness		Stigma of visiting mental health professionals	126
Positive knowledge about the importance of mental health among adolescents, their peers, and parents	344	Fear for leaking of the information regarding their condition	120
Positive Knowledge about the importance of mental health among parents	150	Low self-confidence to contact healthcare professionals	85
Being confident of good results	187	Lack of family support
The reputation of the mental health care system		Lack of family support due to Parents poor knowledge	130
Mental health professionals are competent	100	Lack of financial ability	80
Mental health professionals keep the secretes and maintain confidentiality	75	Time consuming	25
Mental health professionals have a good communication skills	44	–	–

Having an adequate support system

Participants identified the support system as playing a significant role in encouraging or preventing them from visiting mental healthcare professionals. They believed that once they had received support from their family and friends, they might be willing to seek professional help. Adolescents diagnosed with mental illness will visit a psychologist if they believe their friends and family will not abandon them. One adolescent said, ‘I will go with my parents to any place and not only to seek professional mental help’. Another said, ‘Friends are the primary source of our strength, and when they encourage me, I will do it.’

Being positive and knowledgeable about mental illness

Adolescents believed that when they, their peers, and parents have good knowledge about the importance of early diagnosis, treatment of mental illness, and the benefits of visiting mental health care professionals, they will be motivated to seek mental health professionals. One adolescent said, ‘I believe mental health professionals will help in solving my problem.’ Another student reflected on the role of parents in influencing their decision-making: ‘My parents believe that mental health is an important component for a healthy life.’ Another student stated: ‘My friends and I believe that visiting a mental health professional will help in reducing our stress, anxiety, and depression.’

The reputation of the mental health care system

Many participants identified the reputation of the mental healthcare service. Adolescents believe when they find a professional who can listen actively to their concerns, understand them, and maintain their confidential information, they will surely visit the professional facility. One said, ‘When we hear about a good mental health specialist, for sure we will visit him.’ ‘The key element is the communication style and a trusting relationship between the patients and the doctor.’

Perceived barriers to seeking professional help

The barriers were categorised into three main themes: fear (539 answers), lack of family support (235 answers), and time consuming (25 answers). See Table 5 for a list of the most commonly reported barriers.

Feelings of anxiety, stigma, shame, and mistrust

Feelings of anxiety, shame, and mistrust were all described by the students as common barriers which will prevent them from visiting a psychologist if they need to. Ninety-eight responses highlighted the fear of being stigmatised if they were diagnosed with mental illness. They were anxious that if they were diagnosed with a mental illness and their friends found out, they would be stigmatised and alienated. One student reiterated this by saying, ‘I do not know how my family and friends will react. Once they know about my disease, they may alienate me and call me a mentally-ill patient.’ The other 126 answers expressed the shame over if other adolescents discovered their visits to mental health professional. They were of the view that they would be stigmatised based on such visits. Another student said, ‘I do not know what to tell [friends] if they see me with the psychologist.’

Several other adolescents (110 answers) expressed the mistrust in the mental health specialists and how they might not be professionally prepared or have sufficient knowledge to diagnose and treat them. One mentioned, ‘I am scared that the GP will not be able to figure out my disease and solve my problem; he may make me uncomfortable by speaking with my parents about my problem.’

Lack of family support

Some adolescents believed they would not have enough family support if they experienced any mental health issues. One hundred and thirty answers highlighted that parents’ lack of mental health literacy might prevent them from seeking professional mental healthcare advice. One participant said, ‘My family will disagree with seeking help from mental health professionals because they do not have sufficient knowledge about mental illnesses’. Eighty other answers highlighted financial hardships as another factor, which would prevent them from visiting a private psychologist.

Time-consuming

Adolescents believed visiting mental health care providers would be time-consuming. It might require frequent visits and several appointments, and they might not have adequate time. One adolescent said, ‘I have to book an appointment, wait for long hours, and visit the doctors several times. The process needs a lot of time that I cannot afford.’

Discussion

One overall contribution from this study is that we investigated and identified facilitators and barriers in an Arabic context (Oman) among adolescents to fill the gap of knowledge in this regard. This study contributes further to the existing knowledge on significant gender dissimilarities in mental help-seeking behaviours, higher intention to seek help among adolescents and those with no history of mental illness. In addition, the study identified adequate support systems, being positive and knowledgeable about mental illness, and the reputation of the mental health care system as the main facilitating factors for seeking professional mental healthcare. The biggest challenges highlighted by participants were feelings of anxiety, shame, and mistrust; a lack of family support; and the time-consuming process of obtaining mental healthcare (see Figure 1).

Figure 1. Contributing factors, facilitators, and barriers towards help-seeking behaviours.

One of our most interesting findings is the significant difference between male and female adolescents with regards to mental help-seeking attitudes and intentions. The male students showed more positive attitudes and greater intentions towards seeking help than females. This contradicts previous findings of the masculine norms and ideals that inhibit seeking psychological help among males [43], and mediate negative attitudes about and intentions to seek psychological help [44]. Some studies failed to show significant gender differences in the attitudes towards seeking psychological help [45]. A possible explanation of our findings could be the cultural influence that promotes gender differences to favour males. A sample from a similar culture drawn from a population of Kuwaiti students showed that females tend to believe more in the ‘traditional healing system’ and that it is a better alternative for mental health problems than the ‘modern mental (biomedical) health system’ [46]. This may explain the males’ tendency to seek help in the Middle Eastern culture. The females might need more knowledge about the existing modern mental health treatments, which calls for more attention to this part of the population.

Another result from this study is that the older the adolescents are, the higher their intention to seek professional help is, and the less they support the help-seeker stereotype [47]. This result contradicts previous studies’ findings in which older students (undergraduate university students from four different countries) were less affirmative in their intention to seek help when mental health problems occurred [46]. Our findings might reflect the maturity of the adolescents and the amount of knowledge they received during their physical and mental development. Healthcare team members should, therefore, provide information about mental illness and help-seeking behaviour at this critical age, as it will shape their future view of the value of available healthcare services.

In this study, the help-seeking intention was significantly higher in the group with employed fathers, those with a higher monthly income, and those who had already visited a mental healthcare specialist. These findings are similar to studies conducted in similar populations [18,45,48]. Socio-economic factors [18,48] and exposure to mental health services [45,49] are significantly associated with help-seeking intentions. The father’s employment status may influence monthly incomes and limit the anxiety related to healthcare service costs, which the adolescents already identified in this study as a barrier. It is worth mentioning that Oman provides free healthcare coverage for all its citizens. However, since our adolescent participants are young adults, they might still depend on their family’s financial support to reach specialised hospitals and pay the transportation fees as well as the nominal admission/consultation fees. These factors are important for mental health services to acknowledge and consider when dealing with adolescents and planning school-based interventions. It is also important to consider help-seeker stereotyping among adolescents when developing school-based interventions to reverse the current stereotype. One of our results is that less help-seeker stereotyping was reported by adolescents who have a family member with a mental illness. They also showed significantly more positive help-seeking attitudes when they had friends with mental illness. Building an understanding based on the situation of family members and peers is clearly a positive contributory factor that enhances the mental help-seeking attitudes in adolescents. This is supported by the Social Comparison Process (SCP) in which adolescents depend on their peers to build confidence and reduce uncertainty [50]. Thus, exposure to experiences shared by peers may influence help-seeker stereotyping positively. In practice, a monitored platform could be created for adolescents to meet, either online (anonymously) or in person (face-to-face), to share their experiences, thoughts, and views of mental help-seeking.

An interesting finding of this study is that the help-seeking intention was significantly higher in adolescents with no history of mental illness. Conversely, the help-seeker stereotype was more negative in the group with no history of mental illness. When not being influenced by previous experiences of encountering mental health services, the intention to seek mental help seems to increase, according to our findings. These points to the importance of the reputation and quality of the mental health care provided. Adolescents in the current and previous studies still reported a negative view of the mental help seekers [51]. There is a need to develop educational programmes to reverse the current stereotyping of mental help seekers.

Having an adequate support system, being positive and knowledgeable about mental illness, and the reputation of the mental health care system are the main facilitating factors for seeking professional mental health, from the adolescents’ perspective. This study highlights important positive factors that can be discussed about contextual and cultural influences [52,53]. Clark et al. [17] elaborate this and provide factors including a gradual introduction to support, providing a variety of help-seeking options, and school-based programmes as essential facilitating factors. It would be worthwhile including these factors in any future intervention targeting the adolescent population. This study’s results and other evidence-based findings might indicate the socio-cultural influence on the beliefs and interpretation of mental health as well as experience of the available mental health services [54]. Several studies suggested the common belief that people attribute mental illness symptoms to religious or supernatural causes. This attribution often leads to the practice of seeking help from religious figures instead of professional mental healthcare providers [55]. Our qualitative findings may be explained by considering the quantitative data, which shows that cultural factors influence facilitating factors significantly. For example family support is perceived as a central facilitator of help-seeking behaviour [56]. Hence, in future interventions, families, and peers should also be considered. School nurses and counsellors need to be creative and raise students’ awareness about mental illness.

Fear, lack of family support, and time-consuming procedures are the main barriers identified in the qualitative data. The fear for not getting the needed help from the physicians, fear of stigmatisation related to mental health visits or diagnosis with mental health disorder, and fear of leakage of information as well as fear of exposure of the low self-confidence during the encounter with mental health services were all highlighted by the participants in this study. More specifically, the fear of stigma, especially public stigma, and the risk of compromising their social status were feelings narrated by adolescents in the current and previous studies as preventing them from seeking mental help [17]. Seeking help was also seen as a time-consuming activity [17], similar to the time-consuming factor observed in this study. Time investment is a concern for youth regardless of the activity in which they are involved. One may wonder if the time-consuming hindrance identified by the participants in this study concerns the time investment or relates to the fear of stigma, lack of information, and spending time on one’s health. The time-consuming process of help-seeking could be compounded by several other factors, such as poor health literacy and lack of social support, which lead to avoidance of mental help-seeking among adolescents and young adults [57]. However, complementary data based on semi-structured interviews could provide more nuanced narratives on the actual practices, beliefs, and attitudes towards mental help-seeking behaviours. It is further worth mentioning that in Oman, only two hospitals provide mental health services, which puts pressure on health care providers and extends the waiting time for patients. E-health could be a solution to reduce the waiting time. Pretorius et al. [58] propose that the sense of connectedness, accessible information, personalisation, and immediacy are all factors that promote the use of online resources. Therefore, it is crucial to raise awareness about mental illness, the availability of the mental health services, the effectiveness of the services provided, the autonomous nature of attending and using these services, as well as the confidentiality of the clients’ information. Such campaigns might promote and enhance help-seeking behaviours among young people.

One should not forget that the widespread availability of online information and the increased use of internet sources might be an alternative to the existing professional mental help services. Studies conducted on this type of help-seeking behaviour among young people showed high satisfaction rates [58]. However, not all the available information is reliable, and a lot of mental health problems cannot be solved through self-paced online resources, although e-health resources could be a useful supplement to the existing traditional mental health services. Web-based programmes are not only promising in delivering digital assessment methods [59], they are also effective with therapeutic and supportive approaches [60] and may result in a high degree of satisfaction [61]. Online support, with its proven cost-effectiveness [62,63], availability, and proximity to the daily internet behaviours of adolescents, might be a beneficial alternative or complement to existing programmes. Mental health professionals could also provide essential online services and help to ensure easy access to reliable statistics regarding frequent mental health illnesses among teenagers to design better and more focused interventions.

This study is not without limitations. Although no internal dropout was observed in this study, the generalisability is somewhat limited because of the nature of the data collection, involving only adolescents with internet access. For future planning, repeating the study with paper-based surveys is strongly recommended to reach a broader population. Furthermore, semi-structured face-to-face interviews could provide qualitative and enriched data for more detailed and nuanced results.

In conclusion, the complexity of the help-seeking process is an old-new challenge. The young age of the participants in this study, their socio-economic dependence on the family, and their current health-related behaviours all add to the complexity of help-seeking. This study contributes by identifying facilitating factors as well as barriers in an Arabic context (Oman) to fill the exiting knowledge gap; both need to be considered when planning interventions targeting the younger individuals in this society. One cannot ignore barriers, but the study suggests that facilitating factors are the core components in promoting positive attitudes, favourable intentions, and less stereotypical attitudes towards mental help-seeking.

Disclosure statement

There are no relevant financial or non-financial competing interests to report.

Author contributions

OAO is the main contributor to the study conceptualization and supervision during data collection. AK had the main responsibility for the qualitative data analysis and drafted the original manuscript together with OAO and MAQ. SAS conducted the formal analysis together with IAH who also had the main responsibility for the methodology. MAJ and JD assisted in writing, reviewing, and editing of the paper. All authors read the manuscript critically and revised it.

Data availability statement

The SPSS data used to support the findings of this study are restricted by the Research and Ethics Committee in the College of Nursing at Sultan Qaboos University to protect patient privacy. Data are available from Dr. Omar Al Omari, [email protected], for researchers who meet the criteria for access to confidential data.

Additional information

Funding

This work was supported by the College of Nursing at Sultan Qaboos University under grants [IG/CON/FACN/20/03]. Open Access funding is provided by Kristianstad University.