1 Key factors determining help-seeking behavior in individuals with schizophrenia
We identified several key influential factors that determine whether an individual with SZ does or does not seek help.
1.1 Education level and a family history of mental disorders are significantly related to help-seeking behavior. Furthermore, the first choice of help is significantly related to education level, with those of greater education more likely to receive professional psychiatric services.
A family history of mental disorders and level of higher education are strongly associated with seeking help. Part of this correlation is that those with a higher level of education tend to have more readily available professional services. Yet, the relationship between a family history of mental disorders and individuals’ with SZ help-seeking behavior has not been formally studied. Zafar and colleagues found education level to be significantly associated with the help-seeking behavior26. Those with higher education may have a greater mental health literacy and an improved recognition of mental disorders. Our findings indicate that whether individuals with SZ seek help or do not seek help depends primarily on how much they know about the disease and their ability to learn more about it.
This research also found that help-seeking behavior is significantly higher in the 30–60% self-pay ratio group than in the 10–30% group. This implies that the more people pay themselves, the more likely they are to seek help. This phenomenon may be associated with the special medical insurance model in China. Citizens in China receive greater reimbursement from the government when they choose to receive medical services from hospitals near their residence (for example: if a woman lives in a rural county, she would need to pay only 10–13% of the cost of treatment at a rural hospital within the same county; whereas, she would need to pay from 30–60% of the cost if she went to an urban hospital, and nearly 70% of the cost to be treated further within the province or in another province. This may indicate that people who have more money for healthcare may pay more attention to their health, and maybe those with more money are more medically literate. Which lead to higher help-seeking willingness?
1.2 There were no significant differences in whether or not individuals sought help based on gender, monthly family income, having medical insurance, public disruptions, self-injury, suicide attempts, risk assessment, or urban versus rural residence.
Gender, monthly family income, possessing medical insurance, publicly disruptive behavior, self-injury, suicide attempt, and risk assessment, urban versus rural residence did not correlate to help-seeking behavior. These negative findings are inconsistent with some previous studies that find patients’ gender having a close relationship to whether or not patients sought help. They attribute the correlation of gender to help-seeking behavior to differences between the sexes in causal attribution of their illnesses27,28. Karam and colleague’s study shows financial concerns as a common barrier for people with mental illness seeking treatment 29. Kilany (2018) found that healthcare utilization by individuals with severe mental illness influences by medical insurance and urban-rural dispersal 30. Huang and colleague’s 2019 study finds that an individual’s perception of a higher severity level indicates greater impetus for treatment 31. The sample size of our study is not big enough, so we assume that the numbers of public disruptions, self-injury, suicide attempt and risk degree assessment are few and may not be represented in this small sample. Factors including gender, monthly family income and medical insurance, residential did not emerge as related to whether individuals seek help, which may have something to do with the sample source. Uniquely, our population is derived from a community sample, whereas previous studies simply used hospitalized populations. The population of individuals with SZ within the larger community differ from a hospitalized population in the severity of the disease state, with the latter typically more severe than the general population. These populations are not homogeneous.
1.3 A disconcerting number of individuals who can be diagnosed with schizophrenia among the general population do not seek help due to common barriers.
Our study reveals a distressing statistic, that nearly one-third of individuals in the general population who can be diagnosed with SZ do not seek help. Similarly, a study by Zhang and colleagues (2013) found that 28.1% of patients with mental illness in the urban areas of northern China do not seek any form of help either32. These results contradict a study in the rural community of Liuyang, China, which showed far fewer than half of the larger percentages of individuals with SZ not seeking help (only 12.7%)33. This stark contrast may be due to differences in sample sources and study procedures.
In our study, the main reasons for not seeking help include fears of stigmatization and discrimination (72.9%), poor mental health literacy (64.5%), concerns over cost of the treatment (50.6%), and limited access to medical services(47.0%). Research from Mavrogiorgou (2015) shows that roughly 40% of their study participants reported fears of stigmatization and discrimination as major barriers to help-seeking behavior34. Other research also found stigmatization as a serious impediment to obtaining help35. Furthermore, Ho and colleagues (2008) pointed to the lack of knowledge about available treatment, the inability to afford the high cost of treatment, and lack of transportation as the pivotal barriers 36. One study of individuals in Ningxia, China found that a general lack of mental health literacy and limited access to specialized medical institutions were the predominant reasons that individuals with severe mental illness chose non-specialized hospitals or did not seek medical treatment 37. The exact same barriers predominated in our study as well, which indicates that to a large degree social factor dictate help-seeking behavior. Increased social tolerance and acceptance of SZ, improved general awareness of SZ and strengthened access to professional psychiatric services are needed.
2 First choices for help-seeking behavior
2.1 Professional psychiatric services and non-medical options are the preferred resource for individuals with SZ who seek help, with over twice as many choosing professional psychiatric services (64.6%, n = 163) over non-medical options (30.8%, n = 78). The top three choices of non-medical options include relatives, praying to Buddha, and traditional and/or faith healers. This study found psychiatric hospital and relatives to be the most common first choices of individuals with SZ seeking help, whereas some studies show psychiatrists and psychiatric hospitals as the most common first choices16.Nonetheless, other studies show general medical hospitals and physicians as the first choice 10,20. Such disparity in findings may arise from different medical structure and low accessibility of psychiatrists and mental hospitals. Their results also contradict with ours in that general medical support and hospitalization was the most common first choice. Some study also indicate that religion15 and traditional/faith healers12 are the most common first choices. However, our study showed the help-seeking behavior of individuals with SZ in the Hunan province of China is comparatively more scientific. In terms of relatives being an initial means of support, a previous study in southern India states that 16.8% of late adolescents with SZ seek help from their mothers, 13 while a study from Nigeria declares that 91% of individuals’ first contact of treatment is initiated by relatives15. This research indicates that relatives play a very important role in help-seeking behavior of individuals with SZ in Hunan province with family support also being positive and strong in China. Research also indicates that improving basic mental health literacy can expand utilization of mental health services 38.
Novel study design using community-based sampling
We believe this is the first study that has investigated help-seeking behavior in individuals with SZ using a community sample at a provincial level. It is of great significance for public health, because it offers information about the current situation about seeking help behavior of individuals with SZ in China, and indicates future direction of medical education development. Main limitation of this study was as followings: 1) There being too few investigators available for this study, we could not personally interview all of the individuals suspected of having SZ who were screened in the first stage; therefore, a considerable proportion of individuals with SZ may have been missed.2)Our study is a small part of a larger epidemiological study of severe mental illness in the Hunan province, missing values did result the tremendous work load at hand.