Students’ Perceived Public Stigma And Mental Health Help-Seeking Attitudes In Brunei Darussalam

Types of stigma

Corrigan (2004) categorized stigma into two types that were associated with mental health. The first one is public stigma, which refers to the community or society’s negative views and attitudes toward the stigmatized group. People who are being stigmatized by the public often face prejudice, get discriminated and are frowned upon. The second type of stigma according to Corrigan (2004) is self-stigma which refers to an individual’s application of public stigma to him/herself. The person identifies him/herself with the group which is being stigmatized and applies these negative views and attitudes toward him/herself.

On the other hand, there is also another type of stigma called perceived public stigma, which refers to an individual’s perception of public stigma (Corrigan, 2004). Perceived public stigma and self-stigma can give a strong negative impact on a person’s self-efficacy as well as self-esteem.

Seeking professional psychological help

Seeking help is a method in which a person reaches out to other people to assist him/her in overcoming the difficulties that the person could not overcome him/herself. During the process of help seeking, the person seeks for emotional support, information, opinions as well as suggestions to overcome the psychological issues distressing him/her (Mundia, Shahrill, Jaidin, Jawawi, & Mahadi, 2016; Mundia & Shahrill, 2018a, 2018b). According to Rickwood, Deane, Wilson, & Ciarrochi (2005) there are two sources of help seeking: informal; and formal. Informal sources are friends and family whereas formal sources are the professionals who are certified such as psychiatrists, psychologists and counsellors (Rickwood et al., 2005). Thus, seeking professional psychological help is defined as an attempt of a person to reach out and seek treatment from a professional in order to solve his/her psychological issues such as depression, fears, anxieties and other emotional problems (Atkinson & Gim, 1989).

Perceived public stigma and attitudes toward seeking professional psychological help

Vogel, Wade, and Hackler (2007) stated that there was a positive correlation between public perceived stigma and attitudes toward seeking counselling. However, Eisenberg, Downs, Golberstein, & Zivin (2009) found that perceived public stigma was not significantly associated with help-seeking attitudes. In addition, the results from Ina and Morita (2015) contradicted the findings of both Vogel et al. (2007) and Eisenberg et al. (2009) in that they obtained a negative correlation between perceived public stigma and help-seeking attitudes. Furthermore, using hierarchical regression analysis on data from a sample of undergraduate students (84.5% of whom had previously received psychological help), Topkaya (2014) obtained a significant weak correlation between perceived public stigma and attitudes toward seeking psychological help.

Gender difference and attitudes toward seeking professional psychological help

Vogel et al. (2007) examined the gender and found that females were more likely to have positive attitudes toward seeking professional help compared to males. In addition, females were also more likely to seek help from the professionals than males (Vogel et al., 2007). Similarly, the study by Cebi (2009) also found that females had more positive attitudes toward seeking help from the professionals than males. In the study by Sahin and Uyar (2011) female students who previously received help from the professionals had more positive attitudes toward seeking professional psychological help than other participants. In Japan, the studies by Kimura and Mizuno (2008) and Ina and Morita (2015) found no significant difference between males and females in their attitudes toward seeking professional psychological help. Hence, there was a possibility that the inconsistencies in the findings from Japanese and western previous studies might be due to cultural differences.

Gender and stigma

Ina and Morita (2015) investigated the difference between male and female perceived public stigma and self-stigma and found that there was a significant difference between males and females on their perceived public stigma scores. The results showed that women perceived public stigma scores were higher than men’s scores (Ina & Morita, 2005). However, this study was not consistent with that of Komiya, Good, & Sherrod (2000) which found that males experienced more perceived public stigma than females. Hackler, Vogel, and Wade (2010), who conducted a research using a sample of undergraduate students with eating disorders also found that men experienced more perceived public stigma and tended to have had negative attitudes toward seeking professional help. One of the reasons why males tend to seek professional help less often than females is that they probably internalize public stigma more strongly than women (Vogel et al., 2007). Topkaya’s (2014) study stated that men were more likely to experience both perceived public stigma and self-stigma associated with psychological help-seeking compared to women. In addition, the study also revealed that the self-stigma associated with seeking psychological help was more important than the perceived public stigma in explaining attitudes toward seeking help from the professionals (Topkaya, 2014).

Design of study

The study used a field survey design. Under this approach, the first author personally went to the chosen Sixth Form schools, distributed the research questionnaires to selected participants, and collected the completed protocols. The main advantage of this procedure was that items that were not understood by the respondents were clarified and the data were collected quickly. However, the design may have had drawbacks such as negative effects arising from the presence of the researcher (e.g. giving cautious and defensive responses due to social desirability). Every effort was made to ensure that these undesirable effects were minimized.

The participants

The population of this research consisted of Brunei Year 12 and Year 13 students in four government Sixth Form schools located in the Brunei-Muara district. The Sixth Form schools or colleges in the Brunei government education system are intermediary institutions between senior high school and university levels of education. There are seven such schools in Brunei. Of these, five are government schools while two are categorized as private or international schools. All the five Government schools are located in the Brunei-Muara district. Four of the five government schools were selected randomly to participate in the present study.

The Sixth Form level of education in Brunei consists of two class levels: (1) Year 12 also known as General Certificate of Education Advanced Subsidiary Level; and (2) Year 13 referred to as the General Certificate of Education Advanced Level. Student enrolment numbers differ widely in these Year 12 and Year 13 classes from school to school. During the data collection phase for the present study, we found that there were on average five Year 12 and five Year 13 classes at each school. In addition, we also discovered that there were 30-40 students in each class (average = 35). Using these average numbers of classes and students in each class, we estimated that there were 700 Year 12 and 700 Year 13 students altogether in these Sixth Form schools during the academic year we collected the data (giving a total population of about 1,400 Sixth Form students).

In order to conduct this study, 40 participants (20 females and 20 males) were randomly selected from each school. The number 40 was arbitrarily chosen without any special criteria or justification. Hence, the total participants required and recruited were 160 (11.429% of an estimated population of about 1,400). Thus, the sample size was moderate for computing stable statistics at p = 0.05 (two-tailed) according to the table of population and corresponding sample size values developed by Krejcie and Morgan (1970). Only full Brunei citizens and permanent residents were included in the study while foreign students were excluded. The participants were chosen using the simple random selection procedure. Ethnically, the sample consisted of 76.8% Malays, 2% Mixed or part-Malays, 15.9% Chinese, 2% Iban, and 3.3% other groups. The participants’ overall age ranged from 16 to 19 (Mean = 17.090; SD = 0.889). Most of the participants were aged 17. Other gender, age, and school characteristics of the sample are summarized in Table 01 .

Materials used for the study

A short 5-item biographic questionnaire constructed by the researchers was used to collect demographical information (gender, age, school, ethnicity, and citizenship status). These were used as grouping variables during data analyses except for ethnicity.

Data on stigma were collected by the 12-item Perceived Devaluation–Discrimination Scale (Link, Cullen, Frank, & Wozniak, 1987). This is a 6-point Likert-scale with responses ranging from 1 (strongly agree) to 6 (strongly disagree) about the degree to which they believe other people will devalue or discriminate against someone with a mental illness. One example of the statements in this survey is: “Most people would not hire a former mental patient to take care of their children, even if he or she had been well for some time”. In this questionnaire, higher scores indicate more perceived public stigma. The scale has been reported to have good alpha reliability of approximately 0.800 (Yang & Link, 2015). The alpha reliability of this measure based on the Brunei sample in the present study was 0.783.

Attitudes toward help-seeking counselling were measured by using the Attitudes toward Seeking Professional Psychological Help Scale (Fischer & Farina, 1995). This is a 4-point Likert scale with responses ranging from 1 (disagree) to 4 (agree) for each item. The survey consists of 10 items such as “If I believed I was having a mental breakdown; my first inclination would be to get professional attention.” For this questionnaire, higher scores represent having more positive attitudes toward seeking help from the professionals. In a previous study (Türküm, 2004) this instrument had an alpha reliability of 0.880. Using the Brunei sample for the current study, the instrument had an alpha reliability of 0.816.

The two scales used in the present study had good discriminant validity. The correlation between the Attitudes toward Seeking Professional Psychological Help Scale (Fischer & Farina, 1995) and the Perceived Devaluation–Discrimination Scale (Link et al., 1987) based on the data from the current study was low and insignificant [r(160) = 0.082, p = 0.303ns]. The two instruments measure two conceptually different notions or domains, namely help-seeking and stigma. In addition, the data from the two questionnaires also had sufficient ecological validity since the inventories were administered to the participants in their respective schools.

The procedures

This study used data from the Master of Counseling degree research exercise project pursued by the first author in the Sultan Hassanal Bolkiah Institute of Education at the University of Brunei Darussalam. In the first step of conducting the research, the investigator obtained permission letters from the University of Brunei Darussalam as well as from the Department of Schools in the Government of Brunei Darussalam to conduct the study in the Sixth Form schools. Next, the Sultan Hassanal Bolkiah Institute of Education Faculty Ethics Committee approved the study on behalf of the University of Brunei Darussalam Ethics Committee. The study’s approval letters from the Sultan Hassanal Bolkiah Institute of Education, University of Brunei Darussalam, and the Department of Schools were presented to every sixth-form school involved in this study.

On the day of data collection, the students were gathered at in a venue or classroom prepared by the school and a brief explanation was given by the researcher to the students regarding the purpose of the study, ethical issues for participating, and instructions for the data collection instruments. The participants answered the questionnaires anonymously and their identities were kept confidential by the researchers. Names of the four participating schools were also concealed and kept anonymous. In addition, the participants also had the right to withdraw from the study at any stage of the research. Since the rating scales were written in simple English language requiring only Year 8 education to understand, the questionnaires were not translated to Bahasa Melayu, the official language spoken by the majority of the people in Brunei.

Data analysis

The data were analyzed by descriptive statistics, Pearson correlations, t-tests for independent groups, and One-Way ANOVA using Statistical Package for Social Sciences version 22. Statistical significance was set at p< 0.05 level (two-tailed).

Relationship between perceived public stigma and attitudes toward seeking help

According to the results of the current study, there was no significant relationship between perceived public stigma and attitudes toward seeking help [r(160) = 0.082, p = 0.303ns]. This meant that stigma does not greatly influence attitudes toward seeking professional help and vice versa. People who suffer from having a stigma of some kind could be encouraged to seek professional help from mental health specialists. Those who are unable to resolve their own problems could also be encouraged to seek help from mental health providers.

Differences in perceived public stigma and attitudes toward seeking help by gender

As reported in Table 02 , no significant statistical differences were obtained by gender on the participants’ mean scores pertaining to perceived public stigma and attitudes toward seeking help. However, the males’ mean score (14.640) on attitudes toward seeking help was relatively lower than both the females’ mean score (15.220) and the combined genders’ mean score (14.930) on the same variable. This finding suggested a need for males to receive counseling on attitudes toward help-seeking. Similarly, the males’ mean score (28.650) on perceived public stigma was also relatively lower than both the females’ mean score (30.350) and the combined genders’ mean score (29.490) on the same scale. In this case, the finding implied a less need for males to receive counseling on perceived public stigma compared to their female peers (see Table 02 ).

Differences in perceived public stigma and attitudes toward seeking help by age

No statistically significant differences were detected on the samples’ performance on both scales (perceived public stigma and attitudes toward seeking help) as indicated in Table 03 . However, the trend of the mean scores hinted that the older adolescents (19-year olds) would benefit from counseling on both variables (perceived public stigma and attitudes toward seeking help) as they scored lowest and highest respectively on these scales compared to their younger adolescent counterparts, 16-18 year olds (see Table 03 ).

Differences in perceived public stigma and attitudes toward seeking help by school.

According to Table 04 , the participants’ mean scores did not differ significantly in terms of school attended. However, a critical look at the pattern of the mean scores provided a clue that the participants at School C would benefit most from counseling on both attitudes toward seeking help (in which they scored lowest) and perceived public stigma (in which they scored highest) compared to fellow students in Schools A, B, and D.

Relationship between perceived public stigma and attitudes toward seeking help

The outcome of this research was in line with Eisenberg et al. (2009)’s findings, which revealed that there was no significant association between those two variables. According to them, personal stigma - defined as the aggregate of each individual’s stereotypes, prejudices and attitudes towards public stigma that may or may not align with perceived public stigma – was significantly associated with attitudes toward seeking professional help. This may hold true for the current study as well. Perhaps, among Sixth Form students in Brunei, they value their own perceptions and evaluations of mental illness (personal stigma) more than what the others think about mental illness (perceived public stigma). Since the present study only included Perceived Devaluation Discrimination scale, the students only answered the questionnaire in terms of how they think others perceive mental illness, rather than their own judgments about it, hence resulting in no significant association between perceived public stigma and attitudes toward seeking professional help.

On another note, Vogel, Wade and Hackler (2007) conducted a similar study and found a significant association between perceived public stigma and willingness to seek counselling, but only when mediated by self-stigma. Self-stigma, as defined by Vogel and colleagues, is the perception held by the individual that he or she is socially unacceptable, which can lead to a reduction in self-esteem or self-worth if the person seeks psychological help (Vogel, Wade and Hackler, 2007). They reasoned that perceived public stigma contributed to self-stigma, which in turn impacted their attitudes, and eventually their willingness, to seek professional assistance such as counselling. This implies that self-stigma may be the essential element for bridging the relationship between attitudes towards seeking professional help and how a person thinks about the public’s perception towards stigma. Since the current study did not include any questionnaires relating to self-stigma, this may be the reason why the association between perceived public stigma and attitudes towards seeking professional help appeared absent.

Gender differences in attitudes toward seeking professional help

In contrast to previous studies (MollerLeimkuhler, 2002; Topkaya, 2014), the current study found no significant gender difference in attitudes toward seeking professional help among Sixth Form students in Brunei. These discrepancies may be attributed to the fact that in these past studies, the female participants involved had attended counseling and had more exposure to psychological help compared to their male counterparts, whilst Brunei population in general regardless of their gender, had limited access and knowledge to such services, which therefore might have resulted in such lack of gender difference. The scores for most Brunei participants on the Attitudes toward Seeking Professional Help scale were in the 15-30 range, a trend termed as the “middle option” by previous study (Moors, 2008). Wang, Hempton, Dugan, & Komives (2008) reinforced this phenomenon by proposing that Asians were more likely to avoid extreme responses when answering surveys.

Cultural differences may also be another reason that contributed to these contradicting findings, in which the sample in the present study largely comprised of Asian population, whereas past research mostly used Westerners as their participants. This justification could be supported by other similar studies which claimed that in Japan, an Asian country, male and female students did not differ in their attitudes associated with seeking professional help (Ina & Morita, 2015; Kimura & Mizuno, 2008).

Gender difference in perceived public stigma

Similar to that of attitudes toward seeking professional help, the present study also did not find any significant gender difference in perceived public stigma. Many previous studies did not also find any significant statistical differences and most had inconsistent results. For example, Ina and Morita (2015) claimed that women’s perceived public stigma scores were higher than that of men, while others (Komiya et al., 2000; Hackler et al., 2010; Topkaya, 2014) suggested that males experienced more perceived public stigma than females. The apparent absence of gender differences in the present Brunei study might be explained by the fact that the students recruited were from mixed gender or co-educational institutions in which they socialized and lived in a shared school environment that lead them to adopt similar ways of thinking.

Differences in perceived public stigma and attitudes toward help-seeking by age and school

From the many studies reviewed above in this study, none investigated the role of age and school attended in influencing and shaping scores on perceived public stigma and attitudes toward help-seeking. Although the present study did not obtain any significant differences pertaining to age and school variables, important trends and patterns emerged that make the present study unique and novel. As per the results of the current study, the most at-risk and vulnerable participants with regard to both perceived public stigma and attitudes toward help-seeking were students aged 19 and learners attending School C. These would benefit from receiving appropriate counseling and psychotherapy interventions.

The limitations of the study

The current had two important drawbacks. First, it only investigated perceived public stigma excluding personal stigma and self-stigma which would have been more insightful as was done by Eisenberg et al. (2009) and Vogel, Wade and Hackler (2007). This may have led to more detailed findings concerning the relationship between public stigma and attitudes towards seeking professional help. Second, inclusion of a quantitative section would have helped in expanding and clarifying findings from the quantitative survey.