1. Background
The Asian Development Bank has reported that by 2030, the Asian continent will have the highest number of older people globally (1). According to estimates, the number of older adults in Iran is projected to exceed 10 million by 2035, with the percentage of elderly individuals surpassing 11% (2). The increasing number of older adults in societies highlights the importance of considering their health requirements (3). Mental health is a significant concern for older adults, and statistics indicate that over 20% of individuals aged 60 and above experience mental or nervous disorders. Furthermore, mental and neurological disorders among this age group contribute to 6.6% of all disability-adjusted life years (DALY) (4). Many community-level services aim to improve the mental health of older adults, offering support such as counseling and seeking mental health help. However, many older adults do not use these services (5). It is essential to understand why many older adults do not receive help for their mental health problems, even when they are experiencing severe mental health symptoms. This understanding can help develop interventions specifically targeting their needs (6).
Help-seeking behaviors are crucial for elderly individuals to maintain their health, which refers to any actions taken to seek help from healthcare professionals or trusted individuals in the community (7). Help-seeking for mental health issues is the first step toward mental status assessment, proper diagnosis, and subsequent mental health intervention and management by professionals (8). Further, help-seeking is defined as an adaptive coping process and an attempt to obtain external help for dealing with mental health concerns (9).
Mental health help-seeking attitudes affect determining whether elderly individuals will seek mental health assistance, which significantly influences their utilization of mental health services (10, 11). In addition, attitudes are crucial in decision-making when confronted with an event (12). Positive attitudes towards healthcare services significantly impact one's ability to cope with illness and maintain overall well-being (13). In addition, attitudes are essential in adopting self-management measures as a reliable indicator of whether someone will be help-seeking (14). Furthermore, it is essential to acknowledge that older adults face a significant barrier in accessing mental health services due to their negative attitudes towards help-seeking (15).
2. Objectives
This study aimed to examine the attitudes of elderly individuals in Kermanshah City, Iran, towards seeking mental health help.
3. Methods
3.1. Participants
This cross-sectional descriptive study was conducted in the winter of 2022 among 538 individuals over 60 covered by the pension funds in Kermanshah. The sample size was calculated at a 95% significance based on the results of a pilot study, as much as 538 using multi-stage cluster sampling. Initially, a fund was randomly chosen from each national pension fund, armed forces, and social security. Then, a simple random sampling method was employed to select eligible individuals from each center. This process resulted in separate lists of individuals aged 60 to 75 for each fund or insurance company. Next, participants were randomly selected from the retirees covered by each pension fund, and the questionnaires were completed through interviews. The study involved three trained interviewers who had received proper training in communicating with older adults, asking questions, and avoiding bias in the subject matter.
The study included participants between the ages of 60 and 75 who had at least a primary education, were willing to participate, and were covered by the Kermanshah pension fund. Incomplete answers to questionnaire items were considered as exclusion criteria.
3.2. Measure
The data were collected using a two-part questionnaire. A preliminary study was conducted to evaluate the study questionnaires' accuracy before starting the main project. The participants in this preliminary study were 20 older adults, similar to those who participated in the main study. The initial study aimed to gather feedback on the clarity, length, and comprehensiveness and determine the internal consistency measures.
3.3. Demographics
This study examined several background variables, including age (in years), gender (women or men), education level (elementary, secondary, diploma, or academic), marital status (single, married, or widowed), economic status (weak, medium, or good), living arrangements (alone, with spouse and children, with children only, or with spouse only), smoking habits (no or yes), and stress (no or yes).
3.4. Mental Health Help-Seeking Attitude
The Attitudes evaluated a mental health help-seeking attitude Toward Seeking Professional Psychological Help Scale–Short Form (ATSPPH-SF) (16, 17). The ATSPPH-SF consisted of 2 parts: "Openness to seeking professional help for mental health" and "value and need in seeking professional help." The scores were reverse scored, with zero indicating agreement and 3 indicating disagreement. Scale scores ranged from zero to 30, with higher scores indicating a more positive attitude toward seeking help. A cutoff score of greater than 20 points on the scale and greater than 10 points was used for each dimension. Attitudes scoring below these cutoffs were considered negative (16, 17). The reliability of the questionnaire was assessed using Cronbach's alpha coefficient, which was reported as 0.84 in a study conducted with Iranian older adults (18).
3.5. Data Analysis
The data were analyzed by SPSS software version 16 using appropriate statistical tests, including chi-square (relationship between background variables (sex, education level, economic status, marital status, living arrangements, smoking, and having experienced a stressful event in the past year) and mental health help-seeking attitudes), and two-group independent t-tests (relationship between age and health help-seeking attitudes) at 95% significant level. Descriptive data are presented as mean (standard deviation) and number (percentage).
4. Results
The mean age of respondents was 66.01 ± 4.09, ranging from 60 to 75 years. About 40.3% of respondents were women, and 59.7% were men. In addition, 28.4, 12.6, 37.5, and 21.4% of older adults reported having elementary, secondary, diploma, and university education, respectively. Most participants (47.6 %) reported their economic status as a medium. The majority of older adults (76%) were married, and 22.7% had a history of smoking. Additionally, 39.4% of older adults reported experiencing a stressful event in the past year.
Furthermore, 39% (210 people) of older adults had positive mental health help-seeking attitudes, and 61% (328 people) had negative attitudes in this regard. In addition, 41.6% of participants have positive attitudes toward openness to seeking professional help for mental health. About 32.3% of the participants had positive attitudes towards value and need in seeking professional help.
The relationship between background variables and mental health help-seeking attitudes is given in Table 1. The positive attitudes towards mental health help-seeking were more in older adults with higher educational levels (P < 0.001) and better economic status (P= 0.029).
Table 1.Relationship Between Background Variables and Mental Health Help-Seeking Attitudes
| Background Variables | Attitudes | P-Value | |
|---|---|---|---|
| Negative | Positive | ||
| Age | 66.10 (3.97) | 65.86 (4.28) | 0.513 |
| Sex | 0.957 | ||
| Women | 132 (60.8) | 85 (39.2) | |
| Men | 196 (61.1) | 125 (38.9) | |
| Education | < 0.001 | ||
| Elementary | 120 (78.4) | 33 (21.6) | |
| Secondary | 27 (39.7) | 41 (60.3) | |
| Diploma | 128 (63.4 5) | 74 (36.6) | |
| Academic | 53 (46.1 5) | 62 (53.9) | |
| Economic status | 0.029 | ||
| Weak | 147 (67.7) | 70 (32.3) | |
| Medium | 145 (56.6) | 111 (43.4) | |
| Good | 36 (55.4) | 29 (44.6) | |
| Marital status | 0.059 | ||
| Single | 9 (75) | 3 (25) | |
| Married | 238 (58.2) | 171 (41.8) | |
| Widow | 81 (69.2) | 36 (30.8) | |
| Living arrangements | 0.063 | ||
| Alone | 52 (70.3) | 22 (29.7) | |
| Spouse and children | 152 (57.1) | 114 (42.9) | |
| Children | 48 (70.6) | 20 (29.4) | |
| Spouse | 76 (58.5) | 54 (41.5) | |
| Smoking | 0.329 | ||
| No | 249 (59.9) | 167 (40.1) | |
| Yes | 79 (64.8) | 43 (35.2) | |
| Experiencing a stressful event in the past year | 0.390 | ||
| No | 194 (59.5) | 132 (40.5) | |
| Yes | 134 (63.2) | 78 (36.8) | |
The current status of responses to the attitude questionnaire regarding seeking help for mental health is represented in Table 2.
Table 2.Responses to the ATSPPH-SF Items
| Components | Items | Mean ± SD | Total Score |
|---|---|---|---|
| Openness to seeking professional help for mental health | If I believed that I was experiencing a mental breakdown, my initial instinct would be to seek professional help. | 1.98 ± 1.06 | (9.60 ± 3.71) a; positive: 41.6; negative: 58.4 |
| If I were going through a significant emotional crisis right now, I would feel confident that I could find relief through psychotherapy. | 2.08 ± 0.92 | ||
| If I were feeling worried or upset for a prolonged period, I would seek psychological assistance. | 1.98 ± 1.06 | ||
| In the future, I may consider seeking psychological counseling. | 1.76 ± 1.06 | ||
| When individuals are facing emotional issues, it is unlikely that they can resolve them independently. It is often necessary to seek professional assistance to find a solution. | 1.78 ± 0.94 | ||
| Value and need in seeking professional help | I believe that discussing emotional conflicts with a psychologist is ineffective in resolving them. | 2.05 ± 1.06 | (8.81 ± 3.09) a; positive: 32.3; negative: 67.7 |
| There is something commendable about individuals willing to face their conflicts and fears without seeking professional assistance. | 0.95 ± 0.94 | ||
| Given the amount of time and money required for psychotherapy, it is questionable whether it would be beneficial for someone in my situation. | 1.81 ± 1.05 | ||
| Individuals should try to solve their problems before considering psychological counseling as a final option. | 1.68 ± 1.15 | ||
| Personal and emotional problems, like most things, resolve themselves. | 2.31 ± 0.88 |
a Values are presented as mean ± SD.
5. Discussion
The study revealed that 39% of older adults had positive mental health help-seeking attitudes, while 61% had a negative perspective. This result was consistent with a similar study conducted in Saudi Arabia, which found that over half of the participants (54.5%) had negative mental health help-seeking attitudes (19). Another European study found that almost one-third of the respondents believed that professional care for severe emotional problems is either worse or equal to no help-seeking (20). Furthermore, evidence suggests that around 70% of individuals who require mental health services do not receive the service (21). There are various reasons for these negative attitudes toward help-seeking, including cultural, social, and individual factors. One of the harmful consequences of these attitudes is the negative impact on self-esteem. Seeking professional psychological help is often viewed as a threat to one's self-esteem and is seen as a sign of weakness and acceptance of failure (22). These results pose a threat to the well-being of older adults and serve as a warning for health policymakers in Iran. The report emphasizes the importance of giving special attention to this issue to ensure the health and well-being of older adults. Health care providers should consider the development of interventions to promote help-seeking.
There was no significant relationship found between gender and mental health help-seeking attitudes. However, a slightly higher percentage of women (39.2%) compared to men (38.9%) had positive mental health help-seeking attitudes. Mackenzie et al. found that women generally have more positive mental health help-seeking attitudes (23), which could be due to cultural norms that portray men as strong and unsupportive, preventing them from expressing their struggles and failures (24). Additionally, research suggests that women tend to have stronger social relationships than men (25). Therefore, when developing mental health help-seeking attitudes promotion programs in the western region of Iran, it is essential to consider both genders.
The mean age of elderly individuals with a positive mental health help-seeking attitude was slightly lower than those with negative attitudes (65.86 years vs. 66.10 years), although this difference was insignificant. Previous studies have shown that younger people generally have more positive mental health help-seeking attitudes (26, 27). However, Mackenzie et al. concluded that older individuals are more likely to seek help from mental health primary care doctors compared to younger adults, but there was no significant relationship between age and mental health help-seeking attitude (23). Another study by Mackenzie et al. among American adults found that older adults have more positive mental health help-seeking attitudes compared to younger adults (28). These studies highlight inconsistencies between age and mental health help-seeking attitudes, indicating the need for further research.
This study discovered that unmarried individuals had more negative attitudes than those who were married. These findings were consistent with those of Yin et al. on older adults in China. The reason for this difference in attitudes can be attributed to the supportive role of a spouse, which motivates individuals to seek treatment (29). Single individuals should be given priority in the development of interventions to encourage mental health help-seeking, and more attention must be paid to their needs. These findings highlighted the significance of family support and its beneficial effect on mental health.
In this study, older adults with a lower economic status had negative mental health help-seeking. Additionally, those with only a primary education had the lowest percentage of positive mental health help-seeking. A national study in Denmark also found that individuals from lower socioeconomic backgrounds were less likely to use mental health services (30). Abolfotouh et al. showed that a higher income was a significant predictor of having favorable attitudes toward help-seeking professionals (19), possibly due to the high costs associated with mental health services for those with low incomes. Moreover, a cohort study in Iran showed a slightly higher concentration of mental health disorders among socioeconomically disadvantaged adults (31). Education plays a conflicting role in helping behavior, with some studies suggesting that education plays a significant role, but others suggest that individuals with higher education levels seek help from fewer sources due to stigma and attachment factors (32, 33). There is a need for public health campaigns to educate the general public about the treatments available for mental health problems. A campaign in Germany informed people about depression's causes and treatments, with promising results (34). These findings suggested that interventions should focus more on socioeconomically disadvantaged individuals.
5.1. Limitations
Although this research provided valuable insights into the mental health help-seeking attitude among older adults in western Iran, there are some limitations. Firstly, this study is cross-sectional, so causality cannot be established. Secondly, the study was conducted solely on retired older adults in Kermanshah, so the findings may not be generalizable to other older adults. However, there are also strengths to this study, such as the large number of participants. Additionally, interviews were utilized as the research method, and the percentage of unanswered or misunderstood questions was minimal.
5.2. Conclusions
The majority of the older adults had a negative attitude towards mental health help-seeking. These findings highlighted the importance of interventions to improve the attitudes of older adults toward mental health help-seeking. Educational campaigns are necessary to enhance the positive attitude of older adults toward mental health help-seeking, which should mainly focus on those with limited education and lower economic status.
