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5. 6 Relationship Between Stigma and Help-seeking Delay


This study shows that approximately 15% of patients and carers reported help-seeking delays during the last year due to concerns of stigma. This section examines the relationship between stigma and help-seeking delay and how help-seeking delay can be predicted by levels of stigma.

Corrigan (2004) outlined the social cognitive processes that contribute to stigma and how they also contribute to delays in help-seeking. These processes include

behaviours to avoid the label of mental illness and to reduce threats of diminished self esteem due to self stigma. These behaviours can manifest as taking longer to seek help (Corrigan, 2004). In keeping with this, our findings revealed a small but significant positive correlation between public stigma of carers and recent help-seeking delay (rs

= .22). There are a number of reasons that a positive relationship between stigma in carers and help seeking delay may have been found. In Sri Lankan culture the carer plays a pivotal role in help-seeking. This is due to the hierarchical system present in Sri Lankan families where the carer (usually parent) is the one who makes decisions for the patient. Prior research based on a census of over 12,000 community members from 2200 Sri Lankan households, that was conducted on seeking help for general medical problems has shown that there is high involvement of Sri Lankan women in the decision to seek health care (Caldwell, 1996; Peiris & Caldwell, 1997). When the women were asked who decides to take a sick child to a doctor, 48% responded that the mother alone decides this while, 45% said the mother decides this with her husband’s agreement (Peiris & Caldwell, 1997). It was speculated by the authors that the reasons for women being able to seek health care for themselves and their family members on their own initiative was due to the high literacy rate among women (89.2% for females according to Ministry of Healthcare and Nutrition, 2009). High literacy was argued to be related to better education around health and hygiene. Although this study referred to help seeking for children, anecdotal evidence suggests women may be assumed to have these views when it comes to help-seeking for their adult children in the case of mental illness. A majority of the carers in our study were female and help seeking is usually a family venture. Together these factors likely contribute to the finding that carer’s perceived stigma predicted help-seeking behaviour.

There was no significant correlation between either public stigma of patients and recent help-seeking delay or between self stigma of patients and recent help-seeking delay. These findings are important because they focus on the effect of both patients’

and carers’ perceived stigma on treatment delay. Almost all the patients attended the clinic accompanied by their family carer indicating family carers are strongly involved in the help-seeking process. This relationship between perceived stigma of carers and recent help-seeking delay indicates that even relatives can be affected by stigma thereby increasing the time taken to access services. This is consistent with findings of a study conducted in Los Angeles by Okazaki (2000) with 40 caregivers that showed relatives’

reported stigma was significantly and positively related to patients’ treatment delay (r

= .40).

However, some studies did not report an association between stigma and help-seeking delay (Compton & Easterberg, 2005; Golberstein, Eisenberg & Gollust, 2008).

For example, a study on African-American patients with first-episode psychosis failed to find an association between treatment delay and stigma (Compton & Easterberg).

This may be explained by the fact that the study had only patients with acute psychoses.

It is possible that the severity of the presentation and potentially disruptive behaviour associated with psychosis made recognition of the problem as a mental illness much clearer and the length of treatment delay shorter. Although there was no relationship between stigma and treatment delay, Compton and Easterberg did find an association between stigma and perception of greater barriers to seeking psychiatric evaluation.

Golberstein and colleagues conducted their study with undergraduates and graduates and these participants, who were not having mental illnesses, may have accounted for there being no significant relationship between help-seeking delay and stigma

Our findings do not concur with studies that have stated that self stigma of patients has a stronger effect than public stigma on influencing help-seeking (Barney et al., 2006, Vogel et al., 2007). One reason for this may be that prior studies have not surveyed persons identified with mental illness. Barney et al. surveyed members of the general community and Vogel et al. surveyed undergraduates. These community

members and undergraduates would not have felt the effects of mental illness as directly as the patients in our study. Additionally, Barney et al. used vignettes that compared the effect of public and self stigma on help-seeking intentions (likelihood of seeking help

according to a specific source). Barney et al. also studied this association only in relation to a diagnosis of depression whereas we surveyed this relationship in schizophrenia, bipolar disorder as well as depression. Thus, differences in sample characteristics and direct experiences with stigma may have contributed to differences in our findings compared to other studies. Further, in the present study only 10 of the original 22 items from the Ritsher et al. self stigma scale were used. Therefore there is a risk that not all of the elements of self stigma were captured. Finally, it is possible that public stigma plays a more prominent role than self stigma in influencing delay in seeking treatment in the Sri Lankan context.

5. 6. 1 Predicting Help-seeking Delay using Carers’ Stigma Ratings

The relationship between public stigma and help-seeking was examined to look at how we could predict help-seeking delay using the public stigma of carers. Multiple regression analysis found that public stigma (discrimination and disclosure subscales) reported by carers accounted for a significant 20% of the variability in help-seeking delay reported by carers. This was further refined with a quadratic model explaining an additional 5% of variance in help-seeking delay. This quadratic model had the variables discrimination, disclosure, and their squared values and their cross-products as


The contour plot for the quadratic model indicated that as both discrimination and disclosure increase, the help-seeking delay also increased. However, this occurred at an increasing rate as increments of disclosure and discrimination increased. In other words, as disclosure and discrimination increase the increment of the increase in help-seeking delay gets larger (i.e. the contour plot lines get closer). This “bowl ” shape is different from a purely linear shape because it shows that gradient rises slowly at first and then steeply (the lines get closer as the inclination increases). This means that the help-seeking delay due to stigma increases slowly at first and then increases more sharply as stigma increases. Initially small increases in stigma may have a small effect on help-seeking delay but as stigma increases there is an exponential increase in its relationship to help seeking delay.

Treatment delay is important in patients with a psychiatric illness, especially those with a psychosis, because delay potentially worsens the prognosis as does

intermittent treatment (Falloon, 1992; Loebel et al., 1992). The findings of the present study suggest that stigma experienced by carers plays an important role in contributing to treatment delay. Stigma is one component of burden for patients but also a source of additional burden for carers. The next section describes the carer burden due to stigma and other related factors.