literature review help seeking behaviour

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College Student’s Academic Help-Seeking Behavior: A Systematic Literature Review

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Seeking academic help has a positive impact on students’ ability to handle challenges, leading to improved academic success. As the academic landscape becomes more competitive, the importance of students seeking and using academic support is widely recognized for enhancing their learning experience and achievements. The main objective of this study is to review the prior literature that has examined the academic support provided to college students, addressing the knowledge and methods required in an academic help-seeking process. Based on a systematic literature review, this study’s data were gathered from a review of 55 documents from the 11 years between 2012 and 2022. The literature was then individually analyzed using the ATLAS.ti 22 programs. The analysis shows five central themes: (1) Defining student help-seeking; (2) Academic help-seeking and academic performance; (3) Resources of academic help-seeking; (4) Factors of academic help-seeking; (5) Academic Help Seeking Online. This study also identifies potential new directions for future research that could be useful to school administrators in developing policies to assist students with help-seeking behavior, which could have significant implications for the theoretical development and practical guidance of student help-seeking behavior.

1. Introduction

As higher education entered the era of massification in many nations during the 20th century, an increasing number of individuals have been able to attend college [ 1 ]. Meanwhile, university assignments have become increasingly complex and challenging. At college, students face a variety of academic obstacles [ 2 , 3 , 4 , 5 ]. Learning is hardly ever accomplished alone. Therefore, students should seek help from their teachers or peers [ 6 , 7 , 8 ], the school’s counseling service [ 9 ], or the Internet [ 10 ]. The ability to actively seek academic assistance to promote academic success is one of the most important study skills college students must possess. If students struggle with completing their projects, they may want educational support to figure out the issue or challenge themselves [ 11 ]. People may experience this scenario psychologically in many ways, engage in various thought processes, and adopt various behaviors. From a learning adjustment perspective, academic help-seeking (AHS) is often considered to be a more important and effective self-regulation strategy [ 12 , 13 , 14 ]. Obtaining academic help is also an essential self-regulated learning strategy for college students, which plays a significant role in their academic careers [ 15 , 16 , 17 , 18 ]. AHS involves seeking support from individuals and other sources to help students do well in the academic environment [ 10 , 19 ].

Since the 1980s, numerous studies have been published that investigate the definition and structure of AHS as a construct [ 20 , 21 ] and relate it to other key variables in the education disciplines [ 22 , 23 , 24 ]. Nonetheless, due to its social aspects, AHS exhibits diverse individual traits. Its complexity manifests itself on various levels, including the factors that impact AHS, the performance of AHS, and its effects. Interest in this topic has developed during the past decade [ 25 ]. College students’ academic help-seeking behavior is a complex phenomenon that has garnered significant research attention. However, there is a need for a comprehensive understanding of this behavior, including its characteristics, trends, and various aspects related to its definition, relationship with academic performance, available resources, influential factors, and the impact of online platforms. Additionally, a systematic evaluation can synthesize existing research on college students’ academic help-seeking behavior and provide a holistic view of the topic. And hence, this study examines a selection of the literature about college students’ academic help-seeking behavior and focuses on answering the following questions:

RQ1: What are the characteristics and trends of the articles related to college students’ academic help-seeking behavior published between 2012 and 2022, considering the country of origin, journal sources, and publication timeline?

RQ2: What insights can be gained regarding college students’ academic help-seeking behavior, including its definition, relationship with academic performance, available resources, influential factors, and the impact of online platforms?

RQ1 focuses on identifying the characteristics and trends of articles published between 2012 and 2022, considering factors such as the country of origin, journal sources, and publication timeline. This analysis will provide insights into the research landscape, highlighting key contributors and temporal patterns in the field. RQ2 delves into the various aspects of college students’ academic help-seeking behavior, including its definition, relationship with academic performance, available resources, influential factors, and the impact of online platforms. By examining these dimensions, the study aims to uncover valuable insights that can inform the development of effective interventions and support services for college students. Furthermore, this systematic review will identify research gaps and propose future research directions. It will shed light on common barriers and facilitators affecting students’ engagement in academic help-seeking, ultimately contributing to the advancement of knowledge in this field.

2. Background Literature

2.1. academic help-seeking behaviors.

“Help-seeking” is a structured and interactive social behavior that has been found to have a positive correlation with academic achievement among students [ 26 ]. In one of the earlier studies, Karabenick and Knapp [ 14 ] noted that the distinction between formal and informal academic assistance was made. The formal ones included resources from mentors and schools, while the informal ones included friends, peers, and family. Nelson-Le Gall and Jones [ 27 ] found two types of student help-seeking behavior observed: one in which students were more independent in their use of AHS behavior and another in which they were more dependent. When seeking executive assistance, students wish to receive answers to their questions without any effort on their part. When students wish to improve their learning and problem-solving abilities, they seek instrumental assistance. It is also viewed as a self-regulatory learning strategy for students to seek academic assistance [ 28 ]. Another definition of help-seeking is by Ryan and Pintrich [ 29 ], who defined it as the capacity to utilize others or other resources to solve problems when confronted with learning difficulties or challenges and complex situations. Umarani [ 30 ] reminds us that seeking academic help is a learning strategy that can effectively facilitate student learning and ultimately benefit students’ academic performance. About the help-seeking process, Karabenick and Dembo [ 31 ] outlined eight steps: (1) decide whether a problem exists; (2) decide whether assistance is required or desired; (3) determine whether to request assistance; (4) choose the type of help you want (executive or instrumental); (5) choose the person you want to seek for help; (6) ask for help; (7) get help; (8) process the help you got. These steps must be carried out in an effective manner, which calls for cognitive, social, and emotional competencies that are instructible to students who might be lacking in these abilities.

2.2. Relationship between Academic Help-Seeking and Academic Success

For many years, researchers have researched the relationship between AHS and academic performance, with most studies indicating that academic help-seeking behavior has a favorable effect on academic success. Micari and Calkins [ 32 ] showed that teachers who are receptive to students’ requests for assistance will receive increasingly higher grades. In other words, students will have a higher GPA and eventually succeed in college if they ask their teachers for assistance more frequently. One study by Umarani [ 30 ] found that students with academic difficulties who actively seek academic assistance can improve their academic performance. In general, students who refuse academic support perform worse in school than those who regularly interact with their teachers. Another study by Algharaibeh [ 33 ] offered an analysis of the various sources of academic help, including the fact that formal sources are typically school teachers and academic service centers provided by the school, whereas informal sources are typically parents, peers, classmates, etc.

Whether formal or informal, help-seeking can improve academic performance, encourage positive learning, and increase students’ sense of self-efficacy. Previous research on academic help-seeking has demonstrated that seeking assistance from official sources (e.g., teachers and academic service centers) or informal sources (e.g., peers and family) promotes positive learning trends, increased self-efficacy, and enhanced academic performance [ 19 ]. While students’ academic help-seeking behavior is very negative in traditional learning environments, primarily because students believe that asking for academic help in public implies that they are not capable of learning and because they believe it has an impact on their self-esteem [ 34 ].

3. Materials and Methodology

This study employs a literature review approach to fulfill its objective of identifying the key aspects of a subject or topic through analysis of previous research to identify research gaps. Specifically, the study is a thematic review of relevant literature. By allowing for thematic grouping, a thematic literature review enables researchers to showcase the specific topics that are most relevant to their research. The present study employs a thematic literature review as its primary analytical technique, which involves searching for and analyzing relevant data obtained from databases. This approach has been utilized by numerous previous studies [ 35 , 36 , 37 , 38 ]. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were used to manage the literature search [ 39 ].

3.1. Databases and Search Terms

Multiple strategies were employed to obtain a wide range of related studies within the scope of this SLR [ 40 ]. We use the electronic databases Web of Science (WOS) and Scopus, ERIC (Education Resource Information Center), PsycINFO (EBSCO), and ScienceDirect to search the included articles. For each characteristic (help-seeking, college students), we used multiple terms to enhance our ability to find as many relevant articles as possible. For the characteristic of help-seeking, we use terms: Online academic help-seeking OR OAHS OR academic help-seeking OR AHS OR academic help-seeking’ OR ‘academic advising’ OR ‘academic advice’ OR ‘intrusive advising’ OR ‘support service’ OR ‘support services’ OR ‘academic support’ OR “help seeking” OR “help-seeking” OR “Help-seeking behavior” “Help-seeking intentions” OR “Learning strategies” OR “Question asking” OR “self-regulated learning”. For the characteristic of college students, we used the terms: “university” OR “college” OR “academy” OR “higher education” OR ‘university student’ OR ‘university students’ OR ‘college student’ OR ‘college students’. Within each category, keywords were joined with OR, and terms were joined with AND between each category A string was adopted in five databases ( Table 1 ). To ensure the assessment was comprehensive, we also used backward and forward snowball search techniques [ 41 ]. The five focal databases were then mined for a total of 1839 articles.

Search string.

3.2. Inclusion/Exclusion Criteria

All searches were carried out in June 2023. Papers were included for consideration using the following criteria: (1) publication dates range from 2012–2022; (2) the following keywords must be included: college students, academic help-seeking, help-seeking behavior, and undergraduate students; (3) the language used in the article is English; (4) quantitative, qualitative, and mixed methods studies are included to consider this research topic in different dimensions. The chosen period for this study is 2012–2022. This selection is based on several factors. Firstly, during this timeframe, online resources were widely used, allowing us to examine the impact of technology integration on college students’ academic help-seeking behavior. Secondly, focusing on the years 2012–2022 ensures access to recent and relevant literature, enabling us to capture the latest trends and advancements in understanding this behavior. Lastly, a narrower time frame allows for a thorough review of the literature, enhancing our understanding of college students’ academic help-seeking behavior.

Criteria for exclusion: (1). Articles focusing on individuals outside the college student population, such as K12 students, adults, elderly individuals, disabled individuals, and non-college groups, will be excluded from the review. (2). Articles that primarily focus on help-seeking behaviors related to physiological concerns, psychological issues, or mental health conditions, rather than academic help-seeking, will be excluded. (3). Articles that do not directly address the research question and are not related to the definition of academic help-seeking, resources for academic help-seeking, influencing channels, and factors of online academic help-seeking will be excluded. (4). Non-empirical articles, such as literature reviews, theoretical papers, opinion pieces, and editorials, will be excluded from the review. Only empirical studies reporting original research findings will be considered. (5). Articles written in languages other than English will be excluded from the review, as the analysis will focus on English-language publications. (6). Papers that are not available in full text.

3.3. Selection of Articles and Descriptive Overview

All searches were carried out in June 2023. Web of Science (WOS), Scopus, ERIC (Education Resource Information Center), PsycINFO (EBSCO), and ScienceDirect were used to conduct the literature search for this study, and they returned 1839 results. In the first step, 1839 articles were stored in Endnote X9, and 442 duplicates were removed. We went on to remove 156 documents based on the range of time and language. In the second phase, two independent investigators screened the articles against the eligibility criteria based on the title, abstract, and keywords, 1135 articles were removed. After a full-text examination, 55 articles published between 2012 and 2022 were selected for qualitative synthesis. Figure 1 summarizes the three phases of the process of choosing references for analysis and prior studies (identification, screening, and inclusion).

PRISMA flow diagram of the research process.

3.4. Quality Assessment of Included Studies

To assess the quality of each study included in the review, we utilized Crowe’s critical appraisal tool (CCAT). The suitability of this tool for the study was justified by its capability to accommodate various study designs, such as quantitative, qualitative, and mixed-methods studies. Moreover, CCAT is highly reliable [ 42 , 43 ]. The CCAT consists of eight category items, which are Preliminaries, Introduction, Design, Sampling, Data Collection, Ethical Matters, Results, and Discussion. Each category item is scored on a five-point scale, resulting in a maximum aggregate score of 40. (See Appendix A   Table A1 ) The CCAT User Guide provides detailed explanations and references for how each category item can be scored [ 44 ] (See Supplementary Materials ). The CCAT was utilized by the first author for each study, and the second author independently applied it to more than half of the research. Any discrepancies that arose were resolved through ongoing discussions. The characteristics and CCAT scores for all 55 studies are presented in Table A2 (See Appendix B Table A2 ).

3.5. Approach to Analysis and Synthesis

For analysis, 55 articles in total were uploaded to ATLAS.ti 22. And using ATLAS.ti, 22 were used for the literature review analysis introduced by Zairul [ 45 ]. Each article was categorized by the author, journal name, journal number, publisher, and year of publication. Quantitative and qualitative findings are presented in this paper. The quantitative section focuses primarily on the regional, journal, and national distribution of academic research articles. In the section on qualitative data analysis, the primary method employed was thematic analysis, which was used to classify and summarize the articles and ultimately construct the framework while ensuring that the framework and data were linked [ 46 ]. This method involves coding, categorizing, and refining themes extracted from raw data [ 47 ]. The present research follows the 6-step framework outlined by Braun and Clarke [ 48 ]. The steps follow as (1) becoming familiar with the data, (2) generating codes, (3) identifying themes, (4) reviewing themes, (5) defining themes, and (6) explaining themes.

We began the thematic analysis by immersing ourselves in the data and gaining familiarity with the content of the articles about the research question. In the subsequent two steps, we initially assigned codes to the articles based on general themes, using an inductive approach that allowed themes to emerge from specific observations in the empirical studies. This involved focusing on key aspects of the articles, such as the author, year of publication, the country, the purpose of the study, study design, and study conclusions, and extracting recurring subject terms, such as AHS, types of AHS behavior, and online AHS behavior. In the fourth step, we reviewed all established themes and sorted out any overlaps or strongly interrelated themes. In the fifth step, we merged and defined all the shortlisted themes, continuously revising them until all sub-themes were grouped under the main theme. In the final step, we refined and defined the themes further, with the first two authors reaching a consensus on each theme through discussion and consideration of its connection to the research question. If there were any disagreements, a third author was consulted. After reviewing and validating the initial codes, we proceeded to identify and refine the themes. The resulting set of themes and their analysis are presented in the following section. Through an interactive process, we categorized the initial codes into broader subjects and had discussions among the authors, which led to the identification of five themes: (1) Defining student help-seeking, (2) Academic help-seeking and academic performance, (3) Resources for academic help-seeking, (4) Factors influencing academic help-seeking, and (5) Online academic help-seeking.

Two categories of results are presented: quantitative and qualitative. The quantitative portion of the study will address question 1, whereas the qualitative portion will address question 2. Despite an expanding body of research on students’ AHS behaviors, there are currently no review papers that provide a comprehensive study of students’ AHS behaviors as well as a framework for future research.

The word cloud was created in ATLAS.ti 22 software, after adding the keywords “help”, “seeking”, “academic”, and some numbers and special characters to the stop word list. “The results of the word cloud revealed that the most prominent concepts were learning, study, online, support, social, class, and information. (See Figure 2 ). As the number of journal articles on academic research has increased in recent years, from three articles in 2012 to seven articles in 2014 to thirteen articles in 2021 (See Figure 3 ). Importantly, this analysis does not currently exclude any limitations, and the literature being analyzed is the literature chosen for the research question.

Word cloud map generated in 55 documents.

Several papers about college students’ academic help-seeking.

4.1. Quantitative Results

According to the findings, college students’ AHS behaviors were primarily published in these journals. According to the list shown in Table 2 : The top three journals for AHS behavior among college students are Frontiers in Education, Internet and Higher Education, and Journal of Academic Librarianship. The journals International Journal of Educational Technology in Higher education, Journal of College Student Development, and TechTrends published two articles in the last 10 years. The remaining 39 journals published one article on a related topic in the last 10 years. In the process of searching the literature, we found that some of the articles are about academic help-seeking behavior, but the keywords of the articles are self-regulated, learning strategy, asking questions, etc., which are also related to academic help-seeking. Therefore, in the process of searching the literature, we found that if we expand the search terms, we will find that the literature on academic help-seeking behavior has shown a gradual increase in recent years.

The number of articles published in the journal.

The United States, China, Germany, and Australia are the leading regions for academic research on university counts, with the United States publishing the most articles on the AHS behavior of college students over the past decade. One of the papers investigates how the emergence of higher education’s cultural mismatch influences the academic assistance-seeking behavior of first-generation college students [ 49 ]. Payakachat et al. [ 50 ] and Finney et al. [ 51 ] are more focused on College students’ behavior in seeking academic assistance. In Germany, to better understand self-reported help-seeking strategies, Zander and Hoehne [ 52 ] analyzed autonomy-oriented, dependency-oriented, and help-seeking avoidance in undergraduate computing and pedagogy programs. Schlusche et al. [ 53 ] used a survey to investigate the impact of social resources on the relationship between AHS behavior and the academic performance of college students in the lower division. Consideration was given to the regional distribution of the Institute ( Figure 4 ). AHS behavior among college students has long been studied in several countries. There has been a lot of recent research on college students in Asian nations, including Taiwan and mainland China, who seek academic assistance. Nonetheless, the AHS behavior of Asian college students demands additional analysis.

Study countries.

In conclusion, this section responds to RQ1: What are the specific characteristics and trends of the articles published between 2012 and 2022? The reviewed articles discussed AHS behaviors and processes of college students, the most recent of which is more specific about demographics (gender age, and attitudes) that affect students’ behaviors of AHS, but some related research is still less when compared to the K12 study. Meanwhile, almost half of the research is about American students, and other countries are just coming into focus on this top. Especially in China, there are few studies about the AHS behaviors of college students. But it is worth noting that more and more countries are joining and researching college students’ AHS behavior, and the research is increasingly focused and refined.

4.2. Qualitative Results

To respond to the second research query, the literature was further analyzed in the qualitative analysis section. We carefully read and coded 55 articles on the behavior of college students at AHS. Coding was not completed in one sitting. The initial codes must be merged and classified to form the themes. Some codes that are rarely used or cannot be incorporated into the current theme will be eliminated, primarily because we are concentrating on universal elements. Firstly, the definition and categorization of AHS behavior as a concept and behavior of college students. Secondly, various viewpoints are used to analyze the facilitating and impeding factors of AHS behavior, as well as its influencing factors. Thirdly, the use of on-campus and off-campus resources, conventional AHS, and online AHS behavior about AHS behavior. After that, it is discussed how AHS behavior fosters academic progress, and then AHS behavior in the Internet era is examined (See Figure 5 ). Future research directions can be deduced from the existing research and conceptual framework; this section will be developed specifically in the discussion section.

Key themes and subthemes in the literature on academic help-seeking.

4.2.1. Theme 1: Defining Student Help-Seeking

Topic 1 focuses on the definition and theories related to students’ AHS behavior, as well as the reasons why students seek help and the circumstances under which they refuse to seek help. It also describes the classification of student help-seeking behavior and concludes with recent advances in student help-seeking behavior. Ames and Lau [ 54 ] defined AHS as a method of locating and utilizing additional resources for one’s success.”. When an individual recognizes that they cannot overcome their problems on their own, help-seeking behavior develops. In general, the help-seeking process entails acknowledging the need for assistance, locating potential people who can assist, articulating the problem that needs to be solved, and evaluating the outcome of the help-seeking process. Likewise, Almaghaslah and Alsayari [ 9 ] hold the view that the behavioral strategy of actively seeking academic assistance is through social interaction. Beisler and Medaille [ 55 ] explained the students’ perceptions of academic help as an effective problem-solving strategy. According to these studies, asking for AHS is a good learning strategy. Students use AHS behaviors to address their academic challenges and difficulties through their efforts and ultimately to achieve academic success because they are the main subjects of learning in the university setting.

Some authors view AHS as a self-regulation strategy employed by students [ 20 , 26 ]. Unlike other cognitive strategies, this AHS combines cognitive and social integration skills. The first step in a student’s process of seeking help is becoming aware of the need for it. Therefore, when a student seeks assistance, a series of choices are made. These choices could be but are not restricted to becoming aware of the issue and challenge; choosing to seek assistance; choosing from whom to seek assistance; choosing when to seek assistance; selecting the form of assistance to seek [ 51 ]. Recently, Payne utilized Yosso’s community cultural wealth framework, understanding how the academic help-seeking behavior of first-generation college students can lead to success in the field of post-secondary education through the accumulation of their cultural capital. Meanwhile, they conducted a systematic study of first-generation college students’ academic help-seeking behavior and concluded that academic help-seeking provides students with a source of power over their family’s cultural capital as well as the school’s cultural capital collision [ 56 ].

Reeves and Sperling [ 57 ] claimed that a student’s AHS behaviors are significant for predicting performance and assisting students in overcoming academic obstacles by accepting associate instruction from a school. Similarly, Almaghaslah and Alsayari [ 9 ] asserted additional motivation to complete academic courses and improve academic performance improves students’ help-seeking behavior in learning. Academic help-seeking behavior can be extremely beneficial to a student’s academic success, but many students do not use it successfully; for example, Schworm and Gruber [ 58 ] used a survey to find that college students are reluctant to seek academic assistance in traditional classroom settings. This view is explained by Mahasneh et al. [ 59 ], who wrote that this effect may be influenced by the absence of necessary background information and the perception of danger associated with seeking assistance.

A broader perspective has been adopted by Almaghaslah and Alsayari [ 9 ] who argued that in the definition of academics, formal academic help-seeking is generally considered to be seeking help from teachers in the classroom and formal academic institutions in school, whereas informal AHS is primarily seeking help from classmates, friends, peers, or family members. Help-seeking comes in two forms [ 14 , 60 ]: The first type of help-seeking behavior is rapid help-seeking, also known as executive help-seeking, which is primarily characterized by seeking the best solution directly from teachers or peers, without thinking. The second type, referred to as slow help-seeking behavior or instrumental help-seeking, is primarily characterized by the assistance of others who can eventually complete the task on their own [ 52 ]. Beisler and Medaille [ 55 ] described when a student requests quick or executive help, they are searching for an immediate fix and are not concerned with significantly contributing to the help-seeking process. However, students want to be able to develop their learning and problem-solving abilities during the AHS process when the type of help sought is instrumental. There is also a classification by Reeves and Sperling [ 57 ], who identified two orientations of student help-seeking behavior, adaptive, and avoidant. Pupils who are adaptive help-seekers are more capable of engaging in positive academic help-seeking behaviors, whereas those with avoidant orientations are more likely to rely on their strengths to solve problems. The study of students’ academic help-seeking behaviors can now be viewed in a new light thanks to decision-inspired methods. In addition, several research techniques should be used to investigate the types of resources students use to seek academic assistance in their actual behavior [ 61 ].

Current research on students’ help-seeking behavior has concentrated primarily on academic perspectives instead of investigating how students recognize and perceive their help-seeking behavior. Theories of learned help-seeking behavior are more diverse, ranging from a psychological perspective that views it as a learning strategy and dissects the process of help-seeking behaviors to a cultural capital perspective that views it as a type of cultural capital that students can use. Different classifications of help-seeking behavior are made from various perspectives, providing us with a more thorough comprehension of help-seeking behavior.

4.2.2. Theme 2: Academic Help-Seeking and Academic Performance

Active help-seeking in academics is a prosocial, structured, and interactive behavior that promotes students’ academic growth. And in the fields of education and psychology, help-seeking has been one of the key research themes [ 33 ]. The link between academic assistance and academic achievement has been studied for many years, with most studies concluding that academic help-seeking behavior has a positive effect on academic success. Karabenick and Knapp [ 14 ] asserted that a student’s academic performance can be improved by seeking academic assistance from peers and teachers. Schworm and Berndt [ 62 ] found that one of the most crucial study skills for college students to have to succeed in their studies is the ability to ask for AHS which is supported by Payakachat, Gubbins, Ragland, Norman, Flowers, Stowe, DeHart, Pace, and Hastings [ 50 ]. And, Umarani [ 30 ] reminds us AHS is a learning strategy that can effectively facilitate student learning and ultimately benefit students’ academic performance. Micari and Calkins [ 32 ] showed that teachers who are receptive to students’ requests for assistance will receive increasingly higher grades. In other words, students will have a higher GPA and eventually succeed in college if they ask their teachers for assistance more frequently.

One study by Umarani [ 30 ] examined that seeking academic assistance is an academic process learning strategy for students. And, students with academic difficulties who actively seek academic assistance can improve their academic performance. In general, students who refuse academic support perform worse in school than those who regularly interact with their teachers. Another study by Algharaibeh [ 33 ] offers an analysis of the various sources of academic assistance, including the fact that formal sources are typically school teachers and academic service centers provided by the school, whereas informal sources are typically parents, peers, classmates, etc. Help-seeking, whether formal or informal, can improve academic performance, encourage positive learning, and increase students’ sense of self-efficacy. Additionally, there are studies in which researchers have looked at how academic achievement and help-seeking fare across disciplines. In a cross-sectional study conducted by Rini and Wijanarko [ 63 ], it was shown that the Nursing Science Research Project at the Muhammad Foundation in Bali found a positive correlation between seeking academic assistance and student achievement. Sun et al. [ 64 ] also found that there was a significant positive correlation between students’ self-efficacy in learning math, their utilization of help-seeking strategies, and academic achievement in both pre-and in-class learning settings. Zheng and Zhang [ 65 ] contended the use of peer learning and help-seeking positively affected the performance of first- and second-year students in the flipped classroom.

In the realm of educational research, help-seeking behaviors among students have long been acknowledged as crucial determinants of academic development. Nevertheless, not all help-seeking behaviors are created equal. In earlier research, the terms expedient help-seeking and adaptive help-seeking were distinguished [ 20 , 66 ]. Expedient help-seeking typically involves students looking for shortcuts, often expecting others to complete tasks for them or directly asking for solutions without seeking genuine understanding. Such behaviors can be counterproductive, sometimes resulting in poorer academic outcomes and heightened levels of student anxiety. In contrast, adaptive help-seeking behavior, also known as instrumental help-seeking behavior, occurs when students seek assistance by considering other people or resources and eventually solve the problem on their own [ 21 , 67 ].

4.2.3. Theme 3: Resources of Academic Help-Seeking

Early studies on college students’ AHS behavior concentrated on patterns of AHS behavior and the variables affecting that behavior. The use of specific academic resources, such as academic service centers in libraries and schools and online help-seeking within the scope of distance education, has emerged in more recent studies of the academic literature [ 9 ]. The following section discusses the different types of academic assistance resources, such as peers, classmates, friends, teachers, libraries, academic service centers, and the Internet. With varying regularity and efficacy, students use various kinds of academic support tools. Effectiveness, timeliness, cost, accessibility, and for students, user-friendliness is the most important factor to consider when selecting academic support resources [ 9 ].

A mixed study by Beisler and Medaille [ 55 ] described eighty students who used drawings to describe their AHS behavior; the results revealed that 59% of the students sought assistance from a peer or family member, followed by their tutor and the school’s writing center. This view is supported by other scholars who concur that when students encounter academic difficulties, they typically seek assistance from their peers. Mahasneh, Sowan, and Nassar [ 59 ] found that peers are students’ first choice when looking for academic assistance. Moreover, more than forty percent of students who encounter academic difficulties attempt to find solutions on their own. Likewise, Almaghaslah and Alsayari [ 9 ] hold the view that peers, online course portals, and online educational resources are the three most popular types of resources used by students following an academic call for assistance. In the context of higher education, university instructors do need to understand that one of the components of their student’s academic success is their support of them [ 68 ]. The behavior of the instructor in the classroom has a direct impact on the effectiveness of the student’s lessons, their attitudes toward learning methods, and ultimately the quality of their learning [ 32 ]. In a similar vein, Thomas et al. [ 69 ] in their article noted that to succeed academically, students first ask for assistance from their teachers and peers.

When the help-seeking scenario arrived in the school setting, scholars conducted the following research. Giblin, Stefaniak, Eckhoff, and Luo [ 61 ] conducted a similar experiment at a university, and the results revealed distinct manifestations of students’ AHS behavior in and out of the classroom. In the classroom, 43% of students chose their classmates for academic assistance, while 17% chose their notes; however, outside the classroom, 39% chose online resources, and 28% chose classmates or friends. Less frequently did students utilize textbooks, class notes, and their teachers’ instruction. Moreover, the study revealed that students formed study groups and utilized multiple websites to achieve their AHS behavior. Another study showed that email was the most popular resource for academic assistance before and after class, whereas discussion and office hours were the least popular [ 57 ].

Typically, students select their advisor rather than the school’s academic services as the official source of assistance [ 14 ]. Academic services are faced with a new challenge because the majority of undergraduate students do not know how to ask for assistance. Elias et al. [ 70 ] describe the three main aims that most of these services have in common: (1) educating students about online academic support resources; (2) encouragement of students to seek academic assistance; (3) helping learners to use self-directed learning strategies. The library is also underutilized by students. But, most students are unaware of the library’s resources and the assistance offered by the library staff. A study conducted by Beisler and Medaille [ 55 ] indicated that in-class library instruction sessions do seem to have a positive impact on students; however, students do not connect their different research needs with possible library assistance. Wirtz et al. [ 71 ] concluded four new patterns in students’ behavior when looking for assistance: Students AHS will have access to a variety of resources, but the frequency of their use is undesirable; (2) The utility of resources is not the only factor motivating student use of them; (3) The ranking of academic assistance resources by students is primarily based on the availability of resources; (4) The time and location of access to resources explain why students seek help, the more convenient a resource is perceived to be, the more likely a student is to use it.

We can draw the following conclusion from the research: when it comes to academic support, students use resources in various ways. The main consideration for students is how convenient the resource is. In other words, students are more likely to select the most convenient resource for them than the most useful one. Therefore, future research should delve deeper into the determinants of student resource selection. In the field of higher education, academic support resources should be made more accessible so that students can more easily seek assistance.

4.2.4. Theme 4: Factors of Academic Help-Seeking

An extensive and expanding body of literature has investigated what factors influence students’ AHS behaviors. Some of these factors can help or hinder students’ help-seeking behavior, while others may be found to not affect students’ AHS after the study. The elements that affect students’ AHS are specifically described below.

Many students believe that seeking academic assistance from others reveals their academic deficiencies, which can negatively impact their self-esteem. The desire of students to seek assistance will decrease if they believe that doing so will bring down their self-esteem [ 32 ]. Zander and Hoehne [ 52 ] have been able to show that it can lessen students’ behavior toward seeking assistance if they experience exclusion by fellow students. AHS behavior can be reduced by ambivalence and the perception of academic help-seeking threats [ 50 ].

According to one study, students were more likely to see the threatening aspect of asking for academic help in person [ 57 ]. The main cause of students’ perceived help-seeking threats is low self-esteem, which is brought on by reluctance to admit their failings. Additionally, the learning environment and types of resources available for help-seeking influence students’ perceptions of help-seeking threats [ 28 ]. A student may choose not to ask for help for numerous explanations, including the nature of the difficulty they are facing, their study habits and tendencies, their relationship with their preferred potential helper, and the particular circumstances surrounding the request for help at the time [ 55 ]. Similarly, Schworm and Gruber [ 58 ] also mentioned that students may refuse assistance due to a lack of information or the perceived threat of asking for assistance. Thomas and Tagler [ 72 ] in their study used the Reasoned Action Model (RAM) to investigate the determinants of students’ intentions to utilize university-based sources of academic support. They found that perceived normative pressure and attitudes accounted for a considerable amount of variability in intentions to seek help.

Additionally, gender has distinct influences on students’ help-seeking behaviors [ 73 ]. Dunn et al. [ 74 ] found that as individuals grew older, their tendency to seek help decreased. Furthermore, in Calarco’s [ 75 ] study, socio-economic status also influences students’ academic help-seeking behavior; in general, students from lower socio-economic backgrounds believe teachers will respond negatively if they ask for assistance, whereas students from middle-class families do not hold this viewpoint. Commenting on avoiding seeking help, Mahasneh, Sowan and Nassar [ 59 ] argued: to begin with, asking for assistance is a dependent learning strategy, so students may avoid doing so when putting the idea of independent and autonomous learning into practice. The second is that students might interpret asking for assistance as an indication of incompetence. Third, asking for academic help is a socially interactive behavior, so how the student perceives the academic environment around him, or she may have an impact on how the student asks for assistance. There is also a claim that if a student feels uncomfortable in the classroom when interacting with peers or the teacher, this may deter them from asking for assistance.

Significant amounts of the literature have been published on students seeking academic assistance. Several encouraging influences on students’ willingness to ask for help were uncovered by these studies. For example, Beisler and Medaille [ 55 ] uncovered that direct academic instruction in the classroom encourages students to seek out academic help-seeking. Micari and Calkins [ 32 ] showed that positive attitudes toward students’ help-seeking behaviors will result in more academic help-seeking behaviors at the course’s conclusion.

Additionally, if students are given more incentives for helping, their behavior of asking for assistance will support their academic success, and they will be more attentive to the subject matter and engaged in class discussions [ 58 ]. Students’ instrumental help-seeking behavior is influenced, as expected, by a collaborative approach to course learning [ 62 ]. Thus far, Dunn, Rakes, and Rakes [ 74 ] demonstrated that academic self-discipline and thinking critically positively influence academic help-seeking behaviors, and as academic self-discipline and critical thinking increase, so do academic help-seeking behaviors.

And, in a study carried out by Payakachat, Gubbins, Ragland, Norman, Flowers, Stowe, DeHart, Pace, and Hastings [ 50 ], it was shown that how students act when they need help in school can be affected by how smart they think they are and how helpful their teachers are. Brouwer and Engels [ 76 ] greater emphasis was placed on examining the impact of peers on students’ tendencies to seek help, revealing that they were more inclined to seek assistance from a friend. Opdecam et al. [ 77 ] indicate that students who favored team learning had lower ability levels but higher intrinsic motivation, less control over their learning beliefs, increased help-seeking behavior, and a greater willingness to share knowledge with peers. In addition, the similarity of academic achievement among friends contributed to the occurrence of help-seeking behaviors and ultimately led to the formation of the student’s academic help-seeking network. As noted by Won et al. [ 78 ], even when considering the student’s motivation to seek help, the student’s perceived sense of belonging predisposes the student to adaptive academic help-seeking behavior. In the meantime, self-efficacy for self-regulated learning positively predicted adaptive help-seeking strategies as well. When faced with challenges or difficulties in their academic work, college students are more likely to seek assistance if they have greater confidence in their ability to self-regulate their studies. Long and Neff [ 79 ] noted that self-compassion indirectly promotes help-seeking by reducing the fear of positive evaluation. Additionally, self-compassion directly encourages help-seeking due to the focus on personal well-being.

The impact of gender on academic help-seeking is currently viewed in different ways. As noted by Zander and Hoehne [ 52 ], women are typically more proactive than men in seeking academic assistance. While in another two studies, researchers found gender is not a variable that impacts help-seeking [ 80 ]. In another experimental research, Miranda Lery Santos et al. [ 81 ] compare the economic, time, and social costs of help-seeking to the expected benefits, and found participants were more likely to seek help when there was no economic cost to help, but were not as sensitive to the time cost and social cost parameters.

Overall, there seems to be some evidence to indicate numerous factors affect how students behave when they need academic assistance. For instance, while some pursuits of academic excellence and self-affirmation can encourage constructive help-seeking behaviors, others, such as low self-esteem, uncertainty about issues, and failure-related fear, can have an impact on students’ efforts to get assistance. The school environment and the social environment in which students live can also affect students’ help-seeking behaviors, along with gender and age.

4.2.5. Theme 5: Academic Help Seeking Online

Obtaining AHS via the Internet is a novel method. The following section compares the effectiveness of face-to-face help-seeking, hybrid help-seeking, and online help-seeking. In addition, the role of Facebook and live chat in academic help-seeking behavior is described.

To date, several studies have defined what it means to obtain AHS online. Seeking academic assistance through online platforms or tools, such as search engines, email, instant messengers, and social media, is referred to as seeking academic help online [ 82 ]. Students seeking online academic help can receive both formal and informal academic assistance, and doing so is a strategy for succeeding academically [ 83 ]. Broadbent and Lodge [ 84 ] thought that students primarily turn to the Internet for academic help from peers, friends, and teachers to overcome academic obstacles. In addition, email, forums, social media, and classroom questioning interactions were the most common online resources used to seek academic help.

According to a quantitative study of college students in Taiwan, getting academic assistance online is the new way to learn, and these students are more inclined to use online resources to look up solutions to their academic problems [ 85 ]. Students who frequently used Facebook formally and informally for academic support perceived the web as socially interactive, were able to foster a sense of community through online interactions, and were more likely to seek academic assistance online [ 15 ]. Another important study by Broadbent and Lodge [ 84 ] explained why students like to seek help online. Two reasons cited significantly more frequently by online students as justifications for their preference for live chat are highlighted by thematic analysis. Live chat may be the most popular method for online students to seek assistance. This is primarily because they have greater access to the instructor and can communicate in this manner to facilitate face-to-face interaction and because live chat enables the staff to respond quickly.

When compared to face-to-face contact, Mahasneh, Sowan, and Nassar [ 59 ] noted that online learning environments encourage students to use help-seeking techniques more frequently than traditional classroom settings do. However, in a recent quantitative study, Reeves and Sperling [ 57 ] investigated that students still plan to rely more on interpersonal rather than technological channels of support, despite the threat. In one well-known web-based survey, Tang [ 68 ] reported that Students with greater self-efficacy frequently visit the library and seek academic assistance from afar. In-person rather than online academic assistance is preferred by students who live close to their school. Email remains the most common source of academic assistance for students who live far from school.

As Hayman et al. [ 86 ] stated that students use their Facebook confessions in four different ways to support their academic experiences and guide their undergraduate careers: they ask for help on Facebook, give study advice, look for useful information, and control their study habits. Broadbent and Lodge [ 84 ] compared opinions of live chat technology used for online academic help in higher education between online and blended learners. Because they feel more cared for by the teaching team through timely chat, online students are more satisfied with live chat and are more likely than blended students to suggest others use this form of assistance. Furthermore, Hao, Wright, Barnes, and Branch [ 82 ] investigated computer science majors’ online help-seeking behavior was predicted. For each of the three online help-seeking categories, the biggest predictor was the degree of difficulty of the problem. Learners’ ability level, academic performance, and epistemological beliefs were significant predictors of online search and faculty help-seeking. Barnard et al. [ 87 ] conceptualize Self-regulated Learning (SRL) as a complex construct consisting of six dimensions: environment structuring, goal setting, time management, help-seeking, task strategies, and self-evaluation. Vilkova and Shcheglova [ 88 ] survey to evaluate the function of SRL dimensions and found that low communication between MOOC students and instructors during the learning process implies that the dimension ‘help-seeking’ is not effective in the MOOC environment.

Taken together, these studies prove the proposition that academic help-seeking online is accepted by most students. Additionally, requesting assistance online provides better and quicker access to elementary teachers, protecting students’ privacy while also facilitating better access. The resources available for students seeking academic assistance have been further increased by the advancement of Internet technology.

5. Discussion

5.1. purpose and the main findings of the study.

The primary purpose of this review was to provide a comprehensive analysis of the behavior of college students seeking academic assistance. Using the PRISMA method, we reviewed the literature and pulled 55 articles from two databases. Two different approaches were used in this paper based on the analysis of these articles. The first section is quantitative, highlighting numerical data taken from ATLAS.ti 22, and it concentrates on the 55 articles’ study year, their country and region of publication, and the journal. The second section is qualitative and investigates the process of AHS behavior, including whom to ask for help, how to ask for help, the outcomes of help-seeking, and the available resources for help-seeking. The study also looks at the increasingly varied ways that students are using the Internet to get academic assistance since the dawn of the Internet era. The anonymity, timeliness, and convenience of the Internet make it a good option for students looking for assistance. The study also revealed that some students require academic assistance but reject it, which necessitates additional study.

5.2. Research Implications

Both theoretical and applied implications can be drawn from this study. There are two practical implications of this study. The universities can employ to increase the uptake of academic help systems, such as enhancing outreach and communication efforts, reducing barriers to access, and fostering a supportive and inclusive environment. Second, the students themselves, actively seek academic assistance from peers, teachers, and the university’s academic help resource center when they encounter academic challenges on the university campus, realizing that academic assistance is not a failure and is beneficial for promoting their academic progress.

Theoretically speaking, this study offers a systematic overview of students’ AHS behaviors. For instance, in terms of theoretical implications, we discovered that students’ academic help-seeking behaviors can enhance students’ academic performance. Positive factors like a sense of belonging perceived academic ability and perceived faculty benevolence can encourage students’ behavior of asking for help; negative factors primarily include lower socioeconomic status backgrounds, having a sense of exclusion from classmates, a sense of threat, ambivalence, and the perception that doing so poses a threat can hinder students’ help-seeking behavior. The theoretical contribution primarily aims to increase the body of knowledge about academic help-seeking, spot research holes, and suggest future research directions.

5.3. Research Limitations

Like many studies, we acknowledge some limitations to our research. Concerning the limitations of this research, the methodological limitations of the thematic review can be mentioned, such as publication bias [ 89 ]. This is because there may be many studies that were not published. After all, they did not reach statistical significance because there was no way to publish them in the databases that were investigated. The retrospective nature of thematic reviews is also a problem in this case. This means that readings of the results of the studies analyzed could be skewed by interpretations that do not make sense in the context of which the studies were conducted.

Moreover, the combination of our keywords may have restricted our search results. In addition, we omitted other research databases, gray literature, book chapters, and reports. These publications may contain additional vital information regarding the AHS behaviors of college students. Moreover, the review process for this study only considered English-language peer-reviewed articles. Therefore, the findings of this study may not be sufficiently exhaustive. College students’ AHS behaviors are still in a concerning stage. Thus, additional journal articles containing empirical findings will continue to emerge. In future studies, more recently published academic help-seeking research should be considered.

5.4. Research Contributions

Despite some limitations, this review contributes to the research on college students’ academic help-seeking in several ways. First, this study presents the fundamental characteristics of the studies included, such as sample characteristics, research context, and research countries and published journals. Second, this study summarizes students’ AHS behavior, the relationship between academic help-seeking and academic performance, different sources of AHS, AHS facilitating and hindering factors, and how students seek academic help in the Internet era. Third, the findings of this review provide an empirical landscape of research on students at AHS. Further, this paper suggested four future research directions, which may help researchers identify related topics in this subject area.

5.5. Future Studies

Future research could go in new directions, according to the thematic review. Figure 6 provides 19 research directions to better assist students in utilizing the resources at their disposal to further their academic success by better understanding their behavior when seeking academic assistance. The following categories may be used to classify future research based on the current research scenario and the proposed structure:

Future research on the existing discussion for college students’ academic help-seeking.

Academic help-seeking behaviors: The definition of AHS should be broadened, and students should be considered a significant source of AHS. Future studies ought to investigate the types of assistance offered by faculty and their effects on students’ help-seeking behavior. Concurrently, it is necessary to investigate new models of learning behavior and AHS behavior.

Resources for academic help-seeking: How do they choose between formal and informal resources? How do they decide between face-to-face and online help-seeking methods? Future studies should create a networked system of student help-seeking behaviors and offer a more thorough understanding of the help-seeking environment. To help students use a variety of AHS methods to achieve better academic performance, future research should also combine online and face-to-face help-seeking.

Factors of academic help-seeking: Future research should also consider the impact of individual characteristics such as age and experience on the decision to seek academic assistance. Additionally, it would be advantageous to conduct additional research on the influence of cultural and socio-economic background on the assistance-seeking behavior of college students. The influence of academic self-efficacy, other people and environments, and different instructor characteristics on students’ help-seeking behavior is an additional avenue worthy of investigation. The influence of comments and interactions on AHS behavior should be considered when engaging in academic help-seeking behavior on social media.

Methodology: Future research should utilize larger samples from a variety of institutions to obtain a comprehensive and unified view of students’ perceptions of academic support services. Researchers should also employ multiple methodologies to investigate the mechanisms of academic help-seeking behavior in greater detail. In future research, meta-analyses could be conducted, such as examining the association between academic help-seeking behavior and academic achievement or investigating the impact of gender and peer assistance on help-seeking behavior. Meta-analysis allows for the synthesis and summarization of findings from literature reviews or reviews, enabling the aggregation and combination of data from multiple independent studies to provide more persuasive and consistent conclusions.

6. Conclusions

The main conclusion of this review is that student help-seeking behaviors have been mainly studied from the academic perspective and rarely seen from the perspective of students themselves; When examining help-seeking behaviors, more research that directly incorporates students’ perspectives is needed. This will involve considering the experiences, motivations, and challenges students face when seeking academic support, which may provide valuable insights and a more comprehensive understanding of the topic. In addition, the classification of student help-seeking behaviors has been studied in more detail so far. Most research on academic help-seeking behavior and academic performance is favorable, but different types of academic help-seeking behavior have different effects on academic performance. In addition, current research on the factors influencing students’ help-seeking behaviors has been conducted independently, examining the effects of a single component on academic help-seeking behaviors without considering the effects of multiple factors on academic help-seeking behaviors collectively. Moreover, in the Internet era, students have greater access to online help-seeking resources; however, there is a need for continued research on traditional academic help-seeking behaviors and Internet help-seeking behaviors to facilitate students’ academic progress. And, to develop a strong theoretical body on students’ academic help-seeking behaviors, additional research is required to better understand students’ academic help-seeking behaviors, whether there are differences in help-seeking behaviors across disciplines, ages, and school levels, and which types of academic help-seeking behaviors are more conducive to students’ academic progress.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/bs13080637/s1 .

Crowe Critical Appraisal Tool (CCAT) form.

Note: Scoring for each category is based on the guiding principles recommended in the Crowe Critical. Crowe Critical Appraisal Tool (CCAT): Version 1.4 (19 November 2013): Michael Crowe ( [email protected] ).

The characteristics and CCAT scores of the 55 studies.

Funding Statement

This research received no external funding.

Author Contributions

R.L. and N.C.H. were responsible for the conceptualization of the study. R.L. conducted the literature review, database searches, data extraction, quality assessment, synthesis of results, and writing of the original manuscript. N.C.H. and N.S. assisted with quality assessment and reviewing and editing the manuscript drafts. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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• Volume 11, Issue 2
• Help-seeking behaviours among older adults: a scoping review protocol
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• http://orcid.org/0000-0003-2405-6466 Kelly Teo 1 ,
• http://orcid.org/0000-0001-6510-4810 Ryan Churchill 1 ,
• http://orcid.org/0000-0001-6474-5384 Indira Riadi 1 ,
• http://orcid.org/0000-0002-8711-2173 Lucy Kervin 1 ,
• http://orcid.org/0000-0002-9977-8888 Theodore Cosco 1 , 2
• 1 Department of Gerontology , Simon Fraser University , Vancouver , British Columbia , Canada
• 2 Oxford Institute of Population Ageing , University of Oxford , Oxford , Oxfordshire , UK
• Correspondence to Kelly Teo; kteo{at}sfu.ca

Introduction Despite evidence that illustrates the unmet healthcare needs of older adults, there is limited research examining their help-seeking behaviour, of which direct intervention can improve patient outcomes. Research in this area conducted with a focus on ethnic minority older adults is also needed, as their help-seeking behaviours may be influenced by various cultural factors. This scoping review aims to explore the global literature on the factors associated with help-seeking behaviours of older adults and how cultural values and backgrounds may impact ethnic minority older adults’ help-seeking behaviours in different ways.

Methods and analysis The scoping review process will be guided by the methodology framework of Arksey and O’Malley and the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews guidelines. The following electronic databases will be systematically searched from January 2005 onwards: MEDLINE/PubMed, Web of Science, PsycINFO, CINAHL and Scopus. Studies of various designs and methodologies consisting of older adults aged 65 years or older, who are exhibiting help-seeking behaviours for the purpose of remedying a physical or mental health challenge, will be considered for inclusion. Two reviewers will screen full texts and chart data. The results of this scoping review will be summarised quantitatively through numerical counts and qualitatively through a narrative synthesis.

Ethics and dissemination As this is a scoping review of published literature, ethics approval is not required. Results will be disseminated through publication in a peer-reviewed journal.

Discussion This scoping review will synthesise the current literature related to the help-seeking behaviours of older adults and ethnic minority older adults. It will identify current gaps in research and potential ways to move forward in developing or implementing strategies that support the various health needs of the diverse older adult population.

Registration This scoping review protocol has been registered with the Open Science Framework ( https://osf.io/69kmx ).

• geriatric medicine
• primary care
• public health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-043554

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Strengths and limitations of this study

To our knowledge, no previous scoping review has explored the help-seeking behaviours of older adults or spoken to the factors that may impact ethnic minority older adults and their help-seeking behaviours differently.

This study protocol is guided by the methodology framework of Arksey and O’Malley and will follow a systematic approach to data synthesis.

The review will be limited to studies published from 2005 onwards to capture both the current health context and the dynamic nature of this topic.

Due to the scoping review design, quality assessments of the included articles will not be performed.

While there may be little published work in this topic area that will limit the amount of data available, this synthesis of knowledge will serve as a basis for future research and calls to action.

Introduction

Older adults encounter a number of physical and mental health challenges that often require more attention due to their persistent and chronic nature. 1 As a result, older adults use healthcare services at higher rates and account for more of the healthcare expenditures compared with younger populations. 2 Despite this, there is concern that not all older adults adequately access healthcare services, and that this population still experiences difficulties in achieving health and have unmet needs. 3 For example, various studies have found that older adults access mental health services at lower rates than expected, and certain illnesses, such as dementia and glaucoma, continue to go underdiagnosed and undertreated for this group. 3–5 Reasons for these unmet needs remain unclear in the literature and evidence is scarce. 3 6 Woods et al 3 suggested that unmet care needs among older adults may be attributed to either the limited offers of support from healthcare providers or the lack of acceptance of such support from older adults. Another potential contributor to their unmet needs is that most studies focus on samples of older adults who are already existing service users, thereby limiting the information available on older adults who do not seek help in the first place. 6 Consequently, there is a clear lack of research examining older adults’ decision-making processes prior to seeking help as well as what alternatives to formal support services these individuals may use instead. 6 As such, in exploring unmet needs of older adults, understanding their help-seeking behaviour is one of the direct areas where intervention can improve patient outcomes. 7

For the purpose of this scoping review, the definition of help-seeking behaviour will be adapted from a WHO study that examined the help-seeking behaviour of adolescents 8 and will be defined in the following manner 9 10 : any action taken by an older adult who perceives themselves as having a physical or mental health challenge, with the intent to find an appropriate remedy. The type of support that individuals pursue can include seeking formal support services (eg, from clinicians, psychologists, counsellors, religious leaders) or informal support services (eg, from family, friends, the internet).

Within the literature, there are several models that have conceptualised help-seeking behaviour. For example, the health-belief model suggests that an individual’s behaviour and desire to change are tied to their beliefs about their health situations and will depend on factors such as their perceived health threat or susceptibility, the benefits of change and the support of internal or external sources (eg, symptoms or mass media). 11 12 In addition, Andersen’s behavioural model of health service utilisation suggests that service use is impacted by several variables; predisposing variables, enabling variables and need variables. 12 Expansions to this model also recognise how the environment, individual practices and patient satisfaction can influence subsequent help-seeking behaviour. 12 This scoping review will explore how these various factors may impact the diverse older adult population and discuss which factors may be more salient for this group.

In exploring help-seeking behaviour among older adults, it is important to acknowledge and explore the differing experiences of ethnic minorities, due to their continued lack of representation in clinical and health research. 13 Ethnicity itself is a topic that has far-reaching cultural effects and encompasses many social issues such as stigma and discrimination that may influence help-seeking attitudes and disparities in care. For example, among ethnic minority adolescents, studies have shown that discrimination by authorities and healthcare providers, traditional and cultural beliefs about mental illness and family obligation values impact their help-seeking behaviour and underutilisation of services. 14–16 Furthermore, ethnic minority groups have been found to employ alternative and pluralistic help-seeking strategies as opposed to formal primary care services. 17 Given these factors explored among younger ethnic minority groups, there is reason to believe that attitudes and experiences of help-seeking for ethnic minority older adults are similarly shaped by their cultural backgrounds, values and traditions. Subsequently, these cultural factors influence their health outcomes and the types of support that they prefer to seek out. As such, combined with the challenges that older adults already face with increasing age, there is a need to understand what factors influence ethnic minority older adults’ help-seeking behaviour.

This scoping review intends to explore the following research question: Which factors are associated with help-seeking behaviour among older adults? This review also aims to provide answers for the following subquestion: How do cultural backgrounds, values and differences impact help-seeking behaviour among various older adult populations? Due to the exploratory nature of these questions, a scoping review of papers from any country will be conducted to assess the breadth of knowledge in this area. Synthesising this literature can help researchers, healthcare providers and key decision-makers understand the current state of knowledge, identify areas for future research and determine potential ways to influence the help-seeking behaviour of older adults.

Methods and analysis

This scoping review will be prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews guidelines. 18 A scoping review is a systematic way of exploring a topic area, in which main concepts and knowledge gaps are identified within a developing field of research. 18 Unlike systematic reviews, the research questions for a scoping review are often broader and more exploratory 18 and thus appropriate for this topic due to the limited research and lack of synthesised knowledge.

The review process will be guided by the five main steps set forth by Arksey and O’Malley 19 and will follow this approximate timeline:

Identifying the research question—completed in Fall 2020.

Identifying relevant studies—January–February 2021.

Study selection—February 2021.

Charting the data—March 2021.

Collating, summarising,and reporting the results—April 2021.

We will aim to complete the optional sixth stage, (6) consultation, by consulting, discussing and verifying the results of this review with older adults. This review has been registered with the Open Science Framework ( https://osf.io/69kmx ).

Step 1: identifying the research question

In keeping with the exploratory nature of scoping reviews, we identified one main research question: Which factors are associated with help-seeking behaviour among older adults? As part of this, this review will also explore an additional subquestion: How do cultural backgrounds, values and differences impact help-seeking behaviour among various older adult populations?

Step 2: identifying relevant studies

The following electronic databases will be systematically searched: MEDLINE/PubMed, Web of Science, PsycINFO, CINAHL and Scopus. Help-seeking behaviour is originated from the term ‘illness behaviour’ in medical sociology. 10 While one of the earliest definitions of help-seeking behaviour was provided in 1982 and a Willingness to Seek Help Questionnaire was created in 1999, an improved General Help-Seeking Questionnaire was created in 2005 to address previous methodological and instrumental constraints. 10 20 21 As such, searches will be limited from January 2005 to the date of search commencement to ensure that the literature reflects the current health context and the nature of this dynamic process.

Title, abstract and keyword fields will be searched using a combination of the following terms: (“help seek*” OR “treatment seek*” OR “health information seek*” OR “healthcare seek*” OR “care seek*” OR “health seek*”) AND (“older adults” OR “older people” OR “elderly” OR “seniors” OR “geriatrics”). To address the subquestion for ethnic minority older adults, we will also conduct a separate analysis using a combination of the following terms: (“help seek*” OR “treatment seek*” OR “health information seek*” OR “healthcare seek*” OR “care seek*” OR “health seek*”) AND (“older adults” OR “older people” OR “elderly” OR “seniors” OR “geriatrics”) AND (“immigrants” OR “ethnic minority” OR “minority populations”). An example of the electronic search strategy for MEDLINE/PubMed has been included ( online supplemental file 1 ). The reference lists of the included articles will also be reviewed to ensure that all relevant articles have been included. Additional search strategies may be incorporated as the review progresses and any additions or changes will be documented.

Supplemental material

Step 3: study selection.

Two reviewers will screen all articles identified from the databases independently. Titles and abstracts will be reviewed based on the initial search and included based on the eligibility criteria described below. Duplicate articles will be removed; full texts will be examined to create a final list of included studies. Any disagreements on the inclusion of any articles will be resolved through discussion and in consultation with a third reviewer if necessary.

Eligibility Criteria

Studies of various designs and methodologies (ie, quantitative, qualitative, mixed methods design) will be considered for this review. English or non-English studies from any country must (1) address research on the help-seeking behaviours of older adults, (2) be published from January 2005 to the date of search commencement and (3) be full-text peer-reviewed studies. Articles outside of those defined in the inclusion criteria, such as opinion articles, dissertations, conference proceedings or discussion papers, will be excluded.

In addition, the reviewed literature must include populations of (1) only older adults aged 65 years or older, (2) community-dwelling older adults, (3) older adults experiencing a physical and/or mental health challenge and (4) older adults exhibiting help-seeking behaviours or experiencing barriers/challenges to help seeking. Literature including those aged less than 65 years old, hospitalised patients, older adults living in nursing homes or other long-term care facilities as well as non-human studies will be excluded.

Step 4: charting the data

Data from the identified studies will be collected and charted according to key themes. From each eligible article, the reviewers will include authorship, year and journal of publication, the general characteristics of participants (ie, age, gender and ethnicity), geographic location of study, study methods, the identified barriers or facilitators associated with help-seeking behaviours, limitations and any other key findings. A combination of Excel and a reference management software will be used to chart the data and to manage the screening process.

Step 5: collating, summarising and reporting the results

Risk of bias will not be assessed, as this scoping review is only intended to provide an overview of the existing literature, and not to critically appraise the included articles. However, we will include a discussion of any limitations found in the included body of evidence.

The results of this scoping review will be summarised quantitatively through numerical counts (ie, to highlight the amount and type of studies reviewed) and qualitatively through a narrative synthesis. Tables and/or charts will be used to map the study findings and provide an overview, and the screening process will be visualised through a flowchart. Given the exploratory nature of this study, any factors related to help seeking will be considered for review. Facilitators to help seeking will be defined as any factor that has been shown to support or encourage an older adult to seek help for their mental and/or physical health challenges. 22 Barriers to help seeking will be defined as any factor that has been shown to prevent or discourage an older adult from seeking help for their mental and/or physical health challenges. 22 These factors could include, but will not be limited to, the following: the presence or absence of caregivers, a lack of resources, stigma, language barriers or cultural values. The discussion will be structured based on the themes that emerge from the review.

Patient and public involvement

The design of this scoping review protocol did not involve patients or the public, but we will aim to involve older adults in the review process, consulting, discussing and verifying the results of this review.

Ethics and dissemination

As this scoping review is intended to synthesise the current breadth of knowledge on the help-seeking behaviours of older adults, no ethics approval is required. The results of this scoping review will be disseminated through publication in a peer-reviewed journal.

The results of this study will establish what is currently known about the help-seeking behaviours of older adults. To our knowledge, this scoping review protocol is the first on this topic and will identify key themes and gaps in understanding how older adults seek support for their physical and mental health needs. The results in turn can serve as the basis for future research, such as a qualitative exploration of older adults’ decision-making processes when it comes to seeking formal or informal care, a study on how existing help-seeking facilitators or barriers may be influenced by the current COVID-19 pandemic or a systematic review on specific interventions or strategies that may be effective in improving help-seeking behaviour among various older adult populations. Through better understanding how older adults exhibit help-seeking behaviours and the facilitators or barriers that encourage or discourage them from seeking support, healthcare providers and programme implementers can offer formal healthcare services and programmes that are better tailored to suit the needs of this population. Furthermore, this synthesis of knowledge may also benefit older adult caregivers by highlighting additional supports and formal services that older adults can turn to. In identifying alternative strategies for care, such as home care services or online resources, the burden of caring for older adults does not need to fall solely on their caregivers and loved ones.

A secondary objective of this scoping review is to include the perspectives of ethnic minority older adults and to identify how cultural influences may impact their help-seeking behaviour. Dissecting this information will help policymakers, healthcare decision-makers and programme implementers decide how best to allocate limited healthcare resources, such as providing them with rationale to invest in cultural competency training for staff or offering programmes in multiple languages. This is a significant consideration given the rates of immigration and globalisation worldwide and the importance of ensuring the representation of diverse populations in health research. 13 23 Altogether, this synthesis of literature can support the development of new evidence-based practices that will address the difficulties that older adults may experience when seeking care and provide strategies of support that acknowledge the needs of the incredibly diverse older adult demographic and their varying help-seeking behaviours.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors KT, RC, IR, LK and TC contributed to the development of this manuscript. KT conceptualised the research question, designed the study and prepared the first draft of the manuscript. TC helped refine the research question and provide review expertise. All authors contributed to the refining of the study design, as well as to the editing and revising of this protocol. All authors have approved the final manuscript for submission.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Published: 09 August 2022

Explaining adults’ mental health help-seeking through the lens of the theory of planned behavior: a scoping review

• Claire Adams   ORCID: orcid.org/0000-0002-0667-8088 2   nAff1 ,
• Eyal Gringart 1 &
• Natalie Strobel 2  

Systematic Reviews volume  11 , Article number:  160 ( 2022 ) Cite this article

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Despite evidence-based efficacy, mental health services are underutilized due to low rates of help-seeking, leaving unmet mental health needs a global concern. The Theory of Planned Behavior (TPB) has been applied to understand the help-seeking process and in the development of behavior change interventions. The aim of this scoping review was to map the literature on the TPB as applied to mental health help-seeking in adults aged >18 years.

This scoping review was conducted based on the methodology presented by Arksey and O’Malley (2005). Six databases (CINAHL, PsycINFO, MEDLINE, ProQuest Health and Medicine, ProQuest Dissertations and Theses, Web of Science) and two grey literature sources (OpenGrey, Google Scholar) were systematically searched in February 2018 and updated in March 2020. Studies that explicitly discussed the TPB in the context of mental health help-seeking were initially selected; only studies that explored formal help-seeking for mental health problems and were published in English were retained. Data were extracted using Microsoft Excel.

Initially, 8898 records were identified. Of these, 49 met the selection criteria and were included: 32 were journal articles and 17 were theses. Forty-three papers reported on non-intervention studies and seven articles reported on TPB-based interventions. Most studies ( n = 39) identified predictors of help-seeking intentions. Attitudes and perceived behavioral control were significant predictors of intentions in 35 and 34 studies, respectively. Subjective norms were a significant predictor of intentions in 23 studies. Few studies aimed to predict help-seeking behavior ( n = 8). Intentions and perceived behavioral control were significant predictors of behavior in seven and six studies, respectively. Only six TPB-based interventions were identified, all used digital technology to influence help-seeking, with mixed results.

Conclusions

The present scoping review identified a considerable evidence base on the TPB for predicting mental health help-seeking intentions. Attitudes and perceived behavioral control were frequently found to be significant predictors of help-seeking intentions. Knowledge on the TPB for predicting mental health help-seeking behavior, and on TPB-based interventions, is limited. Thus, the role of the TPB in developing help-seeking interventions remains unclear. Recommendations are presented to address such research gaps and inform policy and practice.

Peer Review reports

Mental health problems are a major public health concern. Recent prevalence estimates indicate 10.7% of the world’s population live with a mental health disorder, and the number of years lived with a mental health disorder has increased by 13.5% from 2007 to 2017, which is likely to be a reflection of increasing prevalence rates and greater life expectancy [ 1 , 2 , 3 ]. Associated with the rising prevalence rates of mental health problems is a high level of unmet mental health needs. Unmet mental health needs not only extend the period in which someone lives with the burden of ill mental health, but are also associated with greater levels of disability, reduced quality of life, and an increased likelihood of suicidal ideation and suicide attempts [ 4 , 5 ].

Pervasive unmet mental health needs have been reported in prominent and large-scale studies of mental health such as the World Health Organization (WHO) and World Mental Health Surveys and are reflected in low rates of service utilization [ 6 , 7 , 8 , 9 ]. For example, results of the World Mental Health Surveys conducted across 21 countries revealed only 27.6% of people with anxiety disorders received treatment over the course of one year, and less than one in 10 received adequate treatment [ 10 ]. People in low- and middle-income countries were the least likely to receive treatment (13.1%). Furthermore, national data from Australia and Canada indicate a little over half of the people who experienced emotional distress in 2013 and 2016 received treatment; however, many people (37% in Australia and 30% in Canada) reported that they did not want treatment [ 11 ].

Individual and social factors, such as perceived need for treatment, poor mental health literacy, and low rates of help-seeking have been shown to influence rates of service utilization. Researchers have noted that many people with mental health problems go undiagnosed and untreated, often due to a lack of knowledge about mental health disorders and their treatments, as well as a lack of help-seeking for mental health problems [ 12 , 13 ]. This has led to a widely recognized mental health treatment gap, whereby more individuals are diagnosed with mental health problems than those who receive treatment [ 14 , 15 ]. This treatment gap continues to exist even with the growing evidence base on effective mental health treatments.

The literature indicates that despite the effectiveness of evidence-based mental health treatments, most people do not seek help, or delay seeking help, which has significant personal, social, and economic costs [ 14 , 16 ]. There are many factors that influence help-seeking including stigma, attitudes, knowledge, financial resources, perceived need, and structural barriers/facilitators [ 12 , 17 , 18 , 19 ]. Understanding these factors and addressing the disparity between the need for mental health services and their use are critical to understanding and addressing mental health outcomes. Still, most of the research on mental health help-seeking has been exploratory and devoid of a theoretical orientation, which has been identified as a gap in the body of knowledge. A clear theoretical framework would greatly improve our ability to understand, explain, predict, and address maladaptive behaviors such as refraining from seeking professional mental health support.

In recent years, researchers have attempted to address this gap [ 20 , 21 , 22 ], and a number of theories have been applied to mental health help-seeking [ 23 ]. One such theory is the Theory of Planned Behavior (TPB). The TPB is an extension of Ajzen and Fishbein’s Theory of Reasoned Action (TRA) and suggests people make conscious decisions to act, or not act, based on their attitudes, subjective norms, and perceived behavioral control [ 24 ]. The theory posits that attitudes towards a behavior influence a person’s plan or intention to act, and subsequently, the action or behavior itself [ 25 ]. Subjective norms, defined as perceived social pressures from significant others to perform a behavior, also influence a person’s intentions and behavior [ 26 ]. Perceived behavioral control, which is the perceived opportunities, skills, and resources needed to perform a behavior, can influence behavior directly or indirectly as it affects intentions [ 24 ]. The inclusion of perceived behavioral control as an antecedent to intentions and behavior is the main difference between the TPB and the TRA. By considering the role of perceived behavioral control, the TPB includes non-motivational factors that influence behavior, thereby overcoming criticisms of the TRA [ 26 , 27 ]. Thus, the TPB proposes that attitudes, subjective norms, and perceived behavioral control influence behavioral intentions, which predict behavior [ 24 ].

The utility of the TPB to explain factors that contribute to decision-making, and how behavior change occurs, is thought to be particularly useful in understanding mental health issues, the help-seeking process, and developing interventions to facilitate mental health behavior change [ 28 , 29 , 30 ]. Whilst there is no commonly accepted definition of professional help-seeking, Cornally and Mccarthy [ 31 ] defined help-seeking as “a problem focused, planned behavior, involving interpersonal interaction with a selected health-care professional”. Seeking help from a professional, also known as formal help-seeking, involves seeking help from professional sources who can provide appropriate care [ 16 ]. Seeking help from a professional is considered optimal for the receipt of evidence-based treatments [ 23 , 32 ]. The conceptualization of help-seeking as a planned behavior aligns well with the TPB, as it suggests seeking help involves a conscious or planned decision to seek or not seek support. There is also evidence supporting attitudes and intentions as influential to mental health help-seeking behavior, further substantiating the relevance of the TPB in this area [ 33 ]. Applying theories that encompass attitudes and intentions when investigating behavior, such as the TPB, is recommended by scholars and has been a major focus of research across fields [ 34 ].

Whilst there is no universally accepted theory or model in the area of mental health help-seeking [ 23 ], the body of research applying the TPB to understand mental health help-seeking continues to gain momentum, and the TPB has been favored as the most common approach to frame help-seeking in the literature [ 16 ]. Studies on the TPB have identified predictors of mental health help-seeking intentions as well as behavior. For example, Tomczyk et al. [ 29 ] found attitudes, subjective norms, and self-efficacy (a component of perceived behavioral control), significantly influence intentions, and intentions significantly predict behavior, among people with untreated depressive symptoms in Germany. Moreover, Zorrilla et al. [ 35 ] explored predictors of help-seeking intentions among young adults in the USA and found attitudes was a strong, significant predictor of help-seeking intention for mental health services, followed by perceived behavioral control and subjective norms. Conversely, Bohon et al. [ 36 ] found partial support for the influence of TPB variables on help-seeking, with attitudes and perceived behavioral control significantly predictive of intentions to seek help, but not subjective norms.

There is a need to synthesize what is known about the TPB in the context of mental health help-seeking, to facilitate the identification of factors related to mental health help-seeking, which may provide viable targets for intervention to encourage mental health service utilization and potentially reduce the treatment gap. Recent research has attempted to improve rates of mental health help-seeking through TPB-based interventions [ 37 , 38 , 39 ], however these are yet to be reviewed. It is important to understand what efforts have been made to improve mental health help-seeking to progress the effectiveness of interventions and inform future directions.

The aim of the current scoping review was to map the literature on the TPB when applied to mental health help-seeking. Given the favorable results of the TPB in the health field, and logical expansion of the TPB to mental health help-seeking, this theory provides an important evidence base from which mental health help-seeking can be understood and improved. A scoping review allowed the identification of different types and sources of evidence on this topic, as well as gaps in them, which limit our understanding. The purpose of this scoping review was to:

Identify how the TPB has been applied to mental health help-seeking

Identify and summarize the theoretical factors, which influence help-seeking intentions and behavior

Explore the current state of knowledge on TPB-based interventions designed to improve mental health help-seeking

Highlight how this understanding can inform future research and practice on mental health help-seeking in adult populations.

The current scoping review was based on the methodology outlined by Arksey and O’Malley [ 40 ]. Arksey and O’Malley proposed a five-stage process, which includes (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarizing, and reporting the results. This process was followed, and the scoping review is reported based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (see Additional file 1 ) [ 41 ].

Review protocol

The scoping review protocol was drafted using Arksey and O’Malley’s five-stage process and was published on the Open Science Framework on 9th November 2017 ( https://osf.io/73c5a/ ).

Identifying the research question

The research question for this scoping review was: What is known about the application of the TPB to mental health help-seeking in adults?

Criteria for study inclusion

Table 1 summarizes the study eligibility criteria.

Types of studies

All studies, which explicitly discussed the TPB in the context of mental health help-seeking, independently of the TRA, were included in the current review. Studies that utilized mediation, moderation, and extended models of the TPB were included only if they examined all variables in the TPB model, and these variables were examined independently (attitudes, subjective norms, perceived behavioral control, intentions and, where applicable, behavior). For the purposes of this study, we defined traditional TPB models as models which included only the aforementioned TPB variables and extended TPB models as those which included any additional predictor(s).

Intervention studies were included if they utilized the TPB model in the design and development of the intervention. Editorials, opinion pieces, and conference abstracts were excluded. Qualitative studies were also excluded as these tended to be formative research, which use the TPB as an exploratory framework rather than apply the TPB constructs to mental health help-seeking.

Participants

This review included papers focused on adults aged >18 years. Samples with and without mental health problems were included, as well as samples restricted to specific sociodemographic criteria (such as age, gender, and occupation). Populations with cognitive deficits such as dementia, intellectual disabilities, and head injuries were excluded, as a person’s cognitive ability directly affects their capacity to seek help as well as process the TPB variables. Studies specific to people diagnosed with schizophrenia, drug users, and survivors of cancer were also excluded due to the cognitive impairments often found in these populations resulting from their treatments or drug use.

Only papers focused on formal mental health help-seeking were included in the current review. Formal help-seeking has been defined as seeking help from professional sources who can provide appropriate care [ 16 ]. In the context of mental health help-seeking, a professional source may include a primary health care provider (general practitioner, nurse, medical specialist) or mental health specialist (psychologist, social worker, counselor, psychiatrist). Formal mental health help-seeking may be face-to-face or online (e.g., e-counseling) as long as it was from a professional source. Self-help programs and resources were excluded, and papers which did not distinguish between formal and informal sources of support were also excluded.

Studies were included if the reason for seeking help was for mental health problems or concerns. For the purposes of the current review, a mental health problem included any symptoms of emotional distress or psychological disturbance, to ensure all studies relevant to mental health were encompassed. The mental health problem did not have to be formally diagnosed as a mental disorder or meet established criteria for a mental disorder.

Some mental health problems such as substance abuse and eating disorders have been considered health-related behaviors in previous research [ 42 , 43 ]. In the present review, these conditions were excluded, as our aim was to examine how the TPB has been applied to mental health problems beyond the traditional application of the TPB to health-related behaviors.

Additionally, studies which focused on secondary help-seeking (seeking help for someone else such as a peer, family member, or friend) were excluded as we sought self-agency over help-seeking behavior, in line with the TPB assertion that behavior must be under volitional control [ 24 ].

Standardized quantitative measures of the TPB are scarce, and therefore, all questionnaires and tools that measure TPB variables were included.

The primary outcomes founded in the TPB framework were (1) attitudes: attitudes toward seeking help for mental health problems; (2) subjective norms: beliefs about whether others approve or disapprove of help-seeking; (3) perceived behavioral control: beliefs about one’s own ability to seek help for mental health problems; and (4) help-seeking intentions: conscious decision to seek or not seek help.

The secondary outcome was help-seeking behaviors, defined as actual help-seeking from a health professional.

Identifying relevant studies

Searches were conducted across six databases (CINAHL, PsycINFO, MEDLINE, ProQuest Health and Medicine, ProQuest Dissertations and Theses, and Web of Science) and two gray literature sources (OpenGrey and Google Scholar). Only papers published in English were included. The searches were run during February 2018 and updated in March 2020. With the help of an experienced subject librarian, keywords were selected, which allowed for breadth of coverage (see Table 2 ).

The above search strategy was used for each database search, and keywords from this search strategy were used to search the gray literature sources. Multiple combinations of the keywords were used to conduct the Google Scholar searches, and the first 50 pages (representing 1000 results) were screened using Google search engines relevancy ranking to order the results [ 44 ]. Reference list searches were also conducted from articles selected for inclusion to identify other relevant studies, which may have been absent in the electronic searches.

Study selection

All titles and abstracts retrieved through the literature searches were reviewed independently by two researchers to identify studies that met the inclusion criteria. The reviewers met during the title and abstract screening and at the conclusion of this stage to discuss and resolve conflicts regarding the inclusion of articles. The inclusion criteria at the title and abstract level were limited to any paper that utilized the TPB or any of its primary variables (attitudes, subjective norms, perceived behavioral control) in relation to mental health problems. Studies excluded at this stage were those including children under the age of 18 exclusively, people with cognitive deficits, and studies not published in English. The covidence systematic review platform was used for title and abstract screening [ 45 ].

Once the relevant studies had been selected, the full-text was retrieved and read independently by two researchers to determine eligibility for inclusion, based on the criteria described above. A third senior reviewer was consulted to resolve conflicts regarding the inclusion of articles, and a final decision was reached once a consensus was achieved.

Charting the data

A standard data charting form was developed and pilot-tested in Microsoft Excel before data extraction. Data collected from each study were organized according to key information: basic descriptors (title, first author, year of publication, publication type, country), eligibility information (aim/purpose of the paper, reason for seeking help, source of help), study population (population group, mental health status, sample size, setting, method of recruitment, sociodemographic information), research methods (study design, measures used, analysis, intervention details if applicable), primary and secondary outcome measures (attitudes, subjective norms, perceived behavioral control, intentions, behavior), and description of key findings.

Collating, summarizing, and reporting the results

Descriptive tables were used to outline the key information from each paper. Based on the content of the articles and the present research question, the studies were organized according to non-interventions and interventions. Tables were used to highlight the pertinent information from the non-intervention and intervention studies according to our review objectives.

A PRISMA flow diagram is presented in Fig. 1 , which outlines the process of selecting studies. There were 8898 records identified through the literature searches. After the removal of duplicates, 5626 records were screened for eligibility. There were 5436 records excluded at the title and abstract stage, 143 articles excluded after full-text screening and three articles excluded after data extraction. The reasons for exclusion are provided in Fig. 1 . A further 5 articles were identified through reference list searches and screened. This process resulted in the inclusion of 49 articles.

Flow diagram of study selection

Characteristics of studies

The 49 articles that were chosen were published between 1998 and 2020; 32 (65%) were journal articles and 17 (35%) were theses. Of these, 42 (86%) were non-intervention studies, six (12%) were intervention studies, and one paper (2%) reported on both cross-sectional data and an intervention (Fig. 2 ).

Stacked histogram of the number of studies published per year

Most studies were conducted in North America ( n = 27, 55%), followed by Europe ( n = 9, 19%), Asia ( n = 8, 16%), Oceania ( n = 4, 8%), and Africa ( n = 1, 2%). In terms of the populations, most targeted college students ( n studies = 16, 33%; n participants = 6048), followed by community samples ( n studies = 12, 25%; n participants = 7305), both students and community samples ( n studies = 1, 2%; n students = 320; n community adults = 208), armed forces or emergency service workers ( n studies = 8, 16%; n participants = 1910), older adults ( n studies = 2, 4%; n participants = 568), and other specific populations ( n studies = 10, 20%; n participants = 3137).

Most studies included all participants with and without symptoms of mental health problems ( n studies = 42, 86%; n participants = 17371), three studies (6%; n participants = 1542) only included participants with psychological symptomatology, two studies (4%; n participants = 160) targeted people who screened positive for a mental disorder, one study (2%; n participants = 400) included dysphoric individuals only, and an intervention design paper ( n studies = 1, 2%; n participants = 23) only included young adults with experience in seeking help for mental health issues.

TPB-based non-intervention studies

Forty-three articles reported on non-intervention studies [ 21 , 29 , 35 , 36 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 ]. Of these, 28 (65%) were journal articles and 15 (35%) were theses. A summary of the final selected non-intervention articles is given in Additional file 2 , Supplementary Table 1 .

Two journal articles reported on the same sample [ 77 , 79 ], and one thesis reported pre-intervention cross-sectional data and intervention data and thus was included in both sections [ 58 ]. One study reported on post-intervention data only and was included under non-intervention studies as the intervention was not based on the TPB [ 62 ]. The results of the study are not reported due to the study design.

Most of the non-intervention studies were conducted in North America ( n = 23, 53%), followed by Europe ( n = 9, 21%), Asia ( n = 8, 19%), Oceania ( n = 2, 5%), and Africa ( n studies = 1, 2%). The most commonly targeted populations were students ( n studies = 14, 33%; n participants = 5588), followed by armed forces or emergency service workers ( n studies = 7, 16%; n participants = 1900) and community samples ( n studies = 10, 23%; n participants = 7231).

Of the 43 non-intervention papers, 38 were cross-sectional studies that aimed to identify predictors of mental health help-seeking intentions and/or behaviors. Five of the cross-sectional papers included a psychometric study or elicitation study, which designed and/or evaluated measures to assess TPB variables, for use in the main cross-sectional study [ 36 , 50 , 53 , 54 , 59 ]. Three papers were solely psychometric evaluations, which examined the validity and reliability of attitudinal mental health help-seeking scales. Two centered on the reliability and validity of the Inventory of Attitudes towards Seeking Mental Health Services (IASMHS) [ 49 , 84 ]. The third paper developed and tested the Mental Help-Seeking Attitudes Scale (MHSAS) [ 76 ]. One psychometric study also reported on predictors of help-seeking intentions [ 84 ].

In addition, one paper was an experimental between-group design, which aimed to influence intentions to seek help for depression through evoking positive emotions using nostalgic messages [ 62 ], and one paper presented baseline data from a randomized controlled trial examining students’ intentions to seek help and actual counselling usage [ 58 ].

The type of mental health problem was rarely defined in the literature, most commonly referred to as a psychological problem or mental health problem/concern ( n studies = 21, 49%). Other terms used included psychological stress/distress, personal and/or emotional problems, psychological difficulties, mental health conditions, persistent issues, and common concerns. Some studies gave examples of mental health problems, for example, Mo and Mak [ 21 ] used the term mental health problems and provided a definition to include low mood, tense, anxious, and problems sleeping. Stecker et al. [ 55 ] used the term mental health concerns and defined these to include major depressive disorder, panic disorder, generalized anxiety, post-traumatic stress disorder, and/or alcohol abuse disorder. Some studies presented a list of symptoms or problems such as depressed mood, anxiety, relationship difficulties, personal concerns, memory loss, and alcohol or drug abuse [ 50 , 51 , 59 ].

Depression was the only mental health problem to be examined independently, with eight studies (19%) focusing only on help-seeking for depression, and one study (2%) focusing on depression and suicidal thoughts [ 35 , 36 , 48 , 53 , 58 , 60 , 62 , 72 ]. These studies included all participants irrespective of their mental health status, with the exception of one paper which included only dysphoric individuals [ 60 ]. Additionally, three studies (7%) explored help-seeking for suicidality as well as other emotional or mental health problems [ 54 , 66 , 80 ].

As only formal mental health help-seeking was included, most studies reported the source of help as mental health services, psychological/psychiatric help, mental health professional, or a combination of these terms ( n studies = 27, 63%). Additional terminology included counseling ( n studies = 7, 17%), treatment ( n studies = 5, 12%), cyber-counseling ( n studies = 1, 2%), therapy for depression ( n studies = 1, 2%), psychotherapy ( n studies = 1, 2%), and prison psychologist ( n studies = 1, 2%). Of the studies that defined the type of service, common examples included social workers, counselors, psychologists, and psychiatrists. Six studies (14%) also specified physicians/general practitioners within their definition [ 49 , 55 , 57 , 67 , 71 , 75 ].

Factors which influence help-seeking intentions and behavior

The theoretical factors, which predict help-seeking intentions and behavior, are summarized in Tables 3 and 4 , respectively. Some studies ( n = 13, 33%) used traditional models of the TPB to explore help-seeking, whereby only the original TPB variables (attitudes, subjective norms, perceived behavioral control, intentions, and where applicable, behavior) were included in the model. Other studies ( n = 19, 49%) used extended models of the TPB, in which the original TPB variables and additional variables were included in the model (either as predictors or control variables), to identify further predictors of mental health help-seeking relevant to the population. Seven studies (18%) explored both traditional and extended models.

Overall, 39 studies identified predictors of mental health help-seeking; 31 studies identified predictors of mental health help-seeking intentions only, and eight studies identified predictors of intentions and behavior.

From the 39 studies that identified predictors of mental health help-seeking intentions, attitudes was a significant predictor of intentions in 35 (90%) studies, perceived behavioral control was a significant predictor of intentions in 34 (87%) studies, and subjective norms was a significant predictor of intentions in 23 (59%) studies. The variance in mental health help-seeking intentions explained by the TPB ranged from 7 to 93% for both the traditional and extended models.

There were eight articles that examined factors, which influence mental health help-seeking behavior. Seven of the eight articles (88%) found intentions to be a significant predictor of mental health help-seeking behavior, and six of the eight (75%) articles found perceived behavioral control to be a significant predictor of behavior. Two of the articles (25%), which did not support perceived behavioral control as a predictor of help-seeking behavior only examined one component of this construct, control factors, which may account for the insignificant findings [ 55 , 64 ]. Furthermore, two articles (25%) found perceived behavioral control to be a significant predictor of behavior in the traditional TPB model, but not when the model was extended to include other variables [ 47 , 83 ].

An additional paper examined help-seeking behavior but did not utilize the full TPB model [ 60 ]. In this paper, intentions were found to be a significant direct predictor of prospective help-seeking, and direct relationships were also found between attitudes and prospective help-seeking, and subjective norms and current help-seeking.

Overall, the variance in mental health help-seeking behavior explained by the TPB ranged from 3 to 61% for the traditional models and 10 to 63% for the extended models.

TPB-based interventions

Seven articles were identified on TPB-based interventions; four were journal articles and three were theses [ 30 , 37 , 38 , 39 , 58 , 85 , 86 ]. The seven articles comprised six unique interventions, which used the TPB model to improve intentions or behavior to seek professional help. A summary of the final selected intervention articles is given in Additional file 2 , Supplementary Table 2.

Three of the interventions were evaluated in randomized controlled trials, two were evaluated in pre-post studies, and one was assessed using a randomized post-test-only design. All six interventions used digital technology: two interventions were short videos on seeking counseling services, three were web-based tools, and one was a theory-guided multimedia presentation. The target population were mainly young adults ( n studies = 5, n participants = 704), one study targeted USA war veterans ( n participants = 10), and one study focused on adolescent mothers with a mean age of 18 ( n participants = 289).

The findings from each study were mixed. One study demonstrated improvements in mental health help-seeking intentions and behavior after intervention. Logsdon et al. [ 39 ] employed a pre-post design to evaluate an Internet-based depression intervention encouraging adolescent mothers to seek depression treatment and found a statistically significant increase in both intentions to seek treatment and actually receiving treatment over time in the intervention group compared to the control group. Another study that designed a web-based psychoeducational tool for USA veterans reported an increase in willingness to consider mental health treatment post-intervention [ 30 ].

Two studies, both using video interventions on attending counseling, demonstrated significant improvements in all three TPB predictor variables (attitudes, subjective norms, and perceived behavioral control) immediately after the intervention [ 58 , 85 ]. Chang [ 58 ] also conducted a follow-up and found sustained improvements in subjective norms and perceived behavioral control at 4-weeks post-intervention. In both studies, changes in predictor variables did not translate to improvements in intentions or behavior. Furthermore, Lindsley’s [ 86 ] guided multimedia presentation on treatment seeking reported findings consistent with overall improvements in TPB predictor variables after intervention; however, this declined over time and no differences between the experimental and control group were found. Finally, an online navigation tool for young adults designed to match participants with appropriate services did not demonstrate improvements in help-seeking intentions; changes in other TPB variables were not assessed [ 37 , 38 ].

The current scoping review mapped existing literature on the TPB when applied to mental health help-seeking. Of the 49 articles included, the earliest paper identified was published in 1998, with a rise in the number of studies since 2008, indicating growing interest in this field. Most studies were conducted in western countries (North America and Europe), with college students and community samples the most common populations targeted. Participants with and without mental health problems were typically included, which aligns with an early intervention approach to mental health care [ 87 ].

This body of research typically applied the TPB to predict mental health help-seeking intentions ( n = 39). Most studies found the TPB accounted for a large amount of variance in intentions; however, the range in variance explained was large. Of the theoretical factors, which influence mental health help-seeking intentions, attitudes and perceived behavioral control were frequently found to be significant predictors of help-seeking intentions, and subjective norms were found to be a significant predictor in more than half of the studies. This indicates that across population groups, a person’s favorable or unfavorable evaluation towards using mental health-related services, and their perceived resources, skills, and opportunities to access services, influence their intentions to seek help. For example, the belief that seeing a mental health professional will be helpful, and beliefs regarding potential costs of mental health consultations, influence help-seeking intentions [ 53 ]. The influence of subjective norms on intentions, that is, perceived social pressures to seek help, was less consistent, which may be due to differences in cultural norms and beliefs. For example, western cultures are typically individualistic and therefore, people from these cultures may be more motivated to act according to their own goals and beliefs [ 88 ]. In the present review, we found subjective norms were not statistically significant predictors of help-seeking intentions in some studies conducted in the USA [ 36 , 55 ]. In studies conducted in non-western cultures such as South Asia and among Chinese populations, social pressures were found to significantly predict help-seeking intentions [ 21 , 73 ]. This may be reflective of the collectivistic nature of these societies, which traditionally encourage interconnectedness with others [ 88 ].

Indeed, cultural factors such as race, ethnicity, and religion have been shown to influence help-seeking intentions and behavior. For example, mental health problems are commonly stigmatized in Chinese societies, which hinders people’s intentions to seek help for fear of social rejection [ 50 , 64 ]. In some extended and modified models of the TPB, variables such as adherence to Asian values, shame/izzat, and a Strong Black Woman ideal were included and were shown to significantly predict help-seeking intentions [ 22 , 47 , 72 ]. Some authors have advocated for the use of extended models of the TPB to better explain help-seeking intentions and behavior [ 89 , 90 ]. In the present scoping review, most non-intervention studies (67%) used extended models or both traditional and extended models to conceptualize help-seeking intentions; however, the variances explained by these models were comparable to traditional TPB models. Thus, factors that influence help-seeking intentions beyond the theoretical factors in the TPB require further investigation.

Fewer studies applied the TPB to predict mental health help-seeking behavior ( n = 8). Intentions and perceived behavioral control were significant predictors of behavior in most of these studies, supporting the TPB framework. Of the studies that did predict help-seeking behavior, past and/or present behaviors were commonly used as the outcome. We only located three studies, which explored the ability of the TPB to predict future behavior [ 29 , 55 , 75 ]. This is a key gap in the evidence related to predicting whether people would seek help for mental health problems if a future need arose. Whilst studies have found past behavior to have been a good indicator of future behavior, this is not always the case [ 24 ]. Additionally, there is a widely recognized intention–behavior gap, where positive intentions are not always antecedent for actual behavior [ 91 ]. Thus, there exists an important opportunity to develop TPB models for predicting future behavior, to identify groups who are in need and yet are less likely than other populations to seek help, and to enable targeted interventions to address their needs as well as increase help-seeking behaviors among them.

The current state of knowledge on TPB-based interventions for mental health help-seeking is in its infancy, with few studies published, all within the last decade. It is both difficult and premature to draw conclusions as to the role of the TPB as a framework for developing behavior change interventions for mental health help-seeking, due to the variation in predictor variables examined, lack of diversity in populations, and limited ways in which the interventions were delivered. Of the seven studies we located on TPB-based interventions to improve mental health help-seeking, six used digital technology, mostly to target young adults. This is of concern, given recommendations from researchers to use the TPB to promote behavioral change across populations, and the various approaches which can be trialed to facilitate the greatest change in behavior, e.g., persuasive communications, face-to-face discussions, and observational modeling [ 42 , 92 , 93 ]. There is a need and room for the development and evaluation of TPB-based interventions using different modes of delivery and targeting both community samples and at-risk populations, which may be effective in promoting help-seeking and facilitating service utilization.

There is also space for the TPB to be applied across subgroups who experience disparities in service provision, to explain intentions and behavior towards mental health service utilization; however, this has been largely overlooked in studies to date. Background factors such as age, race, ethnicity, and social class are associated with different behavioral beliefs, behavioral intentions, and prevalence rates of behaviors [ 94 ]. Such factors can be incorporated into the TPB model to identify inequities in health and health-related behaviors and guide the allocation of resources to better meet the needs of diverse communities who have differential access to care [ 94 ]. For example, people from culturally and linguistically diverse groups are less likely to engage mental health services than members of the wider population, due to a lack of knowledge of services and how to access them, communication barriers, financial barriers, racism, and culturally insensitive practices [ 95 , 96 , 97 ]. Moreover, attitudes towards and beliefs about mental health problems and treatments among diverse groups may differ from dominant Western approaches, and access to culturally appropriate care is often limited [ 98 ]. The TPB can be applied to identify background factors that influence help-seeking, and attitudes, norms, and control beliefs associated with help-seeking among racial and ethnic minority groups, providing insight into service access and use. Such research is important to accurately address the needs of marginalized populations and promote inclusive practices.

Implications for future research and practice

The current scoping review provides a resource for researchers and practitioners to understand mental health help-seeking through the lens of TPB. Prominent research gaps are highlighted in Fig. 3 .

Research gaps

There is scope for a number of systematic reviews to determine the most significant predictors of mental health help-seeking intentions and behavior, which can be used as target areas for intervention. Systematic reviewers may wish to focus their investigations on determining the key TPB-based predictors of mental health help-seeking among student samples, given the predominance of studies on this population. There is also scope to conduct a systematic review on methods for measuring TPB variables due to the diversity in quantitative tools used to assess these constructs. This will enable more accurate measurement of these variables and greater ability to compare findings. An investigation of the most reliable evidence for the effects of TPB-based interventions on mental health help-seeking intentions and behaviors is also warranted. Such reviews could provide stakeholders a sound basis for their decisions on how to assess and improve mental health help-seeking.

Strengths and limitations

By employing a scoping review methodology and a systematic approach to the selection of studies, we conducted a comprehensive and structured review of the literature in line with current recommendations for good practice [ 99 ]. This clear structure makes the current results more accessible to stakeholders interested in applying the findings to inform policy and practice [ 40 ]. It is still possible that we did not locate all relevant studies or misclassified relevant papers.

Whilst we aimed to include only those studies relevant to adults, defined as people aged 18 years and over, there were three studies which did not define the age of participants [ 65 , 66 , 68 ]. As the sample in Miller [ 65 ] comprised lawyers, it is safe to assume that the age of participants was >18 years. In Rathbone (2014) and Mills (2010), however, the target samples were college students, and it is, therefore, possible that the mean age of participants in these studies was <18 years [ 66 , 68 ]. As we cannot be certain, these three studies were included in this review to ensure we did not falsely exclude relevant papers.

A further limitation is the paucity of TPB-based standardized questionnaires on mental health help-seeking, which restricts our confidence in the accurate measurement of TPB variables. Many authors have created their own measures or adapted previous measures to fit their study contexts [ 21 , 53 , 78 ]. Additionally, validated tools such as the Attitude Toward Seeking Professional Psychological Help Scale (ATSPPHS) and IASMHS have been constructed and applied to mental health help-seeking, but do not necessarily reflect the true nature of the TPB. For example, the ATSPPHS has been widely used as a measure of help-seeking attitudes; however, this tool precedes the TPB and its development was not guided by any explicit theoretical framework [ 49 , 76 ]. The IASMHS was designed to improve upon this measure by including items, which directly target the TPB predictor variables; however, the three subscales of the IASMHS only loosely reflect the TPB and contain other constructs such as mental health literacy, self-disclosure, avoidance coping, or self-concept clarity [ 49 , 76 ]. We, therefore, cannot detect whether intentions to seek help were influenced by the components of the TPB or the overlapping or related constructs inherent in this measure. Furthermore, studies that used the IASMHS but did not reference the TPB would not have been identified by our searches but may add to our understanding of mental health help-seeking within a TPB framework. More consistency is needed in the assessment of TPB variables to strengthen the conclusions drawn about the explanatory role of the TPB in the present context.

Additionally, we applied a strict inclusion and exclusion criteria, which may have resulted in the exclusion of closely related studies. We chose this approach to strengthen our understanding of the original TPB framework, without modifications.

As the TPB is one of the most prominent theories in the social and behavioral sciences, the current scoping review was prudent to improve our understanding of the role of the TPB in explaining mental health help-seeking among adults. With the increase in effective psychological treatments, there is a pressing need for researchers and clinicians to promote engagement with mental health services to alleviate some of the personal and societal costs associated with ill mental health.

As a result of mapping the evidence base, we have identified a considerable body of research on the TPB for predicting mental health help-seeking intentions. Attitudes and perceived behavioral control, in particular, appear to be well-cited factors influencing people’s intentions to seek or not seek help. Less attention was paid to help-seeking behavior; however, among the eight studies that explored help-seeking behavior, intentions and perceived behavioral control were found to be significant predictors of help-seeking behavior, which further supports the TPB in this context. The evidence base for TPB-based interventions to improve mental health help-seeking is in its early stages, and there appears to be a number of gaps in the literature that limit our understanding of the applicability of the TPB in this context and warrant further research.

An important line of future enquiry could be to utilize the theoretical framework of the TPB to find ways to increase help-seeking behavior to improve mental health outcomes. A particular focus should be paid to groups at-risk of mental health problems, such as veterans, people with chronic illnesses, and immigrants, to reduce the personal and societal burden of unmet mental health needs. The current scoping review provides a broad map of the evidence related to mental health help-seeking, which can inform future research, policy, and practice.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

Attitude Toward Seeking Professional Psychological Help Scale

Inventory of Attitudes towards Seeking Mental Health Services

Mental Help-Seeking Attitudes Scale

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

Theory of Planned Behavior

Theory of Reasoned Action

World Health Organization

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Acknowledgements

The authors would like to thank Dr. Beron Wei Zhong Tan for his assistance during the initial stages of the project.

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CA under the supervison of EG and NS designed the study and drafted the study protocol. CA conducted the systematic searches of databases and gray literature. CA and NS screened and extracted the articles. CA prepared the draft manuscript. EG and NS technically edited the manuscript. The author(s) have read and approved the final manuscript.

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Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2: Table S1

. Characteristics of studies – non-interventions. Table S2 . Characteristics of studies – interventions.

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Adams, C., Gringart, E. & Strobel, N. Explaining adults’ mental health help-seeking through the lens of the theory of planned behavior: a scoping review. Syst Rev 11 , 160 (2022). https://doi.org/10.1186/s13643-022-02034-y

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Help-Seeking: A review of the literature

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This study was supported by grants from the Administration on Aging, #90-A-644, and from the National Institute on Aging, NIA 5-PO1-AG 00123.

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REVIEW article

Patterns of help-seeking behavior among people with mental illness in ethiopia: a systematic review and meta-analysis.

• 1 Department of Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
• 2 Department of Psychiatry, Amhara Public Health Institute, Bahirdar, Ethiopia
• 3 Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
• 4 Department of Anatomy, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
• 5 Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
• 6 Department of Psychiatry, Debre Tabor Comprehensive Specialized Hospital, Debre Tabor, Ethiopia
• 7 Department of Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Background: Despite the availability of evidence-based and effective treatments, significant numbers of people living with mental illness do not receive treatment or do not seek help from providers of formal modern treatment. Although numerous primary studies have been conducted on patterns of help-seeking behavior among individuals with mental illness with respect to modern therapy, the evidence has not been aggregated nationwide. Therefore, the aim of this review was to investigate pooled data on patterns of help-seeking behavior among individuals with mental illness in Ethiopia.

Methods: All available primary studies were searched via the Google Scholar, HINARI, and PubMed databases from June 22 to December 20, 2023; 912 articles were identified. Sixteen articles were included in the final review; data from them were extracted to an Excel spreadsheet and exported to Stata version 17 for analysis. The search terms used were: “Pattern of help-seeking behavior’’ OR “Pattern of treatment-seeking behavior” OR “Health care-seeking behavior” OR “Help-seeking intention” OR “Help-seeking preferences” OR “Perceived need” OR “Pathways to psychiatric care”, AND “Common mental disorders” OR “Mental illness” OR “Mental health problems” OR “Depression”, AND “Predictors” OR “Determinate factors” OR “Associated factors”, AND “Ethiopia”. The quality of the studies included was critically appraised using the modified The Joanna Briggs Institute (JBI) Joanna Briggs Institute quality assessment tool, adapted for observational studies. During critical appraisal, disagreements between the two authors conducting the assessment were resolved by the involvement of a third author. Effect sizes were pooled using the random effects model, and the presence of publication bias was detected based on asymmetry of the funnel plot and a statistically significant result of Egger’s test (p<0.05).

Results: The pooled rate of positive help-seeking behavior with respect to modern treatment among people living with mental illness was 42.21% (95% CI: 29.29, 55.12; I 2 = 99.37%, P=0.00). Factors significantly associated with a positive pattern of help-seeking behavior were: having a secondary education or above (AOR=5.47, 95% CI: 2.33, 12.86); believing that mental illness requires treatment (AOR=2.76, 95% CI: 2.02, 3.78); having strong social support (AOR=2.00, 95% CI: 1.64, 2.44); having a family history of mental illness (AOR=2.68, 95% CI: 1.38, 3.97); having awareness of the availability of treatment (AOR=2.92, 95% CI: 1.56, 5.46); having previously engaged in positive help-seeking behavior (AOR=3.28, 95% CI: 1.63, 6.60); having comorbid disorders (AOR=4.25, 95% CI: 1.69, 10.66); not using alcohol (AOR=3.29, 95% CI: 1.73, 6.27); and the perceived severity of mental illness (AOR=2.54, 95% CI: 1.490, 4.33).

Conclusions: The majority of people with mental illness in Ethiopia exhibited a poor pattern of help-seeking behavior with respect to modern treatment. Therefore, mobilization of the community should be encouraged via regular public awareness campaigns regarding mental illness and the availability of evidence-based and effective modern treatment in Ethiopia. Moreover, the design of effective community-based mental health interventions is recommended in order to improve public attitudes and rates of help-seeking behavior in relation to mental health problems.

Introduction

The World Health Organization (WHO) defines mental health as a subjective state of well-being in which a person recognizes their own potential and is able to manage the typical stressors of everyday life, work productively, and contribute to their community ( 1 ).

Patients’ cultural beliefs about the causes and experience of mental illness affect their attitudes toward effective treatment, as well as the type of treatment they seek. In Ethiopia, mentally ill individuals are frequently blamed for their own condition; alternatively, some may consider mentally ill people to be victims of bad luck, religious and moral transgression, and witchcraft ( 2 – 4 ). This may result in denial on the part of both patients and their families, causing delays in seeking expert treatment.

Myths and beliefs about mental health and sickness exist in every community, and they impact people’s attitudes ( 5 ). Attitudes toward mental illnesses and their treatment among the majority of African societies, including Ethiopian society, differ from scientific views, which may have a negative impact on treatment-seeking behavior ( 6 ).

Mental illness is among the most poorly recognized health issues in Ethiopia. Societal prejudice and stigma against mental illness jeopardize the delivery of high-quality comprehensive patient care and rehabilitation ( 7 , 8 ). Furthermore, negative views in society hinder mentally ill people from seeking and adhering to treatment ( 9 , 10 ).

Mental illnesses and related disorders accounted for 13% of all diseases worldwide in 2019 ( 11 ), and this figure is expected to raise to 15% by 2020. Moreover, behavioral disorders are linked to significant rates of disability in low- and middle-income countries (LMICs). In LMICs, these conditions contribute 25.3% and 33.5%, respectively, of the total years for which a person lives with a disability ( 12 ).

WHO reports indicate that 41% of patients who attend the outpatient department of a psychiatric hospital are diagnosed with schizophrenia, 13% with mood disorders, and 11% with other disorders. Among patients who receive inpatient care, 85% are diagnosed with mood disorders or schizophrenia ( 13 ).

Worldwide, the mental health treatment gap is significant. Treatment for severe mental health problems is never received by up to 85% of patients in low-income countries and 35–50% of patients in high-income countries ( 14 ). Other research also indicates that approximately 70% of people globally who suffer from mental illness never receive treatment from mental health professionals ( 15 ). Despite the fact that mental health disorders are widespread and severely debilitating for people worldwide, there is limited demand from society for the services provided by modern facilities ( 16 ).

It is evident that the rates of help-seeking behavior among people with mental illness with respect to modern treatment in various regions of the world are low. In Rwanda, only 36.0% of respondents to a survey were found to seek help at a modern facility ( 17 ); this figure has been found to be 28% in England ( 18 ), 28.2% in China ( 19 ), 28.4% in Brazil ( 20 ), 32% in Singapore ( 21 ), 46.2% in Indonesia ( 22 ), 52% in another Chinese study ( 23 ), 51.1% in another Brazilian study ( 24 ), 65% in the Netherlands ( 25 ), 58.9% in Zanzibar ( 26 ), 64.6% in Hunan, China ( 27 ), 85% in Australia ( 28 ), 90.3% in Egypt ( 29 ), and 12.7% in another Chinese study ( 30 ). Furthermore, an Indian study revealed that, while a comparatively large number of respondents (35%) preferred traditional healers as providers of treatment for their mental health issues, fewer respondents (18%) said that they may see a psychiatrist if they were experiencing emotional problems ( 9 ). Another study carried out in Nigeria revealed that, in terms of patterns of help-seeking, 46% of respondents preferred traditional medical care as their primary source of assistance, 34% preferred spiritual healing, and 18% preferred informal help over modern medicine ( 31 ).

In Ethiopia, mental illness is the most common form of non-infectious disease, accounting for up to 11% of all illnesses, which is higher than the burden resulting from HIV/AIDS ( 32 ). However, the treatment gap for mental health issues is significant. Most people do not seek help or delay seeking help, which has serious consequences in the form of personal, social, and economic costs ( 33 , 34 ). Some patients have reported being unsure of where to obtain help, and 20.1% say that they do not want others to know about their problems ( 35 ). The community may also transfer patients with mental health problems to modern medical services when they have lost hope, with no progress made after exhausting informal traditional methods, such as herbal treatments and holy water ( 16 , 36 ). Furthermore, in certain regions of Ethiopia, individuals may abandon mentally ill patients if they do not respond to modern therapies and informal source of help. Lastly, some patients may walk the streets in their underwear, or live with family and receive their basic necessities in this way ( 37 ).

Generally, people with mental illnesses in Ethiopia show poor rates of engaging in help-seeking behavior with respect to modern health services, with rates ranging from 16.2 to 81.5% ( 4 , 38 – 52 ). Although several primary studies have been conducted in different areas to examine this problem, there are major discrepancies in the findings, with inconsistent results having been obtained across various regions within Ethiopia. Therefore, the aim of this systematic review and meta-analysis was to synthesize the pooled evidence on patterns of positive help-seeking behavior among people with mental illness with respect to modern treatment, and predictors of this behavior, in Ethiopia. Thus, the current study will provide information for policymakers and concerned stakeholders for the design of prevention strategies and strategies to increase the help-seeking behavior of people with mental illness with respect to modern treatment. Furthermore, the findings of this review can be used as an input for researchers who intend to conduct further investigations in this area.

Reporting and registration protocol

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines ( 53 ) were followed in reporting the results of this systematic review and meta-analysis ( Supplementary Table 1 ). The review protocol was registered with the Prospero database (PROSPERO, 2023: CRD42023437808).

Databases and search strategy

A literature search was conducted using Google Scholar, PubMed, and Hinari. All studies conducted on patterns of help-seeking behavior and associated factors among people with mental illness in Ethiopia were included. To identify relevant data on help-seeking behavior and associated factors among people with mental illness, comprehensive searches were conducted via the mentioned databases using the following search terms and phrases, which were combined using the “OR” and “AND” Boolean operators: “Pattern of help-seeking behavior’’ OR “Pattern of treatment-seeking behavior” OR “Health care-seeking behavior” OR “Help-seeking intention” OR “Help-seeking preferences” OR “perceived need” OR “Pathways to psychiatric care”, AND “Common mental disorders” OR “Mental illness” OR “Mental health problems” OR “Depression”, AND “Predictors” OR “Determinate factors” OR “Associated factors”, AND “Ethiopia”. Finally, all articles that were congruent with the topic of the review were retrieved and screened according to the inclusion criteria. The literature search was conducted from June 22, 2023 to December 20, 2023 and was performed by two independent researchers, with discrepancies resolved by discussion and consensus.

Eligibility criteria

All available primary studies were searched. Initially, all observational studies that measured help-seeking behavior and its predictors among people with mental illness in Ethiopia and that were written in the English language were included. We did not place a limitation on the earliest time of publication. Qualitative studies, case series, and case reports were excluded.

Study selection

All the articles retrieved were exported to EndNote version 7 reference manager, and duplicates were removed using the “find duplicates” function. Subsequently, screening and selection of the studies was conducted in two phases: first, the abstract and title were screened, and then the full text was reviewed. Based on screening of the title and abstract by two independent researchers, articles that reported on patterns of help-seeking behavior among people with mental illness were selected for full-text review. Any article deemed potentially eligible by either reviewer then underwent full-text review and was individually screened by both reviewers. In cases in which the researchers were unable to come to an agreement, a third researcher reviewed the article and resolved the disagreement.

Data extraction

Data were extracted using a standardized data abstraction form, developed in an Excel spreadsheet. For each study, the following data were extracted: author’s name, publication year, study region, study setting, study design, sample size, response rate, and pattern of help-seeking behavior. For each study, data extraction was carried out by two researchers (SA and GW), and the extracted data were then cross-checked for inconsistencies. Disagreements were resolved with the involvement of a third reviewer.

Primary outcome measure of interest

The primary outcome measure of interest was a positive pattern of help-seeking behavior with respect to formal modern treatment among people with mental illness, and the predictors of this behavior, in Ethiopia.

Data analysis

All statistical analyses was performed using STATA version 17. A weighted inverse-variance random-effects model ( 54 ) was used to calculate the overall pooled pattern of positive help-seeking behavior with respect to modern treatment among people with mental illness and the predictors of such behavior. The presence of publication bias was tested for by examining the symmetry of a funnel plot, and Egger’s test (with a p-value threshold of <0.05) was also employed to determine whether significant publication bias was present ( 55 ). The percentage of total variation across studies due to heterogeneity was assessed based on the I 2 statistic ( 56 ). Values of I 2 = 25, 50, and 75% were taken to represent low, moderate, and high heterogeneity, respectively ( 56 ).

A p-value of <0.05 for the I 2 statistic was taken to indicate significant heterogeneity ( 57 , 58 ). To determine the influence of a single study on the overall meta-analysis, a sensitivity analysis was performed. Forest plots were created to estimate the effects of independent factors on the outcome variable, and a measure of association is also reported with the 95% CI. The odds ratio (OR) was the most frequently reported measure of association in the eligible primary studies.

To estimate the pooled OR effect, either a fixed effects or a random effects model can be used. A fixed effects model is appropriate when the results only apply to the studies included in the meta-analysis; there is one common fixed parameter and all studies estimate the same common fixed parameters; it is reasonable to consider the studies similar enough that there is a common effect; all the included studies used comparable methodology; and all samples were drawn from identical populations. In contrast, a random effects model is appropriate when the results extend beyond the included studies; there is no common, fixed parameter, and studies estimate different parameters; the studies are different and it is not reasonable to consider them to be examining a common effect; the included studies used different methodologies; or the samples were drawn from different populations. In the case of our review, the primary studies included used different methodologies and the samples were drawn from several independent populations, resulting in significant heterogeneity and variation in the true effect size across studies. Thus, a random effects model was used in this review.

Search outcomes

Our exhaustive survey of both published and unpublished sources in the database search identified a total of 912 articles. All 912 articles were obtained via the database search. Among these, 585 articles were identified using Google Scholar, 291 using PubMed, and 36 using Hinari. A total of 729 duplicate articles were excluded. After screening of the remaining 183 articles based on their title and abstract, 83 articles were excluded due to not covering the topic of interest.

Next, the remaining 100 articles were assessed for availability of the full text; full text content was available for only 55 of these. After full text review of these 55 articles, 39 were excluded due to a) not being written in English, b) reporting on a study conducted outside Ethiopia, c) reporting on a study with a different target group, or d) the outcomes not being well defined. Finally, articles reporting on a total of 16 empirical studies ( 4 , 38 – 52 ) were included ( Figure 1 ).

Figure 1 PRISMA flow diagram showing the results of the literature search.

Characteristics of the studies included

In this systematic review, a total of 7092 adults living with mental illness were included across all included studies, with approximately half (50.7%) being men. The publication year of the included studies ranged from 1999 to 2021. The smallest and largest sample sizes among the included studies were from studies conducted in the Southern Nations, Nationalities, and Peoples' Region (SNNPR); sample sizes ranged from 100 ( 47 ) to 1135 ( 49 ). All were cross-sectional studies (n = 16, 100%). The majority (n=12, 75%) of the included studies were community-based, while the remainder were conducted in an institutional setting. The response rates of the individual studies ranged from 90.1% to 100%, and the rates of help-seeking behavior among people with mental illness ranged from 16.2% ( 40 ) to 81.5% ( 44 ).

Regarding geographical region, five studies ( 4 , 38 , 40 , 43 , 45 ) were conducted in Oromia, five ( 41 , 44 , 48 , 50 , 52 ) in Amhara, five ( 39 , 42 , 46 , 47 , 49 ) in the SNNPR, and one ( 51 ) in the Tigray region ( Table 1 ).

Table 1 Characteristics of the studies included.

Thematic findings

Sixteen primary studies conducted in four regions of Ethiopia (Amhara, Oromia, the SNNPR, and Tigray) were included in this review.

In a community-based cross-sectional study conducted in Butajira in the SNNPR involving 100 individuals living with mental illness, it was found that 41% of them sought help from a modern health institution for their problems. Another community-based cross-sectional survey conducted in southern Ethiopia, in which 385 mothers with postpartum depression were included, revealed that nearly half (49.9%) of the respondents exhibited a positive pattern of help-seeking behavior with respect to modern treatment. In an institution-based cross-sectional study conducted among 195 patients with depression in Jima in the Oromia region, it was reported that only 33.3% of the participants sought help from modern health facilities. Factors significantly associated with positive help-seeking behavior were being employed (AOR = 4.24, 95% CI: 1. 31, 13.78), having a secondary education or above (AOR= 7.6, 95% CI: 2. 13, 27.11), having a family history of mental illness (AOR= 7.33, 95% CI: 2. 72, 19.80), having ideas about hurting oneself, awareness of the availability of psychiatric services at the hospital, and having previously engaged in positive help-seeking behavior. Similarly, a community based cross-sectional study conducted in the SNNPR comprising 352 patients with depression indicated that 35.3% of them exhibited a positive pattern of help-seeking behavior with respect to modern treatment. The odds of engaging in a positive pattern of help-seeking behavior with respect to modern treatment were increased by 6.27 times among respondents who were aware of the availability of psychiatry services compared with their counterparts (AOR= 6.27, 95% CI: 2. 05, 19.2).

A study conducted in the Oromia region, in which 384 participants living with major depressive disorder, schizophrenia, and other psychotic disorders were included, indicated that 35.2% of them sought help from modern health services. Similarly, a study carried out in Jima in the Oromia region reported that, among 444 respondents with common mental disorders, only 16.2% of them sought help with their problems from a modern health facility. This study indicated that respondents who had a very poor overall level of satisfaction with life were less likely to seek help (p = 0.011) compared with those who had a very good level of satisfaction with life. This study also found that having no previous history of help-seeking behavior was significantly associated with seeking help for their problems (i.e., CMDs; p<0.001). Furthermore, a study of 450 depressed people found that nearly one-quarter (22.9%) of the respondents sought care from modern health institutions for their problems. The findings of this study also revealed that respondents who believed mental illnesses require treatment (AOR= 2.33, 95% CI: 1.25, 4.35), had a secondary education or above (AOR= 2.6, 95% CI: 1.23, 5.43), had engaged in suicidal behavior (AOR= 1.82, 95% CI: 1.08, 3.04), were aware of the availability of modern treatment services (AOR= 1.98, 95% CI: 1.18, 3.31), or had a history of positive help-seeking behavior were more likely to seek help from a health care institution for their problems.

Additionally, in the community-based cross-sectional study conducted in the southern Oromia region among 245 individuals with common mental disorders, it was reported that half (49.9%) of the patients sought professional help for their illness. Factors significantly associated with increased help-seeking behavior for these disorders were: being 48 years old or older (AOR= 10.18, 95% CI: 1.45,71.49); being female (AOR=6.23, 95% CI: 2.41, 16.12); not using khat (AOR= 3.12, 95% CI: 1.28, 7.51), alcohol (AOR= 5.02, 95% CI: 1.55, 16.20), or cigarettes (AOR= 5.24, 95% CI; 1.45, 18.95); and having chronic physical illness (AOR= 10.23, 95% CI: 3.68, 28.48). A cross-sectional community-based study conducted among 226 patients with depression indicated that only 25.66% of the patients sought help from health professionals for their condition. The study also found that being female (AOR = 2.77, 95% CI: 1.280, 5.99), current alcohol consumption (AOR = 2.74, 95% CI: 1.27, 5.94), co-morbid medical–surgical illness (AOR = 4.49, 95% CI: 1.823, 11.07), and perceiving depression as an illness (AOR = 2.44, 95% CI: 1.26, 4.93) were all significantly associated with help-seeking behavior among the participants.

A population-based cross-sectional survey of 119 depressed individuals conducted in the SNNPR indicated that 23.7% of these individuals sought help from health professionals. Respondents who believed that mental illness required treatment (AOR=2.4, 95% CI: 1.26, 4.67), had completed a secondary education or above (AOR=8.7, 95% CI: 5.08, 15.11), or had a family history of mental illness (AOR=7.5, 95% CI: 2.69, 8.76) were more likely to seek help from health professionals. It was also observed that a survey involving 420 people living with mental illnesses in the Jima, Oromia region found that the majority (74.8%) of respondents favored non-medical approaches to treatment. In comparison to other findings, respondents in the Amhara region exhibited a higher rate of positive help-seeking behavior with respect to modern treatment, at 81.5% ( 44 ), 78.5% ( 50 ), and 63.8% ( 52 ). A relatively high rate of help-seeking behavior with respect to modern treatment was also documented in another study conducted in the SNNRP, at 70.5% ( 49 ). Factors with a positive impact on help-seeking intent were: having the belief that mental illness requires treatment (AOR = 3.42, 95% CI: 1.1, 10.55), being 25–34 years old (AOR = 1.46, 95% CI: 1.02, 2.09), having strong social support (AOR = 1.85, 95% CI: 1.25, 2.72), having previously engaged in positive help-seeking behavior (AOR=1.93, 95% CI: 1.07, 3.47), having comorbid medical illness (AOR=2.11, 95% CI: 1.22, 3.66), and a higher perceived severity of mental illness (AOR=2.7, 95% CI: 1.15, 6.34) ( 44 ). Finally, another study conducted in the Tigray region, which included 423 individuals living with mental illnesses, found that approximately one-quarter of them (22.5%) exhibited positive help-seeking behavior with respect to modern treatment.

Operational definition of variables

In this review, a pattern of positive help-seeking behavior was regarded as a preference on the part of the patient to be treated by modern medical services, as opposed to other forms of informal treatment, such as traditional religious treatment.

Quality appraisal of the included studies

Two independent reviewers (SA and TM) appraised the quality of the studies included and scored them on the validity of their results. The quality of each study was evaluated using the Joanna Briggs Institute (JBI) quality appraisal criteria ( 59 ). All sixteen studies included ( 4 , 38 – 52 ) were appraised as cross-sectional studies using JBI checklist. Among the sixteen studies, eleven studies scored “yes” on seven of eight questions (87.5%; low risk), three studies scored “yes” on six of eight questions (75%; low risk), and the remaining two studies scored “yes” on five of eight questions (62.5%; low risk) ( Supplementary Table 2 ). Studies were considered to be at low risk if they scored 50% or higher on the quality assessment indicator. After conducting a thorough quality appraisal, we determined that the primary studies included in our analysis displayed a high level of reliability in their methodological quality scores. All the studies included in this review scored between 5 and 7 out of a total of 8 points. Thus, all studies included in the review ( 4 , 38 – 52 ) were of high quality.

Risk of bias assessment

The adopted assessment tool ( 60 ) was used to assess the risk of bias. This tool consists of ten items that assess four areas of bias, including internal validity and external validity. Items 1–4 evaluate selection bias, non-response bias, and external validity; items 5–10 assess measure bias, analysis-related bias, and internal validity. Among all sixteen included studies, five studies scored “yes” on nine of the ten questions, and the remaining eleven studies scored “yes” on eight of the ten questions. A study was categorized as “low risk” when eight or more questions had a “yes” response, “moderate risk” when six or seven questions had a “yes” response, and “high risk” when five or fewer questions had a “yes” response. Therefore, all studies included ( 4 , 38 – 52 ) had low risk of bias (i.e., were of high quality) ( Supplementary Table 3 ).

Meta-analysis

Pooled data on pattern of positive help-seeking behavior.

Overall, sixteen eligible primary studies ( 4 , 38 – 52 ) were included in the final meta-analysis. Data on rates of help-seeking behavior among people with mental illness were obtained from all sixteen primary studies included ( 4 , 38 – 52 ), while data regarding the predictors of patterns of positive help-seeking behavior were also obtained from ten of these studies. The pooled rate of positive help-seeking behavior among people with mental illness was 42.21% (95% CI: 29.29, 55.12; I 2 = 99.37%, P=0.00) ( Figure 2 ).

Figure 2 Forest plot showing the pooled rate of positive help-seeking behavior with respect to formal modern treatment among people with mental illness in Ethiopia, 2023.

Publication bias

Publication bias was examined via both funnel plots and Egger’s regression test. Funnel plots exhibited an asymmetric shape, which indicates the presence of publication bias among the studies included ( Figure 3A ), and the result of Egger’s regression test was a value of 0.167. Duval and Tweedie nonparametric trim-and-fill analyses were conducted to correct publication bias among the studies. This indicated that publication bias would be controlled if eight additional studies were included in the review ( Figure 3B ).

Figure 3 Funnel plot showing publication bias in studies of help-seeking behavior among people with mental illness in Ethiopia (A) before and (B) after adjustment using trim-and-fill analysis.

Investigation of heterogeneity

The I 2 statistic corresponding to the forest plot indicated marked heterogeneity among the included studies (I 2 = 99.37%, P=0.00) ( Figure 2 ). Hence, sensitivity and sub-group analyses were carried out to minimize heterogeneity.

Sensitivity analysis

In order to determine the influence of each specific study on the overall meta-analysis, we conducted a sensitivity analysis. The forest plot showed that the estimated rate with a single study omitted was close to the combined estimate in each case, which implies that no single study had a major effect on the overall pooled estimate. Thus, it was demonstrated that no single study had a significant impact on the overall outcome of the meta-analysis ( Figure 4 ).

Figure 4 Sensitivity analysis for the rate of positive help-seeking behavior with respect to formal modern treatment among people with mental illness in Ethiopia, 2023.

Subgroup analyses

As part of this meta-analysis, we conducted subgroup analyses based on study region, sample size (<400 vs. >=400), study setting (institutional vs. community-based), and publication year (before 2019 vs. 2019 or later).

Subgroup analysis by region

In the sub-group analysis by region, it was found that people with mental illness exhibited a relatively high pooled rate of positive help-seeking behavior in the Amhara region (54.53%; 95% CI: 30.93, 78.14; I 2 = 99.55%, P=0.00) compared with the SNNR (44.24%; 95% CI: 25.72, 62.76; I 2 = 98.48%, P=0.00), the Oromia region (31.68%; 95% CI: 20.87, 42.49; I 2 = 96.11%, P<0.00), and the Tigray region (25.5%; 95% CI: 18.52, 26.48; I 2 = 0) ( Figure 5 ).

Figure 5 Forest plot showing subgroup analysis by region for rates of help-seeking behavior among people with mental illness in Ethiopia, 2023.

Subgroup analysis by study setting

The findings indicated that studies conducted in a community-based setting found relatively high rates of help-seeking behavior with respect to modern treatment (47.50%; 95% CI: 32.17, 62.83; I 2 = 99.18%, p=0.00) compared with those conducted in an institutional setting (33.45%; 95% CI: 12.82, 54.08: I 2 = 99.41%, p=0.00) ( Figure 6 ).

Figure 6 Forest plot showing the subgroup analysis by study setting for rates of help-seeking behavior among people with mental illness in Ethiopia, 2023.

Subgroup analysis by sample size

The findings of this analysis indicated that studies with a sample size of <400 observed relatively low rates of help-seeking behavior (36.73%; 95% CI: 30.01, 43.45; I 2 = 90.05%, p=0.00) compared to those with a sample size of >=400 (47.66%; 95% CI: 27.62, 67.70; I 2 = 99.66%, p=0.00) ( Figure 7 ).

Figure 7 Forest plot showing the subgroup analysis by sample size for rates of help-seeking behavior among people with mental illness in Ethiopia, 2023.

Subgroup analysis by publication year

The pooled rate of positive help-seeking behavior among people with mental illness in studies conducted before the year 2019 was 35.32% (95% CI: 27.53, 43.12; I 2 = 93.71%, P=0.00), which was lower than the rate observed in studies conducted in 2019 or later (48.98%; 95% CI: 29.49, 68.47; I 2 = 99.61%, P=0.00) ( Figure 8 ).

Figure 8 Forest plot showing the subgroup analysis by publication year for rates of help-seeking behavior with respect to formal modern treatment among people with mental illness in Ethiopia, 2023.

These subgroup analyses revealed that the heterogeneity among the primary studies may be attributable to differences in region, sample size, study setting, and publication year.

Factors associated with positive help-seeking behavior

In this review, three studies ( 38 , 42 , 48 ) reported a significant association between having a secondary education or above and a pattern of positive help-seeking behavior with respect to medical treatment among people with mental illness. The pooled AOR for having attained a secondary education or above for the rate of positive help-seeking behavior with respect to medical treatment among people with mental illness was 5.47 (95% CI: 2.33, 12.86; I 2 = 70.51%; P=0.03) ( Figure 9 ).

Figure 9 Forest plot showing the adjusted odds ratios obtained in different studies, with corresponding 95% CIs, for the association between having a secondary education or above and rates of positive help-seeking behavior with respect to medical treatment among people with mental illness. The midpoint and length of each segment indicate the AOR and 95% CI, respectively; the diamond shape represents the combined AOR over all studies.

Four studies ( 38 , 42 , 44 , 48 ) indicated that a belief that mental illness requires treatment was significantly associated with a pattern of positive help-seeking behavior with respect to medical treatment among people with mental illness. The pooled AOR for the belief that mental illness requires medical treatment for the rate of positive help-seeking behavior among people with mental illness was 2.76 (95% CI: 2.02, 3.78; I 2 = 0.00%; P=0.82) ( Figure 10 ).

Figure 10 Forest plot showing the adjusted odds ratios obtained in different studies, with corresponding 95% CIs, for the association between the belief that mental illness requires treatment and rates of positive help-seeking behavior with respect to medical treatment among people with mental illness. The midpoint and length of each segment indicate the AOR and 95% CI, respectively; the diamond shape represents the combined AOR over all studies.

Two studies ( 38 , 44 ) indicated a significant association between strong social support and a pattern of positive help-seeking behavior with respect to medical treatment among people with mental illness. The pooled AOR for strong social support for the rate of positive help-seeking behavior with respect to medical treatment among people with mental illness was 2.00 (95% CI: 1.64, 2.44; I2 = 0.00%; P=0.66) ( Figure 11 ).

Figure 11 Forest plot showing the adjusted odds ratios obtained in different studies, with corresponding 95% CIs, for the association between strong social support and rates of positive help-seeking behavior with respect to medical treatment among people with mental illness. The midpoint and the length of each segment indicate the AOR and 95% CI, respectively; the diamond shape represents the combined AOR over all studies.

Two studies ( 38 , 42 ) revealed a significant association between family history of mental illness and pattern of good help seeking behavior of people with mental illness to medical treatment. The pooled AOR of pattern of good help seeking behavior of people with mental illness to medical treatment and who had family history of mental illness was 2.68 (95%CI: 1.38, 3.97,I 2 = 74.44%, P<0,048).

Three studies ( 39 , 40 , 48 ) reported a significant association between people living with mental illness who know the availability of medical treatment and their pattern of good help seeking behavior to medical treatment. The pooled AOR pattern of good help seeking behavior of people with mental illness to medical treatment and who know the availability of medical treatment was 2.92(95%CI: 1.56, 5.46,I 2 = 44.83,p<0.163).

Four studies ( 38 , 40 , 44 , 48 ) showed a significant association between people who had previous good help seeking behavior and pattern of good help seeking behavior to the medical treatment. The pooled AOR of pattern of good help seeking behavior to the medical treatment and who had previous good help seeking behavior was 3.28 ((95%CI: 1.63, 6.60).

Three studies ( 4 , 41 , 44 ) also showed significant associations between people have comorbid disorder and pattern of good help seeking behavior to the medical treatment. The pooled AOR of pattern of good help seeking behavior to the medical treatment of patients with mental illness and who had comorbid disorder was 4.25 (95%CI: 1.69, 10.66).

Two studies ( 4 , 41 ) reported a significant association between individuals who did not use alcohol and their pattern of good help seeking behavior to the medical treatment. The pooled AOR of pattern of good help seeking behavior to the medical treatment and individuals who did not use alcohol was 3.29 (95%CI: 1.73, 6.27).

Two studies ( 41 , 44 ) reported a significant association between individuals who had perceived severity of mental illness and their pattern of good help seeking behavior to the medical treatment. The pooled AOR of pattern of good help seeking behavior to the medical treatment and individuals who had perceived severity of mental illness was 2.54 (95%CI: 1.490, 4.33).

Thus, people with mental illness with a secondary school education or above were 5.47 times more likely to exhibit a positive pattern of help-seeking behavior with respect to modern treatment compared with participants who were illiterate.

People with mental illness who believed that mental illness requires treatment were 2.76 times more likely to exhibit a positive pattern of help-seeking behavior with respect to modern treatment compared with participants who did not believe this.

Individuals living with mental illness who had strong social support were 2.00 times more likely to exhibit a positive pattern of help-seeking behavior with respect to modern treatment compared with respondents who had poor social support.

People with mental illness who had a family history of mental illness were 2.68 more likely to seek help from modern health facilities compared with those who had no family history of mental illness.

Likewise, people with mental illness who had knowledge of the availability of modern treatment for mental illness were 2.92 times more likely to exhibit a positive pattern of help-seeking behavior with respect to modern treatment compared with those who were unaware of it.

Similarly, people with mental illness who had previously engaged in positive help-seeking behavior with respect to modern treatment were 3.28 times more likely to exhibit a positive pattern of help-seeking behavior with respect to modern treatment compared with those who had previously engaged in negative help-seeking behavior.

The likelihood of exhibiting a positive pattern of help-seeking behavior was 4.25 times greater among respondents who had comorbid disorders compared with those who did not have such disorders.

Additionally, individuals with mental illness who did not use alcohol were 3.29 times more likely to exhibit a positive pattern of help-seeking behavior with respect to modern treatment compared with those who did use alcohol.

Finally, people with mental illness who perceived their mental illness to be severe were 2.54 times more likely to exhibit a positive pattern of help-seeking behavior with respect to modern treatment compared with respondents who did not have this perception.

In a society where health care facilities are scarce and overburdened with people suffering from communicable diseases, traditional healers will continue to provide therapy for mental disorders for some time. In Ethiopia, traditional methods have been preferred over modern medicine for treating neuropsychiatric disorders, in contrast to the preference to treat physical problems with modern medicine. As a result, working closely with traditional healers would provide primary health workers with a better chance of gaining community acceptability and changing certain detrimental traditional practices.

Thus, we conducted the first systematic review and meta-analysis on patterns of help-seeking behavior with respect to formal modern treatment among people with mental illness, and the predictors of this behavior, in Ethiopia.

We identified a total of 912 articles, among which, 16 studies provided data suitable to be included in the systematic review and meta-analysis. In this review, a total of 7092 adults suffering from mental illness were included across the articles included. The studies included in this analysis were published between 1999 and 2021, with sample sizes ranging from 100 to 1135. All were cross-sectional studies (n = 16; 100%). The majority of the studies included (n=12, 75%) were community-based, with the remainder being based in institutional settings. Individual studies had response rates ranging from 90.1% to 100%, and the rates of help-seeking behavior among people with mental illness ranged from 16.2% to 81.5%. According to individual studies, individuals in the Amhara region exhibited relatively high rates of positive help-seeking behavior, whereas those in the Oromia region had the poorest rates of help-seeking behavior with respect to modern treatment.

The results of our meta-analysis indicated that the overall pooled rate of positive help-seeking behavior with respect to modern treatment among people with mental illness was 42.21% (95% CI: 29.29, 55.12); I 2 = 99.37%; p=0.00), which was in line with the findings of research conducted in Singapore (32%) ( 21 ), Rwanda 36% ( 17 ), Indonesia 46.2% ( 22 ), China (52%) ( 23 ), and Brazil 51.1% ( 24 ). However, the findings of this study indicated a lower rate compared to studies conducted in the Netherlands (65%) ( 25 ), Zanzibar (58.9%) ( 26 ), Hunan, China (64.6%) ( 27 ), Australia(85%) ( 28 ), and Egypt (90.3%) ( 29 ). In contrast, the rate indicated in the current study was higher than that observed in research conducted in other China-based studies (12.7%, 28.2%) ( 19 , 30 ), in Somerset, England (28%) ( 18 ), and in another Brazilian study (28.4%) ( 20 ). This variation might be due to methodological, sample size, and cultural differences.

Furthermore, the finds of this study revealed that individuals with mental illness who had attained education at the secondary school level or above exhibited a positive pattern of help-seeking behavior with respect to modern treatment. This is consistent with studies conducted in Canada and China ( 19 , 61 , 62 ). This may be because people with higher educational attainment have a better understanding of mental health and more favorable attitudes toward those who suffer from mental illness. Consequently, instead of staying at home and relying on informal forms of treatment, they seek assistance from medical facilities, medical specialists, and psychiatrists. Participants who had comorbid medical illness were also more likely to seek help from modern facilities for their mental health issues compared with their counterparts, which is supported by previous research conducted in Brazil, Canada, and China ( 20 , 23 , 63 ). The likelihood of readmission to psychiatric hospital is higher among individuals with mental illnesses who also have medical comorbidities than in individuals without such conditions. This has an impact on the patient’s finances, their overall health, and the health of their family, which makes them more likely to seek out formal modern treatment for their problems.

Similarly, people with mental illness who believed that mental illness requires treatment showed a positive pattern of help-seeking behavior with respect to modern treatment compared with those participants who did not believe that mental illness requires treatment. It is true that individuals who feel that mental illness requires medical attention are more likely to seek help for their mental health issues at a modern health care facility.

People with mental illness who had strong social support networks were more likely to seek treatment for their mental health issues from a modern health care institution. This has also been reported in research conducted in China ( 30 ). It has been demonstrated that family members or friends are crucial in supporting patients as they cope with their disease. They can also assist by suggesting that individuals with mental illnesses finally seek out professional assistance. In addition, this may be because individuals with social support networks are more likely to receive financial support and to obtain more accurate information about the availability of formal medical treatments, both of which encourage patients to seek out medical professionals for assistance. Furthermore, individuals who have a history of mental illness may need to be treated at a modern health care facility for their subsequent mental ill health issues due to their fear of relapsing into a serious condition.

Additionally, this review showed that respondents who were aware that modern formal treatments were available for mental illness were more likely to seek help from mental health professionals for their issues, in contrast to those who were unaware of these treatments. This has also been demonstrated in China, Uganda, and Zanzibar, and in a study conducted in the UK and Nigeria ( 26 , 30 , 64 ). Those with a history of mental illness also exhibited a positive pattern of help-seeking behavior with respect to modern treatment. A history of mental health issues makes people more inclined to seek assistance because they are afraid of suffering, functional impairment, and other issues that may arise from being admitted to the hospital.

Furthermore, those who had a history of positive help-seeking behavior with respect to modern therapy for their condition were more likely to have sought care from a modern health institution for a later episode. This finding was in agreement with previous research conducted in China, Western Australia, and Switzerland ( 65 – 67 ). One explanation for this could be that individuals with mental illnesses who have a history of a positive pattern of help-seeking behavior with respect to current treatments are more likely to improve and may also be satisfied with their prior interactions. This makes it possible for them to make use of the service during their next episode.

Similarly, those with mental illness who had a family history of mental illness exhibited a more positive pattern of help-seeking behavior with respect to modern treatment than those without such a history. This finding is supported by those of studies conducted in Egypt and Hunan, China ( 27 , 29 ). This correlation may be explained by the possibility that individuals with a family history of mental illnesses are more aware of the resources for mental health care that are available and are less likely to feel stigma in relation to obtaining treatment.

In this study, we found that respondents who consumed alcohol had poor rates of engaging in help-seeking behavior with respect to formal modern treatment. This finding is supported by previous work ( 68 ). Since alcohol is a depressive, it slows down neuronal activity and brain function. Like other depressants, it hinders and reduces mental and physical activities. This means that it can disrupt the balance of neurotransmitters in the brain, which can affect the patient’s mood, thoughts, and behavior, and slows down how they process information. Broadly speaking, alcohol consumption has an impact on the patient’s drive to engage in meaningful actions in life, such as seeking treatment for mental health issues at a modern health care institution.

When comparing respondents who perceived their mental illness as serious to those who did not, we found that the former group had a higher likelihood of exhibiting a positive pattern of help-seeking behavior with respect to modern health services. This finding was in line with those of the study conducted in Zanzibar ( 26 ). It is true that people’s perceptions have an impact on their general behavior. In this case, those who view mental illness as a severe condition are more likely to exhibit positive patterns of help-seeking behavior with respect to modern treatment for their illness.

Strengths and limitations of the study

This review has a number of positive features. An extensive search was performed. Three authors participated in the quality assessment. This review is also the first of its kind to present the aggregated results of multiple studies conducted in Ethiopia, which strengths the body of knowledge on patterns of positive help-seeking behavior among people living with mental illness and the predictors of this behavior. This study represents a significant improvement over the primary studies in that large number of study participants (n = 7092) from across sixteen studies were included. Moreover, all the studies included in the review were of good quality.

Despite its strengths, this review has limitations that should be noted for the interpretation of the results. All the included studies analyzed were cross-sectional studies. This review included some studies with small sample sizes, which may have influenced the conclusions. Our search was confined to papers published in English, resulting in the exclusion of some important studies. Finally, since this review included research conducted in only four regions of Ethiopia (Amhara, Oromia, the SNNPR, and Tigray), it is difficult to generalize the findings to all Ethiopians living with mental illness.

Conclusions

The overall pooled rate of positive help-seeking behavior with respect to formal modern treatment among people living with mental illness in Ethiopia was low. Having attained a secondary education or above, believing that mental illness requires treatment, having strong social support, having a family history of mental illness, having awareness of the availability of medical treatment, having previously exhibited positive help-seeking behavior, having comorbid disorders, not using alcohol, and perceiving one’s mental illness to be severe were significantly associated with a positive pattern of help-seeking behavior. The findings indicated that the majority of Ethiopian people living with mental illness either seek help via informal forms of treatment, such as visiting traditional healers or obtaining religious treatment, or decline to receive any kind of treatment and stay at home.

Recommendations for clinical practice

Mobilization of the community should be encouraged via regular public awareness campaigns regarding mental illness and the availability of evidence-based and effective modern treatment in Ethiopia. Likewise, the design of effective community-based mental health interventions is recommended in order to improve public attitudes and rates of help-seeking behavior in relation to mental health problems. Furthermore, it is important to work with closely with providers of informal treatment for mental illness so as to increase awareness of mental illness, its severity, and the availability of evidence-based and effective modern treatment.

Policy implications

The findings of this review have revealed that the majority of individuals suffering from mental illnesses prefer informal forms of treatment and only approach modern health care institutions when traditional treatment has failed repeatedly. As a result, the Ethiopian government should place a high priority on raising levels of knowledge of the causes of mental illness and the availability of evidence-based treatment options through expanded community-based mental health education. Furthermore, it is recommended that a mental health day be celebrated nationwide in order to increase community awareness and to instill a more favorable attitude toward modern therapy.

Scope for further research

This research has highlighted numerous implications for future studies in Ethiopia regarding interventions aiming to boost help-seeking behavior and, as a result, to minimize the treatment gap for mental health disorders. Research in other regions of Ethiopia on help-seeking behaviors with respect to modern treatment is also recommended. Moreover, it would be beneficial to conduct qualitative studies with key community informants, including traditional healers, religious leaders, etc. This would help in exploring the barriers to access to formal mental health services experienced by people living with mental illness in the community.

Author contributions

SA: Writing – original draft, Methodology, Funding acquisition, Formal analysis, Conceptualization, Writing – review & editing. KH: Writing – review & editing, Methodology, Formal analysis, Data curation. BK: Writing – review & editing, Resources, Validation, Formal analysis, Data curation. GW: Writing – review & editing, Resources, Validation, Formal analysis, Data curation. GB: Writing – review & editing, Visualization, Project administration, Validation, Supervision, Formal analysis, Data curation. DF: Writing – review & editing, Funding acquisition, Validation, Supervision, Formal analysis, Data curation. DE: Writing – review & editing, Formal analysis, Data curation. GL: Writing – original draft, Software, Formal analysis, Data curation. BM: Writing – review & editing, Resources, Formal analysis, Data curation. AT: Writing – review & editing, Project administration, Methodology, Data curation. KS: Writing – review & editing, Software, Project administration, Data curation. AB: Project administration, Methodology, Data curation, Writing – review & editing. ES: Writing – review & editing, Methodology, Investigation, Formal analysis, Data curation. TM: Software, Project administration, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2024.1361092/full#supplementary-material

Supplementary Table 1 | PRISMA checklist.

Supplementary Table 2 | Quality and risk of bias assessments of the included studies.

Abbreviations

AOR, Adjusted odds ratio; CI, Confidence interval; DALYs, Disability-adjusted life years; LMICs, Low- and middle-income countries; OR, Odds ratio; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; WHO, World Health Organization.

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Keywords: mental illness, Ethiopia, help seeking behavior, systematic review and meta-analysis, treatment

Citation: Asnakew S, Haile K, Kassa BG, Ayehu GW, Beyene GM, Feleke DG, Endalew DG, Legas G, Munie BM, Tedila A, Shiferaw K, Belete A, Chanie ES and Aytenew TM (2024) Patterns of help-seeking behavior among people with mental illness in Ethiopia: a systematic review and meta-analysis. Front. Psychiatry 15:1361092. doi: 10.3389/fpsyt.2024.1361092

Received: 24 December 2023; Accepted: 21 February 2024; Published: 18 March 2024.

Reviewed by:

Copyright © 2024 Asnakew, Haile, Kassa, Ayehu, Beyene, Feleke, Endalew, Legas, Munie, Tedila, Shiferaw, Belete, Chanie and Aytenew. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Sintayehu Asnakew, [email protected]

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