Predictors of help-seeking behavior: Distinction between help-seeking intentions and help-seeking behavior

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Predictors of help-seeking behavior: Distinction between help-seeking intentions and help-seeking behavior

SATORU NAGAI* Rissho University

Abstract: The overall goals of this research were to: (a) examine whether help- seeking intentions, subjective needs, depressive symptoms, and social support can predict actual help-seeking behavior; and (b) clarify the moderating effects of social support on help-seeking behavior using a longitudinal design. University students (N= 370) completed questionnaires that measured social support, subjective needs, depressive symptoms, and help-seeking intentions during Time1, and questionnaires that measured actual help-seeking behavior during Time2. Only subjective needs showed a positive effect on both help-seeking intentions and actual help-seeking behavior. Although depressive symptoms had a negative effect on help-seeking intentions, they had a positive effect on actual help-seeking behavior. Moreover, social support had a positive effect on help-seeking intentions, and moderated the influence of subjective needs on actual help-seeking behavior. Simple slope analysis indicated that subjective needs did not facilitate help-seeking behavior among those with low levels of social support.

Key words: help-seeking, depression, social support, gender.

Seeking help during difficult times in life is one of the most important problem-solving strate- gies (Fallon & Bowles, 1999). However, people are often reluctant to seek help even if they are suffering from severe problems (e.g., Andrews, Issakidis, & Carter, 2001; Kessler et al., 1994;

Naganuma et al., 2006). Therefore, several studies have sought to examine the reasons why people ask or do not ask for help and have identified factors that facilitate or inhibit help- seeking in the face of social-psychological problems (Offer, Howard, Schonert, & Ostrov, 1991).

Predictors of help-seeking

Researchers have found that various factors affect help-seeking (Mizuno & Ishikuma, 1999;

Rothi & Leavey, 2006). Subjective needs are one of the most significant variables that influence help-seeking. People seek help to solve their problems; hence, awareness of subjective

needs significantly affects the decision of whether or not to seek help (Gross &

McMullen, 1983). In fact, numerous studies have consistently reported a positive relationship between subjective needs and help- seeking. For example, Rickwood and colleagues have reported that those with severe symptoms report a greater tendency to seek informal help from family members or friends (Rickwood, 1995; Rickwood & Braithwaite, 1994). Among Japanese university students, it was also reported that subjective needs facilitate intentions to seek help from family members and friends (e.g., Kimura & Mizuno, 2004; Nagai, 2010). Furthermore, some people may seek help from mental health professionals, such as psychiatrists or clinical psychologists.

Researchers have found that subjective needs are also positively related to attitudes toward seeking professional psychological help (Komiya, Good, & Sherrod, 2000), likelihood

*Correspondence concerning this article should be sent to: Satoru Nagai, Faculty of Psychology, Rissho University, Osaki, Shinagawa-ku, Tokyo 141-8602, Japan. (E-mail: [email protected])

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of seeking professional psychological help (Cepeda-Benito & Short, 1998), and help- seeking intentions (Deane & Chamberlain, 1994; Vogel & Wei, 2005).

Social support is another important factor that affects help-seeking. If a person wishes to seek help, it is necessary to find someone who can provide sufficient help. Because people are most likely to seek help from someone from their social networks (Rickwood &

Braithwaite, 1994; Rothi & Leavey, 2006), those with larger support networks report greater intentions to seek help. For example, adolescents with greater levels of social support showed a greater willingness to seek help from friends, family members, and teachers (Sheffield, Fiorenza, & Sofronoff, 2004). In the academic context, those who had greater social support were able to seek help when they were struggling with difficult tasks (Karabenick &

Sharma, 1994; Ryan & Shim, 2012).

While subjective needs and social support facilitate help-seeking, depressive symptoms have been considered to inhibit help-seeking.

Because some components of depressive symptoms, such as hopelessness and suicidal ideation, reduce motivation to cope with problems, those with high depressive symptoms are less likely to seek help. Indeed, Nagai (2010, 2012) has reported that depressive symptoms are negatively related to intentions to seek help from family and friends. Similarly, suicidal ideation appears to be negatively related to adolescents’ help-seeking intentions from family and friends (Deane, Wilson, &

Ciarrochi, 2001; Wilson, Deane, & Ciarrochi, 2005a). Moreover, several studies have found negative relationships between depressive symptoms and attitudes toward seeking professional psychological help (Calhoun &

Selby, 1974; Garland & Zigler, 1994; Nam et al., 2013).

Another factor commonly assessed in help- seeking studies is gender (Nadler, 1997). In many countries, it has been reported that women seek more help than men. Rose and Rudolph (2006) conducted a systematic review of previous literature about gender difference in peer relationship processes and concluded

that girls seek informal support more frequently than boys. Tamres, Janicki, and Helgeson (2002) performed a meta-analysis of gender differences in coping behavior and reported similar results: women seek social support more frequently than men. For seeking professional psychological help, Nam and colleagues performed a meta-analysis to examine gender differences in attitudes toward professional psychological help among Caucasians, Asian-Americans, and Asians. The results revealed that women showed more favorable attitudes than men across all ethnic groups (Nam et al., 2010). However, if other factors, such as social support or subjective distress, are controlled, the direct relationship between gender and help-seeking disappears (Nagai, 2010; Vogel & Wester, 2003; Vogel, Wester, Wei, & Boysen, 2005). On the basis of these results, gender does not directly promote help- seeking.

To summarize, help-seeking is positively related to subjective needs and social support, and negatively related to depressive symptoms.

Moreover, gender does not directly facilitate help-seeking.

Help-seeking intentions and help-seeking behavior

Despite the vast amount of literature focusing on the predictors of help-seeking, there are considerable limitations of these studies. The most important limitation is that few studies have focused on actual help-seeking behavior.

Instead of actual help-seeking behavior, help- seeking intentions have been measured. Typi- cally, the General Help-Seeking Questionnaire (GHSQ; Wilson, Deane, Ciarrochi, &

Rickwood, 2005b) is used to measure intentions to seek help from informal sources, such as family members and friends (e.g., Wilson et al., 2005a). Researchers have used the Intentions to Seek Counseling Inventory (ISCI; Cash, Begley, McCown, & Weise, 1975) for measuring intentions to seek professional psychological help (e.g., Cepeda-Benito & Short, 1998; Vogel

& Wei, 2005).

Because help-seeking intentions are assumed to be one of the major determinants of help-

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seeking behavior, using help-seeking intentions as an index of bona-fide help-seeking has become broadly accepted among researchers.

According to the theory of planned behavior (TPB; Ajzen, 1991), behavior is mainly deter- mined by behavioral intentions. Armitage and Conner (2001) reviewed the literature on TPB and concluded that behavioral intentions do predict behavior. On the basis of these results, the factors influencing help-seeking intentions have also been considered to predict help- seeking behavior. Nevertheless, help-seeking intentions are not equivalent to help-seeking behavior. Although measuring help-seeking intentions has certain advantages, it is necessary to distinguish between help-seeking intentions and actual help-seeking behavior.

Moreover, the impact of some predictors on help-seeking behavior is expected to differ from their impact on help-seeking intentions.

First, depressive symptoms have been found to decrease help-seeking intentions but actually increase help-seeking behavior. For example, Grella, Kamo, Warda, Moore, and Niv (2009) studied 1602 individuals with a diagnosis of past-year substance dependence. They found that those with a co-occurring mood disorder were more likely to receive professional psychological help for substance abuse. Similarly, Andrews et al. (2001) reported that people with a mental disorder receive more professional psychological help than those who do not.

These findings appear to contradict other findings that suggest that depressive symptoms reduce help-seeking intentions (Garland &

Zigler, 1994). On the basis of these results, depressive symptoms can be considered to have two opposite types of influence on help- seeking. Depressive symptoms may decrease motivation to seek help in the short-term (reduce help-seeking intentions), but continu- ing depressive symptoms may distress individuals and motivate them to seek help in the long- term (i.e., increase actual help-seeking behavior). Indeed, meta-analysis results (Nam et al., 2013) have shown that the relationship between depression and attitudes toward seeking professional psychological help was significant but very weak (r= −.07). This result

may reflect the combination of these two opposing influences. Therefore, it is necessary to further clarify the influence of depressive symptoms on both help-seeking intentions and help-seeking behavior.

Second, social support may moderate the influence of subjective needs on help-seeking behavior. Because social support represents an available source of help (Rickwood, Deane, Wilson, & Ciarrochi, 2005), those who lack social support may not be able to seek informal help, even if they experience subjective need.

For example, it has been reported that socially isolated people experience difficulties with seeking out sufficient help (Hanano, 2000;

Takahashi, Koike, & Ando, 2014). This also suggests the possibility that social support moderates the effect of subjective needs on help- seeking behavior. That is, for those with middle or high levels of social support, subjective needs facilitate help-seeking behavior, as reported in previous studies. On the other hand, under conditions of low levels of social support, subjective needs cannot facilitate help-seeking behavior because of a lack of sources of help.

However, most studies have not focused on this possible moderation effect, which requires explicit examination.

Another limitation of past literature is that almost all studies adopted a cross-sectional design (e.g., Cepeda-Benito & Short, 1998;

Vogel & Wei, 2005; Wilson et al., 2005a). Even in the few studies that focused on actual help- seeking behavior, such behavior was measured retrospectively (e.g., Offer et al., 1991;

Saunders, Resnick, Hoberman, & Blum, 1994).

Thus, these studies cannot determine a causal relationship; moreover, it is still unclear which variables actually predict help-seeking behavior. While a few studies have adopted longitudinal designs, the implications of these studies are restricted because some measured help- seeking behavior using only one dichotomous item (Rickwood, 1995; Rickwood &

Braithwaite, 1994), while others tested only specific relationships between help-seeking behavior and help-seeking intentions (Wilson et al., 2005b). To reveal which factors facilitate or inhibit help-seeking behavior, it is important

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to examine prospective relationships between help-seeking behavior and its predictors using a longitudinal design.

Present study

While several studies have examined the predictors of help-seeking intentions, which factors influence actual help-seeking behavior is still unclear. On the basis of past work, it can be assumed that help-seeking intentions, subjective needs, and depressive symptoms influence actual help-seeking behavior. Moreover, the impact of depressive symptoms and social support on help-seeking behavior are expected to differ from their impact on help-seeking intentions. To clarify these issues, it is necessary to conduct a longitudinal study. Although many studies have highlighted the importance of longitudinal investigations to examine the predictors of actual help-seeking behavior (e.g., Li, Dorstyn, & Denson, 2014; Sheffield et al., 2004), very little evidence exists in this regard.

The purpose of this study is to use a longitudinal design to clarify predictors of help- seeking behavior. In particular, it is hypothesized that help-seeking intentions, subjective needs, and depressive symptoms would positively predict help-seeking behavior (Hypothesis 1). Additionally, it is also hypothesized that social support moderates the effect of subjective needs on help-seeking behavior (Hypothesis 2). Specifically, subjective needs should facilitate help-seeking behavior under conditions of moderate or high levels of social support, which is congruent with previous literature. On the other hand, subjective needs should not influence help-seeking behavior under low social support conditions.

Method

Participants and procedure

We conducted two data collection sessions. A total of 488 university students participated in initial data collection during Time1. Of these students, 76% (n= 370) completed the second questionnaire assessment during Time2 (4 weeks after Time1). A total of 66% (n= 245) of

the participants were women and 34%

(n= 125) were men. Help-seeking intentions, subjective needs, and social support were measured during Time1, and frequency of actual help-seeking behavior during the interval between Time1 and Time2 was measured at Time2. Participants completed the questionnaires anonymously.

Questionnaire

Help-seeking intentions. The Help Seeking Preference Scale (Kimura & Mizuno, 2004) was used to measure participants’ help- seeking intentions. Participants were required to rate the likelihood that they would seek help from their friends if they were experiencing the problems listed in the inventory; the rating scale for each item ranged from 1 (very unlikely) to 5 (very likely). The problem list comprised six common social-psychological problems, including relationship difficulties, depression, and personal worries, frequently experienced by Japanese university students. In the present sample, the alpha coefficient for this scale was .82.

Subjective needs. We used six items to measure subjective needs. Six problems listed in the Help Seeking Preference Scale were pre- sented and respondents were asked whether they had experienced these problems during the last 6 months. Items were rated on a 5-point scale from 1 (never) to 5 (frequently). The alpha coefficient for this study was .69.

Social support. We used the Social Support Scale for University Students (Shima, 1992) to measure respondents’ perceived social support.

This scale is a 12-item measure wherein respondents rate each item from 1 (very unlikely) to 5 (very likely) on the basis of how they perceive support from their friends. In the present sample, the alpha coefficient for this scale was .91.

Depressive symptoms. The Japanese version of the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff,

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1977) translated by Shima, Shikano, Kitamura, and Asai (1985) was used. Participants were asked to indicate whether they had experienced the symptom described in each item during the previous 2 weeks. This scale comprises 20 items, and items are rated on a 4-point scale from 0 (never) to 3 (more than 5 days). The alpha coefficient for this study was .89.

Actual help-seeking behavior. We used the six items from the Help Seeking Preference Scale. First, participants were required to answer the following: “During the past 4 weeks, how often did you seek help from your friends for each of the problems described below?”

Next, participants were asked to rate the frequency of actual help-seeking behavior for the six social-psychological problems. Each item was rated on a 5-point scale from 1 (never) to 5 (frequently). The alpha coefficient for this study was .71.

Results

Prior to the analysis, a dummy code was created to represent gender such that men were coded as 0 and women as 1. Next, correlation coefficients among actual help-seeking behavior, help-seeking intentions, subjective needs, social support, and depressive symptoms were calcu- lated. As shown in Table 1, almost all correlation coefficients were significant except for the correlation between subjective needs and social support, and the correlation between help-seeking intentions and depressive symptoms. Among the significant correlations, only

the relationship between social support and depressive symptoms was negative (r= −.22).

All other significant correlations were positive (r= .10–.53). Specifically, the largest correlation coefficient was that for help-seeking intentions and actual help-seeking behavior (r= .53).

Multiple regression analysis of help-seeking

First, multiple regression analysis was performed using help-seeking intentions as the cri- terion variable and gender, subjective needs, social support, and depressive symptoms as the predictor variables. The model was statistically significant, F(4, 365) = 26.35, p<.001, with a multiple correlation squared of .22 (Table 2).

Each predictor variable except for gender (β= −.01,p= .81) was significant. That is, subjective needs (β= .38, p<.001) and social support (β= .25,p<.001) positively predicted help-seeking intentions. Moreover, depressive symptoms negatively predicted help-seeking intentions (β= −.11,p<.05).

Next, we used a two-step hierarchical multiple regression analysis to test whether help- seeking intentions, subjective needs, social Table 1 Results of correlational analysis

Correlation coefficients Mean (SD)

HSI SN SS DS

Help-seeking behavior .53*** .39*** .24*** .25*** 14.62 (5.49)

HSI .22*** .42*** −.09 20.18 (5.73)

SN .04 .39*** 23.33 (4.60)

SS −.22*** 46.37 (8.26)

DS 17.95 (10.45)

Note. n= 370. *p<.05, **p<.01, ***p<.001. HSI = help-seeking intentions; SN = subjective needs;

SS = social support; DS = depressive symptoms.

Table 2 Results of multiple regression analysis for help-seeking intentions

β

Gender −.01

Subjective needs .38***

Social support .25***

Depressive symptoms −.11*

R² .22

*p<.05,**p<.01,***p<.001.

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support, and depressive symptoms influence actual help-seeking behavior, and whether there was any significant interaction between social support and subjective needs. Fundamen- tal attributes as predictor variables in the first step were help-seeking intentions, subjective needs, social support, and depressive symptoms.

In the second step, the interaction term of social support and subjective needs was entered.

As shown in Table 3, the model was statistically significant at the first step, F(5, 364) = 48.32,p<.001, with a multiple correlation squared of .40. Each predictor variable except for gender (β= −.02,p= .65) was significant. That is, help-seeking intentions (β= .47, p<.001), subjective needs (β= .19, p<.001), social support (β= .10,p<.05), and depressive symptoms (β= .23, p<.001) positively predicted actual help-seeking behavior.

At the second step, the model was again statistically significant,F(6, 363) = 41.80,p<.001, with a multiple correlation squared of .41.

Inspection of the beta values associated with each of the predictors indicated that help- seeking intentions (β= .47,p<.001), subjective needs (β= .18,p<.001), and depressive symptoms (β= .24, p<.001) positively predicted actual help-seeking behavior. The influence of gender (β= −.01, p= .79) was still non- significant, and influence of social support became non-significant (β= .09, p= .38). In addition, the interaction effect of social support and subjective needs was significant (β= .10, p<.05,ΔR²= .01).

As the interaction term was significant, simple slope analysis (Aiken & West, 1991) was performed (Figure 1). Under conditions of high social support (+1SD), subjective needs significantly predicted actual help-seeking behavior (β= .28, p<.001). Similarly, under conditions of moderate social support, subjective needs significantly predicted actual help-seeking behavior (β= .18, p<.001). However, under low social support conditions (−1SD), subjective needs did not predict actual help-seeking behavior (β= .07,p= .25).

Discussion

This study used a longitudinal design to inves- tigate the predictors of help-seeking behavior.

The first goal was to examine whether help- seeking intentions, subjective needs, and depressive symptoms can predict actual help- seeking behavior for social-psychological problems. The second goal was to clarify a possible moderation effect of social support.

Overall, both hypotheses were supported.

First, help-seeking intentions, subjective needs, and depressive symptoms prospectively predicted help-seeking behavior (Hypothesis 1).

Although help-seeking intentions and subjective needs have been considered important predictors of help-seeking behavior (Ajzen, 1991;

Table 3 Results of hierarchical multiple regression analysis for help-seeking behavior

Step1 Step2

β β

Help-seeking intentions .47*** .47***

Gender −.02 −.01

Subjective needs .19*** .18***

Social support .10* .09

Depressive symptoms .23*** .24***

Subjective needs×Social support .10*

R² .40 .41

Change inR² .01

*p<.05,**p<.01,***p<.001.

13.0 14.0 15.0 16.0 17.0

–1SD 0 +1SD

SS-High SS-Moderate SS-Low

Help-seeking Behavior

Subjecve Needs

Figure 1 The interaction of subjective needs with social support (SS) on help-seeking behavior.

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Gross & McMullen, 1983), there has been little direct evidence to support these assumptions.

The present results provide empirical evidence for these assumptions.

As expected, depressive symptoms positively predicted help-seeking behavior. Interestingly, although depressive symptoms were negatively related to intentions to seek help, they appear to show a positive relationship with actual help-seeking behavior. These results suggest that depressive symptoms have two contrasting influences on help-seeking. First, because depressive symptoms entail helplessness, depressive symptoms can reduce help-seeking intentions in the short-term. However, pro- longed depression can cause severe distress, which can eventually motivate people to seek help. Our results provide a potential explana- tion for the contrasting results of previous studies. Nevertheless, it is important to note that a large number of people do not receive any help even if they are experiencing severe depression (Naganuma et al., 2006). Even though those with severe depressive symptoms are likely to seek help compared with those with low depressive symptoms, not all people can seek or access sufficient help.

Our second hypothesis was that social support moderates the impact of subjective needs on help-seeking behavior. Our results support this hypothesis. That is, the impact of subjective needs on help-seeking behavior was weaker for those with low levels of social support compared to those with moderate or high levels of social support. In previous studies, it was assumed that the relationship between subjective needs and help-seeking is simple and linear (e.g., Deane & Chamberlain, 1994; Vogel & Wei, 2005). However, our result suggests that subjective needs do not facilitate help-seeking behavior for people with low levels of social support. Some people fail to seek help even if they are suffering from severe problems (Andrews et al., 2001).

These people may have an inadequate social support network. Therefore, it is necessary to construct programs so that people with limited available sources of help can also obtain sufficient assistance.

Implications and limitations

Very few studies have assessed help-seeking behavior using longitudinal designs. Therefore, our study offers some theoretical and practical suggestions. The first suggestion involves under- standing the importance of distinguishing between help-seeking intentions and help- seeking behavior. In this study, each predictor variable showed the expected influence on help-seeking intentions, as observed in previous studies (e.g., Kimura & Mizuno, 2004;

Rickwood & Braithwaite, 1994). However, some predictor variables showed a different impact on help-seeking behavior. Furthermore, it should be noted that the strength of the relationship between help-seeking intentions and help-seeking behavior is not necessarily high (r= .53). These results suggest that measurement of help-seeking intentions should not be substituted for assessment of help-seeking behavior. In future research, it is necessary to confirm whether some variables used in previous studies as the predictors of help-seeking intentions have the same impact on help- seeking behavior.

The second suggestion involves the importance of considering moderating effects. Most researchers have assumed that the relationship between help-seeking and other variables is simple and linear. However, in this study, social support moderated the influence of subjective needs on help-seeking behavior. Similarly, some researchers have reported that internal working models (Lopez, Melendez, Sauer, Berger, & Wyssmann, 1998) or reciprocity norms (Hashimoto, 2015) moderate the influences of specific variables on help-seeking.

These results suggest the possibility that some variables that are currently regarded as predictors of help-seeking behavior based on previous studies of help-seeking intentions may not in fact have an impact on help-seeking behavior under certain conditions.

This notion has to be considered when imple- menting interventions intended to facilitate help-seeking behavior. Because it is difficult to directly facilitate help-seeking behavior, most interventions aiming to facilitate help-seeking behavior have focused on changing predictors

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of help-seeking rather than help-seeking itself (e.g., Lannin, Guyll, Vogel, & Madon, 2013).

However, if the variables regarded as predictors of help-seeking in previous studies do not actually influence help-seeking behavior in a robust fashion, interventions based on such an approach may not produce sufficient outcomes.

Indeed, it is reported that such interventions have not produced sufficient outcomes to facilitate help-seeking behavior in some systematic reviews (Gulliver, Griffiths, Christensen, &

Brewer, 2012; Ploeg et al., 1996). Thus, it is necessary to clarify which variables actually predict help-seeking behavior, and to design an inter- vention program based on relevant evidence in this regard.

Although the present findings extend previous research and theory, this study has at least three major limitations. First, because all the participants were university students, the results might not be applicable to the general public. It is necessary to test whether our findings can be replicated among other groups.

Second, the appropriateness of the present approach to measuring subjective needs should be examined. In this study, subjective needs were measured by asking about frequency of problems during the last 6 months. However, some studies of stress coping have assessed both frequency of stressful events as well as stress intensity (e.g., DeLongis, Coyne, Dakof, Folkman, & Lazarus, 1982; Folkman, Lazarus, Pimley, & Novacek, 1987; Kanner, Coyne, Schaefer, & Lazarus, 1981). Some researchers have indeed suggested that help-seeking is cor- related with the experience of intense problems, rather than distress duration (Norcross &

Prochaska, 1986). Moreover, because we defined the length of the period being assessed as 6 months, there is the possibility that some problems had been solved at the point of answering the questionnaire. Consequently, measured subjective needs may not be promot- ers of help-seeking for some participants. Of course, the subjective needs assessment used in this study yielded results that are congruent with previous findings. However, it is necessary to examine the most appropriate way to measure subjective needs for predicting help-

seeking in future research. Finally, we focused only on help-seeking for friends. Although friends are an important source of help (e.g., Fallon & Bowles, 1999), other sources of help, such as family, teachers, and mental health professionals, need to be considered. Many researchers have focused on individuals seeking professional psychological help. It is necessary to examine which variable predicts the decision to seek help from mental health professionals through a study that incorporates the same design used here.

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(Received December 13, 2014; accepted May 16, 2015)