INTRODUCTION
Help seeking, as a psychiatric concept, is understood as the attitudes adopted and the ways followed by the psychiatric sufferers and their relatives who are affected by the problems of the individual, to cope with the situation. Help seeking attitude is a function of the seeker, the way the seeker perceives the problem and the provider of the help (1). Perception of disease, the way the illness is experienced and the coping ways, while relating with the cultural background, affect the patients’ style of help seeking (2,3). Cultural differences lead to various beliefs regarding the causes of schizophrenia (4). The psychotic life can be elucidated, under the influence of culture, by unearthly forces, as well as genetic burden, sensitivity to stress and stressful life-styles. The elucidation style, on the other hand, plays a role in the selection of help seeking (5). Social factors are accounted as the leading causes of schizophrenia in developed countries, whereas in developing countries such as India and Morocco, majority of the people regard supernatural events, use of medications, stressful life events, genetic factors or personality disorders as associated with the schizophrenic symptoms. Those convictions are the leading factors that the public refer to seek for different treatment options, delay in demanding for a medical treatment and thus, changing the consequences of the disease, respectively (4,6,7). Indeed, it was recorded in a Nigerian study on first-episode patients that, due to the socio-cultural perspective of patients in favor of an association between the mental illnesses and spiritual phenomenon, they first sought help from traditional and incorporeal healers so that the period of untreated psychosis was prolonged (8). The duration of untreated psychosis is one of the most important prognostic factors in first-episode psychosis (9-11). In a retrospective study evaluating the effects of this period on the long-term consequences of schizophrenia, a better progression of the illness with fewer hospitalizations and better functioning was observed in patients with shorter periods of untreated psychosis (12). Therefore, the cultural characteristics as well as the socio-economic and educational level of a territory occupy an important position among the factors affecting the duration of untreated psychosis, progression and frequency of the disease. In a study investigating the causality perception and help seeking behaviors for schizophrenia in a Pakistani population, it was observed that, even in the study sample consisting of highly educated individuals, few have identified schizophrenia as a mental illness, the majority had superstitions, thus had inappropriate help seeking behaviors (13). In addition to cultural characteristics, help seeking attitudes and behaviors are affected by many other factors such as sex, age, social class, level of education, marital status, stigmatization anxiety, psychiatric problem history, physical health conditions and social support (1). In a study investigating illness description models and help seeking behaviour in psychotic patients in Turkey, it was recorded that less educated patients were more predisposed to seek for a non-medical help and the rate of attendance to a psychiatrist increased with higher education. In the mentioned study, 47% of the patients have attributed their illness to family problems, 42% to inward problems, 19% to economical constraints and 10% to supernatural forces while 51% of the patients sought help by trying out the traditional/convictional healing methods, 19% the physicians and 66% to psychiatrists (14). In a study sample of psychiatry policlinic patients, with the diagnosis of anxiety, depression or somatoform disorder as the first-time applicants in Malatya (Turkey), 43% of the patients have attributed their illness to family problems, 39% to inward problems and 18% to economical constraints while 12% of the patients sought help by trying out the traditional/convictional healing methods, 33% the non-psychiatric physicians and 336% to psychiatrists (15). The lack of access to sufficient psychiatric services for some reason has been regarded as a remarkable public health problem for those people (16).
In this study, help seeking behaviors of schizophrenic outpatients at two provincial similar state hospitals, one from the eastern and the other from the western part of the country, were compared, assuming that the cultural characteristics, socio-economical factors, educational level and accessibility of healthcare services might affect the help seeking behaviors in two different regions of Turkey.
METHOD
The study was carried out in Tatvan State Hospital between June 2006 and February 2007 and in Menemen State Hospital between March 2007 and January 2008, with schizophrenia-only outpatients, who accepted to participate in the study. Exclusion criteria of the study were 1) being in psychotic episode period, 2) having the diagnosis of atypical psychosis, 3) existence of mental retardation and 4) lack of comprehension due to severe cognitive impairment. Due to its potential effect on disease related attributions, cases with comorbidity were excluded. Ethical committee approval was acquired from Van Regional Training and Research Hospital. A questionnaire about sociodemographic data such as age, sex, marital status and income, was applied to participants by an investigator, after getting the informed consent of the patients. The survey form designed by Unal et al. (14) based on Kleinman’s explanatory model for disease (17) was used to elaborate the patients’ help seeking behaviors. There are questions regarding the attributed causes of the illness and the type of the help sought by the patient, help seeking behaviors and treatment expectations of the patient as well as the patient’s opinion about the progression of the disease, in the survey form. Some questions in the survey are “In your opinion, what was the leading factor that led to being ill?”, “In your view, why your disease appeared recently?”, “What were the helps you sought before?”, “How would you seek help if someone from the family had similar complaints?”, “What would a member of your family do if, he/she suffered from the same illness?”, “Who advised you to consult with a psychiatrist?”, “What do you expect the most from the treatment given to you?”, “What kind of treatment do you expect to get?”, “What is your biggest fear about your illness?”.
Statistical Analysis
Data were assessed with SPSS 20.0 for Windows. In the course of evaluation, beyond descriptive methods (mean value, standard deviation), Chi-square test for the assessment of relationship between categorical variables and independent grouped t test for continuous variables were used. For all statistical analyses, p<0.05 was regarded as the level of significance.
RESULTS
Seventy-two patients (31 from Tatvan and 41 from Menemen) participated in the study. None of the patients refused to get involved. 58% of the patients in Tatvan were female whereas 73% of those in Menemen were male (p=0.007). 65% of the patients in Tatvan were married whereas 51% of those in Menemen were single, with no statistically significant difference between sites (p=0.063). 81% of the patients in Tatvan and 65% of those in Menemen were primary school graduates or less (p=0.029). In both groups, the majority have been living in the provincial center (p=0.239). The majority of those in Tatvan were low-income whereas the majority in Menemen were moderate-income, with statistically significant difference (p=0.016). Sociodemographic data of the groups are partially given in Table 1.
The mean ages were 38.6±12.6 and 39.4±11.5 years in Tatvan and Menemen, respectively and there were no statistically significant difference between groups (p=0.767). The mean durations of education were 4.3±4.2 and 6.8±3.5 years in Tatvan and Menemen, respectively (p=0.008) (Table 2).
In overall, there was no statistically significant difference in terms of convictional help seeking between genders (p=0.850), whereas rate of seeking help from a psychiatrist was more in males (p=0.041). While there was no statistically significant difference between those primary school graduates or less and secondary school graduates or more in terms of convictional help seeking behavior (p=0.371), the rate of consulting with a psychiatrist was more among secondary school graduates or more (p=0.039). While there was no statistically significant difference between those low-income patients and moderate-income patients in terms of convictional help seeking behavior (p=0.911), the rate of consulting with a psychiatrist was more in moderate-income group (p=0.002); 70% of low-income patients were observed to be seeking no help from a psychiatrist.
When the answers given by the patients regarding the progression of disease are evaluated (Table 3), it appears to be prominent that the leading attributed cause among patients from Tatvan was the problematic interpersonal relations, while patients from Menemen perceived the inward problems as the primary cause of the illness. The majority of the patients reported lack of opinion about the recent onset of the illness. In both groups, the patients who were willing to have pharmacotherapy were in majority and had no fear about being ill. The type of help seeking behaviors displayed by the patients from Menemen was more in number, than those by the patients in Tatvan (p<0.001).
In particular of the types of help sought in both groups (Table 4), the rates of consulting with a psychiatrist were 85% and only 32% in Menemen and Tatvan, respectively (p<0.001). The percentages of patients seeking a convictional help were 77% and 71% in Tatvan and in Menemen, respectively. The answer “They would seek help from the preacher” was given by 45% and 42% of patients in Tatvan and in Menemen, respectively, for the question “What would the people around you do if they get the same illness?”. In both territories, consulting with a psychiatrist was triggered by the advice of family members and recovery was the common expectation.
DISCUSSION
Disease-related attributions and attitudes of psychiatric patients vary as a function of time and geography (18). Territorial differences, accessibility to psychiatric services, perceptions about mental illnesses and other socio-cultural factors significantly prevails on the diagnosis, treatment and remission of the psychiatric disease through influencing the help seeking behaviors (19). Help seeking behaviors change as a function of time and geography as well as the age, sex, socioeconomical status, marital status and educational level (2). Groups were similar in terms of mean age and marital status. Majority of patients from Tatvan were female and low-income whereas the majority in Menemen was male and moderate-income. Education duration of patients from Tatvan was shorter than patients from Menemen. Overall; the rate of consulting with a psychiatrist was higher in males, secondary school and higher graduates and patients with intermediate level of income. In a study conducted in Malatya about explanation of psychosis and help seeking behaviors, the primary school graduates were recorded to prefer the most popular coping ways of their social network as the help seeking method while the females, widows and low-income individuals were heading towards supernatural treatment methods (5). In another study investigating the professional psychological help seeking attitudes among adults, university graduates were found to have less difficulty in seeking professional psychological help and more trust in the benefits of consulting with a professional in comparison to primary or secondary school graduates. Authors of the study concluded that education improved that knowledge and awareness (1). In consistency with this conclusion, our contention is that a higher educational level might facilitate psychiatric help seeking through making investigation for better understanding of illness and finding ways to cope with the disease. Again in the same study, it was stated that the rate of consulting with a psychiatrist is relatively high among higher-income individuals. Economical power might be facilitator in the utilization of healthcare services.
In our study, the leading attributed cause among patients from Tatvan was the problematic interpersonal relations, while patients from Menemen perceived the inward problems as the primary cause of the illness. This difference can be associated with the difference in distribution of genders between groups and the varying perception of illness between genders. The sex in majority was females in Tatvan whereas males were in majority in Menemen. In their study about explanation of disease and help seeking behaviors among psychiatric patients in an Anatolian city, Gulec et al. reported that the primary factor leading to illness was familial problems in both genders and females expressed their familial problems more than males did and males came out with workplace or inward problems more than females stated (20). Similarly, in the case-scenario study carried out by Kaya and Unal (2), marriage and interpersonal problem were the cause of problem whereas the economical problems were predominant for males.
Both groups reported lack of opinion about the recent onset of the illness. This finding gave us an impression that these patients had no information or belief that the illness could be triggered by life events. The common willingness of having pharmacotherapy and lack of fear about being ill can be explained by the patients’ satisfaction of pharmacotherapy in the past. This result could be the outcome of lack of participants with active psychotic symptoms who were in remission.
The percentages of patients seeking a convictional help were 77% and 71% in Tatvan and in Menemen, respectively. There was no statistically significant difference with respect to seeking a convictional help but there is a relative overage. The most given answer “They would seek help from the preacher” was received from 45% and 42% of patients in Tatvan and in Menemen, respectively, for the question “What would the people around you do if they get the same illness?”. In our study, we detected that both the patients and the people around the patients were seeking a convictional help to cope with schizophrenia in both groups. In a study investigating the help seeking behaviors of patients and their caregiver families in two socioeconomically different cities of India, patients and their families were found to display similar help seeking behaviors and they first sought help from religious healers. In New Delhi, which is more developed based on the biopsychosocial factors, only 1/3 of the population consulted with a psychiatrist even though 2/3 were aware of the existence of a psychiatrist in their proximity while they were seeking help. The patient sample from Bilaspur, which is less developed based on biopsychosocial factors, declared a previous satisfaction with religious healers or supernatural reasons or lack of awareness about the mental illnesses and their treatments as the motive to prefer religious healers. However, being concerned about side-effects of medications or the need for a long time to treat psychiatric diseases or stigmatization were reported as the motive to prefer religious healers by the population in New Delhi (21). Insufficient awareness from psychiatric point of view is an important drawback for help seeking and treatment. In this respect, increasing the awareness of young people and mounting campaigns against stigmatization could be an ideal goal (22). A preference rate of 85% for help seeking from a psychiatrist in Menemen sample was higher than that of Tatvan (32%). A higher educational and economical level as well as better access to psychiatric services might be the underlying factors of higher awareness about the psychiatric diseases and more consulting with a psychiatrist in Menemen group than recorded in Tatvan. Improvements in psychiatric services in Turkey would increase the awareness about the psychiatric diseases and help people seek medical help more, respectively.
In both territories, patients consulted with a psychiatrist upon advice from their families. In a study carried out in a sample of 490 officers working in a state institution in Aydin, about professional help seeking behaviors of adults, it was observed that the majority of individuals consulted first to family members (57.1%) or close friends (31.3%) or as the third place to the psychiatrist (15.5%) to get professional support for fixing their problems (1). In conjunction with this, educating the families about schizophrenia and collaboration with the families in the follow up of patients might help patients visit the psychiatric settings regularly and get proper treatment. It was noted in a study that young people had been using online services regularly for resolving their mental health problems and been generally satisfied (23). In the age of informatics, online services would be an important source for communication and information. Psychiatric services that can be provided on that platform could be emphasized.
The familial preference of referring the patient to a psychiatrist for similar complaints, as the most preferred solution in both territories can be explained by disease awareness, improved insight against the disease and previous satisfaction with psychiatric treatment. In both territories, recovery was the common expectation of the patients.
Our study has some limitations. Having our data from a group of a few hospitalized patient is one of the limitations of our study. Our sample consisting of outpatients could be a biased population for investigating “help seeking behavior”. However, it took 7 months to have only 31 patients recruited from Tatvan, a province with a population of 70.000 inhabitants; and this could indicate how rarely people apply healthcare settings for help seeking. Implementing this study right after having a psychiatrist after a long period of lack of a psychiatrist in charge as well as the psychiatric services in both provinces, might be the reason for insufficient awareness about psychiatric services and the limited number of patients recruited, respectively. In both provinces, inpatient and outpatient psychiatric services have been provided at the nearest psychiatric and neurological diseases hospitals. Thus, carrying out the same study in a psychiatric and neurological diseases hospital, where voluntary and involuntary hospitalizations of schizophrenic patients are implemented in vast numbers can provide a larger sample with better representation power.
Multi-center screening studies are needed in order to explore the explanations, attributions, inferences and help seeking behaviors generated by patients regarding the illness as well as the territorial differences and the ground for those differences in our country.
It was recorded that the patients and the people around the patients are heavily seeking convictional help for coping with schizophrenia. The remarkable importance of duration of untreated psychosis for the prognosis of the illness reveals the need for detailed studies about non-medical help seeking behaviors of patients.
Concurrently, increasing rate of appeals to psychiatry settings in parallel to the level of education exhibits the importance of developing and implementing psychoeducation programs. Because substantially the families refer the patients to the psychiatrist, psychoeducation is primarily important for families. The role of families in the course of convictional help seeking was not evaluated in our study. In this respect, more detailed studies about the patients’ and families’ justifications for seeking non-biomedical treatments are needed.
