Journal of Adolescence 66 (2018) 83–90

Contents lists available at ScienceDirect

Journal of Adolescence
journal homepage: www.elsevier.com/locate/adolescence

Personal and perceived public mental-health stigma as predictors

T
of help-seeking intentions in adolescents
Finiki A. Nearchou∗, Niamh Bird, Audrey Costello, Sophie Duggan, Jessica Gilroy,
Roisin Long, Laura McHugh, Eilis Hennessy
University College Dublin, School of Psychology, Belfield, Dublin 4, Ireland

A R T IC LE I N F O ABS TRA CT

Keywords: This study aimed to determine predictors of help-seeking intentions for symptoms of depression/
Adolescence anxiety and self-harm in adolescents. It focused on personal and perceived public stigma to
Mental health gather data of value for the design of anti-stigma interventions. Participants (n = 722; 368 girls)
Personal stigma were recruited from three cohorts of secondary school students in Ireland (mean ages: 1st = 12.9
Public stigma
years; 3rd = 14.9 years; 5th = 16.6 years). Hierarchical regression models indicated that per-
Help-seeking
ceived public stigma is a significant unique predictor of help-seeking intentions for depression [F
(4, 717) = 13.4, p < .001] and self-harm [F(4, 717) = 13.5, p < .001]. This indicates that
young people's beliefs about other people's stigma towards mental health problems was a
stronger predictor of help-seeking intentions than their own stigma beliefs. These findings
highlight the importance of looking separately at different types of stigma when investigating the
role of stigma in predicting help-seeking intentions.

1. Background

Youth mental health is currently regarded as an issue of acute public health concern. Evidence demonstrates that 75% of adult
mental disorders develop prior to the age of 24 (Lin et al., 2008) and 20% of young people are affected by a mental health problem
annually (Patel, Flisher, Hetrick, & McGorry, 2007). Most people are reluctant to seek help for mental health problems (Gulliver,
Griffiths, & Christensen, 2010) with young people reported as the most unlikely age group to secure professional help (Reavley,
Cvetkovski, Jorm, & Lubman, 2010). A number of studies across different countries indicate that the percentage of adolescents that
seek help for a mental disorder ranges from 18% to 34% (Essau, 2005; Zachrisson, Rödje, & Mykletun, 2006). Given that early
intervention typically results in better health outcomes (Clarke, 2006), it is imperative that variables which influence help-seeking
behavior in young people are fully understood.
Stigma associated with mental health problems has been identified as one such variable in several systematic reviews (Clement
et al., 2015; Schnyder, Panczak, Groth, & Schultze-Lutter, 2017). Schools have a potentially important role to play both in educating
young people about their mental health and in supporting stigma reduction initiatives. To do this effectively, it is essential that
mental health curricula designed for use in schools are based on scientific insight into the role of stigma, as well as demographic
variables, in determining young people's help-seeking intentions. In the absence of detailed understanding of these issues, the present
study examines the role of age, gender and mental health stigma in predicting young people's behavioral intentions regarding help-

∗
Corresponding author.
E-mail addresses: niki.nearchou@ucd.ie (F.A. Nearchou), niamh.bird@ucdconnect.ie (N. Bird), audrey.costello@ucdconnect.ie (A. Costello),
sophie.duggan@ucdconnect.ie (S. Duggan), jessica.gilroy@ucdconnect.ie (J. Gilroy), roisin.long@ucdconnect.ie (R. Long),
laura.mc-hugh.1@ucdconnect.ie (L. McHugh), eilis.hennessy@ucd.ie (E. Hennessy).

https://doi.org/10.1016/j.adolescence.2018.05.003
Received 14 July 2017; Received in revised form 8 May 2018; Accepted 9 May 2018
0140-1971/ © 2018 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
F.A. Nearchou et al. Journal of Adolescence 66 (2018) 83–90

seeking.

1.1. Stigma

Stigma has been defined as a construct comprising three elements: stereotypes (negative beliefs concerning a social group),
prejudice (hostile feelings towards the group) and discrimination (negative behavioral reactions towards members of the group)
(Corrigan & Watson, 2002). For example, people may believe that an individual who has been diagnosed with a mental health
problem is dangerous (stereotype) even if there is no evidence to support this belief. The belief may then induce fear (prejudice)
directed towards the individual and elicit social exclusion (discrimination) by refusing accommodation or work to the individual. A
full understanding of all these elements is essential to gain an insight into the experiences of young people with mental health
problems, and to appreciate why stigma might influence their help-seeking intentions.
Research also distinguishes between perceived ‘public stigma’, which refers to an individual's perceptions of the stereotypes,
prejudices and discriminatory behavior displayed by most members of society, and ‘personal stigma’ which refers to an individual's
reports on his or her own stereotypes, prejudices and behavior (Corrigan & Shapiro, 2010). Analysis of the factor structure of a stigma
scale by Yap, Mackinnon, Reavley, and Jorm (2014) demonstrated that young people's negative stereotypes of individuals with
mental health problems had similar structure for personal and perceived stigma. However, the young people's responses indicated
that they believed that others' negative stereotypes (perceived) were stronger than their own (personal).
The differences between personal and perceived public stigma are not restricted to the strength of endorsement of negative
statements. Many studies have also found that scores on these two constructs are predicted by different demographic variables and, in
turn, are not equally predictive of behavior. For example, Griffiths, Christensen, and Jorm (2008) reported higher personal stigma
among men than women, but no gender differences in perceived public stigma. Similarly, Calear, Griffiths, and Christensen (2011)
reported higher levels of personal stigma in men, whereas women scored higher on perceived public stigma. Familiarity with mental
health problems has also demonstrated a relationship to stigma responses. A recent study with young people found that level of
contact with people who were diagnosed with depression or anxiety and knowledge of these conditions were significant predictors of
personal but not perceived public stigma (Grant, Bruce, & Batterham, 2016). These findings confirm the importance of measuring
personal and perceived public stigma separately.

1.2. Help-seeking

In keeping with our growing understanding of the multifaceted nature of stigma, researchers have recently begun to explore the
question of which aspect is most closely associated with help-seeking intentions (Schnyder et al., 2017). This is important because if
stigma is to be effectively targeted, we must determine the aspect of stigma that should be the focus of interventions. For example, an
intervention focused on perceived public stigma would try to change beliefs about societal stereotypes, prejudices and discriminatory
behavior. Such an intervention might focus on results of community research projects and present information on the numbers of
people with mental health problems who have fulfilling lives and who have not experienced significant levels of discrimination. In
contrast, an intervention that focused on personal stigma would try to change an individual's personal beliefs and might focus on
providing participants with opportunities to meet people with lived experience of mental health problems in order to facilitate the
development of understanding and empathy towards them.
To date, there have been several studies exploring the association between stigma and help-seeking behavior among adult po-
pulations (e.g. Barney, Griffiths, Jorm, & Christensen, 2006; Boerema et al., 2016). However, it has been suggested that more research
is needed with adolescents and young adults (Clement et al., 2015). The need to strengthen the literature on stigma and help-seeking
is in accordance with evidence, primarily from qualitative studies, which suggests that young people perceive stigma and embar-
rassment as being among the most important barriers to help-seeking for mental health problems (Gulliver et al., 2010). The adult
literature goes further and provides important information on the exact types of stigma that predict help-seeking. A systematic review
concluded that personal stigma and stigma of help-seeking significantly predict active help-seeking, whereas perceived public stigma
and self-stigma do not (Schnyder et al., 2017). These authors did not distinguish between adolescents, young adults and older age
groups in their analyses, so we do not know whether there were age related differences in these relationships. A large study involving
university students (Eisenberg, Downs, Golberstein, & Zivin, 2009) used measures of both personal and perceived public stigma and
found that only personal stigma was associated with reports of past help-seeking behavior. Again, this highlights the need to measure
personal and perceived public stigma separately.

1.3. Age and gender

Research on both stigma and help-seeking for mental health problems needs to give careful consideration to gender because
several studies indicate that it may be a significant predictor of a range of stigma-related responses. For example, a study with
adolescents found that girls had higher help-seeking intentions than boys (Rickwood, Deane, Wilson, & Ciarrochi, 2005). Another
study similarly reported that adolescent girls were approximately twice as likely as boys to report willingness to use mental health
services (Chandra & Minkovitz, 2006). Research suggests that stigma of mental health problems may be a particular threat to the
identity of adolescent boys and that this may explain why boys are less willing to seek help (MacLean, Hunt, & Sweeting, 2013).
Evidence on changes in help-seeking intentions over the course of adolescence is scarce as few studies report on the relationship
between age and help-seeking in this age group. This may in part be due to the relatively narrow age range of participants in many

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studies (e.g. Rughani, Deane, & Wilson, 2011; Wilson, Deane, Ciarrochi, & Rickwood, 2005) and the fact that others (e.g. Yap,
Reavley, & Jorm, 2013; Yap, Wright, & Jorm, 2011) focus on comparing adolescents in general with young adults. However, despite a
narrow age range of participants (13–16 years), Farrand, Parker, and Lee (2007) found age differences were linked the nature of the
help sought and the source of help (health professional v. school support). Further evidence on age-related differences comes from
studies of previous help-seeking behavior and confirms that age is an important variable to investigate. For example, Rossow &
Wichstrøm (2010) investigated history of help-seeking for self-harm in 14–19 year olds and found that older participants were more
likely to report having received professional help. Together these findings highlight the importance of investigating age related
differences in help-seeking intentions as a way to ensure that the message of mental health literacy and/or anti-stigma programmes
can be appropriately targeted.

1.4. The present study

To improve rates of help-seeking and provide policy makers with an evidence base on which to develop effective educational and
anti-stigma campaigns for schools, research concerned with understanding the nature of mental health stigma in young people is
imperative (Armstrong & Young, 2015). In response, the present study measures two facets of stigma (personal and perceived public)
as well as help-seeking intentions in relation to depression/anxiety and self-harm in a school-age sample (12–18 years). Depression
and anxiety were chosen because they are relatively common problems in adolescent years (Avenevoli, Swendsen, He, Burstein, &
Merikangas, 2015; Hawton, Saunders, & O'Connor, 2012) and because there has been little research on self-harm in this age group.
The study addresses the following research questions: 1) Do age and gender predict adolescents' intentions to seek-help to deal with
depression/anxiety or deliberate self-harm? 2) Do personal and perceived public stigma predict help-seeking intentions for de-
pression/anxiety or deliberate self-harm above and beyond age and gender?

2. Method

2.1. Participants

Participants in this study (n = 722) were students recruited through schools that were randomly selected from the register of
secondary schools in the Leinster (Eastern) region of Ireland published by the Irish Department of Education and Skills (2016). In
Ireland, children attend primary school for 8 years, up to the age of 12/13 years and then transition to second level school. In total, 84
school principals were invited to consider their students' involvement from 3 target years (1st, 3rd and 5th) within the six of second
level school and 17 granted permission (20.2%). Table 1 illustrates the demographic characteristics of the sample.

2.2. Measures

Mental health stigma. Adolescent stigma was assessed using the Peer Mental Health Stigmatization Scale (PMHSS; McKeague,
Hennessy, O'Driscoll, & Heary, 2015), a measure specifically designed for adolescents and young adults. Through rating 8 positive
and 16 negative statements on a five-point scale, with responses ranging from 1 ‘Disagree completely’ to 5 ‘Agree completely’, the tool
permits the assessment of both favorable and unfavorable statements about peers with mental health problems. The 16 negative
statements measure the dimensions of personal stigma and perceived public stigma in two distinct subscales. The personal stigma
subscale assesses participants' own attitudes/beliefs towards youth with mental disorders (e.g. I believe that teenagers with emotional or
behavioral problems are dangerous), and perceived public stigma assesses their perceptions about the extent to which society has
stigmatizing attitudes towards young people with mental health problems (e.g. Most people believe that teenagers with emotional or
behavioral problems are dangerous). Τhe scale demonstrated adequate discriminant validity, internal consistency (personal stigma:
α = .75; perceived public stigma: α = .71) and test-retest reliability in children and adolescents (McKeague et al., 2015). Each
subscale produces an individual score ranging from 8 to 40. For the purposes of the present study we used only the subscales that
measure perceived public and personal stigma. Cronbach's alpha coefficients were α = .79 for both perceived public and personal

Table 1
Demographic characteristics about age, gender and school
year.
Age Mean (years) SD

Year 1 (n = 221) 12.9 .491

Year 3 (n = 238) 14.9 .559
Year 5 (n = 263) 16.6 .604
Total (n = 722) 14.8 1.58

Gender Freq

Males 354 (49%)

Females 368 (51%)
White Irish 687 (95%)

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stigma subscales demonstrating excellent internal consistency.

Help-seeking intentions. The General Help-Seeking Questionnaire (GHSQ; Wilson et al., 2005) was used to assess adolescents' help-
seeking intentions. The tool asks young people to rate the likelihood that they would seek help from informal and formal sources if
they were to experience particular symptoms of mental health problems. In the present study depression/anxiety and thoughts about
engaging in self-harm were the problems presented. Informal sources of help include an intimate partner, a friend, parent and another
family member. Formal sources include a teacher, a mental health professional, a phone helpline, a General Practitioner (GP) and a
minister or religious leader. Wilson et al. (2005) report adequate internal consistency (α = .85), adequate test-retest reliability
assessed over a three-week period (r = .92) and significant associations between help-seeking intentions and actually help-seeking
from the corresponding source in the following three weeks. In the present study, the problem prompt for measuring depression/
anxiety was: ‘If you were feeling very anxious or depressed, how likely is it that you would seek help from the following people?’ This was
followed by the problem prompt for self-harming thoughts: ‘If you were experiencing thoughts about harming yourself, how likely is it that
you would seek help from the following people?’ Participants' intentions to seek help from each of the sources for both problem types
were rated on a 7-point Likert scale ranging from 1 ‘Extremely unlikely’ to 7 ‘Extremely likely’. Mean scores for help-seeking for both
depression/anxiety and self-harm were computed where higher scores indicted stronger help-seeking intentions (Wilson et al., 2005).
Reliability coefficients indicated that the scale demonstrated good internal consistency for each prompt (depression/anxiety: α = .68,
self-harm: α = .75).

2.3. Procedure

Prior to data collection a pilot study was conducted including 44 students attending one of the schools that were selected to
participate. Analyses of the pilot data indicated that the measures exhibited psychometric properties appropriate for use in the
specific sample. The parents of students in each participating school were provided with an information sheet and consent form.
Written assent was requested only from students with written parental consent. Questionnaires were administered via paper-and-
pencil within a normal class period by trained research assistants without the presence of teachers or other school staff to avoid
response bias. Prior to questionnaire administration and in addition to the information sheet, students were orally given details on the
study topic highlighting that this is not a test, there are no wrong or right answers and that the researchers are interested in students'
personal opinions and views. The option to withdraw at any given point during the data collection was clearly conveyed to students.
Data collection lasted approximately 20–25 min and students were debriefed at the end of the procedure in addition to the support
resources included in the information sheet. No students opted out of the procedure. The Human Research Ethics Committee -
Humanities of the Institution affiliated to the implementation of this study granted ethical approval for the study.

2.4. Data analysis

Descriptive statistics and intercorrelations were calculated for all the study variables. A series of hierarchical regression analyses
were performed to evaluate the significance and strength of the predictive value of age, gender, and two types of stigma to help-
seeking intentions separately for depression/anxiety and self-harm. Model predictors were entered in two steps for each hierarchical
regression. In Step 1 age (in years) and gender (coded 0 for females and 1 for males) were entered as predictors. In Step 2 perceived
public and personal stigma scores were entered to evaluate their contribution after controlling for Step 1 predictors. In the second
step a significant change of R2 value indicated a significant contribution of the two types of stigma to the total amount of variance
above and beyond the predictors entered in Step 1. Confidence Intervals (CIs) and alpha were set to 95% and .05 respectively. Power
calculation showed that a sample size of 410 participants is required for the aforementioned analyses.
A total of 815 students returned the questionnaires. However, 93 questionnaires had to be entirely excluded from the analyses for
reasons including: more than one point in a Likert scale selected; more than 10% of data missing; or illegible responses (e.g. not
clearly marked). After removing these cases data screening identified a random pattern of missing data χ2 (504) = 536.8, p = .85
(Little, 1988). Missing data were imputed using the expectation-maximization algorithm, a likelihood-based estimation method that
assumes a random missing data pattern (Rubin, 1976).

Table 2
Means, standard deviations and bivariate correlations (n = 722).
Variable 1 2 3 4 Mean SD

1. Age – 14.8 1.58

2. PublicS .07 – 23.6 5.68
3. PersonalS -.17** .31** – 16.9 4.89
4. HSDA -.20** -.16** -.08* – 3.89 .946
5. HSSH -.20** -.16** -.01 .74** 3.64 1.14

Note:*P < .05, **P < .001.

PublicS: public stigma, PersonalS: personal stigma, HSDA: help-seeking intentions for depression/anxiety, HSSH: help-seeking intentions for self-
harm.

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Table 3
Hierarchical regression analyses for predictors of help-seeking intentions related to depression/anxiety.
Step Predictor B SE β R2 R2 change

1 .042**
Age -.12 .02 -.20**
Gender -.11 .07 -.06
2 .065** .025**
Age -.12 .02 -.21**
Gender -.09 .07 - .05
PublicS -.02 .006 -.13**
PersonalS -.01 .008 -.07

Note: *P < .05, **P ≤ .001.

PublicS: public stigma, PersonalS: personal stigma.

3. Results

Descriptive statistics and correlations among variables included in this study are presented in Table 2. Age demonstrated a
significant negative correlation with personal stigma but not with perceived public stigma. Negative significant correlations were
evident between age and help-seeking intentions both for depression/anxiety and self-harm. Perceived public stigma demonstrated a
significant negative correlation with both outcome variables, i.e. help-seeking for depression/anxiety and self-harm. Personal stigma
had a significant correlation with help-seeking for depression/anxiety, but a significant correlation was not evident with help-seeking
for self-harm.
Two hierarchical regressions were performed to answer the research questions with help-seeking intentions for depression/
anxiety and for self-harm being the outcome variables. Both regression models were significant, explaining 6.5% of the variance of
help-seeking intention scores for depression/anxiety F(4, 717) = 13.4, p < .001 and self-harm F(4, 717) = 13.5, p < .001 re-
spectively. Tables 3 and 4 present the findings of the two-step hierarchical regression analyses.
The first research question asked about the demographic variables predicting help-seeking intentions. In relation to depression/
anxiety, age and gender were entered as predictor variables in the first step of the regression model. The results showed that together
these variables produced a significant contribution to predicting help-seeking intentions F(2, 719) = 16.8, p < .001 explaining 4.2%
of the variance (see Table 3). Age was a unique significant contributor to the model (p < .001), but gender was not (p = .11). In
relation to the demographic variables predicting help-seeking intentions for self-harm, results showed that together age and gender
explained 4.6% of the variance F(2, 719) = 18.5, p < .001. In this model, age (p < .001) and gender (p = .01) were both significant
unique predictors of the help-seeking intentions (see Table 4). Males were significantly more willing to seek-help (M = 3.74,
SD = 1.33) than their female counterparts (M = 3.54, SD = 1.14).
To answer the second research question, perceived public and personal stigma scores were added as a second step to the hier-
archical regression models after controlling for age and gender. Together these stigma variables produced a significant contribution
to help-seeking intentions both for depression/anxiety and self-harm. As shown in Table 3, stigma added to the explained variance of
help-seeking intentions for depression/anxiety, above and beyond the contribution of age and gender R2 change = .025, F(2,
717) = 9.71, p < .001. Of the two predictors inserted at the second step, perceived public stigma was a significant unique predictor
(p = .001), while personal stigma was not (p = .09). As shown in Table 4, personal and perceived public stigma significantly in-
creased the variance explained for help-seeking intentions related to self-harm R2 change = .021, F(2, 717) = 7.9, p < .001. Again,
perceived public stigma was a significant contributor to the second step (p = .001), while personal stigma was not (p = .51).

4. Discussion

The primary aim of the present study was to better understand the role of stigma in predicting help-seeking intentions in relation

Table 4
Hierarchical regression analyses for predictors of help-seeking intentions related to self-Harm.
Step Predictor B SE β R2 R2 change

1 .046**
Age -.15 .03 -.20**
Gender .22 .08 .09*
2 .065** .021**
Age -.13 .03 -.20**
Gender .18 .08 .09*
PublicS -.03 .008 -.13**
PersonalS .000 .009 -.03

Note: *P < .05, **P < .001.

PublicS: public stigma, PersonalS: personal stigma.

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to depression/anxiety and self-harm during adolescence. To do this we used two-step regression models, with age and gender entered
in the first step, personal and perceived public stigma in the second step. Our results indicated that older adolescents reported lower
intent to seek help than their younger counterparts for both mental health problems. Boys reported significantly greater help-seeking
intentions than girls, but for self-harm only. Perceived public and personal stigma, our variables of primary interest, were added in
the second step of the regression models. Their addition demonstrated that adolescents who gave higher ratings to perceived public
stigma, had lower intent to seek help for either depression/anxiety or self-harm, than adolescents who gave lower ratings to perceived
public stigma.
Our findings offer a timely contribution to a number of areas in mental health related stigma and help-seeking research among
young people. First, our findings indicate that in the 12–18 year age group, older adolescents are less willing to seek help than
younger adolescents. There are some possible reasons for such findings. For example, it has been suggested that older adolescents
may be more concerned about stigma than their younger counterparts (Berger, Hasking, & Martin, 2017).
We found no evidence that girls were more willing to seek help for depression/anxiety than boys, a finding reported by other
research (Chandra & Minkovitz, 2006; Kim, Lim, Chung, Noh, & Shin, 2014). This finding may be attributed, in part, to the fact that
we had a wider age range of participants (12–18 years) than was used in those previous studies. However, we did find a gender
difference in adolescents' help-seeking intentions for self-harm, with boys reporting a greater willingness to seek help than girls.
Previous research on gender differences in help seeking among adolescents have found that boys and girls differ in the types of
services they would be willing to use and in their mental health knowledge (Chandra & Minkovitz, 2006) as well as in their beliefs
about the helpfulness of different types of help (Berger et al., 2017). Together these findings suggest that we should avoid simpli-
fication of gender differences in help seeking intentions and look at young people's intentions to use different sources of help,
knowledge of mental health problems and beliefs about the usefulness of help.
The primary focus of this research was on stigma and the extent to which personal and perceived public stigma influence help-
seeking intentions. In this context, our findings add to a relatively small body of research on the significance of adolescents' perceived
public and personal stigma for their help-seeking intentions. To the best of our knowledge there are only two other studies that have
measured the relationship between perceived public and personal stigma and help-seeking intentions in this age group (Yap et al.,
2011, 2013). In the case of the former study, help-seeking intentions were predicted by personal rather than perceived public stigma.
In the case of the latter, help-seeking for depression from both GP and counselor services was significantly predicted by an aspect of
perceived public stigma. Neither study looked at intentions to seek help for self-harm.
At first glance, therefore, our research findings appear to stand in contrast to the findings of some other studies that have
attempted to better understand how the different forms of stigma are related to help-seeking. However, we believe that because of the
instruments used, direct comparison of the findings of these studies with those of the present study is not appropriate. Specifically,
both of the previous studies presented participants with questions about help-seeking intentions in relation to one of a wide range of
mental health problems (including psychosis and depression among others) and the data was subsequently combined in the analysis.
In contrast, in our study we have looked separately at two common mental health problems. There are also conceptual differences in
the structure of the stigma questionnaires used. In the case of Yap's research their stigma questionnaire focused primarily on a range
of stereotypes and a measure of social distance. The questionnaire in our research included stereotypes, prejudice and behavioral
intentions. Thus, our findings highlight the importance of considering not only the components of stigma measured in each study but
also the nature of the psychometric tool employed to assess stigma.

4.1. Limitations

Despite its strengths the present study has some limitations that should be considered. We did not measure participants' current
mental health status or previous help-seeking experience as this was beyond the scope of this study. There is evidence that previous
experiences of seeking help for a personal mental health problem is associated with greater willingness seek help in the future (Raviv,
Raviv, Vago-Gefen, & Fink, 2009). Therefore, this should be taken into consideration when interpreting the findings of the present
study and we recommend that future studies should extend this area of research by measuring young people's current mental health
status and/or previous help-seeking experience.
The fact that stigma accounted for a relatively small amount of the variance in help seeking intention scores, may in part reflect
the omission of these variables. It is also important to note that we only measured help-seeking intentions, so we cannot make
predictions about the relationship between personal and perceived public stigma and future help-seeking behavior. However, Wilson
et al. (2005) reported that the instrument used here to measure help-seeking intentions did significantly predict future behavior. As in
all studies measuring social attitudes, the possibility of social desirability bias must be acknowledged as participants may have been
reluctant to report stigmatizing attitudes towards their peers. Finally, this is a cross-sectional study design, which does not allow for
monitoring changes in help-seeking intentions over time. Future studies could benefit from a longitudinal study design.

4.2. Implications

Our finding that older participants were significantly less likely than their younger peers to seek help for depression or self-harm
suggests that there is a need to educate adolescents of all ages about the merits of seeking help for mental health problems. Such
education could form part of a wider goal of improving mental health literacy, defined as “knowledge and beliefs about mental
disorders which aid their recognition, management or prevention” (Jorm et al., 1997, p. 182). Existing research findings have
demonstrated considerable gaps in adolescents' knowledge that is relevant to help-seeking. For example, Burns and Rapee (2006)

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found that only 2% of 16-year-olds thought that a medical practitioner was a suitable source of help for a depressed peer. Kelly, Jorm,
and Wright (2007) review the literature on interventions designed to improve mental health literacy in adolescence and offer re-
commendations on how to make an appropriate choice.
Our findings suggest that perceived public stigma is a predictor of help-seeking intentions during adolescence. Previous research
(Eisenberg et al., 2009; Yap et al., 2011, 2013) suggested that personal stigma might be a more important predictor for young people.
This has clear implications for the design and implementation of interventions intended to increase rates of help-seeking for mental
health problems. Specifically, our findings suggest that interventions to increase young people's help-seeking should address their
perceptions of perceived public stigma as well as their personal stigma. This is important as many studies have presented clear
evidence that young people believe that they have less stigmatizing attitudes than ‘other people’ (McKeague et al., 2015; Yap et al.,
2014). In addition, Corrigan and colleagues argue that education and level of contact are both contributing factors to reducing stigma
in adolescents (Corrigan, Morris, Michaels, Rafacz, & Rüsch, 2012). We propose that interventions can be designed and delivered
across three levels. At family level, interventions targeted to caregivers on the importance of raising children's awareness on mental
disorders and encouraging them to seek help when encountering a mental health problem can lead to reducing personal stigma. At
school level, interventions to tackle different aspects of stigma could be integrated in the education curriculum. Although few such
interventions have been rigorously tested, the SchoolSpace, intervention (Chisholm et al., 2016) represents a promising example of a
school-based intervention to tackle stigma that includes contact with a young person with lived experience of mental health pro-
blems. At community level, interventions can be designed to reduce personal and perceived public stigma by increasing mental health
literacy and by creating social opportunities to increase level of contact with people diagnosed with a mental disorder.

4.3. Conclusions

Most research on stigma and help-seeking for mental health problems has been conducted with adults and much less is known
about school-age students. This study found that perceptions of perceived public stigma predicted help-seeking intentions among
adolescents, even when age and gender were controlled. This finding suggests that school-based interventions aiming to promote
help-seeking should focus on teaching young people that there is less stigma about mental health problems than they think, as well as
trying to reduce their personal stigma. The research findings also emphasize the importance of using instruments that reflect the
multifaceted nature of stigma.

Acknowledgements

We would like to thank the students for participating in this study and the school principals and teachers for their collaboration.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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