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Amanda Ivester
Health 2400: Determinants of Health Behavior
Section One

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The World Health Organization (WHO) defines mental health as a state of well-being in
which the individual realizes his or her own abilities, can cope with the normal stresses of life,
can work productively and fruitfully, and is able to make a contribution to his or her community
(World Health Organization, 2004). According to 2004 WHO data, an estimated 26.4% of
Americans have some type of mental health issue. (Wang, 2007). The National Institute of
Mental Health found that in 2008 only 13.4% of adults in the U.S. sought out mental health care
on some kind (National Institute of Mental Health, 2010). The National Institute of Mental
Health also found that during 2008 only 58.7% of Americans with a serious mental illness were
receiving mental health care. Based on the WHO data, it is indicated that the roughly half of
Americans with a serious mental illness who were not receiving care were not receiving that
mental health care because they were choosing not to seek it. A study done by Dr. Maria Oliver
et al confirmed that only about half of those surveyed said that they would seek professional
mental help if they felt their health was suffering (Oliver, 2005). This study by Dr. Oliver begins
to help explain exactly why mental disorders are estimated to be 14% of the overall global
burden of disease; people choose not to seek mental health care (Prince, 2007). This paper will
use behavior theory to analyze the various reasons that individuals do not seek mental health
Due to the wide variety of mental disorders, individuals who do not seek mental health
care can have a very wide range of health issues, many of which are symptoms of their untreated
mental illness. Health problems those that do not seek mental health care can experience include,
but are not limited to, trouble breathing, loss of muscle mass, and lacerations. (Panic Disorder,
Anorexia Nervosa, Self-Harm). In addition to this poor physical health, individuals that do
not seek mental health care frequently have poor social health as well, experiencing damaged
relationships due to lack of motivation and unpredictable mood swings (Depression,
Not seeking mental health care puts an individual at risk for various comorbidities and
mortalities, most of which result from the fact their mental illness is being left untreated. A study

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done by Dr. Pan showed depression was associated with a significantly higher risk of stroke,
with 106 more individuals from the group of people with depression having a stroke (Pan, 2011).
It has also been indicated that the same social factors that are associated with poor mental health
resulting from not seeking mental health treatment are associated with alcohol use, drug use,
crime, and dropping out of school (World Health Organization, 2004). A study published by
Cambridge University done on those with major depressive disorder showed that, of the study
group, 42% had a coexisting fear disorder and 33% had a coexisting distress disorder
(Middeldorp, 2005). This means that choosing not to seek mental health care can result in
exponentially poorer mental health. Yet another marker of the dangers of not seeking care for
mental health issues is the suicide rate, which increased 18.3% from 2000 to 2011 (U.S.
Department of Health and Human Services, 2014).
The rate of individuals seeking mental health care in the U.S. is low enough that there is
a major Healthy People 2020 objective related to attempting to increase treatment seeking.
Healthy People 2020 believes that one of the most important things the U.S. can do in order to
increase mental health care treatment seeking is to increase access to mental health care. Healthy
People 2020 would like to see a ten percent increase in the number of primary care facilities that
provide mental health treatment either onsite of by referral (U.S. Department of Health and
Human Services, 2014).
Much of the literature regarding theories related to seeking mental health treatment
revolves around the idea of self-efficacy and self-esteem. It is widely believed that if individuals
feel capable and worthy they will seek out mental health care. Theories that involve a major
component of self-efficacy include the theory of planned behavior and social cognitive theory.
The transtheoretical model has also been used to help plan appropriate care for different types on
individuals in the hopes that more appropriate care will lead to more individuals seeking
treatment. Understanding these three theories is key to beginning to understand why individuals
do not seek care for mental health issues.

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The transtheoretical model, also known as the stages of change model, is used in order to
decide the best way to provide help to individuals. The transtheoretical model is used in regards
to mental health due to the assumption that individuals are more likely to seek mental health care
if that care feels like it has been personalized to them (Leamy, 2011).
Those in the precontemplation stage often need more information in order to make a
change while those in the maintenance stage have already changed their behavior and formed
new habits. Dr. Mary Leamy led a literature review on personal recovery regarding mental health
and then mapped these results onto the transtheoretical model (Leamy, 2011). This information
can be used to encourage individuals to see mental health care by allowing doctors to provide the
most appropriate care.
For a paper to be included in this review it must not focus entirely on clinical recovery
but on personal recovery as well. The majority of the literature defined personal recovery as the
individual agreeing that they were in recovery, no hospitalization in regards to mental health
within the last twelve months, being mostly symptom free, providing support to others, and
working and living at least semi-independently (Leamy, 2011). This literature review found that
only 44% of individuals believed that recovery is an active process and only 25% believed that
recovery from mental illness is an individual or unique process (Leamy, 2011). According to the
literature review, connectedness was the most important process in order for an individual to
recover from mental illness with 86% of studies citing this as a key component (Leamy, 2011).
From this literature review key stages of recovery were picked out and mapped onto the
transtheoretical model. Feeling stuck, overwhelmed, dependent, unaware, or in a crisis were
considered to be the precontemplation stage. Feelings like accepting help, igniting a spark of
hope, feeling as though one had seen glimpses of recovery, and being at a turning point were

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mapped as being in the contemplation stage. The preparation stage related to feelings of
determination, establishing independence, or decision making. Individuals who were in the
action stage regarding recovery from mental illness felt as though they were on the road to
recovery, living with their disability, learning, and rebuilding. Finally, those who were in the
maintenance stage described living beyond their disability, having high self-esteem, and actively
coping with the stresses of life (Leamy, 2011).
This method of literature review allowed commonalities about recovery from mental
illness to be easily identified. By mapping these commonalities onto the transtheoretical model,
health care professionals can use these key phrases and feelings to assess what stage individuals
are in regarding recovery from mental illness. Simply knowing whether an individual is in the
precontemplation, contemplation, preparation, action, or maintenance stage regarding recovery
from mental illness allows mental health care providers to give specific care to individuals in
order to encourage them to seek care and therefore move along this recovery process (Leamy,
The theory of planned behavior is a multicomponent theory that seeks to explain why
individuals do or do not plan to do certain behaviors, in this case, seeking mental health
treatment. One major concept of the theory of planned behavior is perceived power, meaning
whether or not an individual believes what they do will make an impact. Believing that one has
the ability to make change is to say that one has high self-efficacy (Mann, 2004). Self-esteem is
ones thoughts about oneself as a person. While self-efficacy and self-esteem are fundamentally
different they are often intertwined because they are often either both positive or both negative.
People also experience increased self-esteem in response to increased self-efficacy (Mann,
2004). Recognizing how related these factors are, self-esteem, or ones sense of self-worth, is
then an important consideration as to why individuals do not seek mental health care. Individuals
who are found to have low self-esteem often have the corresponding low self-efficacy. Because
of this these individuals often turn to avoidance behaviors, in this case avoiding recognizing they
might have a mental illness. These avoidance behaviors then result in a decreased ability to

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handle the stresses of everyday life and as such the individual perceives their power as very low.
Due to this low perceived power the individual chooses not to seek mental health care because
they believe it will not matter anyway (Mann, 2004).
While researching self-esteem it was discovered that children who were extremely
socially anxious frequently had low levels of self-esteem. The conclusion was ultimately reached
that self-esteem is a barrier against anxiety (Mann, 2004). This once again ties back to the idea of
perceived power in the theory of planned behavior. Individuals with high anxiety, low selfesteem, and low self-efficacy may feel a sense of dread or discomfort about the idea of making
life changes and seeking mental health treatment. Due to this extreme anxiety and fear they have
very low perceived power and ultimately do not seek mental health treatment.
Low self-esteem can also correlate with a higher motivation to comply with the beliefs of
others. Adolescents with low self-esteem are more frequently engaged in violent behavior and
gang memberships (Mann, 2004). Because these individuals feel poorly about themselves they
frequently fall into gangs because they feel motivated to comply with the beliefs held by those
individuals in the gang. This happens because individuals with low self-esteem frequently seek a
social group to belong to in the hopes to build some self-esteem and will often to conform to any
group that will accept them in order to do so. (Mann, 2004). This same idea applies to why
individuals do not seek care for mental health problems. Society currently holds the belief that
mental health is not important and those with low self-esteem are motivated to comply with this
belief and therefore do not seek mental health treatment.
Social cognitive theory is the idea that the individual, the behavior, and the environment
all influence each other. A major individual construct of the social cognitive theory is the idea of
self-efficacy. An individuals beliefs on whether or not they are able to make a difference through
their own efforts greatly influence whether or not an individual seeks mental health care
(Benight, 2004).

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Individuals who have very low self-efficacy frequently see potential dangers in their
environment and spend much time thinking about the fact that they have poor coping
mechanisms (Benight, 2004). This environmental threat level varies from person to person but
those with low self-efficacy frequently feel doubt about their ability to manage their situation
(Benight, 2004). Because of these expectations about their environment the individual is unlikely
to take advantage of mental health treatment resources. This is due to the fact that they do not
expect the action of seeking help to have a meaningful positive impact because they view their
situation as hostile or dangerous.
In order to change mental health treatment seeking behaviors, Benight suggests the
promotion of thought control efficacy. This means helping individuals to recognize that their
physical environment is largely shaped by their own cognitions (Benight, 2004). The basic
premise of this thought control efficacy consists of attempting to exercise control over ones
thoughts in order to attempt to regulate behaviors and emotions. Thought control efficacy is
particularly effective because it can help to facilitate a positive social environment which is
correlated with increased self-efficacy and increased mental health treatment seeking behavior.
Furthermore, successful thought control efficacy by itself can increase self-efficacy and in turn
can promote mental health treatment seeking behaviors. (Benight, 2004).
Intrapersonal factors are factors within the individual that influence behavior, in this case,
seeking mental health treatment. These include beliefs, values, attitudes, and knowledge about
seeking mental health treatment, demographics and socioeconomic status, and psychological or
personality characteristics.
Beliefs and attitudes about mental health treatment are often very negative. These
negative beliefs greatly contribute to individuals choosing not to seek mental health care. A study
by Dr. Ramin Mojtabai found that only 26.3% of Americans believed that those who seek mental

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health treatment are actually helped (Motjabai, 2007). A survey done asking individuals to rate
the likely helpfulness of various behaviors for treating or alleviating mental illness found that
very few people believed that seeking professional mental health treatment would help (Jorm,
2000). There is also a persistent belief that medications, which are often a large part of seeking
professional mental health treatment, are negative and not helpful (Jorm, 2000). Furthermore it
was also found that 59.8% of Americans would be embarrassed if people knew that they were
seeking professional mental help (Motjabai, 2007). It was also found that much of the public
viewed admission to a psychiatric ward in a hospital as a very negative thing (Jorm, 2000). These
negative beliefs and attitudes also indicate that individuals place a lower value on their mental
health. Because mental health is often valued less than physical health, individuals are less likely
to seek care. Individuals are also frequently misinformed about the causes of various mental
illnesses. For example, many people belief that schizophrenia is caused by life events, when in
reality it is only triggered and made worse by life events. This belief about schizophrenia leads
individuals to believe that seeking mental health treatment is unnecessary and the individual
simply needs make a few life adjustments.
Individuals also frequently have very poor knowledge about getting mental health
treatment. 33% of individuals stated when surveyed that the majority of their knowledge about
mental health treatment came from a friend or family member who had been treated for mental
illness (Jorm, 2000). Much of the other knowledge individuals have about seeking mental health
treatment comes from the media or various unregulated self-help books (Jorm, 2000). Individuals
also frequently lack knowledge about what types of professionals to see out for mental health
care, believing that a general practitioner is almost always sufficient. This poor knowledge about
what mental health treatment is actually like and how to receive it also contributes to why
individuals do not seek mental health care.
There are several demographic groups that are the least likely to seek mental health care.
Men are less likely to see mental health care than women. Individuals of a lower socioeconomic
status are unlikely to seek mental health care (McAlpine, 2004). Being of a lower socioeconomic

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status also typically means that an individual does not have insurance, which further makes them
less likely to seek mental health care (Wang, 2007). Of all races in the United States, African
Americans were the least likely to seek mental health care, being twice as likely as any other
group to choose not to seek care (Conner, 2010; McAlpine, 2004). Older adults seek mental
health care far less often than younger adults do (Segal, 2005). Individuals who are less
educated are also less likely to seek mental health care (McAlpine, 2004). Living in a rural area
makes an individual less likely to seek mental health care (Wang, 2007). Based on this, the least
likely individual to seek care is an unmarried, older, less educated African American male of a
low socioeconomic status living in a rural area (McAlpine, 2004).
Interpersonal factors are factors between the individual and other individuals that make
them more or less likely to do a behavior, in this case, seeking mental health treatment.
Interpersonal factors include support, social interactions, and social influence from family and
friends. Often individuals who would benefit from seeking mental health care do not due
negative social interactions regarding mental illness. Those without a mental illness often label
those with mental illness as having social-skill deficits and poor physical appearance (Corrigan,
2004). The shame and stigma of carrying the label of mentally ill and all that it entails is often
enough to prevent individuals from seeking mental health care. There is also a wide spread
public belief that individuals with mental illness are dangerous, likely to be violent, and likely to
commit crimes (Corrigan, 2004; Jorm, 2000). These negative societal beliefs about mental health
prevent individuals from getting care because they greatly desire to avoid this stigma.
These false negative beliefs about mental illness also rob individuals of social support
from their friends and family. The individual who would benefit from seeking mental health care
then has friends and family who believe that professional mental health treatment is less effective
than self-help and lives in a society that stigmatizes mental illness (Corrigan, 2004; Jorm, 2000)
Furthermore, individuals are unlikely to have anyone to make comparisons against regarding
seeking mental health. If anyone they know is in fact receiving mental health treatment, it is
frequently not made known (Thoits, 2011). This lacking of social reference groups make

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individuals unlikely to seek mental health care. These interpersonal factors ultimately converge
to make individuals far less likely seek mental health care.
Organizational, community, environment, and policy factors are all factors in the external
environment that influence whether or not an individual will seek mental health care.
Organizational factors are related to particular organizations, such as a workplace or college.
Community factors are factors where the individual lives and spends time. Environment factors
refer to things in the individuals physical environment that influence whether or not they seek
mental health treatment. The single biggest environmental factor influencing whether or not
someone will seek mental health care is if there is access to this care. Finally, policy factors are
laws that influence if an individual will seek mental health care.
There are few, if any, workplace based programs that encourage individuals to see
mental health treatment (Wells, 2004). Colleges and schools as organizations typically have more
programs in place for mental health promotion and to encourage treatment seeking. However, a
literature review done by Jane Wells found that only seventeen out of 425 school-based mental
health promotion programs met the required criteria of being unambiguous about their aims,
keeping detailed records, and adjusting the program based on results (Wells, 2004). Many of
these schools were in poor areas with large numbers of ethnic minority groups, meaning that
these programs were intentionally set up in areas where people are unlikely to see mental health
treatment in order to hopefully change that behavior (Wells, 2004). Wells identified three types
of school based-programs that encouraged the seeking of mental health treatment: school-wide,
parts of the school, and classroom based. All of these programs sought to measure how
individuals felt about seeking mental health treatment and set aims to remove negative feelings
about seeking mental health treatment. Classroom-based programs were shown to be more
effective in encouraging the seeking of mental health treatment due to their personalization
(Wells, 2004).
Many community-based factors regarding the likelihood of seeking mental health
treatment stem from church-based health promotion programs. While these programs have the

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potential to reach eighty percent of Americans, they also may be ineffective due to the fact that
people who are religious frequently have social support and better mental health, meaning they
likely already seek mental health care in some form if they need it (Campbell, 2007). Despite this
potential set back of this type of community intervention, they are particularly useful because
they frequently highlight the effect of mental health on physical health (Campbell, 2007). These
church-based programs that promote seeking mental health care attempt to connect established
beliefs back to mental health in the hopes that individuals will see the importance of seeking
care. These programs are one of the only community factors to encourage the seeking of mental
health treatment. Unfortunately these programs are seldom grounded in established theoretical
framework and therefore frequently have less than satisfactory results (Campbell, 2007). One
reason in particular these programs often fail is that they fail to communicate with each other or
with other organizations.
Most environmental factors aimed at increasing mental health treatment seeking
behaviors target the environment. The U.S. Department of Health and Human Services through
the Healthy People 2020 initiative deemed that access to mental health treatment was low
enough to create specific objectives aimed at increasing treatment access in order to encourage
treatment seeking behaviors (U.S. Department of Health and Human Services, 2014). The
biggest thing being done to increase access to mental health treatment, and therefore increase
treatment seeking behaviors, is attempting to integrate primary care and mental health care
(Pomerantz, 2008). Before attempts were made to integrate care within Veterans Affairs
hospitals, acquiring an appointment with a mental health profession could take six week and
sometimes even longer. Nearly half of all people who bothered to make an appointment never
came (Pomerantz, 2008). After these factors were identified, steps were put into place to abolish
these negative environmental factors and instead create an environment that encouraged the
seeking of mental health treatment. By integrating primary care and mental health care wait
times dropped from over two months to less than thirty minutes and twice as many people were
seeking mental health care (Pomerantz, 2008). This Veterans Affairs hospital intervention shows
how vitally important of an environmental factor easy access to mental health treatment is if one
wants to encourage the seeking of mental health treatment.

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While most U.S. laws dealing with mental health revolve around involuntary
commitment to mental institutions, there several notable U.S. policies aimed at increasing the
proportion of individuals that seek mental health treatment. Many of these policies intend to
foster treatment seeking by increasing access to treatment. The Community Mental Health Act
of 1963 was signed into effect by John F. Kennedy and created funding for mental health
facilities (Facilities, 2008). The New Freedom Commission on Mental Health was a committee
created by George W. Bush in 2002. Its purpose was to research the current state of the U.S.
mental health system and identify ways individuals could be encouraged to seek treatment at
national, state, and community levels (Cunningham, 2008). The Mental Health Parity and
Addiction Act of 2008 required insurances to provide the same amount of money and benefits
towards mental health treatments as do towards other medical costs (Wellstone, 2008). The final
U.S. policy that encourages the seeking of mental health treatment is the Mental Health Services
Act of California. This law was established in 2008 and amended in 2012. The Mental Health
Services act of California provides funding for mental health treatment programs (Felton, 2010).
This funding has been used to train individuals to provide care, create community mental health
promotion programs, and monitor the number of individuals seeking mental health treatment
(Felton, 2010).
Predisposing factors are factors that make an individual more likely to do a behavior that
occur before a behavior is done. Enabling factors are factors that make it more likely for an
individual to perform a behavior by making it easier or possible to perform that behavior. Finally,
reinforcing factors are factors that occur after the behavior is done that make it more likely for
the individual to continue the behavior (Wright, 2006).
Predisposing factors regarding seeking mental health treatment were limited knowledge
about treatment available as well as limited knowledge about signs of when to seek treatment
(Wright, 2006; Motjabai, 2007). Other predisposing factors about whether or not an individual
will seek mental health care is the individuals belief that they are not susceptible to mental
illness and fear of stigma or being locked due to seeking mental health treatment (Wright, 2006;

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Jorm, 2000). Individuals are very unlikely to seek mental health treatment if they are unaware of
their options or even that they need it at all. This lack of knowledge compounded with fear
surrounding mental health treatment can make it unlikely for an individual to seek mental health
Enabling factors in regards to seeking mental health care mostly revolve around
accessibility and availability. The most vital enabling factor to target in order to make individuals
more likely to seek mental health care is to improve the knowledge that individuals have about
care, sources of help, and their susceptibility to mental illness (Wright, 2006; Jorm 2000). By
giving individuals more accurate knowledge about mental health treatment you have effectively
increased their access to it. An individual who knows what types of mental health care are
available and when to get it is far more likely to seek out mental health treatment than someone
with incorrect and negative ideas about mental health treatment.
Positive feedback from peers and social support are the most important reinforcing
factors when dealing with seeking mental health treatment (Wright, 2006; Corrigan, 2004).
Individuals stated that they needed someone they knew and trusted to help them recognize that
they had a mental health problem and then encourage them to seek treatment (Wright, 2006;
Corrigan, 2004). By creating this network of social support you make it more likely for an
individual to seek out and continue mental health care, because one of the biggest reasons people
avoid mental health treatment is the stigma surrounding mental health.
There are several factors that could be targeted in order to improve the rate that people
seek mental health treatment. Providing knowledge about mental disorders allows individuals to
recognize when seeking treatment is appropriate and can often increase their knowledge of how
and where to seek help (Jorm, 2000; World Health Organization 2001). The World Health
Organization (WHO) suggests that the environment is another important fact to target to increase
the rate that people seek mental health care. In order to alter the environment to be more friendly

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towards seeking mental health treatment WHO recommends integrating mental health care with
primary care as well are giving care within communities (World Health Organization, 2001).
These two factors, knowledge and environment are the most important factors to target in
order to encourage individuals to seek mental health treatment. Increasing knowledge about
mental illness and mental health treatment is important because it will have a domino-like effect.
Correcting misinformation about mental illness and mental health treatment will in turn change
individuals beliefs about seeking mental health care and when individuals have changed those
beliefs they less likely to stigmatize seeking mental health treatment and become more likely to
provide social support to individuals who seek mental health care (Jorm, 2000). Targeting the
environment in order to increase access to mental health treatment is important because even if
people dont view seeking mental health treatment negatively, if there little treatment to be had
and what is available is difficult to get, individuals will be unlikely to seek mental health care
(Pomerantz, 2008).
Targeting knowledge and access to mental health care is also important because these two
factors can be changed relatively easily and still have a large impact on mental health treatment
seeking behaviors. The effectiveness of targeting access has been shown with Veterans Affairs
hospitals; twice as many individuals were seeking care after there was more care available for
them to get (Pomerantz, 2008).
Strategies for targeting these two factors will include community mental health
promotion programs. These smaller programs will have more ability to change knowledge
(Wells, 2004). In addition to these various community based education programs, there will also
need to be a way to get this increased mental health care access. This can be done by teaching
primary care providers to provide recommendations for mental health treatment and using
community health workers to set up mental health treatment programs within communities.
These strategies should be used because they will be cost-effective and likely to have an impact
because individuals are more likely to seek mental health care if it feels personalized to them
(Wells, 2004).

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