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MENTAL ILLNESS KNOWLEDGE, STIGMA, HELP-SEEKING BEHAVIORS, SPIRITUALITY AND THE AFRICAN AMERICAN CHURCH.

INTRODUCTION

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) reports that the 2014 national average for any mental illness in the past year for adults was 18.1%, compared to 16.3% for African American adults (2014) .An estimated one in five people are affected by mental illness (Conley, 2012; National Alliance of Mental Illness [NAMI], 2015).In 2011, one in 20 Americans lived with a serious mental illness, such as schizophrenia, bipolar disorder, or major depression (U.S. Department of Health and Human Services, 2011).Asnaani and colleagues (2010) reported that 8.6% of African Americans suffer from Social Anxiety Disorder, 4.9% from Generalized Anxiety Disorder, and 3.8% from Panic Disorder. According to the CDC (2010) African-Americans have the highest rate of current depression (12.8%), followed by Hispanics (11.4%), and whites (7.9%). More specifically in African Americans the most common types of mental illness disorders include, major depression, attention deficit hyperactivity disorder, suicide, and posttraumatic stress disorder (Anxiety and Depression Association of America, 2015; NAMI, 2015).

Knowledge and Stigma

Jorm (2011) explained that public knowledge about mental disorders has received significantly less attention than physical diseases. Historically, the Black community has been reluctant to discuss mental health conditions. Many times the lack of knowledge leads this population to believe it is a sign of personal weakness (NAMI, 2015). Pickett-Schneck (2002) notes that distrust of health care providers and a lack of access to resources could contribute to low levels of knowledge in understanding the etiology of mental illness. However, there is a dearth of literature specific to differences in knowledge levels by race or ethnicity.

In 2007, Mental Health America reported that 63% of African-Americans believed depression was a "personal weakness", and only 31% of African-Americans thought depression was a health issue. "Five reasons a majority of the population withheld information on their illness included: concern of hurting the family, it would ruin their career, people might think they are crazy, they cannot afford to appear weak, and shame" (NAMI, 2009, np).

Spirituality & the Role of the Black Church

The church has long been documented as playing a significant role in the spirituality of the African American community (Abdullah, 1999; Jones, 1991) and that African-Americans attend church regularly, participate in private prayer, listen or watch religious programs, use encouragement, and religious coping messages [Chatters et al. (2009) noted in Chatters, Taylor, Lincoln, Nguyen, and & Joe (2011)]. Utsey et al. (2007) points out that involvement in spirituality by Blacks tends to correlate with better mental health and church related support provides vital networks to the African-American population by providing encouragement in physical and mental health (Taylor, Lincoln, & Chatters, 2005; Krause, 2008, as noted in Chatters et al. 2011).Historically, the Black church has served as a place of worship, a place of emotional expressiveness, educational endeavors, civic meetings, pastoral care, and counsel (Armstrong & Crowther, 2002). Further, the clergy are often the initial responders to mental health concerns among the Black culture. Kramer et al. (2007) suggest clergy provide a "cultural bridge between the formal healthcare system and recipients of care" (p. 124). However, a dearth of research was found on demographics of parishioners, beyond race, within the Black churches in relation to support of mental health help-seeking behaviors and thus should be further explored.

Mental Health Help-Seeking Behavior

African-Americans who had more positive attitudes toward mental health services were more likely to report feeling embarrassed if their friends or family knew they used these services and tend to cope with mental health concerns by utilizing support systems such as: church family, family, friends, neighbors, and coworkers rather than seeking medical attention (Matthews & Hughes, 2001; Woodward, Taylor, Bullard, Neighbors, Chatters, & Jackson, 2008). African Americans suppress topics of hardship, depression, and strategies to cope with mood or emotional life changes (NAMI, 2015), utilize mental health professional care assistance at half the rate of Whites(Agency for Healthcare Research and Quality, 2010),and are in general less likely than Whites to seek mental health counseling and instead seek assistance from their primary care physician (Pingitore, Snowden, Sansome, & Klinkman, 2001). Approximately one-quarter of Blacks seek mental health assistance compared to 40% of Whites (NAMI, 2015). Underrepresented groups have been reported to use prayer and spirituality as coping resources in lieu of counseling or psychotherapy (So, Gilbert,& Romero, 2006) and seek help from clergy first to manage mental illness (Young, Griffith, & Williams, 2003).

The following research questions are thus posited: What relationship exists between mental illness knowledge, stigma, spirituality, and reported help seeking behaviors? And, what demographic differences (i.e. age, education, marital status, income, and employment) exist between African Americans who think the Black church should playa role in addressing mental illness versus those who do not?

METHODS

Participants

Utilizing convenience and snowball sampling, African-American adult women and men were recruited from Baptist faith-based organizations. Participants for this study were recruited from two faith-based locations, one organization from the Midwest and one from the Southern part of the United States. Approximately 14,600 parishioners were invited to participate via a combination of newsletter ads and verbal announcements. A total of 350 paper surveys were distributed at church and 567 clicks on the survey link were recorded. In total, 114 paper surveys and 295 online surveys were completed. Resulting in an approximate participation rate of 44.6% (N=409).

Procedures

The Institutional Review Board (IRB) from the University of Cincinnati (UC) reviewed and approved all aspects of the study. Several predominantly African American churches were invited to participate by reaching out to the local church administrations who were identified as gatekeepers to the membership. Two agreed to participate and survey data was collected from both locations. The Mental Health and Spirituality survey was distributed on paper and via an online portal.

Measures

A combination of existing, adapted, and novel questions were utilized to form the study questionnaire in order to measure: (1) knowledge of specific signs of symptoms, (2) stigma, (3) spirituality, (4) help-seeking, (5) role of the church, (6) and demographics.

Knowledge. The top five areas of mental illness are schizophrenia/psychotic disorders, depression, bipolar disorders, panic disorders, and anxiety disorders (Mayo Clinic, 2015). To assess knowledge of mental illness, the authors organized 50 signs and symptoms of these top 5 conditions into 3 sections (a. Feelings of ... b. Experiencing ... & c. Engaging in ...) and presented them to participants. Participants were asked to 'check all that apply'. Knowledge level was measured by adding up the number of signs and symptoms identified by participants (Cronbach's alph = .97).Additionally, four items assessed participant level of agreement with statements related to effectiveness of treatment, contagiousness, and level of effect on one's life related to mental illness, and the concept of being mentally ill equating to being 'crazy' (strongly agree-strongly disagree).

Stigma. A modified 30-item Stigma about Depression Questionnaire by Nieuwsma, Pepper, Maack, and Birgenheir (2011) was used. Nineteen items were selected due to their relevance to the present study. The selected items were then modified to reflect mental illness in general rather than depression specifically. Selected items included among others, feelings toward people living with mental illness, such as burden of society, mental illness patient reflections on society, and growing up in a household with a person who suffers from mental illness and the possibility of shame. Items were measured on a Likert-type scale from 1-4 (1 Strongly disagree--4 Strongly agree). Items 4, 10, 12, 16 and 19 were reverse coded so that agreement would be indicative of stigma. Higher scores indicated higher stigma. Scale scores were calculated by summing across items after reverse coding (Cronbach alpha = .637).

Spirituality. To assess spirituality, participants responded to three sections. First, they were asked how often they attend church (rarely- weekly) and to self-rate how spiritual they were (not at all- a great deal). Secondly, a 5-point Likert type scale (strongly agree-strongly disagree) with 14 items was used to measure spirituality. Thirteen items were adopted from Holt, Clark, and Klem (2007) and a 14th item was added for this study to assess comfort level in talking about personal issues with a person from their clergy. The Cronbach coefficient of reliability was reported as alpha=.81 by Holt, Clark, and Klem (2007) and measured .724 in the present study. A possible scale score between 14 and 70 was computed by summing across all items. Third, the 8-item Spiritual Centered Coping subscale by Utsey, Adams, and Bolden (2000) was used to measure participants' coping behaviors during certain life situations. The internal consistency Cronbach alpha coefficient was reported as .81 (2000) and measured .756 in the present study. A possible scale score between 8 and 32 was computed by summing across all items.

Role of the Church.To assess the perceived role of the church several questions were created. Specifically, participants were asked a) if they thought the church has a role in mental health awareness, b) if their church provides mental health services and c) if their church were to offer these services, would they use them?(yes/no). A fourth question asked their level of agreement with "Faith-based organizations should provide mental health services" (1 strongly disagree - 4 strongly agree). Lastly participants were asked the level at which their faith-based organization a) understood mental health, b) provides mental health support, c) openly discusses mental health, and d) provides mental health support (1 not at all -4 a great deal).

Help-Seeking. Another section measured the participant's attitude toward mental health help-seeking. A selection of 10 items from Fischer and Turner's (1970) Attitudes toward Seeking Professional Help Scale was modified for this study. The selected items assessed level of agreement with statements reflecting if participants received past counseling for emotional issues, the advice they might give to a friend or family member, if they would consider getting aid if the need erupted, and an individual's thoughts on getting help from a mental health specialist among other help seeking behaviors (1 strongly disagree--4 strongly agree). The modified scale had an acceptable Cronbach alpha coefficient of .78. Reverse coding was conducted for items 2, 3, 5, and 7 so that higher scores were indicative of healthier help seeking behaviors. Scale scores were computed by summing across item values and had a possible range of 0 to 40.

Lastly, a series of demographic items were also included in the instrument. These measured age, sex, years of school completed, marital status, employment status, occupation, approximate household income and number of people in household.

Data Analysis

Descriptive statistics were used to assess count, percent, and central tendency. The data was cleaned and assessed for skewness and kurtosis. It was identified that the sample included significantly more females than males and thus non-parametric statistics were used. Spearman Rho correlations were used to assess the relationship between variables and Chi Square was used to compare observed and expected frequencies of selected variables. All data was analyzed using the Software Package for the Social Sciences (v23).

RESULTS

About the Participants

As seen in Table 1, the average age of participants was 44.8 years (SD=12.748). Most were female, married, and worked full time. The average household size was 2.44 (SD=1.408) people with an income mean above $60,000, nearly one third had graduated college and over 40% held a graduate or professional degree. All participants self-identified as African-American.

Knowledge

Results for symptom and sign recognition showed that after summing across all 50 items, participants had an average score of 33.95 (SD=13.98). Over half (52%, n=205)correctly identified at least 70% of the 50 signs and symptoms. Some of the top symptoms identified were anxiety, hopelessness, suicidal thoughts or behaviors, and withdrawal from family members and friends. As seen in Table 2, more than 15% agreed mental illness was infectious, 31% agreed mental illness was the same as craziness, 90% agreed mental illness affects one's whole life, and 72% agreed mental illness can be treated completely.

Stigma toward Mental Illness

The stigma scale results showed an average stigma score of 33.5 (SD=5.142) with a range of scores between 19 and 57(n=352). Higher scores indicate higher stigma. The median score was 33.0 and the mode was 30.0. Table 3 shows detailed data for the 13 stigma laden items. Over half (68%) of the respondents had scores above the mode indicating existing stigma toward mental illness. The three statements with the highest percent of respondents in agreement included "had I received treatment in a mental hospital, I would not feel that it ought to be "covered up or hidden" (49.4%), "there is something admirable in the attitude of a person who is willing to cope with his/ her conflicts and fears without resorting to professional help" (33.6%), and "Having a mental illness reflects poorly on a person and their family" (24.5%).

Mental Health Help-Seeking Behavior

Mental Health Help-Seeking scale scores averaged 32.42 (SD=4.602) and ranged between 0 and 40 (n=375). The most frequent score was 30 and 53.6% scored below the median of 32.The scale scores appear to indicate that participants, as a group, had negative attitudes toward mental health help-seeking behaviors. Individual item analysis shows that more than 83% of respondents stated they would feel uneasy going to a mental health provider because of what some people would think. Another 87% felt that the investment in counseling was not a promised healing aid fortheir emotional problem. Most respondents believed that considering the time and cost involved with seeking mental health help, it would have very little value (86.6%). Almost 92% stated they would rather live with certain mental conflicts than go through mental health treatment. The results also showed that 80% of the adults would rather be advised by a close friend than a specialist for an emotional problem. Only 30% believed they might consider counseling at some point in the future (see table 4).

Spirituality

The scale mean score was 40.38 (SD=4.998) with a range of 14 to 56 (n=375). Higher scores were indicative of higher levels of spirituality. The most frequently occurring score was 39 and 45.6% of participants scored below the median of 40. The Role of Spirituality responses revealed that 65% (n=253) of the participants usually or always have had spirituality play a role in difficult life situations. More than three-fourths of the respondents believed that through their faith in God, they would stay healthy. Just over 70% believed that relying on God is what keeps them healthy (see table 5). However, the majority of the participants acknowledged that though they trust God will take care of them, it is also their responsibility to take care of themselves. More than 97% also believed that God works through medical doctors' skills to help heal the sick. The majority of the respondents believe that it is both God's will and personal responsibility to take care of them, and that strength to care for oneself comes from God.

The Role of the Church

The majority of the participants thought the church should have a role in focusing attention on mental health awareness (93.6%, n=381). The majority of participants state their church provides some source of information on mental health (62.6%, n=238). And, if their church offered services such as counseling, psychology, or referrals, the majority of the sample (70.5%, n=272) would utilize those services.

Inferential Analyses

After analysis of the Kurtosis and Skewness statistics for demographic variables values outside the -2 to +2 were discovered for Kurtosis of the Age variable. According to George and Mallery (2003) it can thus be assumed that the sample is not normally distributed. Therefore Spearman's Rho was utilized instead of Pearson R correlational analysis.

Research question 1. What relationship exists between mental illness knowledge, stigma, spirituality, and reported help seeking behaviors? The Spearman's correlation was utilized to measure the strength of association that exists between mental illness knowledge, stigma, spirituality, and mental health help seeking behaviors scale scores. A Bonferoni correction was utilized to minimize type one error given that 4 variables were compared simultaneously (alpha = .0125).Three significant correlations were identified. First, knowledge was positively correlated with mental health help seeking behaviors (r=.227, alpha <.001) indicating that as knowledge scores increased, mental health help seeking behavior scores increased. Second, knowledge was negatively correlated with stigma (r=-.272, alpha <.001) indicating that as knowledge scores increased, stigma scores decreased. Third, stigma was negatively correlated with mental health help seeking behaviors (r=.440, alpha<.001) indicating that lower stigma is correlated with more positive mental health help seeking behaviors. There were no statistically significant correlationsbetween knowledge, help-seeking, or stigma and spirituality scale scores (see table 6).

Research question 2. Are there demographic differences between African Americans who think the Black church should play a role in addressing mental illness and those who do not? Chi Square tests were utilized to compare the observed frequencies between participants. There were no statistically significant differences between the age, sex, education, marital status, income, or employment of participants and whether they thought the church should be involved in addressing mental illness.

DISCUSSION

Respondents were highly educated (nearly two in ten had a bachelor's degree or higher) and from high-income households (median just over $50,000). This is in contrast to the national numbers from the U.S. Census Bureau that show less than two in ten had a bachelor's degree (2014) and the national median household income was just over $35,000 for black households (DeNavas-Walt & Proctor, 2015). Further, most were women, and worked full time.

All participants were African American and attended church at least monthly. Researchers have previously reported high levels of spirituality, church attendance and prayer among Black communities (Neighbors et al., 1998; Chatters & Taylor, 1989). More recently, the Pew Research Center (2018), reported that 47% of African-Americans confirm they attend religious services at least once per week. Results show that although many participants correctly identified signs and symptoms, nearly one in three could not recognize half of the signs and symptom of mental illness presented. Similarly, Jorn (2011) reported a need for more mental health literacy among minorities and African American communities. Further, Corrigan, Druss, and Perlik (2014) found that knowledge significantly moderated stigma toward mental illness. In the present study, over half of participants agreed with stigma laden statements, a majority showed reluctance toward mental help-seeking, and higher knowledge was positively correlated with increased help-seeking behaviors and negatively correlated with lower stigma. These findings warrant important consideration since it has been documented that minorities are "disproportionately deterred" from seeking mental health services by stigma (Clement, et al., 2015, p.11).

Similar to the findings of Clement, et al. (2015) and Corrigan, Druss, and Perlik (2014), the present study found a negative correlation between stigma and attitudes toward help seeking in that participants who had lower stigma were more likely to have positive attitudes toward mental health help-seeking behaviors. This further supports the need to decrease stigma in order to improve attitudes toward seeking mental health services among African Americans. The church is known to be an integral part of health education in African American communities (Chatters et al., 2011; Roberts, 2007; Saunders, et al., 2015; Young, Griffith, & Willimas, 2003) and can be an effective partner in providing mental health awareness and services (Kramer et al., 2007).

In contradiction with the original prediction that differences in demographic characteristics might exist between those supporting the role of the church in addressing mental health awareness and providing services, the present study did not find this to be true. Most participants thought their church should play a role in addressing mental health. This is not surprising given the long history and established role of the church as a social service provider for the African American community (Hays, 2015). As Brown and McCreary (2014) noted, addressing disparities in mental health care seeking is vital and the use of mental and social resources within the church venue may assist. As presented by Beck et al. (2007), partnerships of bringing awareness to myths, perceptions, knowledge, and negative attitudes or behaviors are important, but may play a specifically critical role to addressing mental health awareness.

Limitations

There are inherent limitations to be considered when interpreting the results of this study. The study utilized self-report data, and as such results could be influenced by a social desirability bias. Further, it is possible that participants misunderstood the questions, had recall bias or other limitations inherent with survey research. Additionally, this study utilized a small convenience sample from only two regions and is not representative of all African Americans who regularly attend church. The majority of the population surveyed reported to have obtained graduate or professional degrees, there could be differences in populations with lower socio-economic status (SES) and lower educational attainment. It is also plausible that spirituality, religiosity, or denomination could have impacted responses. Lastly, given that the sample was composed of a large proportion of women, it is important to consider these findings within that context.

CONCLUSIONS

Faith-based empowerment that lies in the foundational spirituality of Black culture is a vital part of their communities. The results of this study add to our understanding of the relationship between knowledge, stigma and help-seeking behaviors through the church and of the important role the church can play in increasing mental health awareness. Clergy, mental health specialists, and faith-based organizations could partner and focus on community-based health education interventions. Additionally, it is vital to continue investigating the continuing need for mental illness awareness and help-seeking in the Black church and to emphasize the health-promoting resources.

Recommendations

Future research should be conducted with a more representative sample and further investigate the relationship between stigma, knowledge and mental help-seeking behaviors. Specifically, we recommend research to assess the feasibility and efficacy of health education awareness campaigns and mental health service provision in the African American church in developing increased awareness that leads to earlier detection, accurate diagnosis and effective treatment. Any such effort should be culturally appropriate and relevant and include the church community in its development, implementation and evaluation.

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Shameka Y. Neely-Fairbanks, PhD

Liliana Rojas-Guyler, PhD, CHES

Laura Nabors, PhD, ABPP

Otomatayo Banjo, PhD

Corresponding author: Liliana Rojas-Guyler, PhD, ESGF, CHES, University of Cincinnati Health Promotion & Education School of Human Services, CECH, PO Box 21068 (ML0068) TDC 460B Email: guylerlr@ucmail.uc.edu.
Table 1. Demographics

Variable                                         N      %

Age 18-29                                       52    13.0
30-49                                           214   53.5
50-69                                           125   31.3
70+                                              9     2.3
                                        Total   409   100.0
Gender
Male                                            42    10.4
Female                                          363   89.6
                                        Total   405   100.0
Marital Status
Married                                         146   36.2
Widowed                                         10     2.5
Divorced                                        84    20.8
Separated                                        9     2.2
Never married                                   154   38.2
                                        Total   403   100.0
Education
Some High school                                 3     0.7
High school or GED                              22     5.4
Some college/Technical school                   89    22.0
Bachelor's                                      128   31.6
Graduate/Professional degree                    163   40.2
                                        Total   405   100.0
Employment
Working full-time                               286   70.8
Working part-time                               31     7.7
Not currently working                           28     6.9
Homemaker                                        4     1.0
Fulltime student                                13     3.2
Not in work force (retired, disabled,           42    10.4
or other)
                                        Total   404   100.0

Note-Missing data excluded.

Table 2: Knowledge Statements

Rate your level of agreement                   Strongly      Disagree
or disagreement with the                       Disagree
following statements.                         n      %      n      %

Mental illness cannot be treated             123    30.3   168    41.4
completely.

Mental illness is not infectious or           27    6.6     37    9.0
contagious.

Mental illness is not the same as             27    6.6    100    24.4
"craziness."

Mental illness affects one's whole life.      20    4.9     20    4.9

Rate your level of agreement                   Agree       Strongly
or disagreement with the                                     Agree
following statements.                         n      %      n      %

Mental illness cannot be treated              88    21.7    27    6.7
completely.

Mental illness is not infectious or          117    28.6   228    55.7
contagious.

Mental illness is not the same as            144    35.2   138    33.7
"craziness."

Mental illness affects one's whole life.     118    28.9   251    61.4

Note: Missing data excluded

Table 3: Stigma Scale

Stigma laden items                      Strongly      Disagree
                                        Disagree
                                         n      %      n      %

Having a mental illness reflects        174    43.0   132    32.6
poorly on a person and their
family.

People with a mental illness            203    50.2   160    39.6
should only tell family members
about their depression.

People with a mental illness            286    71.1   106    26.4
should keep it to themselves.

I tend to think less of someone         239    59.5   141    35.1
with mental illness.

Mental illness reflects badly on        198    49.3   149    37.1
one's character.

I would feel ashamed if a close         258    63.7   111    27.4
family member suffered from a
mental illness.

Strong people do not suffer from        302    74.9    85    21.1
mental illness.

Having been a mental health              96    24.6    95    24.4
patient carries with it a burden of
shame.

Mental patients are a burden to         196    49.0   161    40.3
the society.

The idea of talking to a mental         253    63.1   118    29.4
health provider is a poor way to
get rid of emotional conflicts.

A person should work out his/           283    70.6    95    23.7
her own problems; getting mental
health counseling would be a last
resort.

Had I received treatment in a            60    15.5   135    35.0
mental hospital, I would not feel
that it ought to be "covered up or
hidden."

There is something admirable in         103    25.8   162    40.6
the attitude of a person who is
willing to cope with his/her
conflicts and fears without resorting
to professional help.

Although there are clinics for          138    34.4   201    50.1
people with mental troubles, I
would not have much faith in
them.

Stigma laden items                      Agree          Strongly
                                                        Agree
                                         n      %      n      %

Having a mental illness reflects         72    17.8    27    6.7
poorly on a person and their
family.

People with a mental illness             21    5.2     20    5.0
should only tell family members
about their depression.

People with a mental illness             5     1.2     5     1.2
should keep it to themselves.

I tend to think less of someone          13    3.2     9     2.2
with mental illness.

Mental illness reflects badly on         48    11.9    7     1.7
one's character.

I would feel ashamed if a close          29    7.2     7     1.7
family member suffered from a
mental illness.

Strong people do not suffer from         6     1.5     10    2.5
mental illness.

Having been a mental health             154    39.5    45    11.5
patient carries with it a burden of
shame.

Mental patients are a burden to          30    7.5     13    3.3
the society.

The idea of talking to a mental          11    2.7     19    4.7
health provider is a poor way to
get rid of emotional conflicts.

A person should work out his/            15    3.7     8     2.0
her own problems; getting mental
health counseling would be a last
resort.

Had I received treatment in a           126    32.6    65    16.8
mental hospital, I would not feel
that it ought to be "covered up or
hidden."

There is something admirable in          81    20.3    53    13.3
the attitude of a person who is
willing to cope with his/her
conflicts and fears without resorting
to professional help.

Although there are clinics for           47    11.7    15    3.7
people with mental troubles, I
would not have much faith in
them.

Note: Missing data excluded

Table 4: Mental Health Help-Seeking Scale Items

Rate the following statements about          Strongly      Disagree
seeking help. (Circle your response)         Disagree
                                              n      %      n      %

If a good friend asked my advice about a      7     1.7     15    3.7
mental problem, I might recommend that
he/she see a mental health specialist.

I would feel uneasy going to a mental         18    4.5     50    12.4
health provider because of what some
people would think.

Considering the time and expense involved     12    3.0     42    10.5
in seeking mental health help, it would
have doubtful value for a person like me.

I would willingly confide intimate matters    15    3.8     17    4.3
to an appropriate professional if I
thought it might help me or a member of my
family.

I would rather live with certain mental       11    2.8     22    5.5
conflicts than go through the ordeal of
getting mental health treatment.

If I believed I was having a mental           24    6.0     66    16.5
breakdown, my first inclination would be
to get professional attention.

I would rather be advised by a close          14    3.5     66    16.5
friend than a mental health provider, even
for an emotional problem.

If I were experiencing a serious emotional    17    4.3     44    11.0
crisis at this point in my life, I would
be confident that I could find relief in
mental health therapy.

At some future time I might want to have      33    8.4     87    22.2
mental health counseling.

If I thought I needed mental health help,     10    2.5     36    9.0
I would get it no matter who knew about
it.

Rate the following statements about          Agree         Strongly
seeking help. (Circle your response)                       Agree
                                              n      %      n      %

If a good friend asked my advice about a     176    43.9   203    50.6
mental problem, I might recommend that
he/she see a mental health specialist.

I would feel uneasy going to a mental        156    38.7   179    44.4
health provider because of what some
people would think.

Considering the time and expense involved    175    43.8   171    42.8
in seeking mental health help, it would
have doubtful value for a person like me.

I would willingly confide intimate matters   153    38.4   213    53.5
to an appropriate professional if I
thought it might help me or a member of my
family.

I would rather live with certain mental      143    35.8   223    55.9
conflicts than go through the ordeal of
getting mental health treatment.

If I believed I was having a mental          145    36.2   166    41.4
breakdown, my first inclination would be
to get professional attention.

I would rather be advised by a close         170    42.5   150    37.5
friend than a mental health provider, even
for an emotional problem.

If I were experiencing a serious emotional   178    44.6   160    40.1
crisis at this point in my life, I would
be confident that I could find relief in
mental health therapy.

At some future time I might want to have     175    44.6    97    24.7
mental health counseling.

If I thought I needed mental health help,    164    41.1   189    47.4
I would get it no matter who knew about
it.

Note: Missing data excluded

Table 5: Spirituality Scale Items

Rate each statement below by                 Strongly      Disagree
selecting your level of agreement            Disagree
or disagreement.                              n      %      n      %

Through my faith in God, I can                9     2.2     68    16.8
stay healthy.

If I lead a good spiritual life, I will       24    6.0    155    38.7
stay healthy.

If I stay healthy, it is because I am         56    13.9   161    39.9
right with God and I take care of
myself.

I rely on God to keep me in good              18    4.5    102    25.2
health.


Even though I trust God will take             2     0.5     5     1.2
care of me, I still need to take
care of myself.

God works through doctors to                  2     0.5     8     2.0
heal us.

Living the way the Lord says I am             8     2.0     28    6.9
supposed to live means I have to
take care of myself.

Prayer is the most important                  5     1.2     54    13.4
thing I do to stay healthy, as well
as exercise.

If I stay well, it is because of the          10    2.5     57    14.2
grace of the good Lord and eating
a balanced diet.

It is ok not to seek medical attention       254    62.9   117    29.0
because I feel that God will
heal me.

There is no point in taking care             303    75.0    87    21.5
of myself when it is all up to God
anyway.

God and I share responsibility for            21    5.2     42    10.4
my health.

God gives me the strength to take             4     1.0     15    3.7
care of myself.

It is difficult to talk about my             101    25.0   158    39.1
personal health with clergyman
or people of the church.

Rate each statement below by                 Agree         Strongly
selecting your level of agreement                          Agree
or disagreement.                              n      %      n      %

Through my faith in God, I can               184    45.4   144    35.6
stay healthy.

If I lead a good spiritual life, I will      145    36.2    77    19.2
stay healthy.

If I stay healthy, it is because I am        113    28.0    74    18.3
right with God and I take care of
myself.

I rely on God to keep me in good             179    44.3   105    26.0
health.

Even though I trust God will take             92    22.7   307    75.6
care of me, I still need to take
care of myself.

God works through doctors to                 143    35.1   254    62.4
heal us.

Living the way the Lord says I am            127    31.4   242    59.8
supposed to live means I have to
take care of myself.

Prayer is the most important                 163    40.5   180    44.8
thing I do to stay healthy, as well
as exercise.

If I stay well, it is because of the         177    44.1   157    39.2
grace of the good Lord and eating
a balanced diet.

It is ok not to seek medical attention        18    4.5     15    3.7
because I feel that God will
heal me.

There is no point in taking care              10    2.5     4     1.0
of myself when it is all up to God
anyway.

God and I share responsibility for           148    36.8   191    47.5
my health.

God gives me the strength to take            163    40.4   221    54.8
care of myself.

It is difficult to talk about my              85    21.0    60    14.9
personal health with clergyman
or people of the church.

Note: Missing data excluded

Table 6: Spearman Results for Correlations

Scale Scores          Knowledge    Help     Spirituality    Stigma
                                  Seeking

Knowledge       r       1.000     .227 **       .004       -.272 **
               Sig.       .        .000         .939         .000
                n        394        361         363          341
Help Seeking    r        --        1.000        .037       -.440 **
               Sig.      --          .          .490         .000
                n        --         375         352          332
Spirituality    r        --         --         1.000        -.056
               Sig.      --         --                       .309
                n        --         --          375          335
Stigma          r        --         --           --         1.000
               Sig.      --         --           --           .
                n        --         --           --          352

Note: Missing data excluded
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Author:Neely-Fairbanks, Shameka Y.; Rojas-Guyler, Liliana; Nabors, Laura; Banjo, Otomatayo
Publication:American Journal of Health Studies
Date:Sep 22, 2018
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