Introduction
The civil war broke out in Syria in 2011. This war has led to mass trauma, human rights violations, the removal of millions of people from their places of residence, and humanitarian disasters in many areas such as social and health. The Presidency of Migration Management gives the number of Syrian refugees in Turkey as 3.579.008 as of 2020, and children and young people constitute more than half of this population (Müdürlüğü, Reference Müdürlüğü2020). While Turkey hosts the largest number of Syrian refugees, it is important to acknowledge that a significant Syrian refugee population also resides in other countries such as Lebanon, Jordan, and Germany, highlighting the global nature of this crisis (Assi, Özger-İlhan, & İlhan, Reference Assi, Özger-İlhan and İlhan2019). The traumatic events and violence they were exposed to in their home country before forced migration have been identified as key factors in the emergence of mental health problems in refugee children and adolescents (Barghadouch et al., Reference Barghadouch, Kristiansen, Jervelund, Hjern, Montgomery and Norredam2016). In addition to the stressors caused by the civil war in Syria, refugee adolescents are exposed to many traumatic events such as starvation, harassment, rape, and loss of family members during migration. When they come to the host country after overcoming many difficulties they face, unfortunately, various difficulties await them that they have not encountered before. Issues such as livelihood, housing and nutrition, language barriers, social isolation, and peer bullying are the most common challenges that can contribute to the maintenance of psychological stress in the host country (Hodes & Vostanis, Reference Hodes and Vostanis2019). Exposure to potentially traumatic events, post-migration challenges, and other psychological stressors suggests that refugee adolescents are at an increased risk for common mental disorders such as post-traumatic stress disorder (PTSD), anxiety, and depression (Kien et al., Reference Kien, Sommer, Faustmann, Gibson, Schneider, Krczal and Kerschner2019). In a population-based study conducted by Scherer et al. (Reference Scherer, Hameed, Acarturk, Deniz, Sheikhani, Volkan and Patterson2020), 23.7% of refugee adolescents reported symptoms of depression, anxiety, and PTSD. Studies conducted with refugee adolescents in Turkey show that mental health problems such as depression and anxiety disorder are quite common, and this situation is similar to the results of studies conducted in the Western countries (Eruyar, Maltby, & Vostanis, Reference Eruyar, Maltby and Vostanis2018; Kien et al., Reference Kien, Sommer, Faustmann, Gibson, Schneider, Krczal and Kerschner2019). Although mental health problems are common among refugee adolescents in studies conducted in Turkey and Western countries, it has been reported that the rate of seeking help for mental health is quite low (Axelsson, Bäärnhielm, Dalman, & Hollander, Reference Axelsson, Bäärnhielm, Dalman and Hollander2020; Fındık et al., Reference Fındık, Ceri, Ünver, Fiş, Arman, Beşer and Anagnostopoulos2021; Satinsky, Fuhr, Woodward, Sondorp, & Roberts, Reference Satinsky, Fuhr, Woodward, Sondorp and Roberts2019). Due to inadequate utilization of mental health services, this highly susceptible population's mental health requirements persist unmet. Furthermore, untreated mental health problems can contribute to a cycle of distress and hinder successful integration into the host society (Hodes & Vostanis, Reference Hodes and Vostanis2019). Failure to address mental health problems can lead to worsening symptoms, impaired functioning, and long-term negative outcomes such as academic difficulties, social isolation, and compromised overall well-being (Hanewald et al., Reference Hanewald, Knipper, Fleck, Pons-Kühnemann, Hahn, Ta and Stingl2020). So, in a country like Turkey where nearly two million refugee adolescents live, identifying the barriers to their psychological help-seeking behaviour is essential for the development of interventions and programs to support refugee adolescents with mental health problems.
One of the primary barriers to refugees' access to health services is language. In Turkey, translators are mostly used in mental health services offered to immigrants due to language problems. Since mental health interpreting is a special field that requires attention, the ‘Mental Health Translator Training Module’ has been prepared in order to increase the awareness and capacity of translators working in both migrant health centres and hospitals. However, the number of available translators seems to be insufficient to serve all those in need (Ekmekci, Reference Ekmekci2017). In response to other challenges such as inadequate amount of mental health providers, unfamiliarity with the health system, and a lack of trust in host services, several recent healthcare system innovations have been implemented in Turkey. These include the implementation of various initiatives such as ‘Improving the Health Status of the Syrian Population under Temporary Protection and Related Services Provided by Turkish Authorities’ (SIHHAT) and ‘The Facility for Refugees in Turkey’ (Pries & Zülfikar Savci, Reference Pries and Zülfikar Savci2023). In 29 provinces with a high concentration of refugees, a network of Migrant Health Centres and Extended Migrant Health Centres was established to provide refugee-centred health care. In order to meet the unique requirements of refugees in these centres, psychologists, social workers, and interpreters are working along with regular medical staff (Ekmekci, Reference Ekmekci2017). In addition to these, psychosocial and mental health services are provided by various non-governmental organizations (NGOs) in cities such as Istanbul, Ankara, and Gaziantep, where Syrian refugees are concentrated (Kantas Yilmaz & Ergül, Reference Kantas Yilmaz and Ergül2021). Besides that, there has been a notable increase in the focus on mental health and psycho-social support services, as evidenced by the expansion of mental health service facilities and the ongoing recruitment of additional psychologists and social workers (Oner, Kahilogullari, Acarlar, Malaj, & Alatas, Reference Oner, Kahilogullari, Acarlar, Malaj and Alatas2020). Although there are a number of centres that provide mental health services for refugees, specialized mental health facilities that offer psychiatric treatment to refugee adolescents in institutional settings are scarce (Çeri et al., Reference Çeri, Ak, Fındık, Arman, Fiş, Beser and Fazel2021). On the other hand, contrary to previous studies (De Anstiss & Ziaian, Reference De Anstiss and Ziaian2010; Satinsky et al., Reference Satinsky, Fuhr, Woodward, Sondorp and Roberts2019), a recent study carried out by a specialized mental health service in Turkey demonstrated that the shortened resettlement duration and language barrier had no effect on the utilization of health services among the refugee group (Fındık et al., Reference Fındık, Ceri, Ünver, Fiş, Arman, Beşer and Anagnostopoulos2021). These results indicate that the relationship between the mental health problems of refugee adolescents in Turkey and their help-seeking behaviours for their mental health needs to be evaluated in more detail.
Help-seeking behaviour is defined as any action or activity performed by the adolescent who perceives that he/she needs personal, psychological, or emotional help or health or social services to meet any need positively (Barker, Reference Barker2007). As a method of seeking help and further treatment, contacting professionals or non-professionals such as family and friends about the psychosocial difficulties experienced is called seeking help for mental health (Rickwood & Thomas, Reference Rickwood and Thomas2012). Although there are few studies linking the severity of symptoms of mental illness with help-seeking in adolescents, higher symptomatology was associated with lower help-seeking intentions and behaviours in these studies. It was emphasized that adolescents with higher symptom severity may be more vulnerable due to fear of stigma in the process of seeking help (Aguirre Velasco, Cruz, Billings, Jimenez, & Rowe, Reference Aguirre Velasco, Cruz, Billings, Jimenez and Rowe2020). Refugee adolescents who suffer from mental health problems may face heightened vulnerability due to the potential convergence of stigmatization. This can arise from their dual identities as individuals with mental illness and as members of a potentially marginalized group within the host country (Majumder, Reference Majumder2019). The embarrassment that people feel about their mental problems can lead to self-stigmatization, which can prevent help-seeking behaviours (Byrow, Pajak, Specker, & Nickerson, Reference Byrow, Pajak, Specker and Nickerson2020). Indeed, self-stigma for mental health has been identified as a significant barrier to help-seeking behaviours in studies with refugee populations (Hodes & Vostanis, Reference Hodes and Vostanis2019; Karamehic-Muratovic, Sichling, & Doherty, Reference Karamehic-Muratovic, Sichling and Doherty2022; Majumder, O'Reilly, Karim, & Vostanis, Reference Majumder, O'Reilly, Karim and Vostanis2015).
Considering self-stigma as a barrier to help-seeking behaviours, it is important to establish links between self-stigma and other forms of stigma in refugee adolescents. Public stigma refers to the societal imposition of stereotypes, prejudice, and discriminatory attitudes towards a particular stigmatized group. Mental illnesses are seen as a stigmatizing or taboo subject in many societies or groups. Self-stigma occurs when a person with a mental illness applies negative public attitudes to themselves. In other words, self-stigma is explained as a person's internalization of public stigma (Vogel, Bitman, Hammer, & Wade, Reference Vogel, Bitman, Hammer and Wade2013). Self-stigma for mental health refers to the negative beliefs an individual has about his or her psychological symptoms or seeking help (Harvey & White, Reference Harvey and White2023). People's perceptions of their mental problems may prevent them from receiving mental health services. Adolescents with mental health problems are often stigmatized by their peers and/or relatives, are more likely to avoid seeking psychological support than their peers without mental health problems, and are less likely to be successful in the future academic life (Aguirre Velasco et al., Reference Aguirre Velasco, Cruz, Billings, Jimenez and Rowe2020). Moreover, adolescents who experience self-stigmatization related to their mental health may exhibit reluctance to seek assistance for their mental health problems due to apprehensions surrounding the potential labelling of being ‘mad’ or ‘nuts’ (Ferrie, Miller, & Hunter, Reference Ferrie, Miller and Hunter2020). Namely, internalizing negative language about mental health may prevent individuals from obtaining access to the required support and facilities. These assertions are also supported by the study that reported that self-stigma is one of the strongest predictors of lower psychological help-seeking behaviours among youth with mental problems (Lannin, Vogel, Brenner, Abraham, & Heath, Reference Lannin, Vogel, Brenner, Abraham and Heath2016). Moreover, studies conducted with refugee adolescents as well as non-refugee adolescents with various psychiatric disorders have shown that there is a negative relationship between the level of self-stigma for mental health and the adolescents’ seeking help for their mental health (Bär et al., Reference Bär, Pabst, Röhr, Luppa, Renner, Nagl and König2021; Dardas et al., Reference Dardas, Silva, van de Water, Vance, Smoski, Noonan and Simmons2019; Jarlby, Goosen, Derluyn, Vitus, & Jervelund, Reference Jarlby, Goosen, Derluyn, Vitus and Jervelund2018). These findings consider that the mental health self-stigma levels of Syrian refugee adolescents living in Turkey may significantly affect their search for help seeking for mental health.
One of the biggest challenges in the field of adolescent mental health is ensuring that at-risk individuals are connected with suited support. Considering the aforementioned literature showing the negative impacts of mental health problems on refugee adolescents’ self-stigma and help-seeking behaviours, it is vital to examine the role of self-stigma in the association between common mental health problems and help-seeking behaviours. Although common mental health problems have been widely studied with self-stigma, few studies have focused on the mediating effect of self-stigma between mental health problems and help-seeking behaviours of refugee adolescents. Therefore, the purpose of the present study was to examine whether self-stigma mitigates the adverse effects of stress, anxiety, and depression symptoms on the help-seeking behaviours of Syrian adolescents living in Turkey. In this regard, we first hypothesised that stress, anxiety, and depression will have positive impacts on self-stigma and negative impacts on help-seeking behaviours. Second, we assumed that self-stigma will have a negative impact on help-seeking behaviours. Finally, we expected that self-stigma will increase the negative impacts of stress, anxiety, and depression symptoms on help-seeking behaviours. The proposed model is presented in Fig. 1.
The proposed structural model.
Method
Participants
This study was conducted in Ankara, one of the 10 provinces in Turkey with the highest number of Syrian refugees, using a descriptive and cross-sectional design. The study sample comprised 557 Syrian refugee adolescents between the ages of 12 and 18 who were attending secondary or high school in Ankara. Among them, 22 adolescents (3.9%) refused to participate in the study, and 47 adolescents (8.4%) were excluded due to missing data. Finally, the participants of this study included 488 Syrian refugee adolescents (63.73% boys and 36.27% girls) living in Turkey. They had a mean age of 15.73 years (s.d. = 1.62). The majority of participants were in the first year of high school (grade 9; 28.07%), had four siblings (26.64%), and reported that their parents were living together (82.58%). A detailed description of the participants is given in Table 1. The sociodemographic characteristics of the adolescents who refused to participate in the study and were excluded due to missing data were similar to those included in the study.
Demographic characteristics of adolescents
Measures
Depression Anxiety and Stress Scale-21
The scale consists of 21 items, three subscales (depression, anxiety, and stress), and a four-point Likert-type scoring system (0: Never to 3: Always). The total score of each subscale is calculated by summing the scores of the items obtained from the subscales. High scores obtained from the subscales mean that the individual's feelings towards the relevant subscale are intense. In the study conducted by Sariçam (Reference Sariçam2018), the Turkish validity and reliability of the scale were shown to be sufficient. In the study, in which the Arabic version of Depression Anxiety and Stress Scale-21 (DASS 21) was shown to be a reliable scale, Cronbach's alpha coefficients were found to be 0.76 for depression, 0.75 for anxiety, and 0.77 for stress (Musa, Pevalin, & Al Khalaileh, Reference Musa, Pevalin and Al Khalaileh2018). In this study, we have utilized the DASS-21 to assess the levels of depression, anxiety, and stress among Syrian refugee adolescents.
General Help-Seeking Questionnaire
The General Help-Seeking Questionnaire (GHSQ) is a flexible tool used to assess intentions to help seeking from different sources (both formal and informal) and from different problems (personal or emotional problems and suicidal feelings). The scale is a seven-point Likert-type scale with 10 items, each item ranging from ‘1 – extremely unlikely’ to ‘7 – extremely likely’. Future help-seeking intentions are measured by listing a range of potential sources of help (e.g. doctor, teacher, chaplain, friend) and asking participants to indicate how likely participants are to seek help from that source for a particular problem, on a seven-point scale from no help-seeking effort to too much. Higher scores on the scale indicate better attitudes for general help-seeking (Wilson, Deane, & Ciarrochi, Reference Wilson, Deane and Ciarrochi2005). The scale was not originally available in Arabic, so it was translated into Arabic for this study using a translation-back translation procedure as described in previous studies (Epstein, Santo, & Guillemin, Reference Epstein, Santo and Guillemin2015; Verbillis-Kolp, Yotebieng, Farmer, Freidman, & Hollifield, Reference Verbillis-Kolp, Yotebieng, Farmer, Freidman and Hollifield2023). In this study, we have used the GHSQ to identify the sources of help from which Syrian refugee adolescents seek help for their mental health problems and to determine their intention to seek help.
Self-Stigma of Seeking Psychology Help Scale
Self-Stigma of Seeking Psychology Help Scale (SSOSH) consists of 10 items that measure individuals' self-stigmatization for seeking psychological help. It is answered in a five-point Likert style ranging from 1 – strongly disagree to 5 – strongly agree. The total score that can be obtained from the scale varies between 10 and 50. High scores obtained from the scale indicate the high level of self-stigmatization in seeking help. The sample item for the scale is ‘I would feel worse about myself if I could not solve my own problems (item 10)’. The Turkish translation, validity, and reliability study of the scale were first performed by Topkaya (Reference Topkaya2011). The scale was not originally available in Arabic, so it was translated into Arabic for this study using a back translation procedure as described in previous studies (Epstein et al., Reference Epstein, Santo and Guillemin2015; Verbillis-Kolp et al., Reference Verbillis-Kolp, Yotebieng, Farmer, Freidman and Hollifield2023). In this study, we have used the SSOSH to identify the level of self-stigma of Syrian refugee adolescents for seeking psychological help.
Procedure
In order to eliminate bias in determining the sample and to obtain a representative sample, participants were recruited using a random sampling method in which all potential participants would have an equal chance to participate in the study (Gravetter & Forzano, Reference Gravetter and Forzano2011). Within the scope of the education policies of the Ministry of National Education, refugee adolescents and local adolescents are educated in mixed classes (i.e. together). In the city of Ankara, where the study was conducted, the Directorate of National Education granted permission to conduct the study in 15 secondary or high schools. In the context of secondary schools, class sizes typically consist of approximately 25 students, while high schools generally accommodate around 30 students per class. To ensure representation from areas with a high concentration of Syrian refugee adolescents, five secondary schools and 10 high schools were randomly selected from those registered with the Ankara Directorate of National Education in the Altındağ, Mamak, and Keçiören districts. In these districts, Syrian refugee adolescents comprised roughly one-third of the students in each class. Then in each determined school, five classes were randomly selected according to the assigned number for each class (e.g. 9AB, 10BB, 11CS) encompassing all grade levels.
Detailed information on the purpose of the study, how the planned scales were applied, and the use of the data to be obtained for scientific purposes was given to the participants by the researchers in both Turkish and Arabic in the presence of an interpreter. The Arabic or Turkish versions of these self-report scales, determined in accordance with the purpose of the study, were administered in approximately 1 class hour (45 min), accompanied by an interpreter, according to the wishes of the adolescents.
Ethical approval
This study received ethical approval (number: 2019/105) from the Clinical Research Ethics Committee at the Yenimahalle Training and Research Hospital and obtained the necessary permissions from the Ankara National Education Directorate. Informed consents in both Turkish and Arabic, in which the purpose and method of the study were explained, were sent to all parents the day before the scales were administered, through the administrations of the schools. Participants were determined among Syrian refugee adolescents, whose parents or legal representatives gave written informed consent in Turkish or Arabic. Before the questionnaires were administered, the participants were informed that their participation would be entirely voluntary, and their answers would remain confidential and anonymous. In addition, the researchers were informed that if they felt unwell in any part of the study after participating in the study or if they wanted to withdraw from the study for any reason, they could withdraw from the study voluntarily without giving any reason. Written informed consents were obtained from the adolescents who verbally agreed to participate in the study.
Data analysis
Before testing the structural mediation models, frequency statistics, descriptive statistics, normality assumption, and correlation analysis were carried out to provide information about the general characteristics of participants and variables of this study. The normality assumption was explored by utilising the values of skewness and kurtosis (Kline, Reference Kline2016). Pearson product-moment correlation analysis was next computed to explore the correlation between self-stigma, help-seeking behaviour, and mental health problems. Afterwards, the mediation analysis was performed to examine the mediating effect of self-stigma on the link between mental health problems and help-seeking behaviours of young individuals by employing the PROCESS macro version 3.4 for SPSS (Hayes, Reference Hayes2017; Preacher & Hayes, Reference Preacher and Hayes2008). In this study, the indirect effects between the study variables were interpreted by utilising the bootstrap approach with 5000 resamples to calculate the 95% confidence. All data analyses were performed using SPSS version 26.
Results
Descriptive and correlation analyses
Descriptive statistics alongside the skewness and kurtosis values for the main variables of this study are given in Table 2. Skewness values ranged from −0.40 to 0.50, and kurtosis scores ranged from −0.49 to 2.04. These findings show that all variables had a relatively normal distribution by falling within the range of |2|. Correlation analysis revealed that self-stigma was negatively correlated with help-seeking behaviours and positively correlated with stress, anxiety, and depression. Help-seeking behaviour was negatively correlated with stress and anxiety (Table 3).
Unstandardized coefficients for the mediation model
Note. The number of bootstrap samples for percentile bootstrap confidence intervals: 5000.
s.e., standard error; Coeff, unstandardized coefficient; X, independent variable; M, mediator variable; Y, outcomes variable.
Descriptive statistics, reliability, and correlation coefficients among the analysed variables
*p < 0.01; **p < 0.05.
Mediation analysis
Following the correlation analysis, mediation analysis was carried out to test the proposed structural model. The results of mediation analyses are presented in Tables 2 and 4 and Fig. 1. The findings revealed that stress (β = 0.19, p < 0.01), anxiety (β = 0.12, p < 0.05), and depression (β = 0.17, p < 0.01) had significant and positive predictive effects on self-stigma, but not on help-seeking behaviours. Stress, anxiety, and depression accounted for 4%, 2%, and 3% of the variance in self-stigma, respectively. Also, self-stigma (β = −0.12, p < 0.01) had a significant negative predictive effect on help-seeking behaviours. The variances in help-seeking behaviors were accounted for by stress-self-stigma, anxiety-self-stigma, and depression-self-stigma at proportions of 2%, 3%, and 2%, respectively. aWith regard to the indirect effects, the findings showed that self-stigma fully mediated the associations between stress – help-seeking [effect = −0.05, 95% confidence interval (CI) −0.11 to −0.01], anxiety – help-seeking (effect = −0.04, 95% CI −0.09 to −0.01), and depression – help-seeking (effect = −0.05, 95% CI −0.12 to −0.01).
Regression coefficients for direct and indirect links among stress, anxiety, self-stigma, and help-seeking behaviour
LLCI, lower limit confidence interval; ULCI, upper limit confidence interval.
Discussion
Although there are studies examining the mental health problems of Syrian refugee adolescents, mental health problems, help-seeking behaviours, and self-stigma levels were evaluated together in this study for the first time as far as we know. When the results were examined, it was determined that depression, anxiety, and stress levels of Syrian refugee adolescents were positive predictors of self-stigma. It has been shown that there is a significant negative relationship between the level of self-stigma of Syrian refugee adolescents and their help-seeking behaviours. In addition, although a negative correlation was found between the help-seeking behaviours of Syrian refugee adolescents and their anxiety and stress levels, no direct relationship was found among their depression, anxiety, and stress levels and their help-seeking behaviours. Consistent with the hypothesized model, this study showed that self-stigma fully mediates the relationship among anxiety, depression, and stress symptoms and help-seeking behaviours in Syrian refugee adolescents. Regarding the mediation analyses, our results show that depression, anxiety, and stress levels determine the level of self-stigma and in this way affect the help-seeking behaviours of Syrian refugees.
In this study, it was determined that depression, anxiety, and stress levels were predictors of self-stigma levels in Syrian refugee adolescents. In parallel with our results, studies conducted with non-refugee adolescents have shown that the severity of mental health problems is a predictor of self-stigma (Chen et al., Reference Chen, Fang, Liu, Hu, Lan and Deng2014; Martínez et al., Reference Martínez, Crockett, Jiménez-Molina, Espinosa-Duque, Barrientos and Ordóñez-Carrasco2020). The relationship between mental problems and self-stigmatization in refugees has generally been evaluated in studies conducted with adults. Studies conducted on Syrian refugee adults in Germany have shown that there is a strong relationship between depression symptoms and self-stigma (Bär et al., Reference Bär, Pabst, Röhr, Luppa, Renner, Nagl and König2021). The results of the qualitative studies conducted with refugee adolescents show that, similar to our results, self-stigma is quite high in refugee adolescents with mental health problems (De Anstiss & Ziaian, Reference De Anstiss and Ziaian2010). However, causality in this context is still unclear, with evidence for both higher symptom burden as a result of higher self-stigma and vice versa (Livingston & Boyd, Reference Livingston and Boyd2010). Therefore, longitudinal studies are needed to explain the causality of the relationship between mental problems and self-stigma in refugee adolescents.
In this study, it was shown that there is a statistically significant negative relationship between the levels of self-stigma and help-seeking behaviours in Syrian refugee adolescents. Beyond the higher prevalence of mental health problems among refugees, the self-stigma remains a major reason why refugees do not seek mental health care (Hodes & Vostanis, Reference Hodes and Vostanis2019; Majumder et al., Reference Majumder, O'Reilly, Karim and Vostanis2015; Satinsky et al., Reference Satinsky, Fuhr, Woodward, Sondorp and Roberts2019). Heidi, Miller, Baldwin, and Abdi (Reference Heidi, Miller, Baldwin and Abdi2011) found that many parents from different refugee community fear that if a child is known to be receiving mental health support, stigma would do more harm to the child than not to receive any care at all. Studies conducted with refugee adolescents have shown that adolescents perceive their psychological help-seeking behaviours as a weakness, and suppose that if they receive a psychiatric diagnosis after receiving professional help, they would be excluded from society (Hassan, Ventevogel, Jefee-Bahloul, Barkil-Oteo, & Kirmayer, Reference Hassan, Ventevogel, Jefee-Bahloul, Barkil-Oteo and Kirmayer2016; Majumder, Reference Majumder2019). Similar to our results, a recent study found that self-stigma and shame prevent Syrian refugee adolescents in both Turkey and the United Kingdom from seeking mental health help (Eruyar, Hunt, O'Reilly, Alowaybil, & Vostanis, Reference Eruyar, Hunt, O'Reilly, Alowaybil and Vostanis2022). Our results support the results of studies showing that there is a negative association between the level of self-stigma and help-seeking behaviours in refugee adolescents with mental health problems (De Anstiss & Ziaian, Reference De Anstiss and Ziaian2010; Eruyar et al., Reference Eruyar, Hunt, O'Reilly, Alowaybil and Vostanis2022; Majumder, Reference Majumder2019; Nickerson et al., Reference Nickerson, Byrow, Pajak, McMahon, Bryant, Christensen and Liddell2020).
In this study, no direct relationship was found among help-seeking behaviours, depression, and anxiety and stress levels in refugee adolescent. However, in the mediation analysis, it was found that self-stigma had an indirect effect on the relationship among help-seeking behaviours, depression, and anxiety and stress levels. In other words, it shows that depression, anxiety, and stress levels of Syrian refugee adolescents do not affect their help-seeking behaviours independent of the effect of self-stigma on help-seeking behaviours. Our findings suggest that the increase in depression, anxiety, and stress levels in Syrian refugee adolescents increases the level of self-stigma, and this may have a negative effect on their help-seeking behaviours. Although there is no available evidence of concurrent relationships between analysed variables in studies with refugee adolescents, the findings from the mediation analysis are in line with findings from similar previously studies from adult refugees and non-refugee adolescents (Byrow, Pajak, McMahon, Rajouria, & Nickerson, Reference Byrow, Pajak, McMahon, Rajouria and Nickerson2019; Chen et al., Reference Chen, Fang, Liu, Hu, Lan and Deng2014). In a study conducted with 251 adolescents who attended high school and secondary school in China and had at least one mental problem, no direct relationship was found between the number of mental health problems and help-seeking behaviours. However, self-stigma was shown to mediate the relationship between the number of mental health problems and the willingness to seek help (Chen et al., Reference Chen, Fang, Liu, Hu, Lan and Deng2014). A recent study of 103 male refugees who spoke Urdu, Farsi, or Tamil showed that self-stigma mediated the relationship between PTSD severity and their intention to seek help (Byrow et al., Reference Byrow, Pajak, McMahon, Rajouria and Nickerson2019).
The most valuable finding of this study is that self-stigma acts a critical role in the relationship among depression, anxiety and stress levels, and help-seeking behaviours in Syrian refugee adolescents. There may be several possible reasons for this result. Firstly, Syrian refugee adolescents have Arabic collectivist culture, which exhibits high stigma towards mental illness and its treatment (Bawadi, Al-Hamdan, Khader, & Aldalaykeh, Reference Bawadi, Al-Hamdan, Khader and Aldalaykeh2022). Individuals from collectivist cultures are highly dependent on familial and social relationships, and their self-identity develops in the context of this extended social community. For this reason, it is thought that the thoughts and beliefs of those in the social environment about mental illness have an important effect on the help-seeking behaviours of the person for their mental health (Özaslan & Yıldırım, Reference Özaslan2021)). As a result, it was hypothesized that greater collectivism might be associated with higher levels of self-stigma (Papadopoulos, Foster, & Caldwell, Reference Papadopoulos, Foster and Caldwell2013). While collectivism represents an important cultural aspect influencing self-stigma among Syrian refugee adolescents, other culturally specific factors should also be considered. For instance, the impact of conventional gender roles, beliefs toward mental health, religious convictions, and societal norms in the country where individuals reside may additionally contribute to the development of self-stigma (Ran et al., Reference Ran, Hall, Su, Prawira, Breth-Petersen, Li and Zhang2021). For instance, the internalized cultural beliefs that people who need mental health support are ‘crazy’ have been reported as a possible reason why Syrian refugees delay or refuse to seek help for their mental health problems (Maconick et al., Reference Maconick, Ansbro, Ellithy, Jobanputra, Tarawneh and Roberts2020). Secondly, experiences of discrimination and racial harassment that many refugees face in their host communities may exacerbate their self-stigma (Majumder, Reference Majumder2019). Thirdly, adolescence itself may explain these results, regardless of culture. Self-identity development is an important step in adolescence, and it is known that ego development significantly affects voluntary behaviours (Chen et al., Reference Chen, Fang, Liu, Hu, Lan and Deng2014). Self-stigma has the potential to inhibit the development of positive compositions of self-identity (Rüsch, Angermeyer, & Corrigan, Reference Rüsch, Angermeyer and Corrigan2005). It has been shown that self-stigma towards mental health negatively affects self-esteem and self-efficacy (Drapalski et al., Reference Drapalski, Lucksted, Perrin, Aakre, Brown, DeForge and Boyd2013). Therefore, Syrian refugee adolescents with high levels of self-stigma may be more reluctant to seek help for mental health.
The findings of this study provide evidence for the development of strategies that can be incorporated into interventions aimed at improving the help-seeking behaviours of Syrian refugee adolescents for their mental problems. However, it is important to highlight that stress, anxiety, and depression explained only 2%, 3%, and 2% of the variance in self-stigma prediction. As per Cohen's (Reference Chen1988) effect size classifications, where 0.02 represents a small effect, 0.15 denotes a medium effect, and 0.35 indicates a large effect, the amount of variance explained, though small, can still hold practical significance. This result suggests that despite the effects being small, the implementation of strategies to reduce the symptoms of mental health on self-stigma at an individual level could potentially yield significant cumulative effects at the population level. Therefore, even small improvements in adolescents' mental health may contribute to significant positive outcomes on a larger scale. First, the increase in the symptoms of depression, anxiety, and stress in Syrian refugee adolescents increases the level of self-stigma and indirectly negatively affects their help-seeking behaviours. In this context, our findings suggest that strategies to be developed to reduce self-stigma in Syrian refugee adolescents may positively affect help-seeking behaviours for mental health. Improving mental health literacy, which is effective in reducing the level of self-stigma (Crowe, Mullen, & Littlewood, Reference Crowe, Mullen and Littlewood2018; Griffiths, Christensen, & Jorm, Reference Griffiths, Christensen and Jorm2008), among Syrian refugee adolescents may be one of them. In addition to increasing mental health literacy among refugee adolescents, it is thought that providing mental health training to refugee parents, teachers at schools where refugee adolescents study, and social workers who deal with them will both positively affect their help-seeking behaviours and reduce self-stigma. Although there are several mental health education programs provided by NGOs in Turkey (Sahin, Dagli, Acarturk, & Sahin Dagli, Reference Sahin, Dagli, Acarturk and Sahin Dagli2021), these services should be enlarged countrywide and more integrated with refugee adolescents. In addition, creating safe and confidential areas where Syrian refugee adolescents can openly discuss their mental health concerns without fear of judgment or discrimination may also encourage them to seek the help they need. Increasing the help-seeking behaviours of Syrian refugee adolescents will contribute to early intervention without increasing the severity of their mental problems. Early intervention for many mental problems that begin in adolescence both positively affects their course in adulthood and prevents complications related to psychiatric disorders in adolescence (Rapee et al., Reference Rapee, Oar, Johnco, Forbes, Fardouly, Magson and Richardson2019). Mental health and psychosocial support (MHPSS) training is provided to Turkish and Syrian doctors on the basis of the WHO Mental Health Gap program in order to identify early, support, and guide refugees in need of mental health or psychosocial support. Although more cases of mental problems are reported from centres providing MHPSS service after these trainings, it has been considered that these centres are not sufficiently culturally sensitive (Woodward et al., Reference Woodward, Fuhr, Barry, Balabanova, Sondorp, Dieleman and Roberts2023). Providing culturally sensitive and accessible mental health services (Bhui, Reference Bhui2022; Martinez, Co, Lau, & Brown, Reference Martinez, Co, Lau and Brown2020) would also help reduce self-stigma and encourage Syrian refugee adolescents to seek the support they need. Therefore, government agencies and NGOs should collaborate to provide more resources that utilize a culturally sensitive approach to meet refugee adolescents' mental health needs and reduce mental health stigma. Emphasizing the importance of self-stigma in mental health or cultural competence training provided to health professionals dealing with refugee adolescents in Turkey can help them better understand the unique challenges refugee adolescents face and identify appropriate support to reduce their level of stigma. Ultimately, if policymakers consider developing a multi-faceted approach that combines mental health literacy training, culturally sensitive approach, and training for healthcare providers, they will significantly contribute to reducing self-stigma and improving mental health outcomes for Syrian refugee adolescents in the future. However, it is essential to recognize that the findings of this study were based on specific conditions in Turkey, where professional support may face unique challenges and availability. Contextual factors, such as social inequality for refugees, and the country's resources and support systems in Turkey could impact refugees’ adolescents’ mental health and self-stigma, influencing help-seeking behaviours. To gain a better understanding, we must consider contextual factors and their potential implications on associations between the aforementioned variables in a better-resourced country. Conducting similar research in other countries with varying support systems would offer a comparative analysis and a broader perspective on the variables in this study.
There are several limitations to this study that should be acknowledged. First, due to the cross-sectional design of the study, no conclusions can be drawn about the causal relationships of our findings. However, our findings may form the basis for future longitudinal research that will examine potential causal relationships between study variables. Secondly, while the level of self-stigma was examined in this study, the public stigma, which is frequently examined in studies conducted with refugees, was not evaluated. Thirdly, we determined the help-seeking behaviours, mental problems, and self-stigma levels of Syrian refugee adolescents using self-report measures, which cannot exclude biased responses due to social desirability (Althubaiti, Reference Althubaiti2016). Considering the reports of parents or teachers in future studies will be beneficial in terms of increasing the reliability, validity, and effectiveness of the findings. Fourth, in this study, parameters such as language barrier, mental health literacy, socioeconomic status, and resettlement difficulties and duration (which may also affect acculturation) associated with help-seeking behaviour in refugee adolescents were not evaluated. It is known that data reliability decreases as the number of questions increases in quantitative studies conducted with adolescents (Matza et al., Reference Matza, Patrick, Riley, Alexander, Rajmil, Pleil and Bullinger2013). Therefore, in line with the hypotheses of this study, mental problems and self-stigma, which are two factors that may be related to help-seeking behaviours in refugee adolescents, were investigated. In future studies, a more comprehensive determination of the factors affecting the help-seeking behaviours of refugee adolescents is important for the development of early interventions for their mental problems.
With the number of refugees reaching unprecedented levels worldwide, it is crucial to develop strategies aimed at reducing self-stigma and encouraging help-seeking among refugee adolescents. Our findings highlight the potential negative effects of self-stigma on help-seeking behaviours of Syrian refugee adolescents, both directly and indirectly. Despite its limitations, the results of this study make an important contribution to existing knowledge regarding mental health, self-stigma, and help-seeking behaviours in refugee adolescents. These results can be used to develop and implement effective and efficient interventions to address the unmet mental health needs of refugee adolescents.
Acknowledgements
We would like to thank the adolescents participating in the study on a voluntary basis.
Financial support
This research fee was supported by Alliance of International Doctors.
Competing interest
The authors declare that they have no conflict of interest. The funding sources had no role in the study design, in the interpretation of data, and in the writing of the manuscript.
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