Nursing Students’ Attitudes Toward Seeking Psychological Help Associated to Self-Stigma and Perceived Social Stigma

Introduction: Nursing students often experience stress due to their educational demands and developmental stage. This study focuses on nursing students to investigate the relationship between their attitudes toward seeking psychological help and their levels of perceived self-stigma and social stigma. Methods: This was a descriptive correlational study, in which 791 nursing students participated through convenience sampling between April and May 2022. Data were collected using the Attitude Towards Seeking Psychological Help Scale-R (ASPH-R), the Stigma Scale for Receiving Psychological Help (SSRPH), and the Self-Stigma of Seeking Help (SSOSH). The data were analyzed using Pearson correlation and multiple linear regression analysis. The article adheres to the STROBE checklist in its organization and presentation. Results: Positive attitudes towards seeking psychological help were negatively correlated with self-stigma (r=-0.39, P<0.01) and social stigma perceptions (r=-0.17, P<0.01), while negative attitudes were positively correlated with self-stigma (r=0.50, P<0.01) and social stigma (r=0.47, P<0.01). Variables of sex, age, self-stigma, and social stigma significantly contributed to explaining attitudes towards seeking psychological help. Conclusion: Social stigma and particularly self-stigma significantly influence nursing students’ attitudes towards seeking psychological help. Therefore, it is recommended that authorities develop psychoeducational interventions aimed at enhancing nursing students’ mental health awareness and reducing self-stigma.

8][19][20][21] Individuals facing psychological challenges refrain from seeking help not only because of concerns about social stigma but also, and perhaps more significantly, because of self-stigmatization concerns. 22tigmatization is defined in two dimensions: social stigmatization and self-stigmatization.Social stigma refers to how society negatively perceives individuals seeking professional help for mental health issues. 23elf-stigmatization, on the other hand, pertains to the internalization of societal norms and biases.Those experiencing self-stigmatization are more likely to perceive seeking professional psychological help as a threat to their sense of self. 24This is because society often labels individuals seeking professional psychological help as undesirable, worthless, inadequate, and weak. 25People with high levels of self-stigma tend to feel embarrassed about seeking professional psychological help, have lower self-esteem, anticipate rejection, and may isolate themselves from social settings. 267][28][29] Stigmatization exacerbates anxiety, somatic and depressive symptoms, diminishes resilience, and can contribute to substance abuse. 30,31he WHO underlines the significance of raising mental awareness and combating stigma to protect mental health. 5In this context, nursing students should be able to seek professional psychological help without fear of stigmatization. 32Psychological help-seeking behavior serves as a crucial resource for nursing students in managing the challenges posed by both university life and vocational education during their academic journey.Therefore, it is of paramount importance to identify the factors influencing the psychological help-seeking behaviors of nursing students.Through this study, it is anticipated that a deeper understanding of nursing students' psychological help-seeking behaviors within the context of stigma will be achieved, ultimately paving the way for the development of effective support mechanisms to enhance their mental well-being.The aim of this study was to examine nursing students' attitudes towards seeking psychological help associated to their self-stigma perceptions and social stigma perceptions.

Research Objective and Type
This descriptive correlational study investigated selfstigma and social stigma on nursing students' attitudes toward seeking psychological help.The sample consisted of 791 nursing students.Data were collected using a personal information questionnaire, the Attitude Towards Seeking Psychological Help Scale-R (ASPH-R), the Stigma Scale for Receiving Psychological Help (SSRPH), and the Self-Stigma of Seeking Help (SSOSH).The following are the research questions: 1.What ASPH-R, SSRPH, and SSOSH scores do participants have?2. Is there a correlation between ASPH-R, SSRPH, and SSOSH scores? 3. Can self-stigma and social stigma predict participants' attitudes toward seeking psychological help?

Population and Sample
The study population comprised 1200 nursing students from the Faculty of Health Sciences at a public university in Turkey between April and May 2022.No sampling was conducted, as the study aimed to encompass as many students as possible.Initially, 853 nursing students were enrolled in this study; however, the final analysis was based on data from 791 participants, as 62 participants did not respond to all research questions.Inclusion criteria consisted of (1) being a nursing student and (2) voluntary participation.

Data Collection Tools
Personal Information Questionnaire The personal information questionnaire was developed by the researchers.It consisted of three items (sex, age, and grade).

Attitude Towards Seeking Psychological Help Scale-R
The ASPH-R was developed by Fisher and Turner (1970) and adapted to Turkish by Türküm. 33The instrument consists of 18 items rated on a five-point Likert-type scale (1 = strongly disagree to 5 = strongly agree).The instrument consists of two subscales: positive attitude and negative attitude.The total score ranges from 18 to 90, with higher scores indicating more positive attitudes toward seeking psychological help. 33In our study, the total scale exhibited a Cronbach's alpha of 0.90, with the subscales 'positive attitude' and 'negative attitude' having Cronbach's alpha scores of 0.67 and 0.90, respectively.

Stigma Scale for Receiving Psychological Help
The SSRPH was developed by Komiya et al in 2000 and adapted to Turkish by Topkaya. 34The instrument consists of five items rated on a four-point Likert-type scale (1 = strongly disagree to 5 = strongly agree).The total score ranges from 5 to 20, with high scores obtained from the scale indicate a higher perception of social stigma regarding seeking psychological help.The scale has a Cronbach's alpha of 0.72, which was 0.74 in the present study.

Self-Stigma of Seeking Help
The SSOSH was developed by Vogel et al (24) and adapted to Turkish by Kapıkıran and Kapıkıran. 27The instrument consists of 10 items rated on a five-point Likert-type scale (1 = strongly disagree to 5 = strongly agree).The total score ranges from 10 to 50, with higher scores indicating a higher level of self-stigma associated with seeking psychological help.The scale has a Cronbach's alpha of .88,which was 0.70 in the present study.

Data Collection
The data were collected online between April and May 2022.It took each participant 20 minutes to fill out the data collection forms.

Data Analysis
The data were analyzed using the Statistical Package for Social Sciences (SPSS, v. 24.0) at a significance level of 0.05.Number, percentage, mean (SD), and standard deviation were used for descriptive statistics.Pearson's correlation coefficient was used to determine the relationship between scale scores.A multiple linear regression analysis was performed to determine the effect of independent variables on the dependent variable.In this study, 'Attitude Towards Seeking Psychological Help' was determined as the dependent variable, while 'Stigma Scale for Receiving Psychological Help,' 'Self-Stigma of Seeking Help,' sex, and age were identified as the independent variables.The article is organized and written according to the STROBE checklist.

Results
Participants had a mean (SD) age of 21.68 (2.49) years (min = 18 -max = 42).More than half of the participants were 18 to 21, while the remaining were older than 21.More than half of the participants were women (55.4%).
Table 1 shows the distribution of scale scores by descriptive characteristics.Female participants had a significantly higher mean Positive Attitude subscale scores of ASPH-R than male participants.Male participants had a significantly higher mean Negative Attitude subscale scores of ASPH-R, SSRPH and SSOSH total scores than female participants.Participants aged 18 to 21 years had a significantly higher mean than those aged 22 and over (Table 1).There was a positive correlation between SSRPH and SSOSH scores (Table 2).Participants had mean (SD) ASPH-R "positive attitude" and "negative attitude" subscale scores of 48.98(7.40)(min = 12-max = 60) and 13.11 (3.89) (min = 6-max = 30), respectively.They had a mean (SD) SSRPH score of 10.67 (3.04) (min = 5-max = 20).They had a mean (SD) SSOSH score of 23.34 (6.48) (min = 10-max = 84).There was a negative correlation between ASPH-R "negative attitude" subscale and SSRPH total scores.There was a negative correlation between ASPH-R "negative attitude" subscale and SSOSH total scores.
Table 3 shows the multiple linear regression analysis results.Two models were developed to assess the effect of each independent variable on the ASPH-R "positive attitude" and "negative attitude" subscale scores.The first model was significant (F = 38.491,P < 0.01).The independent variables explained 16% of the ASPH-R "positive attitude" subscale scores.The SSRPH (β = -0.032)and SSOSH (β = -0.366)total scores and age (β = -0.067)had a significant effect on the ASPH-R "positive attitude" subscale scores.The SSOSH total score had a more explanatory effect than the SSRPH total score.A one-unit change in the mean SSOSH total score led to a -0.366 unit change in the ASPH-R "positive attitude" subscale scores (Table 3).
The second model assessed the effect of independent variables on the ASPH-R "negative attitude" subscale scores.The model was significant (F = 111.959,P < 0.01).The independent variables explained 36.0% of the ASPH-R "negative attitude" subscale scores.The SSRPH (β = 0.332) and SSOSH (β = 0.373) total scores and sex (β = 0.114) had a significant effect.The SSOSH total score had a more explanatory effect.A one-unit change in SSOSH total score average causes a positive 0.373 unit change in the Negative Attitude sub dimension.A oneunit change in the SSOSH total score led to a 0.373 unit change in the ASPH-R "negative attitude" subscale scores.

Discussion
][37] However, they may avoid seeking psychological help due to negative perceptions, attitudes, and stigmatization, leading to this study's focus on nursing students' attitudes and experiences regarding seeking psychological help.
This study aimed to assess whether nursing students' attitudes towards seeking psychological help and their perceptions of self-stigma and social stigma related to seeking psychological help vary based on demographic characteristics.Female participants exhibited more positive attitudes towards seeking psychological help than their male counterparts.Conversely, male participants reported higher levels of self-stigma and social stigma associated with seeking psychological help than their female counterparts.In traditional societies, seeking psychological help may be viewed as a sign of weakness, particularly for men who are expected to embody strength and resilience.Men may be less likely to share their distress with others to avoid appearing weak or vulnerable, leading to a reluctance to accept social and professional support during times of emotional and psychological stress.Consequently, men are more likely to hold negative attitudes towards seeking psychological help due to self-stigmatization or societal stigmatization.
9][40][41] Furthermore, participants aged 18 to 21 exhibited more positive attitudes towards seeking psychological help than those aged 22 and older.Many young people in the 18 to 21 age group experience university life in Turkey, which may lead to greater awareness of seeking professional support for mental health compared to older generations.Increased awareness of mental health is often associated with more positive attitudes towards mental healthcare services.Pompeo-Fargnoli 38 also found that students who were not within the typical university education age range (over 23 years old) exhibited more stigmatizing attitudes towards seeking psychological help than those within the usual university education age range (22 years old and younger).Self-stigma associated with seeking psychological help tends to foster negative attitudes towards it.Negative correlations were observed between positive attitudes towards seeking psychological help and selfstigma as well as social stigma.Notably, participants' perceptions of self-stigma exhibited a stronger correlation with their attitudes towards seeking psychological help compared to their perceptions of social stigma.Previous studies, such as Gürsoy and Gizir 21 and Hilliard, Watson II, and Zizzi, 42 have also identified negative correlations between university students' attitudes towards seeking psychological help and their levels of self-stigma and social stigma.These findings align with existing literature. 39,43In contrast, Shannon et al 43 reported a significant correlation between university students' attitudes towards seeking psychological help and selfstigma but found no significant correlation between social stigma, social approval, and the willingness to seek psychological help.In our study, we also identified a positive correlation between self-stigma associated with seeking psychological help and social stigma.Pompeo-Fargnoli 38 similarly documented a positive relationship between students' perceived social stigma and self-stigma.Additionally, Hilliard et al 42 found a positive relationship between students' perceptions of social and self-stigma and their attitudes towards seeking psychological help.In summary, these results indicate that individuals with more negative perceptions of self-stigma and social stigma tend to hold more negative attitudes towards seeking psychological help.Individuals' stigmatizing attitudes towards mental illnesses can have a detrimental impact on their willingness to seek psychological help.Humans are inherently social beings, and they are profoundly influenced by the behavioral norms, beliefs, and attitudes prevalent within their society.In particular, the gradual adoption of stigmatizing attitudes towards mental illnesses within their social milieu can lead individuals to perceive those with mental health challenges as weak, inadequate, flawed, or deserving of punishment.Consequently, this internalization of societal beliefs and attitudes can pose significant barriers for individuals in recognizing their own need for psychological assistance.As demonstrated in this study, individuals who exhibit high levels of both social and self-stigmatizing attitudes are more likely to harbor negative views regarding seeking psychological help.
A regression analysis was conducted to identify the factors influencing attitudes toward seeking psychological help.Two models were developed.The first model revealed that positive attitudes toward seeking psychological help were significantly impacted by social stigma, self-stigma, and age.Notably, self-stigma emerged as the primary explanatory factor for the inclination to seek psychological help.The second model indicated that negative attitudes toward seeking psychological help were significantly influenced by social stigma, self-stigma, and gender.Both social stigma and self-stigma played substantial roles in shaping negative attitudes toward seeking psychological help.Furthermore, the combined effects of social stigma and self-stigma significantly accounted for the variance in negative attitudes toward seeking psychological help.4][25] A lack of knowledge about mental illnesses and available treatments can amplify stigmatizing attitudes towards mental health issues, subsequently diminishing one's inclination to seek psychological help. 21Initial stigmatizing attitudes surrounding the act of seeking psychological help are often acquired from one's social environment.Over time, individuals internalize these attitudes.2][23][24][25] For those who do seek psychological help, the fear of receiving negative labels such as "crazy," "insane," "pitiable," "helpless," and others from peers or society at large regarding their issues can be a significant deterrent. 38Hence, both self-stigmatization and social stigmatization wield considerable influence over individuals' attitudes towards seeking help for mental health concerns.This finding aligns with the notion that self-stigmatization acts as a formidable barrier to seeking help, as it directly impacts individuals' self-perception and self-esteem.Our findings align with previous research.Hilliard et al 42 reported that both social stigma and self-stigma had negative effects on attitudes and intentions related to seeking psychological help.Additionally, Conceição et al 39 documented that factors such as gender, stigmatizing attitudes toward mental illnesses, and perceived stigma significantly influenced individuals' attitudes toward seeking psychological help.In summary, existing research indicates that self-stigma, social stigma, self-esteem, gender, and age play significant roles in shaping individuals' behaviors concerning seeking psychological help. 21,40,41However, it's worth noting that Shannon et al 43 reported different findings, indicating that self-stigma, social stigma, social approval, and perceived importance did not have a significant effect on university students' attitudes toward seeking psychological help.This study had four limitations.First, the sample consisted of nursing students with similar cultural, ethnic, and socio-demographic characteristics.It is believed that the homogeneity of the sample group has led to participants having similar attitudes related to seeking psychological help and stigma.Second, non-randomized sampling method was used in this study.Third, the results are sample-specific and cannot be generalized to all nursing students.Fourth, this study approached the topic from a quantitative perspective.Therefore, there was no opportunity to evaluate underlying beliefs deeply.

Conclusion
Male and female nursing students have different attitudes toward seeking psychological help.They also perceive self-stigma and social stigma differently.Therefore, authorities should develop interventions tailored to male and female nursing students.Self-stigma and social stigma have a significant impact on psychological help-seeking attitudes.Self-stigmatization attitudes have a more significant effect on psychological help-seeking attitudes than perceptions of social stigma.Researchers should plan psychoeducational interventions to raise students' mental awareness, determine the factors that cause selfstigmatization, and plan interventions that reduce selfstigmatization.
and obtained permission from the university.All eligible students were provided with detailed information regarding the research's objectives and procedures.Informed consent was acquired from those who willingly chose to participate.

Table 1 .
The attitude towards seeking psychological help scale, Stigma Scale for Receiving Psychological Help, and the self-stigma of seeking psychology help scale mean (SD) scores according to sociodemographic characteristics *Significant correlation, (P < 0.05), ** Significant correlation (P < 0.01).

Table 2 .
The relationship between the attitude towards seeking psychological help scale, Stigma Scale for Receiving Psychological Help, and the selfstigma of seeking psychology help scale mean scores

Table 3 .
Multiple linear regression analysis results for the attitude towards seeking psychological help scale, Stigma Scale for Receiving Psychological Help, and the self-stigma of seeking psychology help scale mean scores