Is resilience related to help-seeking behavior? A study on family caregivers of people with mental illness

ABSTRACT


Introduction
A primary health survey of Indonesia in 2013 and 2018 reported an increase in the number of people with severe mental disorders.In 2018, it was found that the number of people with mental disorders is 6.7 per 1000 households compared to the 2013 data; the proportion of mental disorders increased from 1.7 per mil to 7 per mil ((Agency-of-Health-Research-and-Introduction: Caring for family members with mental illness can be challenging and cause a burden of caring.Family caregivers need to adapt to challenging caring tasks by having good resilience that leads to positive help-seeking behavior.Objectives: This study aims to investigate the correlation between resilience and help-seeking behavior among Family Caregivers who care for people with mental illness in Manado City.Methods: This study is a crosssectional study involving 84 family caregivers of people with mental illness.The data was collected using the Walsh Family Resilience Questionnaire (WFR-Q) to measure family caregiver resilience and the Attitudes Toward Seeking Professional Psychological Help (ATSPPH-SF) to measure help-seeking behavior.Data analysis was performed using Pearson correlation to analyze both variables' strengths and direction.Results: This study reported that there was a positive and moderate correlation between resilience and help-seeking behavior among family caregivers of people with mental illness (p = 0.000 r = 0.496), The majority of respondents have cared for people with mental illness for more than five years, and most of them are the children of People with mental illness.Conclusions: These results indicated the importance of resilience and positive help-seeking behavior among Family Caregivers because they influence each other.Programs to strengthen the resilience of family caregivers need to be carried out to improve their caring ability by strengthening positive help-seeking behavior.behavior of families are problems that families in caring for family members with mental disorders (Iseselo, Kajula, & Yahya-Malima, 2016).Family caregivers reported the burden of costs for caring, disturbances in routine activities, family comfort, family interactions, and the impact on their physical and mental health (Von Kardorff, Soltaninejad, Kamali, & Eslami Shahrbabaki, 2016).Psychological distress in families who care for People with Mental Illness (PWMI) affects the ability and the role of families in caring for people with mental disorders (Sulaihah et al., 2020), including help-seeking behavior to get the proper treatment for their family member (Oberoi, Chaudhary, Patnaik, & Singh, 2016).Family caregivers who care for people with mental illness are often delayed in seeking appropriate help because of the feelings of shame and burden experienced.A previous study reported that 54.5% of 650 patients with mental disorders had negative help-seeking behavior; they did not immediately seek help from health professionals (Abolfotouh et al., 2019).Several studies reported that some families still seek first aid from traditional healers or faith healers when their family members experience mental disorders.The studies are due to family difficulties in caring for people with mental illness and the solid public stigma that still exist in society (Mislianti, Yanti, & Sari, 2021;Naik, Pattanayak, Gupta, & Pattanayak, 2012).Some families in Asian countries consider family ties significant, so they tend to choose to care for their family members who suffer from mental disorders at home.This perception is influenced by the culture that they must keep the illness of a sick family member a secret to protect the family's honor.Some families also choose the traditional treatment as an alternative while looking for other better treatments.If they get positive results, they will continue the treatment until they reach their level of satisfaction (Mohamad, Subhi, Zakaria, & Aun, 2013).Previous studies also stated some barriers to seeking medical help, such as reluctance to express health concerns, feelings of shame, anxiety, fear (Yousaf, Grunfeld, & Hunter, 2015), stigma, feelings of guilt, and the ability to access health services (Connor et al., 2016).
Positive help-seeking behavior means that people are actively trying to find a solution to their problems.Help-seeking behavior is influenced by resilience.In general, Jensen and Fraser define resilience as the ability to adapt well to risks and problems that arise (Jenson & Fraser, 2015).Good resilience will positively impact the psychological condition (Wuryaningsih & Holivia, 2019) and the quality of life of the family caregivers (Palacio G, Krikorian, Gómez-Romero, & Limonero, 2020).Resilience is also a moderating variable between stigma and psychological distress that can improve the psychological well-being of Family caregivers (Chen et al., 2016).A better psychological state will positively impact problem-solving and lead to positive help-seeking behavior (Coşkun, Garipağaoğlu, & Tosun, 2014), which means Good resilience influences the behavior of help-seeking by family caregivers more positively.
Research related to stigma and knowledge with help-seeking behavior has been widely studied.However, research related to resilience and help-seeking behavior is still limited.Early and appropriate help-seeking behavior is significant for people with mental disorders to get early treatment to achieve better outcomes (McGorry, 2015).This study aimed to provide evidence about the correlation between resilience and help-seeking behavior of Family caregivers caring for people with mental illness.

Methods
The study is a correlation analytic study with a cross-sectional approach that aims to investigate the relationship between resilience and help-seeking behavior in family caregivers for people with mental illness.The sample size calculation was carried out by using the G*Power software.The number of samples obtained for the correlation test was 84 respondents with a significance level (α = 0.05), using a medium effect size of 0.3 and a Power statistic of 0.80.The Respondents were recruited using consecutive sampling with inclusion criteria: 1) Respondents were primary caregivers of people with mental illness, 2) The caregivers did not experience mental disorders, and 3) The Caregivers were willing to participate in the research.Meanwhile, the exclusion criteria were: 1) Caregivers who could not read and write and 2) Caregivers who did not complete filling out the questionnaire.Respondents who met the inclusion and exclusion criteria were then explained the details of the study, such as the research objectives, data collection process, risks, and benefits of the study.Respondents then signed Informed Consent if they agreed to participate in the study.
Questionnaires were used to collect the data about variables.The family Caregiver Resilience was measured using the Walsh Family Resilience-Questionnaire questionnaire (WFR-Q), which has been used in several previous studies.This questionnaire consists of 32 questions with four answer choices ranging from strongly disagree to Strongly Agree, where the total score on this questionnaire is 128.This questionnaire has been translated into Indonesian and tested for validity with a coefficient of validity (r = 0.851) and reliability (α = 0.868).Furthermore, the Help-Seeking Behavior was measured using a short version of the Attitudes Toward Seeking Professional Psychological Help (ATSPPH-SF) questionnaire developed by Fischer and Farina (1995) (Picco et al., 2016).This questionnaire consists of 10 questions with the interpretation that the higher the score, the more positive a person's behavior is in seeking help.This questionnaire has four choice answers with a total score of 30, and there are five negative question items on question number 2, 4, 8, 9, and 10.This questionnaire has been translated into Indonesian, used in previous similar studies, and tested for reliability with a value of 0.871 (Masita, Buanasari, & Silolonga, 2019).
The data were analyzed using Pearson correlation to measure the strength and direction of the linear relationship of two variables, resilience and help-seeking behavior among Family Caregivers.This research has been conducted by adhering to ethical principles such as anonymity, beneficence, nonmaleficence, and confidentiality.Moreover, he has obtained a research permit from Prof. Dr. VL. Ratumbuysang Mental Health Hospital in Manado City Manado with number 445/RSJ/175/2022.

Results and Discussion
This study was conducted in the outpatient polyclinic and the Emergency Unit of Prof. Dr. VL. Ratumbuysang Hospital in Manado City by involving 84 family caregivers who care for mental illness.Table 1 describes the characteristics of the respondents.The average age of the respondents at the time of the study was 45 years old, with the majority of respondents being female (64.3%).54.8% of respondents had secondary education, and the majority came from lowincome Families (60.7%).20.2% of respondents work as entrepreneurs, while most were in other categories (40.5%) such as honorary employees, motorcycle taxi drivers, daily casual workers, Etc.50% of respondents have cared for sick family members for more than five years, and most of them were the children of the patients (32.1%).Based on the Pearson correlation analysis in Table 2 showed p-value = 0.000 with a coefficient correlation value of 0.496, which means there was a moderate and positive correlation between the two variables that indicated the higher the resilience score, the higher or more positive the help-seeking behavior in family caregivers.Table 2 also showed that the mean score for family caregiver resilience was 94.56, while the mean score for help-seeking behavior was 18.81.it means that the mean score of the two variables was more than half the total score, where the maximum score for resilience is 128 and the maximum score for help-seeking behavior is 30.
This study showed a positive correlation between resilience and help-seeking behavior of family caregivers who care for people with mental Illness in Manado City.This study found that the better the family's resilience, the more positive the help-seeking behavior and vice versa.The phenomenon of help-seeking behavior from mental health professionals in Indonesia is still generally low.Patients and Caregivers still choose traditional treatment before pursuing help from mental health professionals if the symptoms are untreated (Rostina, Adamy, Abdullah, & Chairurrijal, 2020).This help-seeking behavior is not only influenced by family knowledge (Gabra, Ebrahim, Osman, & Al-Attar, 2020) but also by psychosocial factors such as stigma and psychological distress (Ogada, 2019).
Psychosocial problems in caring for people with mental illness could affect the family's ability to care; as reported in a previous study that involved 395 caregivers of Patients with schizophrenia, it was found that knowledge and skills in caring were influenced by the level of stress, anxiety, and depression in caregivers (Zhou et al., 2021).Families need to strengthen resilience because resilience is an essential factor that helps families adapt and overcome the Please cite this article as: Buanasari, A. Rahman, A, and Gannika, L (2023) ' Is resilience related to Help-seeking behavior?A Study on Family Caregivers of People with mental Illness ', Journal Keperawatan.University of Muhammadiyah Malang, 14 (1), pp.33-40.doi: 10.22219/jk.v14i01.22140burden of caring and stigma because of having family members with a mental disorder (Saleem, Arouj, Zaman, & Shaheen, 2021).The previous study also revealed that resilience could increase the role of families in caring for family members with mental illness (Sulaihah et al., 2020).Good resilience characterized by mood control, self-plasticity, and coping flexibility can also promote an upbeat coping style (Wu et al., 2020).It means families with good resilience will be able to survive and develop positive coping in dealing with problems when caring for their loved one who has a mental illness; this positive coping then leads to a better family's decision to seek help.
Resilience and help-seeking behavior can influence each other.When people have positive help-seeking behavior, they will get better solutions and treatment so that they become more resilient (Crowe, Averett, & Glass, 2016).Positive help-seeking behavior is a coping mechanism that can foster resilience by increasing positive emotions (Gloria & Steinhardt, 2016).When facing crises or stressful life events like caring for sick family members, family caregivers will be more resilient if they have good knowledge, get support from other family members, have good access to health facilities, and have suitable coping mechanisms (Han et al., 2019) and family caregivers can achieve this if they have positive help-seeking attitude.
A study showing the relationship between resilience and help-seeking behavior has been proven previously but in different participants (Crowe et al., 2016).However, there was also a previous study reporting that there was no relationship between resilience and help-seeking behavior in Indian American respondents.The previous study may be due to other factors that affect the relationship between the two variables, such as cultural factors where the respondents involved were second-generation immigrants who have absorbed more Western culture.Another factor stated in this article was about data collection that was carried out online, thereby increasing the chance of bias during data collection (Thomas, 2019).
This study showed that the mean score of family caregiver resilience was 94.56, which indicated that family caregivers have a moderate level of resilience.The study might be because most respondents have developed adaptations to caring for family members with mental disorders with a longer duration of more than five years.The previous study revealed that exposure to stressors could promote personal growth when successfully overcome and increase the capacity of resilience as a result (Crane & Searle, 2016).Caring for families with mental illness will improve the caregiver's ability to adapt and increase resilience.It also explains how a person dealing with stressors and adversity that is considered a threat can provide positive outcomes as a result of the adaptation process (Palacio G et al., 2020).
This study also found that the mean score of the help-seeking behavior for Family caregivers was 18.81(more than half the maximum scores), indicating that Family Caregivers have moderate help-seeking behavior.This result was also affected by the high resilience score of the Family caregivers, as reported in a previous study that good resilience can reduce negative attitudes toward seeking help caused by stigma (Kulesza, Pedersen, Corrigan, & Marshall, 2015).The education level of Family caregivers may also support positive behavior towards helpseeking, the majority of whom have attended secondary education to college, so it can be assumed that they have better knowledge about mental health issues (Wong, Tong, Daud, Aziz, & Midin, 2019).
Although, in general, the score of help-seeking behavior of Family caregivers was good, the majority of respondents gave a low score on the question item "a person should solve the emotional problems he or she faced alone, and that seeking help from a mental health professional is the last option ."Theemotional could be affected by cultural factors where people are still taboo to ask help from mental health professionals.Even though the cultural aspect was not studied in this research, this has been discussed in a previous study conducted on Southeast Asian people.Respondents revealed that their families considered their depression happened because they were weak, lazy, and uninspired characters.The depression caused the patients to reluctantly seek help because of a strong negative stigma attached to people with mental Illness (Samari et al., 2022).The religious character of Indonesian society can also be a factor influencing helpseeking behavior.They prefer to use religious coping to deal with problems they face by seeking support from the religious community and asking for help from God.However, religious coping can also be damaging when someone questions and blames God for what happened to him and makes him passive in finding solutions (Avent Harris, Wahesh, Barrow, & Fripp, 2021;Syafitri & Rahmah, 2021).This study revealed a positive correlation between resilience and help-seeking behavior.However, this study also has a limitation; some factors that might affect resilience and helpseeking behavior, such as knowledge, culture, stigma, and accessibility to healthcare services, were not controlled and investigated.The study may lead to biased results and a need for more richness of information.Future studies should investigate moderating or mediating variables between resilience and help-seeking behavior.

Conclusion
It is concluded that the higher the resilience of the family caregivers who care for people with mental illness, the more positive the help-seeking behavior is and vice versa.Although, in general, the resilience scores and help-seeking behavior are pretty good, based on the questionnaire, most respondents answered that emotional problems must be resolved by themselves and visiting mental health professionals is the last option.This study indicated the importance of establishing a resilience-strengthening program for families who take care of people with mental illness to provide better care for themselves and their families through positive help-seeking behavior.