Racial and ethnic disparities in mental health service utilisation and access is well established. Mental illness is common among Arab populations globally, but most individuals display negative attitudes towards mental health and do not seek professional help. The aim of this systematic review was to determine 1) help-seeking behaviours 2) help-seeking attitudes and 3) help-seeking barriers and facilitators, related to mental health services among Arab adults.
Method
A pre-defined search strategy and eligibility criteria allowed for database searching using terms related to: mental health, Arabs, help-seeking, as well as experiences and behaviours. Seventy-four articles were included and analysed through narrative synthesis. Results were reported using the PRISMA guidelines. The review protocol was registered prospectively on PROSPERO (CRD42022319889).
Results
Arabs across the world have negative attitudes towards formal help-seeking and are reluctant to seek help, despite the presence of psychological distress. There is little information on factors that influence help-seeking behaviours and rates of service use. Preference for informal help sources such as family and friends were expressed and considered more acceptable. Low mental health literacy, stigma, gender, age, education, religion, acculturation, and immigrant status were the most common factors influencing help-seeking attitudes. Barriers to help-seeking included stigma, privacy and confidentiality, trust, mental health literacy, language, logistics, and culture related barriers. Increasing societal and family awareness, external support and encouragement, shared culture between the client and therapist, quality of doctor patient relationship, and feelings of connectedness with the host country among refugees were mentioned facilitators. Mixed findings for the role of religion, and family and community, in relation to facilitating or hindering help-seeking were reported.
Conclusions
There is an increased likelihood and preference to seek informal sources of psychological support among Arabs. Contextual and cultural factors impeding help-seeking for Arabs are common across the world. Future research should address actual utilisation rates of services to better understand factors that influence help-seeking behaviours and facilitators to help-seeking. Increasing mental health literacy and developing anti stigma campaigns is necessary. Developing culturally informed interventions should inform future efforts to promote help-seeking among this population.
Hania El Khatib, Aisha Alyafei and Madiha Shaikh contributed equally to this work.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Background
There is an increasing acknowledgement of the importance of mental health as a leading cause of disability which has significant effects on daily functioning [1]. There is a need for mental health support, however, the gap between the number of individuals needing care and those seeking help or receiving services remains substantial [2]. Of the people who need support or treatment, only an estimated 10% receive the necessary help [3]. Rickwood and Thomas [4], propose that there is no agreed and commonly used definition or measurement for help-seeking. Help-seeking is generally understood as an adaptive coping process of seeking external assistance to deal with mental health difficulties, including formal (e.g., psychologists and psychiatrists) and informal (friends and family) help [5]. According to Rothi and Leavey [6], help-seeking progresses through three phases: a) recognition, b) decision and c) action. Additionally, Andersen’s healthcare utilisation model draws on three dynamics determining the usage of health services: Predisposing factors such as race. age, and health beliefs, enabling factors such as family support, and need, including actual or perceived need for care [7]. While these models appear to operate in simple stages on the surface, numerous factors facilitating or obstructing this process are complex and poorly understood. Moreover, identifying and responding to mental health difficulties largely varies, and mental health help-seeking experiences differ across contexts and populations.
There is disparity in the use of and access to mental health services in racial and ethnic minority populations partly due to stigma and psychocultural variables in seeking psychological help [8‐10]. A recent systematic review established that Filipinos across the world have general reluctance and unfavourable attitude towards formal help-seeking despite high rates of psychological distress, due to cultural, logistical barriers and immigration experiences in host countries [11]. Language, lack of awareness of available services, stigma and negative attitudes towards treatment and providers, are highlighted barriers to access to mental health services for refugees and asylum seekers in Europe [12]. Similar findings in existing Arab mental health literature demonstrate that individuals tend to underutilize mental health services, displaying negative attitudes toward mental health and psychological services [13]. Although help-seeking among Arabs has not been substantially researched, Arab culture influences the definition and conceptualization of psychiatric disorders [14]. A systematic review identified the prevalence of stigmatising beliefs and attitudes toward treatment of mental illness in patients, care providers, and the public, highlighting reluctance to seek help among this population [15].
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The Arab world includes diverse groups of Arabic speaking individuals who share similar cultural values, originating from 22 Arab countries including: Lebanon, Syria, Egypt, Palestine, Iraq, Algeria, Bahrain, the Comoros Islands, Djibouti, Jordan, Kuwait, Libya, Morocco, Mauritania, Oman, Qatar, Saudi Arabia, Somalia, Sudan, Tunisia, the United Arab Emirates (UAE), and Yemen [16, 17]. This group has a combined population of over 400 million, and the number of international Arab migrants increased from 19 to 34 million in 10 years [18]. Little is known about the mental health of Arabs, even with its large population size. There is a lack of updated reliable epidemiological psychiatric data and very little published on national lifetime prevalence and treatment of mental disorders in the region [19]. Studies have so far focused on small populations in Egypt, Morocco, Iraq, Morocco, Qatar, and UAE, establishing comparable rates of psychological disorders to western countries [20]. However, studies report substantial delays between the onset of disorders and onset of treatment, and highlight that only a minority of Arabs with any mental disorder ever received professional treatment [19].
To date, a systematic review found that in addition to stigma, factors that affect attitude toward counselling among Arabs include barriers such as fear of self-disclosing, traditional healing methods, mental illness conceptualization, culture, family, and religious leaders [21]. This review also documented that Arabs visit psychologists, counsellors, and psychiatrists, less than other ethnic groups. While interesting, this review only included papers from 2003 to 2017, and participants were limited to students and hospital patients. Moreover, the review did not mention all 22 Arab countries, making it challenging to compare Arabs residing in the Middle East, North Africa, and other Western countries.
Despite the evident psychological distress in Arab populations, treatment rates and help seeking remain low [22]. Studies considered attitudes and factors influencing help seeking among Arabs as well as service utilisation patterns, but experiences of mental health help seeking have not been reviewed systematically. The literature has not considered how help seeking experiences and deterrents to seeking help differ for Arab individuals in different geographical contexts. Importantly, most of the research focuses solely on barriers to help seeking rather than facilitators. There is limited knowledge on why help seeking remains low for Arabs across different countries and how to promote it remains unclear.
In turn, understanding Arab mental health help-seeking behaviours will aid to improve service uptake and reduce mental health burden. The number of international Arab migrants and refugees increased considerably in the last few years [23], as armed conflicts and political instability in countries of origin forced many to relocate, significantly impacting their mental health [24]. Post migration stressors leave individuals particularly vulnerable to mental health illnesses because of language difficulties, cultural isolation, and socioeconomic factors shaping their experiences in new settings [25, 26]. The health of international Arab migrants has become both a global and a regional public health issue, as cultural and religious differences between migrants and host country populations exacerbate this [23]. Capturing the heterogeneity of help seeking experiences among Arab diaspora can inform interventions promoting help seeking and improve quality of psychological support for Arabs in different regions of the world. Additionally, exploring help seeking behaviours and attitudes from the perspective of both professionals and individuals themselves, is critical to bridging the gap between evident mental health difficulties and formal mental health services.
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Aims & objectives
The aim of this review is to understand experiences of mental health help seeking in Arab adults across different geographical contexts. The paper focuses on Arabs in different regions, identifying: 1) help-seeking behaviours, 2) help-seeking attitudes, and 3) help-seeking barriers and facilitators, relating to mental health.
Methods
This review was registered on PROSPERO (CRD42022319889), and reported in accordance with the PRISMA guidelines [27].
Search strategy
An initial search was performed in March 2022 and then updated on June 1st, 2022 to include papers published from inception up to that date. Five databases were systematically searched including MEDLINE, PsycINFO, Embase, CINAHL, and ProQuest Middle East & African database. Grey literature from the mentioned databases was included. The search terms were developed using PICO framework and synonymous text words and MeSH terms were used to inform search terms associated with the following four concepts: 1) Mental Health, 2) Arabs, 3) Help Seeking, 4) Experiences and behaviours. The search was limited to English, and search terms were tailored to each database and combined using Boolean operators. Studies identified in this process were exported to EndNote 20 and then to Covidence (a systematic review manager). Duplicate papers were removed, and a priori inclusion/ exclusion criteria applied to initial screening of titles and abstracts, and then for full text review. Full text papers that could not be retrieved were accessed upon request from the UCL library services. 50% of the included full text papers were screened by an independent reviewer. Any conflicts were resolved in consultation with two independent reviewers (MS & AA).
Eligibility criteria
Inclusion
Both qualitative and quantitative studies on mental health help-seeking behaviours, attitudes, and facilitators or barriers to help-seeking were included. Studies reporting on factors that influence mental health help-seeking in Arabs were also included. Mixed-methods studies were included when providing relevant qualitative and/or quantitative data. This review included papers that reported on these outcomes even if not identified a priori as a research objective. Help-seeking was understood as seeking help from informal sources (family, friends, online sources, self-help resources) or formal treatment (GP, mental health professionals, etc.). Participants had to be 18 years or older and from Arab ethnicities from any of the 22: (Bahrain, Lebanon, Jordan, Iraq, Oman, Qatar, Saudi Arabia, Syria, Egypt, Palestine, Kuwait, UAE, Yemen, Algeria, Libya, Morocco, Somalia, Sudan, Tunisia, Djibouti, Comoros, Mauritania) and were considered regardless of geographical location, gender, or religion. Papers with immigrant and refugee Arab populations were included to capture similarities and differences in experiences compared to those residing in Arab countries. The review included the perspectives of clinicians and carers to understand their different perspectives, if any. All studies on Arabs and mental health help seeking were included ranging from inpatients, outpatients, and other informal sources to those that have never sought support or services. For this review, no limitations were placed on the type of mental illness or concern to capture experiences and perspectives of non-diagnosed individuals as well.
Exclusion
Papers that addressed help-seeking in relation to non-mental health concerns and/organic causes such as physical or developmental illnesses were excluded. Studies with participants below 18 years of age or with parents seeking help for their children were excluded. Studies were excluded if data for Arab participants could not be extracted independently from the rest of the sample. Articles written in languages other than English, literature and commentary reviews, protocols, and case studies were excluded.
Data extraction
Data for included studies were extracted using a predefined form and identified: Author, year of publication, country, study design, sample number, demographic characteristics (age/nationality), outcomes, and key findings on attitudes, behaviours, and factors influencing mental health help seeking.
Quality assessment
The Mixed Methods Appraisal Tool (MMAT) [28] previously validated and used in various mixed methods systematic reviews [29] was used for quality assessment, given the variety of study designs included in this review. The MMAT included a specific checklist to evaluate main features of each study design. Each checklist had criteria to evaluate the most relevant aspects of the specific study design (e.g.: for qualitative papers, “was the qualitative data collection method adequate to address the research question?”) with possible responses of “yes”, “no”, and “can’t tell”. An independent second reviewer (AB) rated 10% of included studies for quality assessment, assessing an equal number of papers from each study design. Overall study quality was not used as an exclusion criterion because we opted to be overly inclusive to gain a sense of the methodological quality of available evidence and provide a comprehensive overview of mental health help-seeking experiences in Arabs across countries.
Data synthesis
A narrative synthesis was adopted to synthesise results by describing, comparing, and combining findings across included studies [30]. Due to the overlap between quantitative and qualitative data, findings were identified and grouped based on the outcomes of the review: help-seeking behaviours, attitudes, and barriers and facilitators. Results for each outcome were discussed by organising findings into prominent themes evident across studies. Differences and similarities of help seeking experiences for Arabs immigrants and refugees compared to Arabs in Arab countries were highlighted. Relevant findings are discussed from various perspectives such as mental health professionals and carers when applicable.
Results
A total of 4215 papers were identified through database searching. After removing duplicates, 2824 papers were screened for titles and abstracts, and 2645 records were excluded. Access to one paper was not provided during the screening period and 179 articles were then retrieved for full-text screening. A total of 74 studies were eligible for inclusion. Reasons for exclusion of full-text papers after the screening stage and details of the literature search are reported in Fig. 1.
Fig. 1
PRISMA diagram. Flowchart for study selection and inclusion
×
Characteristics of included studies
The final 74 studies in this review included qualitative (n = 28), quantitative (n = 41), and five mixed methods studies. Nine PhD dissertations were retrieved from the initial search and included as grey literature. The characteristics of each study are presented in Table 1. Most of the studies were conducted in the United States (n = 12), followed by Israel (n = 8), and both Jordan (n = 6) and Australia (n = 6). One study collected data in three countries (Palestine, Egypt, and Kuwait), and one study was conducted online across several countries. All studies were published between 2002 and 2022.
Willingness among majority to seek help for psychological problems
Barriers: social stigma, misconception of role of psychologists or services, lack of awareness or knowledge of psychological disorders, mistrust, and lack of confidence in professionals, financial difficulties
> 20 year old carers of mentally ill patients and psychiatrists
Barriers to mental health services utilization
Barriers: beliefs around mental illness, resorting to alternative treatments (religious and traditional healers), centralization of mental health services, inadequate number of mental health staff, and mental health not being a priority by policy makers
Psychiatric consultants identified stigma, cost of medications, and worries about medication’s side effects
Attitudes and mental health-seeking patterns in 3 major religious minorities
Higher interpersonal openness, less stigmata towards services, less likely to use traditional healing systems in Christians compared to Druze and Muslims
Attitudes towards seeking and formal MH services influenced by cultural and traditional beliefs about MH problems, knowledge and familiarity of services, perceived societal stigma, use of informal services
> 24 year old Jordanian and Syrian Mental health professionals working with refugees
Barriers to seeking mental health treatment and ability of local systems to provide services
Barriers: Financial, stigma, systemic/organizational (distrust in the system, accessibility, misdiagnosis, and lack of screening in primary settings, shortage of mental health professionals, communication and language, legal/immigration barriers), stigma, awareness and education, limited accessibility
Moroccan migrants did not differ in uptake of specialized mental health services compared to other non-Arab ethnicities in presence of a common mental disorder
Difference in uptake for psychological distress. Moroccan migrants less likely to report uptake of primary care for mental health problems
Factors promoting seeking mental health care and beliefs about counselling
Religion, education, age
Use of help from community members
Distrust and Ambivalence for Western Mental Health Care
Barriers to Western Mental Health Care: confidentiality and stigmatization of mental health, experiences as refugees and as a cultural minority in dominant culture, assumed lack of multicultural competence ascribed to mental health practitioners
Help-seeking behaviours and barriers to accessing care
Preferred sources of help in order: self-help, family/friends, professional services last
Barriers: preferred to handle problem alone, did not know where to go, stigma/infrastructural barriers (wait times, travel distance, not having needs met)
Challenges and experiences in assessing mental health problems and barriers to accessing mental health care
Barriers: language, lack of knowledge about existing services
Health provider's mentioned barriers: higher prioritization of daily life challenges, physical health problems and their low level of awareness on available services
Determinants and barriers of seeking help for mental
disorders
Barriers: perceived severity of problem and perceived need, financial, uncertainty about where to go and who to see, logistic (transportation/appointments), dissatisfied with previous treatment
Female gender, higher education, and income predictors of positive attitudes to help seeking
Structural and socio-cultural barriers to accessing
mental healthcare
Basic needs prioritized, gender, mismatch between western system of diagnosis and needs perceived by refugees, stigma, lack of awareness of services, lack of resources, language, lack of awareness of the health system
Views on accessing appropriate healthcare and ideas to improve access and reduce barriers
Religious healing, medication, community support and services expressed as potentially helpful treatments
Barriers: unsure where to access services, language barriers, long waiting times and a lack of continuity with seeing different medical professionals, mistrust of perceived authority figures and fear of going to the doctor or getting treated due to potential economic repercussions
Knowledge, attitudes and perceptions towards health services and barriers that affect willingness to seek psychiatric help
Many unaware about psychiatric services available in the kingdom
Reports of not seeking help when needed psychiatric help when needed
Shame felt in relation to help-seeking
Male gender, > 20 years old, not knowing whether a relative is suffering from mental illness and not knowing about the services provided by psychiatric health services associated with unwillingness to seek psychiatrist consultation
Understand preferred coping strategies (in this paper
refers to the way in which people prefer to react to or
deal with depression, including help seeking behavior
and preferred treatment)
Strong preference for coping with depression by religious practices and reliance on family, friends, and religious community, rather than by seeking professional treatment from public health services
Barriers and facilitators of seeking mental health support
Barriers: public stigma and lack of awareness, unprofessional practitioners, lack of accessibility to services and information, unsupportive families, intrapersonal dilemmas, and misconceptions based on religious beliefs
Facilitators: increasing societal and family awareness, promoting the accessibility of services, enhancing sources of external support, personal motivation to change, and online therapy
> 18 year old Lebanese hosts and Syrian refugee community members
Health seeking behaviors and barriers to health
access
Women more likely to seek support
Informal help sources first choice of support
Barriers: significant delays in seeking help from formal services, social stigma, service costs, lack of health coverage, limited awareness of service availability, limited trust in the quality of services available
Views on Western-based professional help and barriers
to treatment
Barriers: stigma, difficulty disclosing (fear of judgement, privacy, cultural norms of enduring difficulties), GP lack awareness of cultural backgrounds, fear of diagnosis and treatment,
M = 28 year working and non-working Egyptian Females
Stigma and attitudes toward seeking psychological
help
Social support and personal stigma predict total self-stigma and attitude towards seeking mental health services
Less stigmatized views in working females
Help-seeking was operationalized differently across studies and included information on help from professional personnel and formal services, as well as support from informal sources like friends, family, the internet/digital help, and religious faith healers. Since information on the mental health status of participants was not always provided and data focused on hypothetical scenarios, conclusions drawn by many of the articles were therefore based on attitudes towards help-seeking and help-seeking intentions regardless of if individuals ever sought support, rather than actual behaviours.
Overall, measures of help-seeking were heterogeneous across studies. Of the studies that used quantitative measures related to help-seeking outcomes, 21 studies utilised tools developed by the researchers consisting of questionnaires and surveys relying on self-report. Other studies used validated measures related to help-seeking attitudes and behaviours such as the Attitudes Toward Seeking Professional Psychological Help (ATSPPH).
Quality assessment
According to The Mixed Methods Appraisal Tool (MMAT), the studies included in this review ranged in methodological quality and the supplementary file provides detailed information on the quality of every study. 19 papers totally met the specified criteria for qualitative studies (i.e. had “yes” as an answer on all five criteria), and nine papers partially met the criteria (i.e. had “yes” as an answer on 2 to 4 of the five criteria). No papers did not meet the criteria (i.e. had “yes” as answer on 0 to 1 of the five criteria). Overall quality of papers was good given that appropriate qualitative approaches were adopted and adequate data collection methods such as in-depth interviews and focus groups were used depending on the research questions. The main issue identified was the interpretation of results not always sufficiently substantiated by data. Papers did not always provide quotes from participants to support the interpretations of themes, which is especially important given that many papers performed a thematic analysis. Additionally, few papers provided a clear strategy addressing the subjectivity of the author’s position in terms of data interpretation and hence researcher reflexivity was not sufficiently addressed.
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The majority of quantitative descriptive studies (n = 35) partially met, one study totally met, and two studies did not meet the specified criteria. In terms of quantitative non-randomized studies, all three included papers partially met the specified criteria. The most common problem linked to inconsistency regarding measurements of help-seeking, most studies using self-developed tools to address help-seeking rather than standardised measures. Use of purposive or convenience sampling in most of the studies made it difficult to ensure that participants were representative of the target population. Additionally, description of characteristics of non-responders was not given, making it difficult to generalise results of studies. Use of self-report measures may have also increased risk of biased findings, however anonymous questionnaires could have decreased the effects of social desirability on participant responses. Importantly, many studies did not provide clear information on missing data, and most studies did not consider the role of confounders which could affect the interpretation of results.
Lastly, two mixed methods partially met the specified criteria, two studies did not meet the criteria, and one study totally met the specified criteria. The main consideration is that some studies did not provide an adequate justification for using a mixed methods design or effectively integrate the qualitative and quantitative findings. Divergences between qualitative and quantitative results weren’t addressed in multiple papers. The studies also presented some inconsistencies in addressing specific components of both qualitative and quantitative research. Hence, the overall quality of the empirical work in this area is of a useful research standard, however limitations to presented results should be taken into consideration.
Outcomes and related themes
Help-Seeking behaviours and attitudes
Few studies addressed help-seeking behaviours and included information on actual help-seeking rates and use of support or services (n = 11). Many studies provided information on help-seeking attitudes (n = 47), however, definitions varied across papers encompassing a range of concepts including help-seeking preferences, perceptions, acceptability, as well as intentions (likelihood/willingness). Papers reported on more than one dimension of help-seeking attitudes.
Rate of help-seeking and service utilisation
Despite the need for psychological support, studies generally indicated low rates of service utilisation. Arabs (whether in Arab countries, immigrants, or refugees) were less likely to visit mental health professionals and reluctant to seek help for mental health problems from formal services compared to other non-Arab ethnicities. One study found Arabs immigrants were equally likely as Turks to access specialised services for a common mental disorder, however less likely to use primary care services in relation to psychological distress [59]. Six studies considered associations between factors such as gender, symptomatology, age, and help-seeking behaviours. Papers reported that men used services more than women [44, 96, 100]. Several papers suggested that distress and level of symptomatology, mostly past traumatic events, are associated with increased use of mental health services in contrast to other studies reporting no association [85, 90]. One study mentioned that being older was associated with increased help-seeking [101]. However, another study did not find associations between neither age or sex and help-seeking behaviours [98].
Help-seeking perceptions and preferences
Fiftteen studies discussed help-seeking perceptions. Overall, less favourable and fewer positive perceptions were expressed towards use of formal service, and this was true when comparing Arabs to other ethnicities. One study indicated high acceptability and willingness to try an internet-delivered treatment [70]. Three studies with student participants highlighted enthusiastic and positive attitudes towards counselling and professional care [35, 38, 79]. Two studies highlighted mixed views to therapy, in both refugee and immigrant samples [50, 99]. One study found differences based on nationality, whereby Palestinian and Israeli Arabs reported a greater preference to seek mental health treatment for a psychological problem when compared to Kuwaiti and Egyptian Arabs [45], however, another did not find differences based on country of origin [71].
Twenty-three studies described help-seeking preferences and indicated Arabs largely endorsed traditional and informal help sources. Arabs residing in different countries, immigrants, and refugees, were all more likely to use culturally accepted means of help such as friends, family, religion, or self-help. Faith was an important help strategy and talking to or confiding in family members was considered important. Surprisingly, three studies reported a preference for seeking help from mental health professionals and mentioned physicians and GP as first line of contact [71, 75, 93]. Primary care providers in one study did not endorse religion or self-help when identifying informal help-seeking behaviours [52]. Interestingly, other results indicated that Arabs born in Australia were more likely than Arabs born in Algeria, Egypt, Iraq, and Yemen to willingly consult a mental health professional [70]. Suggested reasons included not being able to afford visits to mental health professionals due to high poverty rates for Arabs living in Arab countries, and low levels of mental health literacy compared to Arabs living in Australia.
Factors influencing help-seeking attitudes
A total of 21 studies considered factors influencing help-seeking attitudes. Almost all studies considered student and immigrant samples, and the most common factors were mental health literacy, stigma, gender, age, education, religion, acculturation, and immigrant status. Three studies suggested that beliefs and knowledge about mental health and awareness of services predicted favourable help seeking intentions [49, 60, 78]. Only one study found no relationship between beliefs towards mental illness and help-seeking [79]. One study reported that mental health courses had positive effects on attitudes toward seeking professional psychological help [33], suggesting the importance of psychoeducation, mental health literacy, and anti-stigma campaigns.
Eight studies suggested stigma predicted lower help seeking intention and less favourable attitudes. Only one study reported that shame-focused attitudes did not predict help-seeking attitudes [64]. Mixed findings for religion as a predictor of help-seeking among students was indicated. Compared to Druze and Muslims, Christian subjects in one study were higher in interpersonal openness, perceived mental health services as less stigmatising, and were less likely to use traditional healing systems and therefore more likely to seek formal help if needed [46]. Contrastingly, religiosity did not have a significant relationship on help-seeking attitudes in other studies [58, 71].
Nine studies reported that gender predicted help-seeking attitudes, whereby females reported higher help-seeking intentions than men and more positive attitudes. One study considered that females showed higher knowledge of mental illness which could explain higher levels in help-seeking intentions [60], and another study suggested men were more likely to feel stigmatised [35]. Two studies did not find a significance for gender in relation to help-seeking attitudes [64, 71].
Four studies indicated age predicted help-seeking attitudes. Two studies supported that younger respondent had fewer positive attitudes compared to older individuals. Additionally, educational attainment was a predictor of positive attitudes to help-seeking in four studies, one study indicating that first- and second-year students had fewer positive attitudes [47].
Four studies suggested association between acculturation and help-seeking. One study did not [58]. Studies generally reported that higher acculturation impacted attitudes to formal services and one study suggested that the adoption of mainstream culture was associated with semiformal and formal help-seeking [82]. Interestingly, immigrants in one study with greater levels of mainstream acculturation had higher levels and willingness to seek help [53], and another study suggested that greater time in host country predicted more positive attitudes among immigrants [64]. Furthermore, second generation immigrants were more likely to utilize mental health services compared to first generation, who were more likely to use culturally accepted means like friends and family [32].
Help-seeking barriers and facilitators
Barriers and facilitators to help-seeking were significantly reported (n = 46) and were conceptualised as factors hindering or promoting help-seeking attitudes and behaviours. The majority of findings were reported in relation to formal mental health care rather than informal sources of support.
Help-seeking barriers
Stigma
More than half the studies (n = 34) referred to stigma as a primary obstacle to help-seeking. Both individuals residing in Arab countries and non-Arab countries including refugee and immigrant samples mentioned existing stigma at multiple levels of immediate and larger environments. Refugees experienced stigma, reporting discrimination by mental health professionals in host countries as a barrier to help-seeking, whereas clinicians reported refugee’s avoidance of care due to stigmatisation related to psychiatric diagnosis or treatment.
Privacy and confidentiality
To a lesser extent, eight studies reported the issue of privacy and confidentiality as a barrier to seeking help. Overall, individuals worried their confidentiality might be breached or knowledge of their mental health issues might circulate around the community, defecting their image or reputation. Only one study considered electronic mental health services among Arab students in Egypt [80], and another study considered refugees and Lebanese community members in Lebanon [88]. Issues surrounding privacy and confidentiality were otherwise only conveyed by refugee and immigrant samples, however this was less of an issue in host countries compared to their countries of origin [34]. Interestingly, worries about confidentiality were expressed in relation to the use of interpreters in two studies [31, 76], whereby individuals hesitated to share their experiences with professionals in the presence of interpreters describing them as unreliable and non-confidential, especially within a small community of Arabs.
Mental health literacy
The second most mentioned barrier was mental health literacy which refers to the knowledge and beliefs about mental illness and available help including recognition, management, and prevention [105]. 28 studies reported lack of awareness regarding where to access mental health services and knowledge on mental health in general across respondents in different countries, professionals, and carers, as well as refugees. This included misattribution of symptoms and causes of mental health, and misconceptions of the role of psychologists. Only one study indicated high levels of mental health literacy regarding knowledge of available professional help [72]. Perceived severity of the problem and ability to recognize need for help, explained preferences to deal with the problem alone. Those who never had a mental health issue preferred self-treatment compared to people who experienced mental health issues before or knew someone who did [67]. Unfamiliarity and beliefs about treatment were also cited as a reason for not seeking help from formal services.
Logistical barriers
Seventeen studies referred to logistical barriers which hindered help-seeking. Long wait times for appointments, financial costs, availability of services and staff, and transportation were commonly reported. Arab adults residing in Arab countries, refugees, and immigrants, as well as service providers and family carers reported financial limitations specifically, including issues with initial consultation, continuing care, and medication costs. One quantitative study exceptionally found lower financial issues among refugees to be associated with lower help-seeking [101]. This could be that refugees experiencing financial hardships and other difficulties were receiving support from other social services.
Language
Language and communication barriers were reported in ten studies, primarily by refugee populations and Arabs in non-Arabic speaking countries. Service providers working with a refugee population in one study mutually reported language as a barrier [51]. Individuals reported difficulties in approaching professionals due to language barriers finding it challenging to express themselves. Language differences between host communities and the refugees made it tough for individuals to articulate needs and explain problems when speaking to a professional. The use of interpreters facilitating language differences also raised concerns regarding misinterpretation and miscommunication in translation.
Cultural barriers
Cultural barriers to help-seeking were mentioned in ten studies. Lack of multicultural competence of professionals and difficulties feeling understood were especially reported by refugees and immigrant minorities in non-Arab countries, whereby individuals expressed a mismatch between needs and available western mental health services. Resorting to alternative ways to getting better that were more culturally appropriate such as religious or traditional healers also influenced the likelihood to seek help from formal services. Interestingly, one study reported cultural norms of enduring difficulties rather than seeking help [92]. One study mentioned that Syrian refugees were more likely to seek help from formal services in Norway compared to Syria due to cultural differences between the two countries and acceptability of treatment [31]. Service providers in one study [41], and refugees in another study [73], mentioned higher prioritisation of daily life challenges and physical health problems as reasons to not seek help.
Trust
Ten studies revealed trust as an important barrier. Immigrant and refugee populations in two studies expressed distrust in western mental health care systems [62, 94], and this was supported by one study with mental health professionals working with refugees [51]. Issues surrounding mistrust and lack of confidence in competency and transparency of professionals were revealed, mostly in refugee and immigrant samples. Participants felt reluctant to disclose personal information having limited trust in the quality of services.
Help-seeking facilitators
Out of the 74 included studies, facilitators to help-seeking were significantly less reported (n = 4). One study mentioned increasing societal and family awareness, external support, encouragement of seeking support, the want to change, and online services, as facilitators to help seeking [88]. Professionals in two qualitative studies working in Arab and non-Arab countries expressed that a shared culture between client and therapist is an important facilitator to treatment [63] and the quality of doctor patient relationship influences likelihood of seeking or continuing treatment [37]. Refugees in one quantitative study established that feelings of connectedness with the host country and social integration play a role in promoting help seeking from a GP [65].
Other factors
Some studies reported mixed findings for the role of religion, and family and community, in relation to facilitating or hindering help-seeking. Two studies regarded religion as a barrier, and this was expressed by carers of people with mental illness and psychiatrists [41, 99]. Interestingly, being from a certain religion compared to others either facilitated or hindered help-seeking. Refugees and immigrants in two studies indicated certain interpretations in Islam perceived mental illness as a form of punishment from God and therefore considered seeking treatment to be against God’s will [83, 94]. Seeking help from religious healers was less stigmatising and more confidential. However, in one study, Arabs described how faith facilitated help-seeking and described the convergence between Muslim values and help-seeking [39].
The role of family and community members was expressed as a barrier to help-seeking in two studies, with individuals expressing discouragement from family members to seek psychiatric help [66, 103]. Conversely, two studies described how positive influence from social networks facilitated help-seeking [75, 77]. Three studies identified the role of family and community support as being both facilitating and hindering help seeking [40, 63, 88]. One study found no association between parental support and help-seeking attitudes [79].
Discussion
To our knowledge, this systematic review was first to explore experiences of mental health help-seeking among Arab populations globally. The 74 identified studies demonstrated that Arabs across countries portrayed similarities in help-seeking behaviours and attitudes, identifying common barriers and facilitators in their experiences. Participants largely varied in age, gender, occupation, geographic location or residence, and range of mental health problems.
Results indicate common mental health difficulties among Arabs across countries, however, rates of help-seeking are generally low and individuals use formal services less than other non-Arab ethnicities. This is consistent with findings from a systematic review on Filipino ethnic minorities across countries, where high levels of psychological distress but low utilisation of mental health services were found [11], and comparable to Chinese, South Asian, and Southeast Asian immigrants [106], African American and Hispanic populations [107], and other ethnic minorities [108]. There is a lack of data regarding factors influencing help-seeking behaviours. Mixed findings associating higher distress levels and symptomatology and increased help-seeking were found. Research generally reports on levels of distress in relation to help-seeking attitudes rather than behaviours, however, clinical characteristics partially explain the type of help-seeking in Chinese populations [109]. Older people and males were more likely to use services in this review. These factors are also reported as determinants to help-seeking in the literature [110, 111]. People might perhaps not seek help in a timely way when symptoms emerge, or younger individuals might start with lower symptom levels therefore not seeking help at a young age. However, as people get older and remaining difficulties increase in severity, they might be more likely to seek help.
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Furthermore, Arabs across countries have negative attitudes towards formal help-seeking, reluctance to seek help, and preferred informal sources of psychological support. These findings are consistent with help-seeking attitudes in Filipino [11], Asian American [112], and Indian ethnic minority populations [113]. Differences in help-seeking attitudes among Arabs from different countries is not thoroughly addressed in existing literature, and only one study found differences [45], while another did not [47]. Therefore, future research should consider how a country of origin may influence help-seeking attitudes. Contextual influences on Arab help-seeking attitudes should also be considered in future research, as only two studies highlighted that Arabs in non-Arab countries show higher willingness and acceptability to visit a mental health professional overseas in contrast to their native country [31, 70]. However, included studies generally suggested that higher acculturation and more years spent in host countries by refugees and immigrants predicted favourable attitudes to help-seeking. A study with similar results indicated higher levels of acculturation meant more positive attitudes toward seeking help among Vietnamese Americans [114]. This could explain exposure and acculturation to cultures that are more tolerant of mental health stigma, probably influencing more favourable attitudes to formal services.
The influence of stigma and gender on help-seeking attitudes was highlighted in included studies. Conceptualizations of mental illness and societal stigma influenced willingness and intentions to seek help and predicted fewer positive attitudes to help-seeking. This is consistent among European ethnicities [115]. Gender predicted help-seeking attitudes and although men had higher rates of service use, they endorsed less favourable attitudes to help-seeking compared to women. This contrasts with studies suggesting attitudinal barriers as predictive of service utilisation [116], where men displayed less favourable attitudes and lower help-seeking behaviours [117]. It is unclear why high intentions to seek help among women did not reflect higher help-seeking behaviours, but this may suggest differences in barriers to help-seeking between men and women. Gender differences in help-seeking attitudes compare to other findings [118], and a previous systematic review suggested conformity to traditional masculine gender norms impacts attitudes related to help-seeking and may explain less favourable attitudes among men [119]. It might be that Arab men are less likely to seek informal support from friends and family due to stigma and fear of how they may be perceived as weak and more likely to utilise formal services. However, results from one study highlight that women and men have largely similar attitudes about informal help seeking, and only differ in attitudes towards formal help-seeking [120].
Although other factors affecting help-seeking attitudes such as mental health literacy, age, educational attainment, and religion were not among the most cited in the review, some interesting points can be made. Mental health literacy predicted more positive attitudes to help-seeking and this is comparable to other populations [121], and to Arab student’s attitudes in this review. Only one study contrastingly documented pessimistic attitudes and high levels of mental health literacy among students in this review [72]. Studies simultaneously indicated that older age and higher educational attainment were associated with more positive attitudes to help-seeking. These findings are contradictory, suggesting other factors specific to the populations sampled in the included studies may explain these observations.
Prominent barrier themes to help-seeking in this review are consistent with commonly reported obstacles to accessing care and seeking psychological support among Asian Americans [122], Asian and Latin American adolescents [123], and refugees in high income countries [124]. Stigmatisation of Arab individuals by society and one’s own stigma toward mental health treatment remained a major barrier to mental health treatment. Stigma is repeatedly reported as a significant barrier to help-seeking in previous reviews [11, 125, 126], and among ethnic minority populations and refugees across regions [127, 128]. Fear of cultural and societal stigma stemmed from individuals possibly being treated differently and marginalised because of labels, avoided in social situations, or isolated by community members. Mental health literacy was the second most prominent barrier to help-seeking, and misinformation or a lack of information about mental health and available services was also a barrier in a review on East Asian immigrants [129]. Practical barriers to the use of mental health services like accessibility and financial constraints also hindered help-seeking in similarity to reported barriers among ethnically diverse and impoverished women [130] and black and ethnic minority communities [131]. The deterrent roles of language differences, trust, privacy, and cultural differences were reported less, however, they were especially applicable to immigrant and refugee populations. Similar findings have been reported in non-Arab refugee and immigrant samples suggesting negative experiences in host countries may discourage individuals from seeking help [132].
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Facilitators to help-seeking were much less reported, precluding many conclusions from being drawn. Facilitators including social integration in host countries and culturally competent staff were expressed by refugees and immigrants as promoting treatment. Most literature only reports barriers to treatment among refugees. However, one study considered use of services aiming to facilitate settlement reporting a positive association between inter-ethnic networks and use of those services [133]. It is difficult to conclude a certain association between refugee integration and mental health help-seeking, but literature suggests the importance of social integration on mental health [134].
One study in the review reported that quality of doctor-patient relationship influences the likelihood of seeking and continuing treatment [37]. A systematic review reported that certain characteristics and behaviours of professionals such as empathy and trustworthiness helped patients with post-traumatic stress disorder (PTSD) feel comfortable, and competent caring providers were key in initiating help-seeking and continuing care [135]. Immigrant and refugee women with postpartum depression (PPD) also reported health care relationship as a critical determinant to seek and accept help [136]. More research is needed to understand facilitators to help-seeking for Arabs, especially among non-refugee and non-immigrant Arab samples. Consideration of adults who sought help from services would aid our understanding of real-life factors leading to seeking help.
Conflicting findings on factors that served both as facilitators and barriers to Arab help-seeking were concluded upon synthesis of the studies, specifically: (1) Role of family and community; (2) Religion.
O’Mahony et al. [136] similarly reported social networks as being supportive or non-supportive with effects on psychological health and well-being, and perceptions of need for care within close networks (i.e., told by family/friends to seek professional help) were reported as significant predictors of service use among Latinos in the United States [137]. A study documented spouses and children as key reasons patients were motivated to engage in treatment [135], and social support from family and friends played an important role in professional help-seeking for suicidality [138]. Contrastingly, lower perceived social support from family was a significant predictor of positive help-seeking attitudes and greater help-seeking behaviour among Mexican American students [139]. This could be individuals feeling an increased need to seek out help if they sense a lack of support from social networks around them.
Religion is not consistently reported in the literature and one study documented religion and spirituality as barriers to mental health help-seeking among African American youth [140]. Greater distrust towards healthcare systems and concern surrounding social stigma associated with seeking treatment was expressed among religious clients in one study [141]. Literature suggests that mental health attributions and causal beliefs regarding the aetiology of mental illness influence help-seeking behaviours [142], whereby ethnic minorities are more likely to mention spirituality causes to mental illness [143]. This might explain why individuals are less likely to access formal services and rely on faith-based healers and spiritual treatments.
Strengths and limitation
This review was first to assess a wide range of mental health help-seeking related outcomes in Arab populations around the world. The robust systematic search strategy aimed to strike a balance between precision and sensitivity, using optimal database combination. We chose to preserve sensitivity and comprehensiveness to capture relevant published literature. We adhered to the PRISMA guidelines to conduct and report systematic reviews, and independent reviewers were included in the screening stage. The mixed methods appraisal tool (MMAT) utilised in previous systematic reviews and with demonstrated validity and reliability was chosen to assess quality of included studies.
Several limitations also need to be considered. Firstly, participants of included studies had to be 18 years of age or older, meaning studies with elderly populations were included, and help-seeking for younger and older adults may differ due to generational differences [32]. Additionally, needs of refugee populations may differ from immigrants and therefore require alternative help-seeking pathways. Moreover, this review prioritised the overinclusion of studies for a comprehensive picture of the existing evidence regarding mental health help-seeking in Arabs. As a result, the analysis included low quality studies, and this affected the interpretation of the findings. Additionally, most quantitative studies were cross-sectional, making it difficult to determine temporal directions of associations which is necessary to establish causality. Many of the included studies were low in external validity using convenience sampling, making it difficult to generalise results. A crucial limitation pertained to differences in help-seeking measures and definitions used, making comparison of results difficult. The heterogeneous nature of studies did not allow for a meta-synthesis. The measures were western-based inventories, and therefore may not have suited cross-cultural research on Arab participants. Lastly, the search was restricted to the English language. However, no appropriate papers in a non-English language were found during the soft search prior to the systematic search and therefore this is unlikely to have been a considerable limitation.
Implications
This review highlights gaps in the literature proposing several implications for research, practice, and policy. Although help-seeking behaviours and attitudes are separate constructs, many studies in this review reported help-seeking intentions and attitudes as actual behaviours. Hence, future research needs to further operationalize these definitions. Most data reported on help-seeking attitudes and intentions rather than actual behaviours, therefore, future research should focus on actual utilisation rates of services to gain better understanding of factors that influence help-seeking behaviours. Majority of studies discussed help-seeking barriers rather than facilitators and a focus on factors promoting help-seeking is needed in future research. Results showed that help-seeking is more problematic for Arabs in their native countries and that acculturation in host countries allows for better engagement with services and help sources. Therefore, increasing mental health literacy to reduce stigma through psychoeducation and anti-stigma campaigns could be employed to encourage help-seeking. Interventions targeting friends and family could be useful in changing help-seeking attitudes and behaviours, as they might motivate and encourage individuals to seek help from mental health services. The importance of culturally informed interventions and the need for Black, Asian and minority ethnic (BAME) representation amongst healthcare professionals has been documented in various studies [129, 144, 145]. Such efforts may provide solutions in overcoming barriers to help-seeking among Arabs, allowing individuals to receive treatment from professionals they can relate to on an ethnic and cultural basis. Finally, mental health legislations should focus on areas such as prevention, early identification and intervention, and integrated care and recovery, for Arab populations in different countries. Policies designed to address the status of Arab immigrants and refugees in order to recognize, protect, and facilitate their ability to seek mental health support is especially needed.
Conclusion
The findings of this review highlight that help-seeking among Arab populations globally, is influenced by cultural and to some extent by religious values, mental health literacy, and stigma.
Despite expectations of the role of migration and acculturation that might influence help-seeking behaviours and attitudes, only few findings showed that the process of acculturation in host countries can increase the likelihood and acceptability of help-seeking. There still remains a high proportion of those in need of mental health support who may not access services, as individuals fundamentally hold onto cultural beliefs regardless of where they live. Additional logistical barriers that influence help-seeking in host countries among immigrated individuals include factors related to language and culture.
This review highlights the importance of increasing mental health literacy through psychoeducation and anti-stigma campaigns, developing culturally appropriate and accessible clinical interventions, and ensuring that clinicians are representative of the populations they serve.
Acknowledgements
Veronica Parisi.
Declarations
Ethics approval and consent to participate
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Competing interests
The authors declare no competing interests.
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