Theoretical Framework and Rationale for study

A number of theoretical models have been adopted to explain health-seeking behaviours (see the review by MacKian, 2003). Among the most widely investigated are the Health Belief Model (Hochbaum, 1958) and The Theory of Planned Behaviour (Azjen, 1991). The explanatory power of the Health Belief Model (HBM) is based on the individual's perceptions of susceptibility (beliefs regarding the prospect of getting the disease or being harmed by the condition), severity (appraisal of the disease consequences), benefits (a consideration that the benefits of a prescribed action outweigh its barriers) and barriers (e.g. the embarrassment that may go with seeking help or material limitations). Other predictive variables of this model include the presence of an internal or external stimulus (cue-to-action), health motivation (a general predisposition towards health) and self-efficacy. The Theory of Planned Behaviour (TPB) implies rational processes in deciding whether or not to perform a given behaviour. It proposes that behaviour is informed by the strength of the subject’s intention (the cognitive representation of one’s readiness to carry out a given behaviour) and the degree of actual control the individual has over carrying out the behaviour (the extent to which a subject posses the requisite skills and resources necessary for the performance of a given behaviour). Strength of intention is determined by attitude (conceptualized as the

181 degree of an individual’s overall favourable or unfavourable evaluation of the behaviour being appraised), the subjective norm of the subject (social pressures and the motivation to comply with these expectations) and perceived behavioural control (subjects’ perceptions of their capacity to carry out the behaviour).

A meta-analysis of the Theory of Planned Behaviour (Armitage & Conner, 2001) supported the effectiveness of the theory which accounted for 39% and 27% of the variance in intention and behaviour respectively. The utility of TPB in understanding a variety of health behaviours has also been noted including; condom use (Albarracin, Johnson, Fishbein & Muellerleile, 2001), physical exercise (Hagger et al., 2007), cancer symptoms detection (Hunter, Grunfeld & Ramirez, 2003) and smoking cessation (Higgins & Conner, 2003). As MacKian crucially observed however, the central flaw of these models that evolved in the West is the over-reliance on the individual and the centrality of cognitive processes. This loses the sense that individuals are rooted in social contexts that affect in a far more complex manner the way they process and act on information. This becomes even more overriding in collectivist cultures and may explain why ethnicity considered non-central to these models has proved to be an important determinant of help- seeking behaviour (Edge & MacKian 2010; Shefer et al., 2013; Cheng, Kwan, & Sevig, 2013; Conner et al., 2010). Indeed, the complex interactions between culture and other contexts that so often characterise the lives of those at risk of psychological disorders have been identified at the centre rather than the periphery of human development (Cauce et al., 2002).

Whereas Ajzen expected universal patterns of influence across the key TPB constructs, sample-specific variations on the relative contributions of the constructs c a n b e observed (Deane, Skogstad & Williams, 1999; Walker, Courneya & Deng, 2006). For instance, the degree to which the views of significant others would count in the ultimate decision to seek help is expected to vary between individualistic and collectivist

182 cultures. Predictably, based on Western samples, the subjective norm (social forces) is generally considered a weaker predictor of intention compared to the more persona- centred attitude construct (see the meta-analysis by Armitage & Conner, 2001). It accounted for only 3% of the variance in the intention to seek help compared to the 23% of attitude (Bayer & Peay, 1997). Considering it inadequate and rarely predicting intention, some researchers have removed it from analysis (Sparks, Shepherd, Wieringa, & Zimmermanns, 1995). On the contrary, significant others including family and friends were major determinants of intention to seek help in samples from collectivist cultures. In a Northern Nigerian sample, initial contact with care providers was initiated by relatives and friends in over 4 in 5 of the cases (Aghukwa, 2012). Similarly, among a south-eastern Nigerian sample, initial contact with services was initiated by significant others in nearly 91% of cases (Aniebue & Ekwueme, 2009).

Focus on the individual and symptom rather than on the experience of the individual may illustrate the Western bias toward scientific objectivism (Cauce et al., 2002). Hence, such theories are limited in applicability to inform decisive intervention plans in cross-cultural settings. Furthermore, considered from such person-centred perspective, the concept of help- seeking appears somewhat over-utilised for describing how individuals engage with services but under-theorised for understanding how populations engage with health systems (Mackian, 2003). MacPhail and Campbell (2001) underscored the need to develop a more critical approach to the conceptualisation of health seeking behaviour which takes into account the neglected societal, normative and cultural contexts in which individual-level phenomena such as knowledge, attitudes and behaviour are negotiated or constructed especially in the developing world. Adams ( 2003) notes that reflexive thinking is always bounded, if not exhausted, by the e x i s ti n g cu l ture and society which historically s tructures our sense of self and the world beyond. Emphasis need to be led on the way in which groups of

183 individuals in given social contexts relate to create and reinforce distinct ways of behaving and the emergent health implications. Exploring the underlying socio- cultural factors that underpin decision-making processes with regard to help-seeking therefore becomes an imperative for improving care.

Accessibility of care is equally expected to vary between developing and industrialised societies where the effect of income is considerably less or nonexistent (Zimmerman, 2005). In the light of the limited resources available to support mental health services in the developing world, White (2013) have questioned whether it makes sense to export systems of service delivery that have been developed in high-income countries to Low and Middle Income Countries. Cauce and colleagues (2002) make the important submission that help- seeking is not simply a matter of attitude or personal choices, neither is it merely a reflection of cultural differences, but arise out of a dynamic interaction between individual and family choice, cultural values and beliefs regarding mental health and help-seeking, and contextual and systemic factors such as availability of services within the community and social networks that can provide referrals for them. As earlier noted (cf. Chapter Three), delays in seeking help for mental health problems lead to poorer outcomes. Identifying potential barriers to mental healthcare would therefore inform decisive interventions. Disturbingly, the health seeking behaviour of the poor is a neglected theme in literature (Mackian, 2003) and mental health is generally under-researched in sub-Saharan Africa (Gureje et al., 2005). This undermines the prospects of plugging the striking gaps in treatment in this region and has led to as much as 70% of mental health services in Nigeria being delivered through alternative pathways (Adewuya & Makanjuola, 2009).

The aims of this segment of the research therefore include;

1. To determine to what degree ideological (cultural and mental health literacy) vs. instrumental (systemic and financial) impediments are perceived to constrain mental healthcare among the Igbo people (Nigeria vs. UK based).

184 2. To determine the demographic predictors of ideological and instrumental barriers to mental healthcare.

3. To compare barriers to mental healthcare across demographic groups.

4. To consider the determinant factors for ideological and instrumental barriers. 5. To propose possible means of addressing barriers to mental healthcare in the region. 6. To develop materials for a new measure of barriers to accessing mental healthcare.

Determining the relative weight, significance and determinants of ideological vs. instrumental barriers to mental healthcare would make for prioritised policy interventions. There are three parts to the study; Study 4a developed the quantitative instrument used in the rest of the study, Study 4b is the initial exploratory study and Study 4c is the substantive confirmatory study.

4.2 Methods

4.2.1 Participants and Sampling Technique