Objective To determine the barriers to seeking help from healthcare services reported by medical students at an Indian medical school, and to compare the barriers for using physical health services with those for using mental health services.
Methods In 2014, we invited all medical students across the nine semesters of training at a government medical college in Puducherry, India, to complete a 28 item questionnaire about perceived barriers to seeking healthcare services. The questionnaire enquired about barriers to using physical and mental healthcare services separately.
Results Completed responses were available from 461 of 509 students (response rate 90.6%). Stigma, confidentiality issues, lack of awareness about where to seek help and fear of unwanted intervention were more commonly reported for mental healthcare seeking (OR 4.21, 4.01, 3.19 and 2.43, respectively), while issues relating to cost, lack of time and fear of side effects were observed less frequently (OR 0.45, 0.46 and 0.57, respectively) compared with physical healthcare seeking. In comparison with physical health, students were more indifferent to their mental health issues and preferred self-diagnosis and informal consultations over formal documented care.
Conclusions Barriers to seeking healthcare services differ for mental and physical health issues. Many system based barriers such as stigma, confidentiality issues and poor awareness of service location were reported by students. Institutional programmes should use this information for improving the usage, satisfaction and effectiveness of healthcare delivery systems for medical students.
- HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- MEDICAL EDUCATION & TRAINING
- MENTAL HEALTH
- PUBLIC HEALTH
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Globally, it is well documented that graduate medical students experience considerable stress during their training period.1–4 Indian and international studies have estimated that the rates of depression are 6–8 times higher among medical students compared with the general population, indicating significant psychological morbidity.5–9 The implications are manifold, as poor psychological health may adversely affect quality of life and result in student burnout.10 Excessive stress and depression among medical students may increase the risk of medical errors, thereby compromising patient safety.11 It is therefore important, even from a public health standpoint, to provide the right kind of help for the common mental health issues faced by medical students so that their academic pursuits go uninterrupted and society eventually benefits from their services.
A growing body of evidence suggests that medical students are disinclined to seek professional help for their health issues and prefer to self-medicate or seek prescriptions from their peers, both of which are fraught with risks.12–14 A 2003 expert consensus statement published in the Journal of the American Medical Association draws attention to the “high threshold for seeking professional help among physicians and the low priority accorded to physician mental health”.15 This leads to a paradoxical situation wherein, despite the availability of round the clock professional help at close quarters, students are unable or unwilling to avail of the same. A better understanding of student perceptions and self-reported barriers to healthcare service utilisation is essential for addressing their unmet needs.
The literature on healthcare seeking among medical students is sparse, and has focused primarily on mental health counselling.16 However, published literature on non-medical university student populations have identified a variety of barriers to service utilisation, such as knowledge and attitudes about services, including stigma and confidentiality.17–19 The magnitude of these barriers is likely to be different for physical and mental health ailments, and may also vary across cultures.
In the absence of literature on healthcare seeking behaviours in Indian medical students, we conducted this study to assess self-reported barriers to seeking help from healthcare services. We also sought to compare the self-reported barriers for mental and physical health problems separately, as we hypothesised that student perceptions and needs would differ for their mental and physical health issues.
We invited all medical students at a government medical college in Puducherry, South India, to take part in the cross sectional study. The salient features of the context, student selection at the medical school and course curriculum are shown in box 1. We approached all students from semesters 1–9 of training via an allied department (eg, anatomy for semesters 1 and 2) to fix a mutually convenient day and time to administer the questionnaire. To achieve broad based participation, there were no exclusion criteria except failure to give informed consent.
Context of the study
General context of the setting
Setting: Centrally funded government medical college.
Location: Puducherry, India.
Participants: Undergraduate medical students, pursuing the Bachelor of Medicine and Bachelor of Surgery (MBBS) course.
Student selection for MBBS course at the medical school
Through nationally based competitive examinations, held once a year.
Quota based reservation system is followed to give adequate representation for weaker sections of the society.
A proportion of seats for students from Puducherry, foreign nationals.
Gradual increase in the number of seats in accordance with union government's vision to have more medical graduates.
Seat matrix for 2014: unreserved category (n=50), other backward classes (n=28), scheduled castes (n=16), scheduled tribes (n=11), Puducherry quota (n=40), non-resident Indian/overseas citizen of India (n=5).
Nine semesters of 6 months each:
Semesters 1 and 2—anatomy/physiology/biochemistry.
Semesters 3, 4 and 5—microbiology/pathology/pharmacology/forensic medicine.
Semesters 6 and 7—ear, nose and throat/ophthalmology/preventive and social medicine.
Semesters 8 and 9—internal medicine/surgery/obstetrics and gynaecology/paediatrics.
Successful completion of the nine semesters is followed by an internship for 1 year.
The course curriculum is in concordance with the guidelines of the Medical Council of India (MCI).
Information was gathered from the participants using a structured anonymised questionnaire. Demographic information such as age, gender, current semester of study and residential background were enquired. Self-reported medical and psychological illnesses were elicited along with any self-medication or help/consultation sought from peers or seniors for these problems. Participants were also asked about use of alcohol, tobacco and cannabis, and any harm accrued from such substance use.
The students were then asked to report on their perceived barriers to physical and mental healthcare seeking using a checklist. The checklist comprised items such as lack of time, fear of unwanted intervention, unsure where to seek help, confidentiality issues, stigma, cost, fear of side effects and fear of impact on academic performance. These items were derived from review of the previous literature and discussion among the investigators. The students were asked to tick as many options as deemed applicable. They were also encouraged to add any other option applicable to them by a question ‘Any others’ listed at the end. Subsequently, the students were asked to complete the Barriers to Healthcare Seeking Questionnaire (BHSQ) designed to tap into the implicit perceptions about healthcare seeking.
On the designated day, one of the authors (VM or SS) physically distributed the questionnaire forms and collected the completed response sheets. They were also available for any clarifications or queries on the part of the students during this process. Non-responders were not contacted or followed-up.
For the purpose of this research, we developed a new 28 item questionnaire, the BHSQ for medical students, intended to elicit the self-reported barriers to mental and physical healthcare. The scale was designed after going through the relevant literature and identifying important themes related to healthcare barriers applicable to medical students. As most students have a good working knowledge of English, the questionnaire was developed in the English language, which is also the medium of instruction across medical schools in India.
Initially, 32 statements, 16 each relating to physical and mental healthcare, were generated. The equivalent items for physical and mental healthcare were arranged consecutively so that comprehension and reporting were easier. The items included statements such as “If I developed a mental health problem, it may be viewed as a sign of weakness by my teachers and peers”. Responses were graded on a four point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. This questionnaire was discussed among three experts (which also included a medical educationist) for face and content validity as well as cultural acceptance of items. After due deliberations and consensus, four items were removed and some statements were reworded for better cultural acceptance. Hence the final questionnaire comprised 28 items, and the score ranged from 28 to 112, with higher scores reflecting greater perceived barriers to treatment. The scale yielded two subscale scores—namely, physical healthcare barriers and mental healthcare barriers (score range 14–56 each).
2. Reliability testing
Subsequently, the test–retest reliability of the instrument was assessed in a small sample of students (n=13). The questionnaire was administered to them 1 week apart and the correlation between total scale and subscale scores at these two time points were examined.
Responses to the questionnaire items were evaluated to help identify the perceived barriers to utilising healthcare services. The subscale scores on mental and physical healthcare were computed to yield domain specific barriers, respectively.
Statistical analysis was performed using SPSS V.20.0 (Statistical Package for the Social Sciences, Armonk, NY, USA). Descriptive statistics were used for representing the demographic and clinical variables. Variables were compared over the different semesters using the χ2 test. Barriers to mental and physical healthcare seeking reported on the checklist were compared in frequency using the paired McNemar's test, with the χ2 test adjusted for continuity correction. ORs with CIs were also computed for these comparisons. The complementary Likert responses of mental and physical healthcare on the BHSQ were compared using the paired Wilcoxon signed rank test. Mental and physical barrier subscale scores and total scores were generated, and correlations among these were assessed. The subscale and total scores were also compared with other variables of interest. To control for multiple simultaneous comparisons, Bonferroni's correction was applied, and a p value <0.001 (ie, 0.05/number of simultaneous comparisons) was considered significant. The required sample size for a power of 0.80, to detect a difference of 10% in the reported rates of barriers between physical and mental healthcare using a basal hypothetical rate of barriers reported as 30%, was 384. Missing value imputation was not done, and only those records were analysed which had information about age, gender, background and completed responses on the BHSQ.
Ethics committee permission
The study protocol had prior approval from the Institutional Review Board and the Institute Human Ethics Committee (registration No ECR/687/Jipmer/Inst/PY/2013).
In total, 461/509 students completed the questionnaire (response rate 90.6%). This included 119/147 (81%) first semester students, 115/129 (89.1%) third semester, 101/101 (100%) fifth semester, 68/70 (97.1%) seventh semester and 58/62 (93.5%) ninth semester students.
Mean age of the participants of the first, third, fifth, seventh and ninth semesters were 17.9, 18.9, 20.0, 21.0 and 22.2 years, respectively. A total of 248 men (53.8%) and 213 women (46.2%) responded. The majority of the students came from urban backgrounds (n=392, 85.0%). The prevalence of any substance use was 21.7% (n=100). Participant characteristics are summarised in table 1. Increasing seniority was associated with use of alcohol (χ2=38.439, p<0.001), tobacco (χ2=39.323, p<0.001) and cannabis (χ2=35.123, p<0.001), and the harms experienced with alcohol use (χ2=30.350, p<0.001). Increasing seniority also had a significant association with tendency to self-medicate for mental health issues (χ2=23.834, p <0.001) but not for physical health problems.
Questionnaire reliability testing
Regarding the test–retest reliability of the instrument, the correlation of total scores and the subscale scores were moderate to good (Spearman rs=0.714, p=0.006, rs=0.761, p=0.003 and rs=0.674, p=0.012 for total scale score, mental healthcare barrier and physical healthcare barrier, respectively).
Barriers to healthcare seeking
Lack of confidentiality, fear of unwanted intervention and poor knowledge about location of mental health services were the most common mental healthcare barriers reported (by 61.2%, 56.4% and 50.3% of participants, respectively). In contrast, lack of time, fear of side effects and fear of unwanted interventions were the most common barriers to physical healthcare seeking (reported by 59.0%, 43.0% and 34.7% of participants, respectively). The number of barriers reported ranged from 0 to 8 for both mental and physical healthcare seeking. The mean number of barriers reported for mental healthcare seeking was 3.4 (median 3), while the mean number of barriers for physical healthcare seeking was 2.6 (median 2). The type of barriers reported differed between mental and physical healthcare (table 2). While stigma, confidentiality issues, lack of awareness about where to seek help and fear of unwanted intervention were more commonly reported for mental healthcare seeking (ORs 4.21, 4.01, 3.19 and 2.43, respectively), issues relating to cost, lack of time and fear of side effects were observed less frequently (OR 0.45, 0.46 and 0.57, respectively) compared with physical healthcare seeking. The fear of impact on academic performance did not differ significantly between the groups.
Responses on the BHSQ
Barriers to mental healthcare treatment were different compared with those for physical healthcare (table 3). For instance, students were more likely to have the opinion that a medical student would not require mental health services (paired Wilcoxon test p<0.001), and a mental health problem may be viewed as a sign of weakness (paired Wilcoxon test p<0.001). They considered formal help less beneficial for mental healthcare compared with physical healthcare (paired Wilcoxon test p<0.001). Undergoing a formal consultation for mental healthcare was associated with future academic concerns, stigma, confidentiality issues and fear of social ostracism (paired Wilcoxon test p<0.001 for all comparisons). Informal consultations (paired Wilcoxon test p<0.001) or self-diagnosis (paired Wilcoxon test p=0.005) were preferred for mental healthcare than for physical healthcare.
The mean (SD) mental healthcare barrier subscale score was 33.1 (4.4) and the physical healthcare barrier subscale score was 29.1 (4.4), with a total barrier score of 62.2 (7.7). The mental healthcare and physical healthcare scores correlated with each other to a moderate degree (Pearson r=0.547, p<0.001). The full scale scores or the mental and physical healthcare subscale scores did not have a significant relationship with gender, semester of study, residential background, presence of a physical or psychological illness, or presence of substance use.
The study identified several barriers reported by medical students for seeking healthcare services, and the barriers differed for seeking help for mental and physical health problems. Issues such as stigma, confidentiality, lack of knowledge about location of mental health services and fear of excessive interventions were the common deterrents for seeking help from mental health services. Worryingly, students viewed mental health consultations as only minimally beneficial, and felt that mental illness would be viewed as a sign of weakness among their peers, evoking social ostracism. This might result in distressed students not receiving help from mental healthcare services, perpetuating their problems and hampering their learning outcomes. It has been suggested that feelings of shame and embarrassment regarding mental illness and negative perceptions about its treatment may dissuade young adults from accepting formal care.20 ,21 However, conflicting evidence also exists.22
Lack of time, fear of side effects and negative academic impact were the most common barriers to the use of health services in general. These are broadly congruent with published reports by researchers who have found acceptability and accessibility as the major barriers in using health services among non-medical university student populations.23 Hence we may surmise that medical students broadly share the same concerns as other university students about accessing health services. This also means that educational campaigns targeting poor knowledge about availability, location and potential benefits of services that have been suggested in other student groups24 may also be reasonably extrapolated to medical students.
Although there is a paucity of comparable literature from developing countries, many of the barriers reported by our students are similar to the findings from the west carried out among medical students and interns.16 ,25 ,26 All of these studies focused exclusively on the barriers to use of mental health services and hence were unable to evaluate differing perspectives on seeking help for physical and mental healthcare issues. Brimstone and colleagues,27 in their research, explored the help seeking behaviours of students and concluded that there are many barriers linked to physical and mental health issues that may preclude students from accessing professional help. Previously, negative implications of service utilisation on future academic prospects have also been reported by trainee physicians as a prominent concern12 ,28 while over a third of our students also reported this barrier for mental health services usage. Cost was not an issue for most of the students, probably as the institute delivers highly subsidised medical care and out of pocket expenditures are very minimal.
Based on the above findings, we propose several suggestions to improve health services delivery in medical campuses. Firstly, adequate orientation to health issues and existing services, including hospital layout, may help in acquainting new medical students about accessing healthcare services in the hospital. Secondly, this knowledge can be periodically refreshed at the beginning of every new academic session to enhance awareness. Previous surveys of mental healthcare concerns of medical students have shown that they may lack adequate information regarding mental health services.29 ,30 Thirdly, we observed that stigma and misconceptions related to mental health continue to act as a deterrent, and therefore mental health professionals may help to clear these myths and misconceptions. Fourthly, a separate student clinic located away from the busy outpatient department with satellite centres in the hostels may help to resolve the barriers of lack of time and non-awareness of locations for seeking help and improve ease of use, accessibility and satisfaction with services.
The strength of this study lies in attempting to elicit perceptions and barriers to seeking healthcare services from a medical student's perspective—an issue which is relevant but not adequately addressed. The study provides an evidence base for institutions to take the necessary measures in order to optimise student performance. The high response rate (>90%) and representative sampling of students from all the years are other major strengths. Limitations include the cross sectional design, possibility of respondent bias, exploring finite domains of healthcare seeking barriers, single centre sample and categorising various forms of medical/surgical healthcare into a single ‘physical’ healthcare group.
In conclusion, the perceived needs and barriers of medical students are different for mental and physical health issues. While many of these issues can be addressed through adequate orientation sessions involving a psychiatrist and having separate student clinics, issues such as stigma and negative stereotypes about mental health problems and its treatment may need a more broad based approach. Proper and timely attention needs to be paid to the barriers reported by medical students, as insufficient treatment for their health problems can impact on their training and future performance as clinicians. Further multicentre research may help in finding cross cutting and institution specific barriers to seeking healthcare services. Also, further evaluations may address changes in barriers perceived and experienced with educational and systemic interventions.
Student perspectives and needs differ between mental and physical healthcare.
Lack of time, concerns about excessive and unwanted intervention, and negative implications on future academic career were general deterrents for service utilisation.
Many systemic barriers, such as stigma and confidentiality issues, apart from lack of knowledge of where to seek help, were reported exclusively for usage of mental health services.
Givens JL, Tija J. Depressed medical students' use of mental health services and barriers to use. Acad Med 2002;77:918–21.
Vidourek RA, King KA, Nabors LA, et al. Students' benefits and barriers to mental health help-seeking. Health Psychol Behav Med 2014;2:1009–22.
Chew-Graham CA, Rogers A, Yassin N. “I wouldn't want it on my CV or their records”: medical students' experiences of help-seeking for mental health problems. Med Educ 2003;37:873–80.
Brimstone R, Thistlethwaite JE, Quirk F. Behaviour of medical students in seeking mental and physical health care: exploration and comparison with psychology students. Med Educ 2007;41:74–83.
Current research questions
What is the long term impact of structured intervention programmes on medical student attitudes, mental health and career?
What is the optimal method of service delivery in order to reduce stigma and enhance service utilisation?
How can student wellness programmes be blended into the main curriculum for maximum benefits?
We thank the institute authorities for permitting usage of the resources for the conduct of this research. We also thank all of the participants for their time and honest reporting.
Contributors VM led the design, literature review, data collection, interpretation of the results and wrote the first draft of the manuscript. SS was involved in the literature review, helped in data collection, performed the data analysis and revised the manuscript for important intellectual content. SK was involved in the conception of the work and revised the manuscript for important intellectual content. All authors gave their approval to the final version to be published.
Competing interests None declared.
Ethics approval Ethics approval was granted for the study (project reference No JIP/IEC/2014/4/285) involving human subjects by JIPMER Institute Ethics Committee (Human Studies) (registration No ECR/687/Jipmer/Inst/PY/2013) in its circular dated 10 July 2014.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The authors are happy to share their data on request. Please contact the corresponding author.