Perceived Anxiety Stigma, Anxiety Literacy and Help-Seeking Attitudes among Swedish Teachers
Denise Winroth Master of Psychology
Supervisor: Laura Ferrer-Wreder
MASTER’S DEGREE PROJECT IN PSYCHOLOGY,
30 ECTS CREDITS, VT20
STOCKHOLM UNIVERSITY
PERCIEVED ANXIETY STIGMA, ANXIETY LITERACY AND HELP-SEEKING ATTITUDES AMONG SWEDISH TEACHERS
Denise Winroth
Anxiety is becoming more prevalent among Swedish youth. Anxiety can range from momentary symptoms to lifelong disorders, where generalised anxiety disorder (GAD) is one of the most common anxiety disorders (Allgulander, 2012). Yet relative to those who are older, young individuals are less likely to seek psychological help. Previous research has focused on the role of mental health literacy and stigma in help-seeking behaviours among students. This cross-sectional study explored possible associations between GAD literacy, perceived GAD stigma, and psychological help-seeking attitudes among Swedish regular and special education teachers (N = 647) using an internet-based survey. Results revealed a significant positive association between GAD literacy and help-seeking attitudes among regular education teachers and not for special education teachers. Overall, this study provides insight into the current levels of GAD literacy, perceived GAD stigma, and help-seeking attitudes among Swedish teachers of different professional training and has implications for intervention development among regular education teachers.
Anxiety is a common internalising problem among children and adolescents in Sweden (Blomqvist, Blom, Hägglöf, & Hammarström, 2019). Recent reports indicate a rising
prevalence of internalising symptoms among the younger population, including self-reported anxiety (Blomqvist et al., 2019; Folkhälsomyndigheten, 2020). Anxiety can range from momentary feelings of worry, to more severe symptoms, including the development of an anxiety disorder (Folkhälsomyndigheten, 2020). Generalised anxiety disorder (GAD) is the most common anxiety disorder, with reportedly great financial costs for society, and psychological burden for the individual (Allgulander, 2012).
The community faces the challenge, beyond ensuring evidence-based treatments for anxiety, to assist those in need (Goetter et al., 2020). Despite the high prevalence, younger relative to older individuals are less likely to seek help for anxiety, and other mental health problems (Calear, Batterham, Torok, & McCallum, 2020; Gulliver et al., 2012; Kutcher et al., 2016). Anxiety disorders are also reported to have among the longest delays of treatment, meaning that individuals in need of treatment tend to go untreated longer relative to those experiencing other types of mental ill-health (Calear et al., 2020). The delay or absence of treatment
however, could have negative consequences on functioning and long-term prognosis (Calear et al., 2020; Goetter et al., 2020). Anxiety disorders in younger individuals are treatable and possibly preventable (Gulliver, Farrer, Bennett, & Griffiths, 2019). It is, therefore, vital to consider factors that could influence help-seeking behaviours for anxiety at an early age and early on in the development of significant problems.
Factors in the school context and from the perspective of teachers that may influence student’s willingness to seek help for anxiety, remain largely unexplored. This study,
therefore, focused on the constructs of mental health literacy about GAD, perceived stigma of GAD and help-seeking attitudes from the perspective of teachers. Mental health literacy about GAD refers to knowledge and beliefs about recognising, managing and preventing GAD (Calear et al., 2020; Griffiths, Batterham, Barney, & Parsons, 2011). Furthermore, perceived stigma about GAD is described as the perceived negative attitudes and beliefs of others towards GAD (Calear et al., 2020; Griffiths et al., 2011). Help-seeking attitudes refers to the attitudes towards psychological help-seeking behaviours (Fischer & Farina, 1995). Teachers are a key part of the school context and hold a unique and influential role in their student’s psychosocial environment (Folkhälsomyndigheten, 2020). Teachers, therefore, play an important role in addressing high rates of anxiety and internalising problems
(Folkhälsomyndigheten, 2020; Ivarsson, Skarphedinsson, Andersson, & Jarbin, 2018). Different types of teachers have different education, professional development and cultures, including regular education teachers and special education teachers. The education of special education teachers in Sweden is more specialised and focused on the mental health need and well-being of the students, to enable and encourage more learning opportunities, whereas, regular education teachers have learning as their primary focus. Thus, special education teachers are educated teachers that are employed at any educational level to assist and teach students with greater need of learning opportunities.
Because children and adolescents spend much of their time in school, it is necessary to uncover factors that could assist students’ willingness to seek help (Folkhälsomyndigheten, 2020). Nevertheless, evidence indicates that approximately 60% of teachers in Sweden report having adequate knowledge and competence to support children with mental ill-health and other types of atypical development (Folkhälsomyndigheten, 2020). Findings from several studies suggest that mental health literacy, mental health stigma and self-reliance are factors that are important to psychological help-seeking among students (Calear et al., 2020; Gulliver et al., 2012). To date, however, there are few previously published studies with a specific focus on the association between mental health literacy and mental health stigma about generalised anxiety disorder, and attitudes towards psychological help-seeking from the perspective of teachers.
Mental Health Literacy in Schools
As mentioned, previous research within this field has established schools as a vital context for addressing several aspects of mental health, including prevention, promotion, and support for children and adolescents (Dods, 2016; Kutcher et al., 2016). Mental health literacy
(MHL) in particular, has been identified as key to improving early recognition, help-seeking efficacy, and health care accessibility, in addition to reducing stigma attached to mental ill-health (Campos, Dias, Palha, Duarte, & Veiga, 2014; Kutcher et al., 2015; Wei, Carr, Alaffe, & Kutcher, 2020). A number of studies have shown that increased MHL among teachers has positive outcomes for both students and teachers (Wei et al., 2020). In fact, the integration of MHL in classroom curricula, such as the curriculum resource guide (the High School Mental Health Curriculum Guide), along with professional development on the usage of the
aforementioned guide, have demonstrated significant, and lasting improvements in MHL for teachers, and students alike (Kutcher et al., 2015; Wei et al., 2020). These promising findings have been found in several school settings across multiple nations (Kutcher et al., 2015; Kutcher et al., 2016; Mcluckie, Kutcher, Wei, & Weaver, 2014; Skre et al., 2013).
It is therefore, troubling, with reports suggesting that teachers have limited knowledge and education about mental health (Dods, 2016; Frauenholtz, Mendenhall, & Moon, 2017; Wei et al., 2020). Teachers commonly hold positive attitudes towards helping and supporting the health and well-being of their students (Dods, 2016; Wei et al., 2020). Yet, several studies have reported that teachers lack confidence in their ability to assist and support students with mental ill-health (Armstrong, Macleod, & Brough, 2019; Dods, 2016; Frauenholtz, Williford, & Mendenhall, 2015). These findings were also reported among pre-service teacher (i.e. student teachers) who reported having previous experience with mental health (Dods, 2016). In contrast, special education teachers, instead report a more knowledgeable approach to respond to students socio-emotional needs (Broomhead, 2016). Personal experience with mental health, has previously been shown to increase levels of MHL (Dods, 2016). Direct personal experience of mental ill-health related issues has also been associated with more positive attitudes towards help-seeking and reduced stigmatising beliefs and attitudes (Dods, 2016; Finkelstein, Lapshin, & Wasserman, 2008).
Mental Health Literacy, Mental Health Stigma, and Help-Seeking Attitudes in Schools
Recently there has been a growing body of research focused on MHL, mental health stigma, and psychological help-seeking attitudes in school settings. A recent study with university teachers found MHL about depression, to be significantly higher among females, where greater depression literacy was associated with lower levels of depression stigma, and a greater likelihood of approaching students about mental ill-health (Gulliver et al., 2019). Another study found that depression literacy among high school teachers was significantly and positively associated with depression literacy among their students (Miller et al., 2019), which indicates a possible positive effect of teachers on students. A systematic review, further found MHL interventions for teachers, to have significant and sustained
improvements in knowledge, destigmatising views, as well as, confidence and behaviours to help struggling students (Yamaguchi et al., 2020). Although, some of these studies had questionable scientific quality including lack of randomisation and control groups, risk of bias, and not controlling for confounding variables (Yamaguchi et al., 2020). Contrastingly, one study on pre-service teachers found significant, but not lasting improvements in help-seeking attitudes following a MHL intervention (Wei et al., 2020).
Mental Health Literacy of Generalised Anxiety
In the research literature, MHL, is described as “knowledge and beliefs about mental health problems which aid their recognition, management or prevention” (Jorm et al., 1997, as cited in Yamaguchi et al., 2020, p. 14). Generalised anxiety literacy therefore, refers to knowledge and beliefs about recognising, managing and preventing GAD (Calear et al., 2020; Griffiths et al., 2011). A more recent definition of MHL, includes: knowledge of mental disorders, their treatments, how to obtain and maintain positive mental health, reducing stigma, and improving help-seeking efficacy (Kutcher et al., 2016). For this study, the former definition was used, since no firmly established and highly replicated relations have been identified between mental health stigma, literacy and help-seeking attitudes in regard to anxiety
disorders and GAD in particular. Nonetheless, teachers with greater MHL, may consequently, aid the welfare of students, while ensuring their own well-being (Armstrong et al., 2019; Yamaguchi et al., 2020). Evidence suggests that teachers with the resources to address students who experience psychological distress, also report greater levels of well-being and self-efficacy (Armstrong et al., 2019). Thus, increasing teachers’ ability to attend to students with generalised anxiety, and other symptoms of mental ill-health, is a public health interest with potential to improve mental health outcomes.
The literature on generalised anxiety literacy specifically, is to date, less extensive. A recent study with adolescents did however, find generalised anxiety literacy to be limited (Calear et al., 2020). This study also reported that higher levels of GAD literacy was associated with lower personal, but not perceived GAD stigma, and more positive attitudes toward help-seeking (Calear et al., 2020). Findings have also revealed that levels of personal GAD stigma is typically lower compared to reportedly higher levels of perceived GAD stigma among others in the general population (Batterham, Griffiths, Barney, & Parsons, 2013; Calear et al., 2020; Griffiths et al., 2011). This trend, of higher levels of perceived general public stigma, and lower levels of personal stigma is also evident in regards to depression (Griffiths et al., 2011). Furthermore, an Australian sample revealed that previous exposure to anxiety disorders, was a robust predictor of reduced personal stigma, whereas previous exposure, especially through indirect contact (media), contrastingly, predicted increased levels of perceived general public anxiety stigma; perception of stigma in the wider society (Batterham et al., 2013). The aforementioned study, also found greater perceived GAD stigma to be associated with being male, and a rural resident (Batterham et al., 2013). Moreover, students
who report greater perceived stigma within their proximity (family, friends) however, are less likely to seek help (Gulliver et al., 2019).
Perceived Stigma about Generalised Anxiety
Stigma is, thus, a major factor described in the research literature as a barrier to psychological help-seeking (Cheng, Wang, McDermott, Kridel, & Rislin, 2018; Griffiths et al., 2011). Stigma involves negative labelling of deviations from the social norm, including that of, anxiety and mental ill-health (Finkelstein et al., 2008). Stigma labels are attached to
individuals or groups who deviate from the norm, and whom may consequently, be subject to discrimination (Finkelstein et al., 2008). Beyond the negative implications for help-seeking, stigma may carry negative consequences for employment, accommodation, quality of life and self-esteem (Batterham et al., 2013; Finkelstein et al., 2008; Griffiths et al., 2011). Mental health professionals have been reported to hold negative beliefs and attitudes about people with mental ill-health, contributing to general public stigma (Finkelstein et al., 2008). Thus, stigma around mental health appears to be present at all stages of the help-seeking process, from the initial stage to the rehabilitation process. Individuals who need or seek
psychological help must therefore, overcome perceived stigma in addition to potential experienced self-stigma (Cheng et al., 2018).
Perceived stigma is described as the view of an individual in regards to attitudes and beliefs of others towards a condition (Calear et al., 2020). Specifically, perceived stigma about mental ill-health can be in a broad and inclusive sense or can be more specific about
particular disorders, and stigma about anxiety disorders or symptoms can take the form of an individual’s perception of the negative attitudes of others towards GAD (Calear et al., 2020; Griffiths et al., 2011). The aforementioned disorder is characterised by symptoms of tension, and uncontrollable worry (Allgulander, 2012; Goetter et al., 2020). Despite the fact that, GAD is a common disorder, stigma associated with anxiety disorders including GAD remains problematic (Griffiths et al., 2011; Gulliver et al., 2012). Previous research on stigma has predominantly focused on stigma associated with depression and schizophrenia, where less research attention and effort has been directed towards anxiety stigma in general and GAD in particular (Coles, Schubert, Heimberg, & Weiss, 2014; Griffiths et al., 2011). The limited literature on anxiety stigma is of great concern, because GAD is a debilitating and prevelant condition (Griffiths et al., 2011). Although, evidence-based options are available to treat GAD, most individuals diagnosed with GAD go untreated, particularly in comparison with other mental health disorders (Goetter et al., 2020; Griffiths et al., 2011). Assigning efforts to
increase help-seeking for anxiety disorders, including GAD is therefore particularly important.
Schools, Teachers, and Stigma
Teachers play a key role in facilitating help-seeking behaviours in students (Yamaguchi et al., 2020). Due to young students difficulty in recognising mental ill-health (literacy), and their reluctance towards help-seeking, adult intervention may be necessary (Calear et al., 2020; Campos et al., 2014; Yamaguchi et al., 2020). However, this approach assumes that teachers have the knowledge and means to provide the required support. While research on a general population sample of adults implied difficulties in identifying anxiety disorders (Coles et al., 2014), evidence indicates that pre-service teachers are in fact, more capable of recognising signs of anxiety (and ADHD), than symptoms of depression (Whitley & Gooderham, 2016). Teachers may still hold stigmatising views, which may interfere with their ability to support, and encourage help-seeking among students (Yamaguchi et al., 2020). Previous research has found that increased MHL, both reduced stigmatising attitudes towards anxiety and increased supportive behaviours among teachers (Yamaguchi et al., 2020). Thus, teachers with greater knowledge should be better equipped to recognise anxiety and other mental disorders, and are consequently, more able to support and direct students to appropriate mental health services (Broomhead, 2016; Yamaguchi et al., 2020). However, the association of these constructs in samples of teachers is not robust, as follow-up tests and effect sizes have been mixed
(Yamaguchi et al., 2020).
Attitudes towards Help-Seeking Behaviours
The current literature is hence, proposing an interplay between stigma, literacy and attitudes towards help-seeking behaviours (Calear et al., 2020; Cheng et al., 2018). Although, the association of these construct in regard to GAD is not established. The help-seeking process among the younger population may nonetheless, be complex, involving several dynamic interactions and factors (Calear et al., 2020). These may range from individual factors, like values, knowledge and beliefs about mental help-seeking, to family influences, and service accessibility (Calear et al., 2020). Previous research has examined the role of close networks, including parents, family and friends, on help-seeking behaviours among young individuals (Calear et al., 2020). Less is known about the role and attitudes of teachers in supporting help-seeking behaviours of their students. Yet, teachers possess a unique position in the recognition of anxiety, and other psychological symptoms that can be evidenced by students
(Yamaguchi et al., 2020). Consequently, teachers could provide the intermediate link
between recognising students who requires help, and referring these students to professional services such as school counsellors and psychologists (Yamaguchi et al., 2020). The
significant role of teachers in the school context will be further discussed in light of the ecological system theory of development by Bronfenbrenner (1979).
Ecological Systems Theory by Bronfenbrenner
Bronfenbrenner’s ecological systems theory (1979) was used as a meta theoretical framework for this study to emphasise the role of teachers in the development and health of their
students. The ecological systems theory places the individual (child or adolescent) in the epicentre of a complex system, where concentric circles represents different levels that affect the individual, and the impact is bi-directional with the individual also having an impact on these interconnected systems (Bronfenbrenner, 1979). These conceptual levels (microsystem, mesosystem, exosystem, and macrosystem) are all of importance, as interactions within each level, also effects the other levels (dependence within and between each level) concurrently, and over time (Bronfenbrenner, 1979). The levels constitute as a continuum, from proximate
to more distant systems (Bronfenbrenner, 1979). According to this ecological model, there are a multitude of factors which impact the health of the individual, on both a proximal and societal level (Bronfenbrenner, 1979).
For this study, the aim was to explore a part of the school context, namely, the perspective of teachers (regular education as well as special education teachers). In the ecological model by Bronfenbrenner (1979), the microsystem consists of the proximal environment of the
individual (See Figure 1), which comprises behaviours, activities, and interpersonal relations. Interpersonal interactions within given contexts are bi-directional, where the behaviours and thoughts of the individual are both influenced by others, and affects others (Cross & Hong, 2012). However, interactions that occur between microsystems (family, school,
neighbourhood) are referred to as the mesosystem (Bronfenbrenner, 1979). Implications of the present study involves the need to bridge the interconnections across microsystems (home, school, and mental health services) to allow appropriate care and support for students. According to Bronfenbrenner (1979), the individual is less likely to get the necessary support when there is a gap between these microsystems. Moreover, several factors within schools, have been shown to have a determining role in the mental health of students, particularly of internalising problems (Folkhälsomyndigheten, 2020). The school context, therefore, plays a significant role in the well-being and health of students (Folkhälsomyndigheten, 2020).
Figure 1. The ecological systems theory by Bronfenbrenner (1979).
Among the reciprocal relations (peers, friends etc.) within the school context, the student-teacher relationship is of utmost importance for the health and development of the student (Folkhälsomyndigheten, 2020; Ibrahim & El Zataari, 2020). An established and positive relationship, or dyad, between student and teacher, could prove protective against adverse circumstances (Ibrahim & El Zataari, 2020). Findings have shown that social support from
teachers can be a protective factor against depression (Folkhälsomyndigheten, 2020). Thus, establishing a positive student-relationship may lead to positive development and health (Ibrahim & El Zataari, 2020). Beyond the positive effects on health, a strong reciprocal student-teacher relation, may inspire students to seek help from their teachers, and allow teachers to recognise internalising symptoms and approach students in need. However, there are factors which may have bearing on the ability of teachers to provide students with support. These may include the level of mental health literacy, perceptions of stigma, and attitudes held towards help-seeking behaviours.
The aim of the current cross-sectional study was to investigate perceived stigma about generalised anxiety, mental health literacy regarding generalised anxiety, in addition to attitudes towards help-seeking behaviours among regular education teachers and special education teachers currently, or previously employed in Swedish schools. This study was conducted to examine possible associations between the aforementioned constructs. No hypotheses were formulated for this particular study due to the limited prior research in this area of investigation as it relates to GAD specifically. An exploratory approach was therefore used, to answer the main research question, which was, are there significant associations between perceived stigma about generalised anxiety (i.e. GAD Stigma), mental health
literacy regarding generalised anxiety (i.e. GAD Literacy), and attitudes towards help-seeking behaviours among regular education teachers and special education teachers?
Methods
Participants
The participants consisted of 647 adults who had previously been or are currently employed as a regular education teacher or special education teacher in Sweden. The ages of the participants ranged from 21 to 82 years old (M = 45.04, SD = 10.92). Demographic data of participants in the sample is presented in Table 1.
Table 1
Characteristics of Participants by Occupation
Parameter Regular Education Teachers
(n = 577)
Special Education Teachers (n = 70) Frequency (%) Gender Female 341 (59.1) 55 (78.6) Male 233 (40.4) 13 (18.6) Unknown 3 (0.5) 2 (2.9) Level of teaching Preschool 5 (0.9) 2 (2.9) Primary / secondary 181 (31.4) 45 (64.3) Upper secondary / Highschool 231 (40.0) 18 (25.7) University / college 160 (27.7) 5 (7.1) Mean (SD) Age 44.6 (10.9) 48.5 (10.4)
Experience 13.5 (9.5) 12.4 (9.8)+
Perceived GAD stigma 17.0 (6.5) 17.0 (6.5)
GAD Literacy 12.0 (3.8) 12.8 (3.8)
Help-seeking attitudes 22.6 (5.2)* 24.7 (4.1)*
Note. Experience represents years in occupation. +n = 69 due to an erroneous response. *A
MANOVA indicated that these means are significantly different.
Measures
Demographics.
The demographics questionnaire was used to gather information about
participants’ age, gender, and occupation (regular education teacher or special
education teacher). Additional questions about participants’ level of teaching (preschool, primary/secondary school, high school, or college/university) and amount of
experience (years and months) employed within the given occupation were also included.
Perceived stigma about generalised anxiety (GAD Stigma).
Participants’ views about stigmatising attitudes of others towards generalised anxiety was measured with one of the subscales from the Generalised Anxiety Stigma Scale (GASS-perceived; Griffiths et al., 2011). The GASS-perceived consists of 10 items measuring the respondent’s belief of other’s stigmatising views of GAD (e.g., “Most people think that an anxiety disorder is a sign of personal weakness”). Items are rated on a 5-point Likert-type scale ranging from 0 (strongly disagree) to 4 (strongly agree). Higher scores indicate higher degrees of perceived stigma towards GAD (all ten items are summed and ranged from 0 to 40). Internal consistency using Cronbach’s alpha was good (a = .88) in the current study. The GASS-perceived scale has previously been shown to have acceptable internal consistency, construct validity and test-retest reliability (Griffiths et al., 2011).
Mental health literacy of generalised anxiety (GAD Literacy).
To measure mental health literacy specific to generalised anxiety, the Anxiety Literacy Questionnaire (A-Lit: Gulliver et al., 2012) was used. The A-Lit is a 22-item scale assessing the respondent’s understanding of GAD in terms of symptoms and treatment (e.g.,
“Irritability may be a symptom of anxiety disorder” and “Antidepressants are addictive”). Items are scored based on correct responses from three optional choices (true, false, or I don’t
know), where each correct response equal to a score of one (and a false response equal to no
score). Higher scores indicate higher mental health literacy of anxiety (all 22 items are
summed and ranged from 0 to 22). Internal reliability was acceptable (a =.75) in this study. Previous reports indicate that A-Lit has adequate internal consistency, and test-retest reliability (Gulliver et al., 2012).
Attitudes toward seeking psychological help.
The respondent’s attitudes of seeking psychological help was assessed using the Attitudes Toward Seeking Professional Psychological Help Scale–Short Form (ATSPPH-SF; Fischer & Farina, 1995). The ATSPPH-SF is a shortened version that have demonstrated high
correlation with the original ATSPPH scale (Fischer & Turner, 1970, as cited in Cheng et al., 2018). The ATSPPH-SF comprises of 10 items measuring help-seeking attitudes (e.g., “I might want to have psychological counselling in the future”). Items are rated using a 4-point Likert-type scale, ranging from 0 (disagree) to 3 (agree). Higher scores reflect more positive attitudes towards psychological help-seeking (all ten items are summed and ranged from 0 to
30). Internal consistency in the present study was good (a = .80). The ATSPPH-SF has been reported to have adequate internal consistency in previous studies (Calear et al., 2020; Cheng et al., 2018).
Procedure
This was a cross-sectional study with all data completed at one point in time. Participants completed an anonymous internet-based survey. The study response rate could not be calculated due to the various forms of primarily online recruitment. The participants were recruited through social media posts (on Facebook), advertisement on a research recruitment platform (www.studentkaninen.se), and via e-mails directed at regular education teachers and special education teachers employed at schools, ranging from preschools to universities operating in the county of Stockholm. The recruitment via e-mail included distribution to 12,256 regular education teachers and special education teachers with public e-mails that were gathered from national websites (www.skollistan.eu and www.studentum.se). The sample, however, may include participants outside the aforementioned region.
The participants were required to meet the inclusion criteria of being above the age of 18 and being proficient in English, in addition to being currently or previously employed as a regular education teacher or special education teacher. This study included different types of teachers due to the limited prior research in this area of investigation. Earlier research has focused on either type of teachers separately, whereas no previous studies, to our knowledge, have included both types, and the possible differences in the study constructs across type of teacher. The respondents volunteered and were not given any incentives for their participation. An ethics declaration was completed before the data collection as per the guidelines outlined by Stockholm University.
Plan for Statistical Analyses
Descriptive statistics were used to identify demographic characteristics and the levels of each of the main constructs in the sample including perceived stigma and literacy of GAD, and attitudes towards psychological help-seeking. Two MANOVAs were conducted to explore important group differences in participants on the main study constructs by present
employment status (teacher was at retirement age or not) and occupation type (regular or special education teacher). A correlation analysis using Pearson’s correlational coefficient (r) was used to examine the strength of the association between perceived GAD stigma, GAD literacy, and help-seeking attitudes. The data analyses were conducted using SPSS Statistics 26.
Results
Preliminary Analyses
Before conducting the primary analyses, the data was screened for normality, linearity,
homoscedasticity, and outliers. There was no clear evidence of violations of the assumptions of linearity and homoscedasticity. However, the preliminary analyses revealed non-normality and the presence of outliers. Tests of normality using Shapiro-Wilk showed significant deviations of normality. A visual inspection of the data revealed small deviations in
normality in scores of GAD stigma and GAD literacy, and a negatively skewed distribution in help-seeking attitudes. No outliers were evident in the variable of perceived GAD stigma, although, multiple outliers were present in the variables of GAD literacy and help-seeking attitudes. Due to the large sample size, the violation of normality and presence of outliers was
not a major concern (Cheng et al., 2018). The outliers were less than 2% of the sample, and should thus, be acceptable in the main analyses (Cheng et al., 2018). The primary analyses were performed with and without outliers. The main study results and conclusions from those results were unaffected by the exclusion of outliers. The results are therefore, reported with outliers.
Because of the sample that was recruited, further analyses were conducted to examine
whether there was a difference in scores between participants who were previously employed as a teacher (above the age of 65, which is the age of retirement in Sweden) and teachers who are currently employed (under the age of 65). Before conducting the analyses, the
assumptions were checked. There were no violations of assumptions of independence, multicollinearity, homogeneity of variance-covariance, or presence of multivariate outliers. However, there were violations of cell sizes, linearity and normality. Test revealed that univariate normality of distributions was violated, although a visual inspection of box plots did not reveal major violations with the exception of the presence of univariate outliers. A multivariate analysis of variance (MANOVA) showed that there was no significant difference between the employment (current or previously employed) groups in perceived GAD stigma, GAD literacy, and help-seeking attitudes. Pillai’s Trace was used due to the violations of assumptions.
An additional MANOVA was employed to assess whether there was a difference in mean scores in the main constructs between regular education teachers and special education teachers. This analysis was performed because of the limited previous research on different types of teachers, and the lack of knowledge of whether there are differences in the levels of the main constructs in this study. Before performing the MANOVA, the assumptions were checked. There were no violations of assumptions of independence, multicollinearity, homogeneity of variance-covariance, or presence of multivariate outliers. There were, however, violations of the assumptions of normality, linearity and cell sizes. Due to the violations of assumptions, Pillai’s Trace was used and indicated that there was a significant difference in help-seeking scores on the combined dependent variables, F(3, 643) = 4.05, p = .007, hp2 = .019. Analysis of the dependent variables individually indicated that the
help-seeking attitude variable was significant at a Bonferroni adjusted alpha level of .017 (to control for family-wise error), F(1, 645) = 11.25, p = .001, hp2 = .017 across type of teacher (See Table 1 for means and standard deviations), with special education teachers being more favourable to help-seeking relative to regular education teachers.
If the MANOVA results did not indicate any significant difference across type of teacher, both groups of teachers would have been treated and analysed as one sample. However, due to the identified difference in help-seeking attitudes by type of teacher, separate analyses to address the main research question were performed for regular education teachers and special education teachers.
Primary Analyses
Associations between GAD stigma, GAD literacy and help-seeking attitudes.
The results of the correlation analysis that address the main research question are presented in Table 2. There were no significant associations evident in the group of special education teachers for perceived stigma of GAD, literacy about GAD, and help-seeking attitudes. There was, however, a significant positive association between GAD literacy and help-seeking
attitudes in the group of regular education teachers, Pearson’s r(577) = .21, p < .01. There were no other statistically significant correlations evident among regular education teachers. Table 2
Correlation matrix by Occupation
Regular Education Teachers (n = 577)
Special Education Teachers (n = 70) 1 2 3 1 2 3 1. Perceived GAD stigma - - 0.060 0.159 2. GAD literacy 0.079 - - 0.161 3. Help-seeking attitudes -0.039 0.214* - - Note. * p < 0.01 Discussion
The current study used an exploratory approach to assess the possible associations between perceived GAD stigma, GAD literacy, and attitudes towards psychological help-seeking in a sample of Swedish regular education teachers and special education teachers. The inclusion of both types of teachers (regular and special) was done due to the gap in the research literature on the possible differences across type of teacher for the main study constructs of interest in this study.
The preliminary findings revealed that there was no significant difference on scores of perceived GAD stigma, GAD literacy or help-seeking attitudes between previously and currently employed teachers. These results were interpreted with the assumption that teachers above the age of 65; the age of retirement in Sweden, were not currently employed as
teachers. Moreover, further findings showed that there was no difference in average scores of GAD literacy, or perceived GAD stigma between regular education teachers and special education teachers. However, help-seeking attitudes among special education teachers was significantly greater relative to regular education teachers. These findings indicate that relative to regular education teachers, special education teachers may be more favourably inclined to possibly refer students to seek help. More positive help-seeking attitudes among special education teachers, could be due to the fact that a large proportion of this subsample consisted of females. Factors like direct personal contact and experience with students with mental health symptoms could also explain the difference in help-seeking attitudes. Previous research has found personal experience of mental ill-health related issues to be associated with more positive help-seeking attitudes (Dods, 2016; Finkelstein et al., 2008). Education may also be an important factor, with special education teachers being better equipped due to more specialised education, while having a different professional role, and therefore, having greater knowledge and experience beyond anxiety literacy per se.
The level across both teacher groups in perceived GAD stigma was somewhat low, and also lower compared to previous studies using the same measurement in Australian community samples (Batterham et al., 2013; Griffiths et al., 2011). Contrastingly, GAD literacy and help-seeking attitudes seemed to be more common relative to views on these constructs in
previous studies using the same measurements, although these consisted of samples of students (Calear et al., 2020; Cheng et al., 2018). Overall, help-seeking attitudes were relatively high, whilst GAD literacy appeared to be moderate across the sample. However, the measurements used in this study, have not been previously used on a Swedish sample of regular education teachers and special education teachers. The relatively low levels of perceived GAD stigma in the current study, could be explained by the progressive social changes and efforts that have been made to improve equal rights in the Swedish society for individuals with disabilities, including disability related to mental ill-health.
The main results showed that there was a significant positive association between GAD literacy and help-seeking attitudes among regular education teachers and not for special education teachers. However, the effect size of this association was small. In general, there were no significant associations evident between the main constructs in the group of special education teachers. It is unclear why the association between GAD literacy and help-seeking attitudes was only evident among the regular education teachers. The different results across groups, could potentially be due to the fact that the sample size of regular education teachers was comparatively larger than the group of special education teachers.
The findings in the group of regular education teachers in some ways align with previous results, suggesting that greater levels of GAD literacy is associated with more positive help-seeking attitudes among adolescents (Calear et al., 2020). The aforementioned study, further found lower personal GAD stigma associated with greater levels of help-seeking attitudes (Calear et al., 2020). There was, however, no association between perceived GAD stigma and help-seeking attitudes in the Calear et al. study (2020) or the present study. Other studies have had samples of students and adults in the general population, non-teachers, in Australia and America (Batterham et al., 2013; Cheng et al., 2018; Griffiths et al., 2011).
In agreement with the main study findings among regular education teachers, previous
research has also demonstrated that improving knowledge about mental health, through MHL interventions, has yielded more positive help-seeking attitudes (Kutcher et al., 2015; Wei et al., 2020). Along the same lines, are findings indicating that teachers with higher levels of MHL, including depression literacy, are more likely to approach and support their students (Gulliver et al., 2019; Yamaguchi et al., 2020). Notably, some of the aforementioned studies further found greater MHL, to also reduce stigmatising views (Kutcher et al., 2015; Wei et al., 2020; Yamaguchi et al., 2020), which was not evident in the present study. As explained, this may be due to the different type of stigma (personal and perceived) measured in the previous studies. For example, a pilot study with secondary school teachers found a mental health first aid training to significantly reduce stigmatising views about anxiety, while improving confidence and skills to help others (Kidger et al., 2016). Notably, in the previous study (Kidger et al., 2016), a different measurement was used compared to this study, similar to personal and not perceived GAD stigma (Calear et al., 2020). The literature on the specific constructs used in the present study on samples with teachers, is however, limited. Thus, due to the previously different samples used, it is difficult to make direct comparison across the main study constructs.
Nevertheless, due to the exploratory nature of the study, no hypotheses were posited, and the main research question was partially supported only for regular education teachers, and there was a significant association between some of the main study constructs (i.e. GAD literacy and help-seeking attitudes).
Interpretation
Gathered from these results, hypotheses for future research can be extracted. Findings from the present study, as mentioned, indicated more positive attitudes towards psychological help-seeking among special education teachers in comparison to regular education teachers, despite the similar average scores evident in the other constructs of GAD literacy and perceived GAD stigma. Hence, in alignment with previous research, special education teachers appear to hold a more informed and supportive approach to respond to students’ mental health needs (Broomhead, 2016) and may therefore be more open and accepting to the idea of help-seeking. Notably, in previous research studies some teachers were employed at a special education school for students with behavioural, emotional, and social difficulties (Broomhead, 2016). The type of employment the special education teachers had in different educational settings in this study was not assessed, and future research may include such an assessment focus. It may be hypothesised that special education teachers, hold more positive help-seeking attitudes that go beyond literacy, and perceived stigma of generalised anxiety, but were not captured by the measurement used in this study.
It can be further hypothesised from the results of this study, that greater levels of generalised anxiety literacy, is associated with more positive help-seeking attitudes in regular education teachers. These results are indeed, in agreement with previous evidence indicating that greater levels of GAD literacy, was associated with more positive help-seeking attitudes, and lower personal GAD stigma, but not perceived GAD stigma (Calear et al., 2020). Earlier research has also proposed help-seeking attitudes to be predicted by personal stigma, and MHL (Cheng et al., 2018). Although, personal stigma was not measured in this study, it may be that GAD stigma is more easily attributed to others, as previous research has indicated substantially lower personal than perceived stigma of GAD (Batterham et al., 2013; Griffiths et al., 2011). However, compared to aforementioned results, perceived GAD stigma in this study, was reportedly lower. Importantly, personal and perceived GAD stigma, may thus, be important to help-seeking attitudes in different ways. The described hypotheses herein, however, cannot be deducted for special education teachers.
The current results can further be interpreted from the perspective of Bronfenbrenner’s ecological systems theory (1979). As mentioned, teachers make up a significant part of the microsystem that are schools (Bronfenbrenner, 1979). Although not tested in this study, it can be theorised that the level of GAD literacy, and perceived GAD stigma of teachers could have an impact of the respective levels of literacy and stigma of GAD of their students. This was in fact shown, in a study revealing depression literacy of teachers, to be associated with greater levels of depression literacy among their students (Miller et al., 2019). Moreover, current findings did indeed show that greater levels of GAD literacy were associated with more positive help-seeking attitudes among regular education teachers, which may indicate that teachers with greater knowledge, may be more supporting and encouraging of their students to seek help for generalised anxiety symptoms. Establishing a strong student-teacher relationship could be another factor that determines the willingness of students to seek help from teachers, and also the ability of the teacher to support and direct the students to the appropriate mental health service.
Beyond addressing the issue of increasing prevalence of anxiety among young individuals, on a microlevel, it is vital to incorporate the mesosystem, and its influence on the individual (Bronfenbrenner, 1979). Research within this field, has the potential of bridging the gap between schools, homes and mental health services with the benefits of improving
barriers of psychological help-seeking prevailing among the younger population, and the lack of knowledge of where to seek treatment (Goetter et al., 2020), teachers can provide
assistance to minimise this gap of help-seeking. Hence, equipping teachers with adequate literacy of anxiety, and other psychological symptoms, could lead to improved confidence in how to support and where to direct their students to ensure them with the necessary
treatments (Yamaguchi et al., 2020). Schools, therefore, play a valuable role, in particular, for individuals who experience mental ill-health, in addition, to adverse family conditions with little or no support (Calear et al., 2020). In addition, individuals who experience more severe symptoms, also have a lower likelihood of seeking help (Calear et al., 2020; Goetter et al., 2020). Therefore, focusing on how to encourage help-seeking for anxiety, and other internalising symptoms at an early phase, could reduce the psychological burden of the individual, and the financial costs for the society (Allgulander, 2012).
Implications
The findings of this study have implications for intervention development, teacher education and professional development. Because increased GAD literacy, have the potential to
improve psychological help-seeking attitudes in regular education teachers, future
intervention designs may include measures to improve knowledge about generalised anxiety among teachers. Previous MHL interventions have shown to be effective in enhancing literacy (Wei et al., 2020). These effects have been substantial and sustained over time, when interventions have combined professional development, and the incorporation of classroom curricula of MHL (Wei et al., 2020). Therefore, implementing further professional
development for in-service teachers, that extend beyond their existing education, may prove fruitful in enhancing MHL for regular education teachers and students. Yet, the present results indicate a significant difference in help-seeking attitudes between special education teachers and regular education teachers. It may, therefore, be essential to further examine the role of existing teacher education. Special education teachers have a more specialised
education, that may enable more positive help-seeking attitudes. It is of importance to consider how education for future teachers, could be improved. Based on this study, it could be vital to incorporate components including mental health education in the curriculum for all pre-service teachers, to better equip and prepare all teachers to support and assist student’s well-being and mental health.
Limitations and Future Research Directions
There are several strengths and limitations of the current study. The main strengths of this study include the large sample size, and the inclusion of both regular and special education teachers, in addition to the specific focus on generalised anxiety, and Swedish teachers. Yet, the limitations need consideration. A major limitation includes the use of English in the survey, where the level of English could have varied largely among the sample. This was however, not accounted for. Thus, this could have made it more difficult for participants to respond to the best of their ability, in particular, to items with double negative connotation (reverse scoring). The next limitation includes the fact, that all participants volunteered (without incentives), which could have resulted in selection bias. Further with online recruitment studies with different recruitment methods, it is difficult to determine how representative this sample is of the population of Swedish teachers, regular and special education. Considering that a major part of the recruitment included distribution of e-mails directed to teachers within the county of Stockholm, further limits the generalisability of these study findings. Because previous research have found a difference in perceived GAD stigma between urban and rural residents (Batterham et al., 2013), this may be an important factor to incorporate in future studies.
A further limitation concerns the issue of how and if psychological help-seeking attitudes may or may not translate to the actual behaviours of teachers. Thus, whether more positive help-seeking attitudes are associated with behaviours of teachers directed to help students, cannot be concluded, as experiences and teacher behaviour was not measured in this study. Moreover, the current findings do not indicate if improved levels of the main constructs among teachers, bridge the gap across microsystems and the individual. This study did not include factors such as history of mental health symptoms, treatment and help-seeking history and experience, and personal and professional experience with mental health, which could have influenced the findings. Another limitation is that causality cannot be inferred in the current study due to the cross-sectional study design. Moreover, the series of analyses employed, could have also increased the risk of Type I errors. Furthermore, the results
indicated a significant but small association between GAD literacy and help-seeking attitudes among regular education teachers, which suggests the need for further investigation. Finally, there were violations of the assumptions evident before conducting the MANOVAs, which suggest that further exploration of the difference between special and regular education teachers in regard to the main study construct is recommended.
For future research, it would be insightful to measure the association between levels of generalised anxiety literacy and stigma, and help-seeking attitudes of teachers with that of, their students. Further research could also examine how the aforementioned constructs, translate into action and behaviours of both teachers and students by implementing longitudinal and experimental designs. Moreover, investigating the role of teachers in supporting, directing, and encouraging help-seeking behaviours of students can be further examined while accounting for interactions across microsystems (mesosystem). Due to the results of this study, education, self-efficacy, and other potential factors which may influence help-seeking attitudes, could be investigated. Finally, future research could implement interventions specifically to increase generalised anxiety literacy, to measure its impact on both generalised anxiety stigma, personal and perceived, and the effect on help-seeking attitudes across teachers, and students.
Conclusion
In conclusion, this exploratory study provides insight into the current levels of generalised anxiety literacy, perceived stigma about generalised anxiety, and help-seeking attitudes among both regular education teachers and special education teachers in Sweden. It can be further concluded that higher levels of GAD literacy, is positively associated with more positive help-seeking attitudes among regular education teachers, but not special education teachers. Future research could thus, incorporate further efforts to design and test
interventions aimed at increasing literacy about generalised anxiety, to promote psychological help-seeking attitudes and behaviours across schools, particularly in the training and further education of regular education teachers. Implementing more
experimental designs in this area, in a Swedish educational context, would also advance efforts to improve developmental and health outcomes for students and teachers.
References
Allgulander, C. (2012). Generalized anxiety disorder: a review of recent findings. Journal of Experimental &
Clinical Medicine, 4(2), 88-91.doi: doi:10.1016/j.jecm.2012.01.006
Armstrong, D., Macleod, G., & Brough, C. (2019). Work Done in the Margins: A Comparative Study of Mental Health Literacy in Pre-Service Teacher Education in Australia and in Scotland. Journal of Research in Special
Educational Needs, 19(4), 334–343.doi: 10.1111/1471-3802.12452
Batterham, P. J., Griffiths, K. M., Barney, L. J., & Parsons, A. (2013). Predictors of Generalized Anxiety Disorder stigma. Psychiatry Research, 206(2/3), 282–286. http://dx.doi.org/10.1016/j.psychres.2012.11.018 Blomqvist, I., Blom, E. H., Hägglöf, B., & Hammarström, A. (2019). Increase of internalized mental health symptoms among adolescents during the last three decades. European Journal of Public Health, 29(5), 925– 931. https://doi.org/10.1093/eurpub/ckz028
Bronfenbrenner, U. (1979). Contexts of child rearing: Problems and prospects. American Psychologist, 34(10), 844–850. https://doi.org/10.1037/0003-066X.34.10.844
Broomhead, K. E. (2016). “They Think That if You’re a Teacher Here?…?You’re Not Clever Enough to Be a Proper Teacher”: The Courtesy Stigma Experienced by Teachers Employed at Schools for Pupils with Behavioural, Emotional and Social Difficulties (BESD). Journal of Research in Special Educational Needs,
16(1), 57–64. doi: 10.1111/1471-3802.12056
Calear, A. L., Batterham, P. J., Torok, M., & McCallum, S. (2020). Help-seeking attitudes and intentions for generalised anxiety disorder in adolescents: the role of anxiety literacy and stigma. European Child &
Adolescent Psychiatry. https://doi.org/10.1007/s00787-020-01512-9
Campos, L., Dias, P., Palha, F., Duarte, A., & Veiga, E. (2014). Finding Space to Mental Health - Promoting mental health in adolescents (12- to 14 year olds): Preliminary results of the intervention’s effectiveness. Abrir
Espacio Para La Salud Mental -- Promoción de La Salud Mental En Adolescentes (12-14 Años): Los Resultados Preliminares de La Eficacia de La Intervención., 10(19), 107–116.
https://ezp.sub.su.se/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=fua&AN=98972269&sit e=ehost-live&scope=site
Cheng, H., Wang, C., McDermott, R. C., Kridel, M., & Rislin, J. L. (2018). Self-Stigma, Mental Health Literacy, and Attitudes Toward Seeking Psychological Help. Journal of Counseling & Development, 96(1), 64– 74. http://10.0.3.234/jcad.12178
Coles, M. E., Schubert, J. R., Heimberg, R. G., & Weiss, B. D. (2014). Disseminating treatment for anxiety disorders: Step 1: Recognizing the problem as a precursor to seeking help. Journal of Anxiety Disorders, 28(8), 737–740. http://10.0.3.248/j.janxdis.2014.07.011
Cross, D. I., & Hong, J. Y. (2012). An Ecological Examination of Teachers’ Emotions in the School Context.
Teaching and Teacher Education: An International Journal of Research and Studies, 28(7), 957–967.
doi:10.1016/j.tate.2012.05.001
Dods, J. (2016). Teacher Candidate Mental Health and Mental Health Literacy. Exceptionality Education
International, 26(2), 42–61. Retrieved from https://ir.lib.uwo.ca/eei/vol26/iss2/4
Finkelstein, J., Lapshin, O., & Wasserman, E. (2008). Randomized study of different anti-stigma media. Patient
Education & Counseling, 71(2), 204–214. doi:10.1016/j.pec.2008.01.002
Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychological help: A shortened form and considerations for research. Journal of College Student Development, 36(4), 368–373.
https://psycnet.apa.org/record/1996-10056-001
Folkhälsomyndigheten (2020). Skolans betydelse för inåtvända psykiska problem bland skolbarn: En kartläggning av systematiska litteraturöversikter. Retrieved from
https://www.folkhalsomyndigheten.se/publicerat-material/publikationsarkiv/s/skolans-betydelse-for-inatvanda-psykiska-problem-bland-skolbarn-/?pub=67680
Frauenholtz, S., Mendenhall, A. N., & Moon, J. (2017). Role of School Employees’ Mental Health Knowledge in Interdisciplinary Collaborations to Support the Academic Success of Students Experiencing Mental Health Distress. Children & Schools, 39(2), 71–79. http://10.0.4.69/cs/cdx004
Frauenholtz, S., Williford, A., & Mendenhall, A. N. (2015). Assessing School Employees’ Abilities to Respond to Children’s Mental Health Needs: Implications for School Social Work. School Social Work Journal (Follmer
Group), 39(2), 46–62.
https://ezp.sub.su.se/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=110257164&si te=ehost-live&scope=site
Goetter, E. M., Frumkin, M. R., Palitz, S. A., Swee, M. B., Baker, A. W., Bui, E., & Simon, N. M. (2020). Barriers to mental health treatment among individuals with social anxiety disorder and generalized anxiety disorder. Psychological Services, 17(1), 5–12. https://doi.org/10.1037/ser0000254
Griffiths, K. M., Batterham, P. J., Barney, L., & Parsons, A. (2011). The Generalised Anxiety Stigma Scale (GASS): psychometric properties in a community sample. BMC Psychiatry, 11, 184.
https://doi.org/10.1186/1471-244X-11-184
Gulliver, A., Farrer, L., Bennett, K., & Griffiths, K. M. (2019). University staff mental health literacy, stigma and their experience of students with mental health problems. Journal of Further & Higher Education, 43(3), 434–442. http://10.0.4.56/0309877X.2017.1367370
Gulliver, A., Griffiths, K. M., Christensen, H., Mackinnon, A., Calear, A. L., Parsons, A., Bennett, K.,
Batterham, P. J., & Stanimirovic, R. (2012). Internet-based interventions to promote mental health help-seeking in elite athletes: an exploratory randomized controlled trial. Journal Of Medical Internet Research, 14(3), e69– e69. https://doi.org/10.2196/jmir.1864
Ibrahim, A., & El Zataari, W. (2020). The teacher–student relationship and adolescents’ sense of school belonging. International Journal of Adolescence and Youth, 25(1), 382–395.
https://doi.org/http://dx.doi.org/10.1080/02673843.2019.1660998
Ivarsson, T., Skarphedinsson, G., Andersson, M., & Jarbin, H. (2018). The Validity of the Screen for Child Anxiety Related Emotional Disorders Revised (SCARED-R) Scale and Sub-Scales in Swedish Youth. Child
Psychiatry & Human Development, 49(2), 234–243. http://10.0.3.239/s10578-017-0746-8
Kidger, J., Stone, T., Tilling, K., Brockman, R., Campbell, R., Ford, T., ... Gunnell, D. (2016). A pilot cluster randomised controlled trial of a sup- port and training intervention to improve the mental health of secondary school teachers and students—the WISE (Wellbeing in Secondary Education) study. BMC Public Health, 16, 1060. https://doi.org/10. 1186/s12889-016-3737-y
Kutcher, S, Gilberds, H., Morgan, C., Greene, R., Hamwaka, K., & Perkins, K. (2015). Improving Malawian teachers’ mental health knowledge and attitudes: an integrated school mental health literacy approach. Global
Mental Health (Cambridge, England), 2, e1–e1. https://doi.org/10.1017/gmh.2014.8
Kutcher, Stan, Wei, Y., Gilberds, H., Ubuguyu, O., Njau, T., Brown, A., Sabuni, N., Magimba, A., & Perkins, K. (2016). A school mental health literacy curriculum resource training approach: effects on Tanzanian teachers’ mental health knowledge, stigma and help-seeking efficacy. International Journal of Mental Health
Systems, 10, 1–9. http://10.0.4.162/s13033-016-0082-6
Mcluckie, A., Kutcher, S., Wei, Y., & Weaver, C. (2014). Sustained improvements in students’ mental health literacy with use of a mental health curriculum in Canadian schools. BMC Psychiatry, 14(1), 90–103. http://10.0.4.162/s12888-014-0379-4
Miller, L., Musci, R., D’Agati, D., Alfes, C., Beaudry, M. B., Swartz, K., & Wilcox, H. (2019). Teacher Mental Health Literacy Is Associated with Student Literacy in the Adolescent Depression Awareness Program. School
Skre, I., Friborg, O., Breivik, C., Johnsen, L. I., Arnesen, Y., & Arfwedson Wang, C. E. (2013). A school intervention for mental health literacy in adolescents: effects of a non-randomized cluster controlled trial. BMC
Public Health, 13(1), 1–15. http://10.0.4.162/1471-2458-13-873
Wei, Y., Carr, W., Alaffe, R., & Kutcher, S. (2020). Mental Health Literacy Development: Application of Online and In-Person Professional Development for Preservice Teachers to Address Knowledge, Stigma, and Help-Seeking Intentions. Canadian Journal of Behavioural Science, 52(2), 107–114.
http://10.0.4.13/cbs0000164
Whitley, J., & Gooderham, S. (2016). Exploring Mental Health Literacy among Pre-Service Teachers.
Exceptionality Education International, 26(2), 62–92. Retrieved from https://ir.lib.uwo.ca/eei/vol26/iss2/5
Yamaguchi, S., Foo, J. C., Nishida, A., Ogawa, S., Togo, F., & Sasaki, T. (2020). Mental health literacy programs for school teachers: A systematic review and narrative synthesis. Early Intervention in Psychiatry,
