Journal of Anxiety Disorders 76 (2020) 102292

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

journal homepage: www.elsevier.com/locate/janxdis

Investigating the impact of masculinity on the relationship between anxiety

specific mental health literacy and mental health help-seeking in
adolescent males
Laura H. Clark a, Jennifer L. Hudson b, *, Ronald M. Rapee b, Katrina L. Grasby c
a
Department of Psychology, Durham University, Durham, UK
b
Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia
c
QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Poor mental health literacy and greater alignment with norms of hegemonic masculinity are
Help-seeking established barriers to mental health help-seeking in men. However, little is known about how these variables
Mental health literacy influence adolescent male help-seeking and in particular, help-seeking for anxiety disorders. This study inves­
Masculinity
tigated the relationship between i) anxiety mental health literacy, ii) alignment with traditional masculinity
Adolescents
Anxiety
norms and iii) help-seeking attitudes, intentions and behaviour in a sample of adolescent males.
Methods: 1732 adolescent males (aged 12–18 years) participated online whilst at school.
Results: Participant attitudes towards formal help-seeking, intentions to seek help from a family member and
from an online source were found to predict professional help-seeking behaviour by the adolescent and/or by
their parents on the adolescents’ behalf. In adolescents with a low or average personal alignment with norms of
hegemonic masculinity, greater anxiety mental health literacy was positively associated with more favourable
attitudes towards formal and informal help-seeking. However, this relationship was not found in adolescent
males with a greater alignment with norms of hegemonic masculinity.
Limitations: The study had a correlational research design and used self-report measures.
Conclusions: Mental health initiatives which consider the impact of masculinity and gender stereotypes have the
potential to significantly improve help-seeking in this population.

1. Introduction
Mental health help-seeking refers to obtaining understanding,
advice, information, treatment, and general support in response to a
mental health problem or distressing experience (Rickwood, Deane,
Wilson, & Ciarrochi, 2005). Mental health help-seeking research tradi­
tionally investigates help-seeking attitudes (thoughts or feelings towards
help-seeking), intentions (an individual’s intention to seek help if they
were to experience an emotional difficulty) and/or actual behaviour. In
accordance with the Theory of Planned Behaviour (Ajzen, 1991), an
individual’s attitude towards a behaviour (along with subjective norms
and perceived behavioral control) shapes an individual’s behavioural
intentions and the behaviour itself. There is a growing awareness of the
importance of research investigating mental health help-seeking in
young people (14–24 years old). Adolescent males in particular, have
higher rates of mental health disorders but lower rates of mental health
help-seeking when compared to other populations (Slade, Johnston,
Oakley Browne, Andrews, & Whiteford, 2009). Epidemiological studies
have consistently demonstrated that fewer adolescent males with mental
health disorders seek psychological assistance when compared to
adolescent females (Merikangas et al., 2011; Slade et al., 2009).
Poor mental health literacy, stigma, a preference for self-reliance and
concern about confidentiality have all been associated with at least one
component (either attitudes, intentions or behaviour) of youth mental
health help-seeking (Gulliver, Griffiths, & Christensen, 2010). In
particular, poor mental health literacy has been identified as a barrier to
mental health help-seeking behaviour in both men (Harding & Fox,
2015) and adolescent males (Gulliver et al., 2010). Mental health lit­
eracy refers to “knowledge and beliefs about mental disorders which aid
their recognition, management or prevention” (Jorm et al., 1997, p.

* Corresponding author.
E-mail address: jennie.hudson@mq.edu.au (J.L. Hudson).

https://doi.org/10.1016/j.janxdis.2020.102292
Received 14 November 2019; Received in revised form 4 August 2020; Accepted 10 August 2020
Available online 3 September 2020
0887-6185/© 2020 Published by Elsevier Ltd.
L.H. Clark et al.
182). Adolescent males consistently demonstrate lower levels of mental
health literacy when compared to adolescent females (Burns & Rapee,
2006; Cotton, Wright, Harris, Jorm, & McGorry, 2006).
School based educational programs are the most common method of
promoting youth mental health literacy, however, it has yet to be
conclusively demonstrated that exposure to mental health literacy pro­
grams result in greater rates of adolescent help-seeking. A systematic
review by Wei, Hayden, Kutcher, Zygmunt, and McGrath (2013)
investigated the efficacy of school mental health literacy programs in
enhancing knowledge, reducing stigmatizing attitudes and improving
help-seeking behaviours among youth (12–25 years of age). Wei et al.
identified only three studies which included specific help-seeking mea­
sures (based in the US, Germany and Australia). These studies found
mental health literacy programs to have a positive impact on a
help-seeking outcome (Battaglia, Coverdale, & Bushong, 1990; Paulus
et al., 2009; Rickwood, Cavanagh, Curtis, & Sakrouge, 2004). However,
none of the aforementioned studies investigated help-seeking behaviour
directly, investigating only help-seeking attitudes (Battaglia et al., 1990)
and intentions (Paulus et al., 2009; Rickwood et al., 2004). Furthermore,
the studies by Paulus et al. and Rickwood et al. reported that the mental
health intervention had a relatively weak impact on help-seeking in­
tentions. A recent study by Perry et al. (2014) investigated the impact of
a school-based educational intervention on mental health literacy,
stigma and help-seeking in a sample of Australian adolescents. Despite
significant increases in participant mental health literacy and reductions
in mental health stigma following the intervention, there was no sig­
nificant change in participants’ attitudes towards mental health
help-seeking. Consequently, further research into the association be­
tween mental health literacy and help-seeking in youth is required.
There is evidence that, in both adult and adolescent male samples,
mental health help-seeking is inhibited by greater alignment with norms
of hegemonic masculinity and a socially constructed ‘men don’t seek
help’ gender stereotype (Seidler, Dawes, Rice, Oliffe, & Dhillon, 2016).
Traditional masculinity is comprised of social norms that include an
emphasis on competition, strength, avoiding emotions and perceived
femininity, and being action-orientated (Coleman, 2015). The tradi­
tional male gender-role in Western societies and cultures often encour­
ages not perceiving or admitting anxiety or fear (Möller-Leimkühler,
2002). This approach is incongruent to help-seeking where it is neces­
sary to express emotions. A number of qualitative help-seeking in­
vestigations have identified social norms of traditional hegemonic
masculinity as a barrier to male mental health help-seeking due to a fear
of stigma (Gair & Camilleri, 2003; Gilchrist & Sullivan, 2006). Specif­
ically, adolescents in these studies described help-seeking as being
“weak”, “pathetic” and being incongruent to “a tough or self-reliant
male” (Gilchrist & Sullivan, 2006, p. 9).
Cross sectional studies investigating mental health literacy and/or
help-seeking also suggest that mental health disorders tend to be less
recognised or acknowledged in males (Bruno, McCarthy, & Kramer,
2015; Burns & Rapee, 2006; Swami, 2012). A greater percentage of
adolescent males (aged 12–18) were able to identify depression symp­
toms in a female vignette than a male vignette (Bruno et al., 2015; Burns
& Rapee, 2006). Consequently, adolescent males with greater affiliation
to masculine identity norms may be at greater risk of unmet mental
health needs. To maximize the benefit of adolescent male help-seeking
initiatives, research into the impact of mental health literacy and
help-seeking in the context of masculine identity norms is required.
Mental health literacy research in adolescents (both male and fe­
male) has typically presented participants with vignettes followed by
either open-ended or closed response questions (Burns & Rapee, 2006;
Eckert, Kutek, Dunn, Air, & Goldney, 2010). Despite anxiety disorders
being the most common mental health condition in adolescence (Law­
rence et al., 2015), few mental health literacy studies have included
anxiety disorder vignettes. Where studies have investigated anxiety
disorders, these have been restricted to vignettes of social anxiety dis­
order (SAD; Coles et al., 2016; Mason, Hart, Rossetto, & Jorm, 2015) and
2
Journal of Anxiety Disorders 76 (2020) 102292
post-traumatic stress disorder (PTSD; Reavley & Jorm, 2011). These
studies suggest that adolescents have lower rates of symptom recogni­
tion and help-seeking encouragement and greater rates of certain forms
of stigma in response to an anxiety vignette compared to other disorders
measured (Reavley & Jorm, 2011; Yap, Wright, & Jorm, 2011). Conse­
quently, empirical research into help-seeking for anxious adolescent
males is particularly needed.
The current study aimed to investigate the relationships between
traditional masculine identity norms, anxiety mental health literacy and
help-seeking attitudes, intentions and behaviour in a sample of Austra­
lian adolescent males. Greater anxiety mental health literacy was
hypothesised to be positively associated with more favourable formal
and informal help-seeking attitudes and intentions whereas greater
alignment with masculinity norms were hypothesised to be negatively
associated with formal and informal help-seeking attitudes and in­
tentions. Participants’ alignment with traditional masculinity norms
were hypothesised to moderate the relationship between anxiety mental
health literacy and help-seeking attitudes and intentions. Greater help-
seeking intentions, more favourable help-seeking attitudes, greater
anxiety mental health literacy, lower alignment with traditional mas­
culinity norms were hypothesised to predict professional mental health
help-seeking behaviour (either by the adolescent and/or by their parents
on the adolescents’ behalf).
2. Material and methods
2.1. Method
2.1.1. Participants
Data was collected as part of a randomized controlled trial (RCT)
investigating mental health service utilisation in adolescent males
(Hudson, Brockveld, Byrow, Stow, & Clark, 2016). Demographic data
was collected at baseline. To participate in the trial, adolescents were
required to be male and aged between 12 and 18 years of age. A total of
3276 adolescent males in grades 7–11 participated in the trial. After
completing the baseline component, participants were randomly allo­
cated to this research project and project specific questionnaires were
administered. A total of 1737 (53 % of participants in the trial)
adolescent males, aged 12–18 (M = 14.83, SD = 1.33) completed
measures relating to the current investigation.
The trial participants (including the current study participants) were
recruited from six non-government schools, based in Sydney and Can­
berra, Australia. Schools were selected based on the following inclusion
criteria: pupils were aged 12–18 years, based in Australia and being an
independent organisation. Schools were excluded if female students
attended. The schools had Index of Community Socio-Educational
Advantage (ICSEA; a scale of socioeducational advantage computed
for each Australian school) scores ranging between 1002 and 1175
(Australian Curriculum, Assessment & Reporting Authority [ACARA],
2015). In Australia, ICSEA has a median of 1000 and a standard devi­
ation of 100 (Australian Curriculum Assessment & Reporting Authority,
2015).
2.1.2. Demographics/Sample characteristics
Most participants (79 %) had married parents. The largest portion of
the sample identified their mother’s and father’s ethnicity (40 % and 37
% of participants) as Oceanic (e.g. Australian, Aboriginal, Torres Strait
Islander, and New Zealander). In general, parents were professionally
employed, with 46 % of mothers and 65 % of fathers employed as a
‘manager’, ‘professional’ or ‘technician’. The majority of participants
(73 %) had either one or two siblings.
A total of 234 participants (13 %) scored as having ‘elevated’ levels
of anxiety (scores 33+) using the Spence Child Anxiety Scale or ‘SCAS’
measure of childhood anxiety. Furthermore, 112 of all participants (6 %)
scored in the ‘clinical’ range (scores 42+) on the SCAS. A total of 336
participants (19 %) scored as experiencing ‘elevated’ levels of
L.H. Clark et al.
depression symptoms (scores 8+) using the Short Mood and Feelings
Questionnaire or ‘SMFQ’ measure of depressive symptoms in childhood.
A total of 166 (10 %) participants scored in the ‘clinical’ range (scores
12+) on the SMFQ. The clinical cut-off points for the anxiety and
depression measures are reported in 2.3.4 and 2.3.5 respectively. Two
hundred and eighteen participants (13 %) scored in the clinical range for
SMFQ and/or SCAS and, of this group of participants, 65 (30 %) had
sought professional help for mental disorders.
Independent sample t-tests, Chi-square and Mann Whitney U tests
were conducted to investigate differences between the trial participants
and the subsample that participated in the current study on de­
mographic and study variables. No significant differences were found
between groups on the demographic variables with the exception of
anxiety, depression and rates of professional help-seeking behaviour.
These analyses are provided in the supplementary information (S3).
2.2. Measures
Participants were presented with an online, forced item response
battery of self-report questionnaires and demographic data questions.
The anxiety mental health literacy, anxiety and depression measures
were completed by all participants as part of the trial. The masculinity
and help-seeking measures were specific to the current investigation
and, as described above, participants who completed these measures
were included in the current study.
2.2.1. Anxiety mental health literacy
The Friend in Need Questionnaire (FIN; Burns & Rapee, 2006) was
adapted to assess anxiety mental health literacy relating to anxiety
disorders. The original questionnaire used depression vignettes con­
taining both male and female adolescents but these were replaced with
male only anxiety vignettes in the current study (see Appendix A). The
vignette ‘Jack’ was experiencing symptoms consistent with social anx­
iety disorder (SAD) as described in the Diagnostic and Statistical Manual
of Mental Disorders – Fifth Edition (DSM-5: American Psychiatric As­
sociation, 2013). The vignette ‘Tony’ was experiencing symptoms
consistent with generalized anxiety disorder (GAD). The vignette ‘Craig’
described a normal (non-clinical) level of anxiety to an event (leaving
home to go to university). While this vignette described Craig as feeling
anxious, there was no evidence of clinical anxiety symptomatology.
Participants were asked to answer questions about how worried they
were about each young person in the vignettes; what they thought was
the matter with each person; what parts of the vignettes were the
strongest hints that the young person was experiencing emotional dif­
ficulties; how long they thought it would take for each young person to
feel better; and who they thought the young person needed help from to
cope with their problems.
The participants’ responses to the FIN were coded and a total anxiety
mental health literacy score was calculated. Firstly, responses to the
question “what do you think is the matter with Craig/Jack/Tony?” were
coded as anxiety identified (one point) or anxiety not identified/inad­
equate response (no points). The responses ‘worried’, ‘embarrassed’,
‘stressed’, ‘shy’, ‘self-conscious’, ‘scared’, ‘fearful’, ‘anxious’, ‘nervous’,
‘afraid’, ‘separation’, ‘stressed’, ‘no social skills’ and ‘do or say some­
thing stupid’ were all coded as anxiety. Responses to the question in
each vignette “what parts of the vignette were the strongest hints that
Craig/Jack/Tony was experiencing emotional difficulties” was coded
firstly as a ‘relevant response’ (one point) or ‘non-relevant response’ (no
points). Participants were then awarded points for identifying key
characteristics of the vignettes. In the Craig vignette, participants were
awarded up to three points if they identified i) social fears, ii) fears about
the self and iii) fears about distance (one point each). In the Jack
vignette, participants were awarded up to three points if they identified
i) social fears, ii) physical symptoms and iii) avoidance/safety behav­
iours (one point each). In the Tony vignette, participants were awarded
up to two points if they identified i) worry and ii) physical symptoms
3
Journal of Anxiety Disorders 76 (2020) 102292
(one point each). Participants could score a maximum of 14 points for
anxiety mental health literacy. The FIN data were coded by a secondary
coder (25 %) in order to establish inter-rater reliability. An intraclass
correlation indicated high inter-rater agreement (.95).
2.2.2. Help seeking
Formal help-seeking behaviour by the adolescent and/or by their
parents on the adolescents’ behalf was measured by the question “Have
you or your parents seen any mental health professionals to get help
with your mental health (for when you felt fearful, anxious, stressed out,
down, depressed, angry etc)?” (yes/no). Where participants indicated
that they had sought help for a mental health problem, they were asked
questions about the source of help and helpfulness of the experience.
A shortened version (10 items) of the Attitudes Towards Seeking
Professional Help Scale (ATSPHS; Fischer & Farina, 1995) measured
participants’ general attitudes toward seeking help from formal sources.
Items were rated on a 4-point Likert scale (0 = disagree, 1 = partly
disagree, 2 = partly agree and 3 = agree) and averaged to form a com­
posite score with higher scores indicating more positive attitudes to­
wards seeking professional help. The revised and original versions of the
scale are correlated at .87 (Fischer & Farina, 1995). Good internal
consistency (r = .84) and 1-month test–retest reliability (r = .80) have
been reported for college student samples using the shortened version
(Fischer & Farina, 1995). A Cronbach alpha’s of .79 (omega = .87) was
found in the current study. The question “I wouldn’t talk to friends or
family when I felt down or upset” was added to the battery in order to
elicit participants’ attitudes towards informal sources of help.
Help-seeking intentions were measured using an adolescent version
of the General Help Seeking Questionnaire (GHSQ; Wilson, Deane,
Ciarrochi, & Rickwood, 2005). The original measure includes two scales
- suicidal problems and non-suicidal problems. The current study uti­
lized only the non-suicidal subscale with the instruction “If you were
having a personal or emotional problem, how likely is it that you would
seek help from each of the following sources?”. Participants rated their
likelihood of seeking help from 14 sources of help (containing formal
and informal help sources) on a 7-point scale (ranging from 1 =
extremely unlikely to 7 = extremely likely). At the time of investigation the
GHSQ was the only help-seeking measure found to be psychometrically
valid in adolescents (Rickwood & Thomas, 2012; Wilson et al., 2005)
and the sub-scale utilized (non-suicidal) has been demonstrated to have
satisfactory reliability (Cronbach’s alpha = .70, test-retest reliability
assessed over a three-week period = .86) (Wilson et al., 2007). A
Cronbach’s alpha of .88 (omega = .91) was found in the current study.
Exploratory Factor Analysis (EFA) using principal axial factoring (PAF)
with an oblique rotation was used to uncover factor structure of the
GHSQ (see results section).
2.2.3. Masculinity
The Adolescent Masculinity Ideology in Relationships Scale (AMIRS;
Chu, Porche, & Tolman, 2005) was used to measure participants’ affil­
iations with traditional norms of masculinity (ATNM). The scale in­
vestigates the concept of masculinity within the context of interpersonal
relationships where masculine norms are hypothesised to become
personally meaningful and directly consequential to adolescent boys.
The scale comprised of 12 belief statements and respondents indicated
their agreement using a four-point anchor, ranging from disagree a lot (1)
to agree a lot (4). Negatively worded items received a reversed score.
Composite scores were calculated by summing the items. Higher scores
reflect greater alignment with norms of hegemonic masculinity.
Acceptable internal consistency (Cronbach’s alpha, α = .70) has been
reported for adolescent male samples using the AMIRS (Chu et al.,
2005). A Cronbach’s α of .78 (omega, Ω = .84) was found in the current
study.
2.2.4. Anxiety symptoms
Participants completed the Spence Children’s Anxiety Scale – Child
L.H. Clark et al. Journal of Anxiety Disorders 76 (2020) 102292

Version (SCAS-C; Spence, Barrett, & Turner, 2003). This 45-item
(including six positive filler items) questionnaire has six subscales
measuring separation anxiety, social phobia, obsessions/compulsion,
panic/agoraphobia, generalized anxiety and fear of physical injury.
Symptoms are rated on a 4-point Likert scale (1 = never, 2 = sometimes, 3
= often and 4 = always). Responses were summed to a composite score;
higher scores indicated higher levels of anxiety. The scale has been
found to be psychometrically sound with good internal consistency (α =
.92 child-report version) and convergent and divergent validity (Nauta
et al., 2004; Spence, 1998). In this study, internal consistency was α =
.90. According to normative data using the SCAS total scores, in­
dividuals scoring 33 points and higher are considered to have elevated
levels of anxiety. Individuals scoring 42 points or higher are considered
to have clinical levels of anxiety (Spence et al., 2003).
2.2.5. Depression
The Short Mood and Feelings Questionnaire (SMFQ) (Angold et al.,
1995) was used to assess child reported depression symptoms. Accord­
ing to normative data, individuals scoring eight points or higher are
experiencing elevated levels of depression, and individuals scoring 12
points or higher are likely to be experiencing clinical levels of depres­
sion. The measure has been found to have good psychometric properties
(Angold et al., 1995; Kent, Vostanis, & Feehan, 1997). In this study,
internal consistency was high (α = .90).
2.3. Procedure
Ethical approval for this study was obtained from the Macquarie
University Human Research Ethics Committee. Approximately 41 in­
dependent boys’ schools based in New South Wales (predominantly in
Sydney) were offered the opportunity to participate in the trial. The
school recruitment process involved simultaneously contacting the
school counsellor and head teacher of the school initially through letter
and/or email and then by phone. Recruitment ceased when six schools
that fitted this inclusion criteria (i.e., no female students and non-
government) were recruited. Parents of all students aged between
12–18 years who were enrolled at the participating schools received a
written consent and information sheet about the larger trial and the
current study. In consultation with the school, when children were
judged mature enough to understand and consent, only written child
consent was required. Two schools requested both child and parent
consent and four schools required child consent only. One school
requested an incentive (movie tickets) to encourage the return of con­
sent forms. Approximately 5062 students’ families from the six schools
were sent a letter invitation to participate in the trial. A total of 3276
(64.72 %) adolescent males in grades 7–11 participated in the larger
trial. Adolescents completed a series of online questionnaires during a
one-hour data collection session within school time as part of the trial.
As described above, time permitted, they were randomly allocated
additional measures associated with the current study. A total of 1737
(53 %) of these students participated in the current study. Participants at
the school screening or interventions stage of the project were contacted
and referred if they showed any signs of being at risk to themselves or
others and/or severe depression.
2.4. Data preparation and analyses
except for online help-seeking intentions, which showed positive skew
(1.56) and kurtosis (2.62). Spearman’s correlations were initially run to
investigate the bivariate relationships between variables. Given the data
were collected from students attending one of six schools, linear or
generalized linear mixed models were used to test the hypothesised
relationships between anxiety mental health literacy, masculinity, and
help-seeking intentions, attitudes, and behaviour. In each of these
models, age was included as a covariate, and school was included as a
random effect on the intercepts. Independent variables were centred to
facilitate interpretation of fixed effects and convergence of the mixed
models, age was centred at the youngest age (age 12), descriptive sta­
tistics prior to centring are in Table 1. Unstandardised betas are reported
(b). The likelihood ratio test was used to assess if school was a significant
random effect, when the random effect was not significant the results
from the more parsimonious linear or generalised linear model were
reported. For the ordinal variable, informal help-seeking attitude, a
proportional odds ordinal regression was run with a cumulative logit
link and flexible thresholds, and for the binary variable, help-seeking
behaviour, a logistic regression was run with a logit link. Residual
plots were examined for outliers, linearity, normality, and leverage. The
proportional odds assumption was checked for the ordinal regression
and linearity of the logit was checked against the predictors for the lo­
gistic regression. There was evidence of nonlinearity and hetero­
scedasticity in the residuals of the models predicting intentions to seek
help from family, formal, and online sources, these regression models
were bootstrapped 5000 times, bootstrapped estimates are reported and
95 % confidence intervals used to determine significance with an α of
.05. There were no issues with the assumptions for any of the other
regression models. Any significant moderation term was taken forward
to test the slopes at the mean and 1 SD above and below the mean.
Statistical analyses were conducted in R (version 3.6.0), using the
packages lme4 and ordinal.
3. Results
3.1. Preliminary analysis
Exploratory Factor Analysis (EFA) using principal axial factoring
(PAF) with an oblique rotation was used to uncover the factor structure
of the GHSQ. PAF was chosen because variance unique to individual
items as well as error variance is excluded from the analysis (Tabach­
nick, Fidell, & Osterlind, 2001). Preliminary analysis identified a
violation of assumptions (significant skewness) on several items. How­
ever, a significant Bartlett’s test of Sphericity (χ 2 = 12162.793, df = 105,
p < .001) and a Kaiser-Meyer-Olkin measure of sampling adequacy
(KMO) of .88 suggested that an EFA was appropriate. The factors
identified through the EFA were considered consistent with existing
youth help-seeking literature from the perspective that adolescents
clearly differentiate between and state a preference for informal over
formal help-seeking options (Gulliver et al., 2010). Four components
with eigenvalues greater than one emerged and examination of the
Table 1
Descriptive Statistics of Measures.
Measures N M SD Min Max

Age 1737 14.83 1.33 12 19

Initially an exploratory factor analysis was conducted in SPSS Mental Health Literacy 1737 7.27 2.99 0 14
(version 23.0) on the GHSQ items in order to identify how the GHSQ Masculinity 1737 22.53 6.24 12 45
items should be most appropriately utilised in the main analyses (see Intentions Peer 1732 8.64 3.36 2 14
Intentions Family 1733 14.76 5.28 3 21
below). Anxiety mental health literacy, masculinity, the four help-
Intentions Formal 1732 17.33 9.25 6 42
seeking intention variables, and formal help-seeking attitudes were Intentions Online 1733 6.4 3.9 3 21
continuous variables. Informal help-seeking attitude was ordinal (four Attitudes Informal 1735 2.02 1.03 0 3
levels). Formal help-seeking behaviour was categorical (yes/no). No Attitudes Formal 1736 1.74 0.52 0 3
extreme outliers were identified on boxplots and histograms. Skew and Help-seeking Behaviour 1735 165 1570
Yes No
kurtosis was acceptable (between -1 and 1) for all continuous variables

4
L.H. Clark et al. Journal of Anxiety Disorders 76 (2020) 102292

screeplot also revealed a four factor solution to be most optimal. The
first factor, accounting for 35 % of the variance, included items relating
to ‘Formal’ help-seeking: Phone help-line, GP, Mental Health Profes­
sional, Youth Worker, Religious Figure, Teacher. The second factor,
accounting for 12 % of the variance, included seeking help from a
website or an internet chat room and was termed ‘Online’. The third
factor, accounting for 6 % of the variance, included seeking help from
friends or partner and was labelled ‘Informal Peer’. The final factor,
labelled ‘Informal Family’, included seeking help from parents or other
relatives and accounted for a further 4 % of the variance.
During the factor analysis, the GHSQ items ‘I would not seek help
from anyone’ and ‘I would seek help from someone else’ were found to
load on to the second factor. However, including the former item
significantly reduced the internal consistency of the subscale (α = .29).
As neither item were felt to be a theoretical ‘fit’ with the other items they
were removed from further analysis. Due to the significant research
interest in online help-seeking for adolescent males the online items
were explored independently. The internal consistencies (α) of the
subscales in this study were: α = .64/ Ω = .64 (informal peer), α = .85/ Ω
= .86 (informal family), α = .90/ Ω = .93 (formal) and α = .69/ Ω = .70
(online).
3.2. Bivariate relationships
Anxiety mental health literacy scores were positively correlated with
formal and informal help-seeking attitudes and intention to seek help
from family but were negatively associated with alignment with mas­
culinity norms (see Table 2). Age was also positively correlated with
anxiety mental health literacy, confirming the importance of including
age as a covariate in subsequent models. Higher masculinity scores were
associated with adolescents having less favourable attitudes towards
formal and informal help-seeking and lower intentions to seek help from
peers, family and formal sources but greater intentions to seek help from
online sources.
SE = 0.01, t = -5.71, p < .001), family (b = -0.15, SE = 0.02, 95 % CI
[-0.20, -0.10]), and formal (b = -0.25, SE = 0.04, 95 % CI [-0.32, -0.17])
sources, and with less favourable attitudes to informal (b = -0.06, SE =
0.01, t = -7.57, p < .001) or formal (b = -0.03, SE = 0.002, t = -17.62, p <
.001) help-seeking. In contrast, higher masculinity was associated with a
higher intention to seek help from online sources (b = 0.05, SE = 0.01,
95 % CI [0.02, 0.07]). Anxiety mental health literacy was not significant
as a main effect. Moderation analyses were conducted to investigate the
effect of masculinity on the relationship between anxiety mental health
literacy and all help-seeking variables. Masculinity was not found to be a
significant moderator between mental health literacy and attitudes to­
wards seeking help from informal sources, intentions to seek help from
either online or formal sources. However, there was a significant
moderating effect of masculinity on the relationship between anxiety
mental health literacy and attitudes to formal help-seeking (b = -0.0016,
SE = 0.0006, t = -2.72, p = .006). Simple slopes were tested at the mean
and 1 SD above and below the mean score for masculinity. Fig. 1 dem­
onstrates that for adolescents with low alignment to masculinity norms,
then higher anxiety mental health literacy was associated with more
positive attitudes towards formal help-seeking (b = 0.018, SE = .006, t =
2.93, p = .003). At the mean score for masculinity the relationship was in
the same direction and almost significant (b = 0.008, SE = .004, t = 1.95,
p = .052). However, for adolescents with high alignment to masculinity
norms there was no significant relationship between anxiety mental

3.3. Anxiety mental health literacy, masculinity and help-seeking

attitudes/intentions

Moderation analyses were conducted to examine whether alignment

with masculinity norms moderated the relationship between anxiety
mental health literacy and the identified help-seeking variables, and to
test for unique predictive relationships between anxiety mental health
literacy and masculinity and help-seeking behaviours. School accounted
for less than 1 % of the variance in the all measures, except for help-
seeking behaviour where it accounted for 1.8 %. School was not a sig­
nificant random effect in any of the mixed model, so results are reported
from the linear or generalised linear models (see Supplementary
Fig. 1. Adherence to traditional norms of masculinity moderates the relation­
Table S1). Masculinity was a significant predictor of all help-seeking
ship between mental health literacy and attitudes towards seeking help from
attitudes and intentions. Higher alignment with masculinity norms
formal sources. Shading indicates 95 % confidence intervals.
was associated with lower intentions to seek help from peers (b = -0.08,

Table 2
Spearman’s Correlations between Mental Health Literacy, Masculinity and Help-seeking Intentions and Attitudes.
Variable 1 2 3 4 5 6 7 8 9

1. Mental health literacy − .30*** .01 .05* .03 .03 .06* .17*** .07**
2. Masculinity − .13*** − .16*** − .16*** .06* − .19*** − .42*** -.04
Intentions
3. Informal Peer .28*** .25*** .20*** .08*** .14*** .13***
4. Informal Family .50*** .13*** .14*** .22*** − .16***
5. Formal .44*** .03 .32*** − .09***
6. Online − .10*** .03 .05*
Attitudes
7. Informal .22*** -.02
8. Formal .04
9. Age

Note. *** p < .001, ** p < .01, * p < .05.

5
L.H. Clark et al. Journal of Anxiety Disorders 76 (2020) 102292

health literacy and attitudes towards formal help-seeking (b = -0.002, SE Table 4

= 0.005, t = -0.42, p = .678). Predictor Coefficients for the Model Predicting Formal Help-Seeking Behaviour
in Participants with Clinical Levels of Anxiety or Depression (N = 1727).
3.4. Anxiety mental health literacy, masculinity and formal help-seeking Measures b SE (b) p OR [95 % CI]
behaviour Constant − 0.48 0.38
Mental health literacy 0.07 0.06 0.200 1.07 [0.96, 1.20]
A total of 165 (9.5 %) participants reported that they and/or their Masculinity − 0.06 0.03 0.038 0.94 [0.89, 1.00]
Intentions
parent(s) had sought professional help for their (the participant’s)
Informal Peer 0.03 0.05 0.547 1.03 [0.94, 1.13]
mental health problem (see Supplementary Table S2 - for a breakdown Informal Family − 0.08 0.04 0.021 0.92 [0.86, 0.99]
of the type of help sought). Formal 0.003 0.02 0.907 1.00 [0.96, 1.05]
A logistic mixed model investigated whether help-seeking attitudes, Online 0.004 0.04 0.925 1.00 [0.92, 1.09]
intentions, anxiety mental health literacy, masculinity, and age pre­ Attitudes
Informal 0.17 0.16 0.268 1.19 [0.88, 1.62]
dicted professional mental health help-seeking behaviour. The random
Formal 0.97 0.4 0.015 2.64 [1.24, 5.98]
effect of school was not significant and was dropped from the model (see Age − 0.12 0.12 0.319 0.89 [0.70, 1.12]
Supplementary Table S1). The model was significant (χ 2(9) = 65.7, p <
Note. CI = Confidence Interval.
.001; McFadden’s pseudo R2 = 0.06). As detailed in Table 3, participant
attitudes towards formal help-seeking, intentions to seek help from a
family member and a formal source were significant predictors in the literacy programs would be more effective at improving help-seeking
model. Of the 1728 participants with data on all of the logistic regression rates in this population.
variables, 218 had clinical scores on either anxiety or depression. When Consistent with studies that have found higher levels of mental
testing which measures were significant predictors of help-seeking health literacy to be positively associated with help-seeking attitudes
behaviour among participants with anxiety or depression, the model and intentions in young adults (Battaglia et al., 1990; Paulus et al., 2009;
was significant (χ 2(9) = 29.3, p < .001; McFadden’s pseudo R2 = .11). Rickwood et al., 2004), the current study found anxiety mental health
Among participants with anxiety or depression symptoms, attitudes to­ literacy scores to be positively correlated with attitudes to formal and
wards formal help-seeking and intentions to seek help from a family informal help-seeking and intentions to seek-help from family. However,
member were still significant predictors of help-seeking behaviour, and these effects were no longer significant when the relationship between
in addition higher affinity to masculinity norms was associated with anxiety mental health literacy with masculinity and help-seeking vari­
being less likely to seek help (details in Table 4). ables was investigated and age was accounted for. This finding indicates
that the unique contribution of anxiety mental health literacy on in­
4. Discussion tentions and attitudes is not only small, but also shared with masculinity
and/or age. Consistent with a systematic review by Gulliver, Griffiths,
In this study we examined the associations between anxiety mental Christensen, and Brewer (2012), anxiety mental health literacy was not
health literacy, masculinity and mental health help-seeking. Participant found to predict help-seeking behaviour itself. Only formal help-seeking
alignment with norms of masculinity was found to moderate the rela­ was investigated in the current study and the relationship between
tionship between anxiety mental health literacy and attitudes towards anxiety mental health literacy and informal help-seeking behaviour
formal mental health help-seeking. More specifically, higher anxiety cannot be inferred.
mental health literacy was positively associated with more favourable In regards to psychological help-seeking, although 13 % of the
attitudes towards formal help-seeking in adolescents with low or sample scored in the clinical range on the anxiety and/or depression
average alignment with norms of hegemonic masculinity. However, no measures, only 30 % of these participants had sought professional help
relationship between anxiety mental health literacy and help-seeking for mental disorders. This is comparable to adolescent male service
attitudes was found in adolescents with a greater alignment with utilisation rates found in large epidemiological surveys (Merikangas
norms of hegemonic masculinity. These findings are consistent with et al., 2011; Slade et al., 2009) and suggests the sample was represen­
previous research which have found associations between affiliation tative in regards to help-seeking behaviour in this population. Partici­
with traditional masculinity ideology and attitudes towards formal help- pant attitudes towards formal help-seeking, intentions to seek help from
seeking in males (Pederson & Vogel, 2007; Yousaf, Popat, & Hunter, a family member and from a formal source were found to be significant
2015). The study findings suggest that adolescent males with greater predictors of professional help-seeking behaviour. Whereas, anxiety
affiliation to social masculinity norms may be more resistant to anxiety mental health literacy, masculinity, intention to seek help from a friend
mental health initiatives designed to improve help-seeking. Further or online and attitudes towards informal help were found to be
work is needed to investigate if male-orientated anxiety mental health non-significant predictors of help-seeking behaviour. It is unclear why
intention to seek help from a family member predicted less help-seeking
behaviour. A greater intention to seek help from family members may
Table 3
suggest that individuals who had sought help from parents may have
Predictor Coefficients for the Model Predicting Formal Help-Seeking Behaviour
(N = 1727). received more practical support and did not require or did not think they
required support from formal mental health services. This negative
Measures b SE (b) p OR [95 % CI]
relationship between intentions to seek help from family and formal
Constant − 2.43 0.09 help-seeking behaviour held true when assessed only in participants
Mental health literacy − 0.00 0.03 0.996 1.00 [0.94, 1.06]
with clinical levels of anxiety or depression. This suggests that family
Masculinity − 0.03 0.02 0.071 0.97 [0.94, 1.00]
Intentions support might not translate to young people with mental health prob­
Informal Peer 0.03 0.03 0.202 1.03 [0.98, 1.09] lems accessing mental health services. This finding may relate to com­
Informal Family − 0.12 0.02 3.05 x 10− 10
0.88 [0.85, 0.92] mon mental health problems, such as GAD, where regular reassurance
Formal 0.03 0.01 0.041 1.03 [1.00, 1.05] (which in the case of an adolescent usually comes from a parent) reduces
Online − 0.03 0.03 0.316 0.97 [0.92, 1.02]
Attitudes
short-term distress despite ultimately maintaining the anxiety disorder
Informal − 0.11 0.08 0.208 0.9 [0.77, 1.06] (Dugas & Robichaud, 2007). Consequently, adolescents seeking support
Formal 0.77 0.19 4.44 x 10− 5
2.16 [1.49, 3.13] in the form of reassurance from family members may be less likely to
Age − 0.08 0.06 0.184 0.92 [0.81, 1.04] seek formal help. In addition, higher masculinity was also associated
Note. CI = Confidence Interval. with being less likely to seek formal help. The only measure that

6
L.H. Clark et al.
predicted a greater likelihood of seeking help was the adolescent’s
attitude to formal help-seeking, for each unit increase in attitude to seek
formal help, then help-seeking behaviour was at least doubled.
4.1. Limitations
Several limitations of the study should be acknowledged. A number
of study measures were not widely used and/or psychometrically
established measures and were chosen or developed due to a lack of such
measures. The study used single item measures to assess multifacted
concepts such as masculinity and formal mental health help-seeking
behaviour and are thus limited. Furthermore, it should be highlighted
that the question assessing formal help seeking includes reference to
both adolescent help-seeking and parent help-seeking on behalf of the
adolescent. In some cases, parents may have sought help for their son
without his agreement/consent. This information should be taken into
account when interpreting the findings relating to this measure. It
should also be noted that the predictor variables in this analysis, relating
to formal mental health help-seeking, refer to adolescent self-report
measures not parent report measures. Consequently, the results may
be more indicative of parent help-seeking behaviour and/or parent
facilitated help-seeking rather than adolescent help-seeking. Also, the
Friend in Need, although widely used, is not a psychometrically estab­
lished measure of mental health literacy. Furthermore, some compo­
nents of mental health literacy as identified by Jorm (2012), such as
knowing how to prevent mental disorders and knowing about self-help
strategies, were not measured in the study. In order to reliably test the
impact of anxiety mental health literacy on help-seeking, future research
should include these additional elements of mental health literacy.
Significant differences were identified between the participant
sample and adolescents who participated as part of the larger trial
(please see method for details). Adolescent males who completed the
current investigation were found to have greater levels of anxiety mental
health literacy and yet more negative attitudes towards and to be less
likely to have sought help from a mental health professional. Students
completing the study measures may have also differed in other ways
such as cognitive processing speed, given the study measures were only
offered if time allowed. It should also be noted that it is not possible to
conclude that the identified associations are specific to males. The study
findings may equally apply to female adolescents and research is needed
to investigate social norms and mental health help-seeking in this
population.
The conceptualisation of help-seeking intentions (i.e. informal fam­
ily, informal peer, formal and online) was based on a factor analysis of
the GHSQ measure due to a lack of a clear conceptualisation of forms of
help-seeking intentions in the literature. However, it should be noted
that there may be limitations with this categorisation of help-seeking
intentions. For example, there are many professional services provided
online and so online help-seeking could be regarded as informal or
formal. Consequently, the analysis where the help-seeking intentions
variables have been utilised should be interpreted with caution.
The participants in the current study attended fee paying (i.e. pri­
vate) schools. Adolescents attending fee paying schools are likely to
come from households with high socioeconomic status (SES). The rela­
tionship between lower SES and a greater likelihood of experiencing
mental health issues is fairly established (Reiss, 2013). Although more
research is needed to understand the role of SES on mental health
help-seeking, children from higher SES backgrounds are likely to have
more options available in terms of private mental health care and may
even have parents with greater mental health literacy (Knesebeck et al.,
2013).
4.2. Conclusions
The study results indicate that further research is needed to under­
stand the relationship between masculine identity norms, anxiety
7
Journal of Anxiety Disorders 76 (2020) 102292
mental health literacy and help-seeking in adolescent males. The
development of a range of mental health programs that appeal to
adolescent males, with varying levels of alignment with norms of heg­
emonic masculinity, has the potential to significantly increase mental
health help-seeking in young men.
Authors’ contributions
LC and JH designed and conducted the investigation. LC conducted
the statistical analysis and drafted the manuscript. JH supervised the
statistical analysis and contributed to the development and refinement
of the manuscript. RR and KLG supported the statistical analysis,
interpretation of the data and development of the manuscript. All au­
thors contributed to and have approved the final version of the
manuscript.
Funding
This study was funded by the Beyondblue National Priority Driven
Research Program, AustraliaMEN0029. During the time of the analysis,
KLG was supported by a grant from the NHMRC, Australia
(APP1173025).
Declaration of Competing Interest
All authors declare that they have no conflicts of interest.
Acknowledgements
The authors wish to thank the adolescents, parents and schools who
participated in the study.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.janxdis.2020.102292.
References
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human
Decision Processes, 50(2), 179–211.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Angold, A., Costello, E. J., Messer, S. C., Pickles, A., Winder, F., & Silver, D. (1995).
Development of a short questionnaire for use in epidemiological studies of
depression in children and adolescents. International Journal of Methods in Psychiatric
Research, 5(4), 237–249.
Australian Curriculum Assessment and Reporting Authority. (2015). ICSEA 2014:
Technical report. Sydney: ACARA.
Australian Curriculum, Assessment and Reporting Authority [ACARA]. (2015). What does
the ICSEA value mean?. http://docs.acara.edu.au/resources/About_icsea_2014.pdf.
Battaglia, J., Coverdale, J. H., & Bushong, C. P. (1990). Evaluation of a mental illness
awareness week program. The American Journal of Psychiatry, 147, 324–329. https://
doi.org/10.1176/ajp.147.3.324
Bruno, M., McCarthy, J., & Kramer, C. (2015). Mental health literacy and depression
among older adolescent males. Journal of Asia Pacific Counseling, 5(2), 63–64.
https://doi.org/10.18401/2015.5.2.1
Burns, J. R., & Rapee, R. M. (2006). Adolescent mental health literacy: Young people’s
knowledge of depression and help seeking. Journal of Adolescence, 29(2), 225–239.
https://doi.org/10.1016/j.adolescence.2005.05.004
Chu, J. Y., Porche, M. V., & Tolman, D. L. (2005). The adolescent masculinity ideology in
relationships scale development and validation of a new measure for boys. Men and
Masculinities, 8(1), 93–115. https://doi.org/10.1177/1097184X03257453
Coleman, D. (2015). Traditional masculinity as a risk factor for suicidal ideation: Cross-
sectional and prospective evidence from a study of young adults. Archives of Suicide
Research, 19(3), 366–384. https://doi.org/10.1080/13811118.2014.957453
Coles, M. E., Ravid, A., Gibb, B., George-Denn, D., Bronstein, L. R., & McLeod, S. (2016).
Adolescent mental health literacy: Young people’s knowledge of depression and
social anxiety disorder. Journal of Adolescent Health, 58(1), 57–62. https://doi.org/
10.1016/j.jadohealth.2015.09.017
Cotton, S. M., Wright, A., Harris, M. G., Jorm, A. F., & McGorry, P. D. (2006). Influence of
gender on mental health literacy in young Australians. The Australian and New
Zealand Journal of Psychiatry, 40(9), 790–796. https://doi.org/10.1080/j.1440-
1614.2006.01885.x
L.H. Clark et al.
Dugas, M. J., & Robichaud, M. (2007). Cognitive-behavioral treatment for generalized
anxiety disorder: From science to practice. Taylor & Francis.
Eckert, K. A., Kutek, S. M., Dunn, K. I., Air, T. M., & Goldney, R. D. (2010). Changes in
depression-related mental health literacy in young men from rural and urban South
Australia. The Australian Journal of Rural Health, 18(4), 153–158. https://doi.org/
10.1111/j.1440-1584.2010.01135.x
Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychologial
help: A shortened form and considerations for research. Journal of College Student
Development, 36(4), 368–373.
Gair, S., & Camilleri, P. (2003). Attempting suicide and help-seeking behaviours: Using
stories from young people to inform social work practice. Australian Social Work, 56
(2), 83–93. https://doi.org/10.1046/j.0312-407X.2003.00064.x
Gilchrist, H., & Sullivan, G. (2006). Barriers to help-seeking in young people: Community
beliefs about youth suicide. Australian Social Work, 59(1), 73–85. https://doi.org/
10.1080/0312407050044979
Gulliver, A., Griffiths, K. M., & Christensen, H. (2010). Perceived barriers and facilitators
to mental health help-seeking in young people: A systematic review. BMC Psychiatry,
10(1), 113–128. https://doi.org/10.1186/1471-244X-10-113
Gulliver, A., Griffiths, K. M., Christensen, H., & Brewer, J. L. (2012). A systematic review
of help-seeking interventions for depression, anxiety and general psychological
distress. BMC Psychiatry, 12, 81. https://doi.org/10.1186/1471-244X-12-81
Harding, C., & Fox, C. (2015). It’s not about “freudian couches and personality changing
drugs”: An investigation into men’s mental health help-seeking enablers. American
Journal of Men’s Health, 9(6), 451–463. https://doi.org/10.1177/
1557988314550194
Hudson, J., Brockveld, K., Byrow, Y., Stow, L., & Clark, L. (2016). The male adolescent
anxiety study: Beyondblue research trial report. Macquarie University.
Jorm, A. F. (2012). Mental health literacy: Empowering the community to take action for
better mental health. The American Psychologist, 67(3), 231–243. https://doi.org/
10.1037/a0025957
Jorm, A. F., Korten, A., Jacomb, P., Christensen, H., Rodgers, B., & Pollitt, P. (1997).
“Mental health literacy. A survey of the public”s ability to recognise mental disorders
and their beliefs about the effectiveness of treatment. The Medical Journal of
Australia, 166(4), 182–186.
Kent, L., Vostanis, P., & Feehan, C. (1997). Detection of major and minor depression in
children and adolescents: Evaluation of the Mood and Feelings Questionnaire.
Journal of Child Psychology and Psychiatry, 38(5), 565–573. https://doi.org/10.1111/
j.1469-7610.1997.tb01543.x
Knesebeck, O. V. D., Mnich, E., Daubmann, A., Wegscheider, K., Angermeyer, M. C.,
Lambert, M., … Kofahl, C. (2013). Socioeconomic status and beliefs about
depression, schizophrenia and eating disorders. Social Psychiatry and Psychiatric
Epidemiology, 48, 775–782.
Lawrence, D., Johnson, S., Hafekost, J., Boterhaven de Haan, K., Sawyer, M., Ainley, J.,
… Zubrick, S. (2015). The Mental Health of Children and Adolescents: Report on the
second Australian child and adolescent survey of mental health and wellbeing. Telethon
Kids Institute.
Mason, R. J., Hart, L. M., Rossetto, A., & Jorm, A. F. (2015). Quality and predictors of
adolescents‫ ׳‬first aid intentions and actions towards a peer with a mental health
problem. Psychiatry Research, 228(1), 31–38. https://doi.org/10.1016/j.
psychres.2015.03.036
Merikangas, K. R., He, J.-p., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., …
Olfson, M. (2011). Service utilization for lifetime mental disorders in US adolescents:
results of the National Comorbidity Survey–Adolescent Supplement (NCS-A). Journal
of the American Academy of Child and Adolescent Psychiatry, 50(1), 32–345. https://
doi.org/10.1016/j.jaac.2010.10.006
Möller-Leimkühler, A. M. (2002). Barriers to help-seeking by men: A review of
sociocultural and clinical literature with particular reference to depression. Journal
of Affective Disorders, 71(1), 1–9. https://doi.org/10.1016/S0165-0327(01)00379
Nauta, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H., & Waters, A. (2004).
A parent-report measure of children’s anxiety: Psychometric properties and
comparison with child-report in a clinic and normal sample. Behaviour Research and
Therapy, 42(7), 813–839. https://doi.org/10.1016/S0005-7967(03)00200-6
Journal of Anxiety Disorders 76 (2020) 102292
Paulus, P., Conrad, I., Dietrich, S., Heider, D., Blume, A., Angermeyer, M. C., … Riedel-
Heller, S. (2009). “Crazy? So what!”: A school programme to promote mental health
and reduce stigma-results of a pilot study. Health Education, 109(4), 314–328.
https://doi.org/10.1108/09654280910970893
Pederson, E. L., & Vogel, D. L. (2007). Male gender role conflict and willingness to seek
counseling: Testing a mediation model on college-aged men. Journal of Counseling
Psychology, 54(4), 373–384. https://doi.org/10.1037/0022-0167.54.4.373
Perry, Y., Petrie, K., Buckley, H., Cavanagh, L., Clarke, D., Winslade, M., …
Christensen, H. (2014). Effects of a classroom-based educational resource on
adolescent mental health literacy: A cluster randomised controlled trial. Journal of
Adolescence, 37(7), 1143–1151. https://doi.org/10.1016/j.adolescence.2014.08.001
Reavley, N. J., & Jorm, A. F. (2011). Stigmatizing attitudes towards people with mental
disorders: Findings from an Australian National Survey of Mental Health Literacy
and Stigma. The Australian and New Zealand Journal of Psychiatry, 45(12),
1086–1093.
Reiss, F. (2013). Socioeconomic inequalities and mental health problems in children and
adolescents: A systematic review. Social Science & Medicine, 90, 24–31.
Rickwood, D., & Thomas, K. (2012). Conceptual measurement framework for help-
seeking for mental health problems. Psychology Research and Behavior Management, 5,
173–183. https://doi.org/10.2147/PRBM.S38707
Rickwood, D., Cavanagh, S., Curtis, L., & Sakrouge, R. (2004). Educating young people
about mental health and mental illness: Evaluating a school-based programme. The
International Journal of Mental Health Promotion, 6(4), 23–32. https://doi.org/
10.1080/14623730.2004.9721941
Rickwood, D., Deane, F. P., Wilson, C. J., & Ciarrochi, J. (2005). Young people’s help-
seeking for mental health problems. Advances in Mental Health, 4(3), 218–251.
https://doi.org/10.5172/jamh.4.3.218
Seidler, Z. E., Dawes, A. J., Rice, S. M., Oliffe, J. L., & Dhillon, H. M. (2016). The role of
masculinity in men’s help-seeking for depression: A systematic review. Clinical
Psychology, 46, 106–118. https://doi.org/10.1016/j.cpr.2016.09.002
Slade, T., Johnston, A., Oakley Browne, M. A., Andrews, G., & Whiteford, H. (2009).
2007 National Survey of Mental Health and Wellbeing: Methods and key findings.
Australasian Psychiatry, 43(7), 594–605. https://doi.org/10.1080/
00048670902970882
Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour
Research and Therapy, 36(5), 545–566. https://doi.org/10.1016/S0005-7967(98)
00034-5
Spence, S. H., Barrett, P. M., & Turner, C. M. (2003). Psychometric properties of the
Spence Children’s Anxiety Scale with young adolescents. Journal of Anxiety Disorders,
17(6), 605–625. https://doi.org/10.1016/S0887-6185(02)00236-0
Swami, V. (2012). Mental health literacy of depression: Gender differences and
attitudinal antecedents in a representative British sample. PloS One, 7(11), 1–6.
https://doi.org/10.1371/journal.pone.0049779
Tabachnick, B. G., Fidell, L. S., & Osterlind, S. J. (2001). Using multivariate statistics.
Retrieved from http://tocs.ulb.tu-darmstadt.de/135813948.pdf.
Wei, Y., Hayden, J. A., Kutcher, S., Zygmunt, A., & McGrath, P. (2013). The effectiveness
of school mental health literacy programs to address knowledge, attitudes and help
seeking among youth. Early Intervention in Psychiatry, 7(2), 109–121. https://doi.
org/10.1111/eip.12010
Wilson, C. J., Deane, F. P., Ciarrochi, J., & Rickwood, D. (2005). Measuring help-seeking
intentions: Properties of the general help-seeking questionnaire. Canadian Journal of
Counselling, 39(1), 15–28.
Wilson, C., Rickwood, D., & Deane, F. (2007). Depressive symptoms and help-seeking
intentions in young people. Clinical Psychologist, 11(3), 98–107. https://doi.org/
10.1080/13284200701870954
Yap, M. B., Wright, A., & Jorm, A. F. (2011). The influence of stigma on young people’s
help-seeking intentions and beliefs about the helpfulness of various sources of help.
Social Psychiatry and Psychiatric Epidemiology, 46(12), 1257–1265. https://doi.org/
10.1007/s00127-010-0300-5
Yousaf, O., Popat, A., & Hunter, M. S. (2015). An investigation of masculinity attitudes,
gender, and attitudes toward psychological help-seeking. Psychology of Men &
Masculinity, 16(2), 234–237. https://doi.org/10.1037/a0036241