European Journal of Higher Education

ISSN: 2156-8235 (Print) 2156-8243 (Online) Journal homepage: www.tandfonline.com/journals/rehe20

Perceived barriers to mental health services:

a mixed-method study with Ukrainian college
students

V. Burlaka, I. Churakova, O.A. Aavik & D. Goldstein

To cite this article: V. Burlaka, I. Churakova, O.A. Aavik & D. Goldstein (2014) Perceived barriers
to mental health services: a mixed-method study with Ukrainian college students, European
Journal of Higher Education, 4:2, 167-183, DOI: 10.1080/21568235.2014.890524

To link to this article: https://doi.org/10.1080/21568235.2014.890524

Published online: 26 Feb 2014.

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European Journal of Higher Education, 2014
Vol. 4, No. 2, 167–183, http://dx.doi.org/10.1080/21568235.2014.890524

Perceived barriers to mental health services: a mixed-method study

with Ukrainian college students
V. Burlakaa*, I. Churakovab, O.A. Aavikb and D. Goldsteinb
a
School of Social Work and Department of Psychology, University of Michigan, Ann Arbor, MI,
USA; bDepartment of Psychology, University of Michigan, Ann Arbor, MI, USA
(Received 30 October 2013; accepted 30 January 2014)

We examined perceived barriers to professional help among Ukrainian college

students, psychologists and psychiatrists. Students from eight universities and
psychologists participated in qualitative stage. A survey of barriers to mental health
treatment was developed based on qualitative data and used with psychiatrists to
validate understanding of help-seeking strategies gained in qualitative stage. Qualit-
ative stage revealed two major sets of barriers. Some barriers were perceived as being
caused by the structure in which services are rendered (e.g., availability of services,
inconvenient location and hours), and other barriers were thought to be attitudinal (e.g.,
stigma, acceptance and trust). Psychiatrists supported categories that were found in the
qualitative stage, still, they mostly believed that fear of hospitalization, anonymity
concerns and hope to manage on one’s own were three major barriers to seeking
professional help. These results raise significant concerns of trust and ethics of the care
providers in the post-soviet Ukraine.
Keywords: post-soviet Ukraine; college students; mental health; mixed methods;
service utilization; barriers

Background
While the main purpose of the university is to provide best learning environment,
multiple factors outside instructional process, including mental health and psychosocial
distress, can influence student learning outcomes (Richardson, Abraham, and Bond
2012). For example, some students may experience anxiety that will affect their ability to
perform well during tests or speak publically, decrease their self-efficacy and interfere
with effective time management (Brackney and Karabenick 1995). Other students may
experience other life events, such as conflicts with family and peers or have symptoms of
mental disorders. In fact, some research indicates that severity and chronicity of student
psychological concerns is increasing (Erdur-Baker et al. 2006), which increases the
urgency for educators to be able to recognize signs of mental health problems, such as
moodiness, aggression and helplessness in order to refer students to psychological
counselling services (Svinicki and McKeachie 2012).
The concept of mental health refers to psychological well-being (Pilgrim 2009) and
the ability to be productive and creative. Good mental health contributes to mutually
satisfying relationships with other people (Gross and Muñoz 1995). Mental health is a set

*Corresponding author. Email: vburlaka@umich.edu

© 2014 Taylor & Francis
168 V. Burlaka et al.

of behaviours, emotions and attitudes that together contribute to the person’s sense of
self-efficacy, success and fulfilment (Banks et al. 1980). Finally, good mental health
means that the person’s daily psychosocial functioning is not hindered by mental illness
(Banks et al. 1980). Mental health service can be defined as help from ‘a medical doctor
or other professional about any problems with emotions or mental health’ (Alonso et al.
2004, 49).
It is likely that mental health problems are a part of human life regardless of the
occupational status. One study (Blanco et al. 2008) found that the rates of mental illness
are similar among college students and their peers who do not attend colleges. In a
nationally representative sample of Ukrainian adults that included student populations,
the age of onset of mental disorder was early 20s and the prevalence of lifetime mental
illness was 31% (Bromet et al. 2005). Despite the high prevalence of mental health
problems, only 25% of adults with mental illness reported that they received professional
help (Bromet et al. 2005).
A number of researchers tried to understand barriers to mental health services, while a
few studies were specifically focused on college students. One study reported that
students did not obtain mental health care because of lower perceived need for help, lack
of time, unawareness of services and absence of insurance coverage, as well as beliefs
that treatment is ineffective (Eisenberg, Golberstein, and Gollust 2007). Other factors,
such as coming from a family with low income or belonging to Asian or Pacific Islander
ethnicity, were also related to lower service utilization, indicating that, at least for some
students, the decision to seek help is influenced by social and cultural factors. Other
studies identified stigmatizing attitudes about mental illness, hopes to independently
solve the problem, beliefs that a problem is not serious and would go away on its own,
lack of established services, transportation and the inconvenience of participating in
treatment as potential barriers to care (Bruffaerts et al. 2011; Eisenberg et al. 2009).
Additionally, Bruffaerts et al. (2011) described that barriers reported by non-seekers of
professional mental health services were similar across different countries in the world.
In another study, Gulliver, Griffiths, and Christensen (2010) meta-analysed interna-
tional qualitative and quantitative studies from the USA, Australia, the UK and China
and identified barriers to help-seeking among adolescents and young adults. This study
suggested that stigma, trust and confidentiality, low mental health literacy, stress from
help-seeking, poor access to services, perceived difficulties in discussing emotions,
unwillingness to be perceived as a burden for others, use of friends and family instead
of professional services, concerns about the possible impact of treatment on career
and perceived lack of understanding from others were the main barriers to service
utilization. It is possible that Ukrainian college students experience similar barriers
to service utilization. Still, we believe that additional barriers inherited from the
country’s history of communist rule, may affect Ukrainian students with mental health
problems.
One of the barriers relates to the image that mental health profession received during
Soviet Union times, when psychiatric system was used for non-medical purposes,
including political prosecutions (Polubinskaya 2000). The Soviet psychiatrists created
fear hospitalizing persons without mental illnesses, provided low-quality coercive and
inhuman treatments and had closer cooperation with police than with other doctors
(Bonnie and Polubinskaya 1999). The Ukrainian Law on Psychiatric Help (Verkhovna
Rada of Ukraine 2000) has restricted involuntary hospitalizations and introduced the
notion of patient confidentiality. Currently, there are 3265 psychiatric doctors in Ukraine
 European Journal of Higher Education 169

(Ministry of Health of Ukraine 2013). Services are delivered by a network of acute

hospitals and polyclinics that provide primary and secondary outpatient services
(Martsenkovsky, Martyniuk, and Ougrin 2009).
Ukrainian legislation requires initial and regular psychiatric check-ups of millions of
citizens, including students, preschool and schoolteachers, university professors, restaur-
ant workers, pilots, drivers, railway workers, miners, law enforcement officers, fire-
fighters and health care personnel (Cabinet of Ministers of Ukraine 2012). Citizens must
provide psychiatrists with their private data, show passports and pay for the check-ups
that are said to protect these workers and people using their services (Health Ministry of
Ukraine 2013). When conducting the check-ups, psychiatrists review clients’ history of
receiving any mental health services in the past. The Health Ministry’s instruction
stipulates that psychiatrists should suspect existence of mental health disorder if there is
evidence that the person received psychiatric care during last five years. Suspicion should
also be used if the person has psychological issues, somatic problems, unusual behaviour,
stress, memory problems, psychotic problem, bad mood, unemployment and lower social
functioning. The psychiatrist will also take into account anxiety, sexual problems or a
personality disorder.
Results of these investigations are kept in the health care system for five years, while
the workers are issued a certificate with description of their mental health status that they
then bring to their employers. Failure to obtain a diagnose-free certificate makes people
unemployable. Ukrainian psychiatrists believe that ‘the process of diagnosing, engaging
and treating patients with psychiatric disorders is still governed by a stigmatizing and
over-controlling system of “registration” and compulsory follow-up’ (Martsenkovsky,
Martyniuk, and Ougrin 2009, 3). Moreover, including ‘suspect’ mental health conditions
in the governmental instructions contributes to biased psychiatric examinations and sets
the negative, investigative tone during assessments. Besides, it shows that psychiatrists
are not independent from the government because they need to follow the ministry’s
instruction instead of standards of their profession.
Per capita government spending on health care in Ukraine equals US$294 per annum,
which is approximately 15 times lower than in the USA and 10 times lower than in
Sweden (Rogers 2012). The combination of insufficient funding and the power to
influence people’s employability leads to heavy corruption. Research shows that informal
payments are an acceptable way to reimburse doctors in Ukraine (Stepurko et al. 2013).
Pinchuk (2008) describes that outpatient psychiatric service units are primitive and lack
psychiatrists, psychologists and social workers.
When colleges focus exclusively on curriculum and teaching methods, they may
overlook the needs of students who experience, for example, depression, post-traumatic
stress disorder or substance abuse. To provide adequate psychosocial interventions and
put students in a better position for feeling safe and being able to learn, the Ministry of
Education of Ukraine (1999) authorized colleges that have necessary resources and
commitment to create psychological services. Schools can employ no more than one
psychologist and one social pedagogue per 700 students in urban and 300 students in
rural areas to provide diagnostic, correctional, rehabilitation and prevention services to
students. Psychologists ‘educate, bring up and holistically develop students’, test their
psycho-educational readiness, design and implements age- and gender-sensitive ‘correc-
tional’ programmes, help choosing profession and ‘form psychological culture of
students, instructors, and parents’ (Ministry of Education of Ukraine 1999, 3). Social
pedagogues ‘examine performance of students, classes and school collectives as a whole,
170 V. Burlaka et al.

as well as activities of youth organizations’ (1999, 3). Furthermore, they assess the impact
environment and family have on the students, provide recommendations and counselling
to organizations and students in difficult life situations, protect students’ rights, develop
norm-following behaviour, including having healthy lifestyles, provide social services
and occupational counselling.
Ukrainian psychological science has an unusual history. Between the 1920s and early
1940s, Vygotskiy and members of his school, including Alexander Luria and Aleksei
Leontiev, developed foundations of the social development theory in a laboratory in the
Eastern Ukrainian city of Kharkiv. This group’s research focused on culture, social
environment and language as mediators of children’s development of thought, emotions
and actions (Vygotskiy and Cole 1978). Sadly, between 1927 and 1953, the Communist
party perceived psychologists as ‘Menshevik idealists’ and development of social
sciences was suppressed (Gielen, Loeb-Adler, and Milgram 1992, 55). Soviet authorities
feared that intelligence tests that were then used by psychologists would ‘discredit
intellectual abilities of the “working people and peasantry”’ (Korolenko and Kensin 2002,
56). This policy has also led to removal of psychological content from education of
psychiatrists. After 1953, psychological research and education have been restored
(Panok, Pavlenko, and Korallo 2006), however, because of the disconnect and language
barriers, the work of key Soviet psychologists is virtually unknown in the West (Gielen,
Loeb-Adler, and Milgram 1992; Korolenko and Kensin 2002, 56). Furthermore,
Ukrainian psychological research does not translate into evidence-based practices.
Traditionally, psychology is ‘hardly considered a service profession’ and it does not
require professional licensure (Gielen, Loeb-Adler, and Milgram 1992, 59). Most of
psychologists are employed in schools and some work in the social services for youth
helping people between 15 and 28 years of age who live in families with social problems
(Panok, Pavlenko, and Korallo 2006).
The profession of a social pedagogue was introduced in Ukraine in 1990s and
because this profession is new, Ukrainian people often confuse it with psychology or a
social work (SMCPPSW 2014). Social pedagogues work in schools and are equivalent
to the Western school social workers. The functions of practical psychologists and
social pedagogues are vaguely defined. Still, practical psychologists are encouraged
to make assessments, design and implement programmes with focus on individuals
while social pedagogues are not required to design their own interventions and can
work with both the individuals and the social contexts (Ministry of Education of
Ukraine 1999).
A number of Ukrainian universities currently train social workers using interna-
tionally recognized curricula. Ukrainian social workers can effectively work with
individuals and contexts and perform a number of roles to enable, mediate and
coordinate change processes (Burlaka and Semyhina 2001). Still, social workers are not
included in the Ministry of Education’s list of professionals who can be hired by the
schools.
Prior research (Burlaka et al. 2014) revealed that Ukrainian students with mental
health problems primarily seek help from friends and partners, and alcohol use. When
these strategies fail, students turn for help to their family networks. And only when
friends, substance use and family cannot help, students begin seeking services from non-
traditional healers and conventional mental health professionals.
 European Journal of Higher Education 171

The present study

In this study, we specifically wanted to investigate the barriers that precluded students
from using the professional mental health services using intracultural understanding of
these barriers from perspectives of people who had experienced them in their life
(Thakkera, Ward, and Strongman 1999). We aimed to analyse ways in which
professionals who are supposed to provide mental health services to students understand
students’ perceptions of these barriers using a sequential mixed-methods design that
integrates qualitative and quantitative collection and analysis of the data (Tashakkori and
Teddlie 2010). In the qualitative stage, we examined beliefs about barriers to help-seeking
using open-ended questions with Ukrainian students and university psychologists. Next,
we tested the key barrier themes identified in the qualitative stage using a survey in a
sample of Ukrainian psychiatrists. Since psychiatrists are the main providers of mental
health services in Ukraine (Martsenkovsky, Martyniuk, and Ougrin 2009), we wanted to
explore whether they would agree with the barriers indicated by students. We
hypothesized that there would be no preference for or against beliefs generated in the
qualitative stage of the study, i.e., null hypothesis H0: p = 0.5, where p denotes a
proportion of psychiatrists endorsing barrier beliefs. Lastly, we integrated results from
both stages of the study (Creswell and Clark, 2011) to better understand ways in which
barriers emerge across life contexts of students with mental health problems.

Methods
Study design
In this study, we used sequential mixed design with a qualitative phase preceding and
informing the quantitative phase (Tashakkori and Teddlie 2010). Consistent with
Sandelowski (2000), qualitative data were used to identify students’ beliefs about barriers
to help-seeking. Then, we utilized numerical data to validate these beliefs with service
providers. Finally, we integrated findings from both stages to better understand the nature
of consumer–provider relationships across different social contexts (Creswell 2013).

Participants
This study used multiple informants’ perspectives on mental health services available for
students. Three groups of participants were included in the study: students, psychologists
and psychiatrists. Forty students represented eight Ukrainian universities (see Table 1).
Students were on average 20.6 years of age (SD = 2.5, 75% females) and the mean age of
six participating psychologists was 31 years (SD = 3, 83% females). None of the students
has had an insurance. Students and psychologists participated in focus groups
implemented in the qualitative stage.
In the quantitative stage, a survey was administered to 29 psychiatrists (mean age =
44.6 years, SD = 15.1, 82% females) to examine their perceptions of barriers to seeking
professional help experienced by college students. These psychiatrists were employed as
doctors in polyclinics, district psychiatrists, heads of psychiatric units in the hospitals,
researchers at the National Scientific Research Institute of Social and Forensic Psychiatry
and Addictions and practitioners for an average of 16 years (SD = 13.3). They provided
mental health services in 21 Ukrainian cities in Kyiv, Vinnytsia, Chernihiv, Dniprope-
trovsk, Poltava, Donetsk, Kharkiv, Luhansk, Lutsk, Kherson, Ivano-Frankivsk and Odesa
regions.
172 V. Burlaka et al.

Table 1. Number of participating students, university names and student enrolment.

University Type Participants/enrolmenta

Kyiv Dragomanov Pedagogic University Public 14/22,000

Vinnytsia Ukraine University Private 9/2000
Dnipropetrovs’k National Metallurgic Academy Public 3/7000
Dnipropetrovs’k Internal Affairs University Public 1/10,000
Kharkiv Yaroslav Mudry National Law Academy Public 1/20,000
Dnipropetrovs’k State University of Agriculture Public 1/6000
Mykolayiv Chernomorski State University Public 1/4500
Dnipropetrovs’k Oles Honchar National University Public 10/13,000
Total 40/84,500
Note: aNumber of study participants/total enrollment at university.

Procedure
This project was implemented in collaboration between US and Ukrainian researchers.
All procedures and materials used in the study were approved by the University of
Michigan Health Sciences and Behavioral Sciences Institutional Review Board (IRB;
HUM00048282). Data were collected from May to June 2011 during two stages,
qualitative and quantitative.
In the qualitative stage, individual pre-screening interviews with students were
conducted by the PI (the first author of this paper) to identify students who had
experiences with mental health problems and who could describe barriers to seeking help
for these problems. Students gave informed consent at the beginning of the interviews.
Next, five focus groups were conducted with students and one focus group with
psychologists who worked as counsellors and faculty. Psychologists gave their consent to
participate in the study in the beginning of the focus group. Focus groups were 60–90
minutes long. Data were collected during daytime hours that were convenient for
participants in the rooms provided by health care centres and universities. All interviews
and focus groups were facilitated in Russian and Ukrainian languages by a doctoral
candidate in social work and clinical psychology (the first author) and audio-recorded.
Consistent with Sandelowski (2000), data from focus groups were then analysed and
utilized to develop the quantitative instrument that was subsequently answered by a group
of psychiatrists who participated in a national-level continued education programme.

Data collection
The qualitative data reflecting student and psychologist beliefs about barriers to help-
seeking were collected using open-ended questions. These questions were informed by
prior research on student help-seeking behaviours and use of mental health services
(Eisenberg, Golberstein, and Gollust 2007). We used categories that were derived from
the focus groups data to develop a survey for psychiatrists.
This survey was used in the quantitative stage and included questions about age and
gender as well as questions about barriers to service use. The survey included 11 barriers
that were identified in the focus groups and an open-ended category to report beliefs that
were not identified in the qualitative stage. Psychiatrists were asked to rank order the
barriers seen as most to least important. The most influential barrier was coded as ‘1’ and
the least influential barrier was coded as ‘3’.
 European Journal of Higher Education 173

Data analysis
We conducted separate analyses for qualitative and quantitative data. In the first step, a
native Russian/Ukrainian professional translator translated data into English. Then, US
research assistants and the translator examined all texts together for cultural and idiomatic
concordance. Data were then coded by three research assistants to derive salient themes
using NVivo software (QSR International 2008). We used Cohen’s weighted kappa inter-
rater agreement coefficient (Sim and Wright 2005) as a conservative way of measuring
the inter-rater agreement across categories taking into account the differences in the size
of sources. According to the guidelines of Landis and Koch (1977), the kappa ≤0 = poor,
.01–.20 = slight, .21–.40 = fair, .41–.60 = moderate, .61–.80 = substantial and .81–1 =
almost perfect reliability. There was a very strong agreement among the raters in this
study (wkappa = .82), which was achieved in discussions between coders during several
meetings.
In the quantitative step, we analysed psychiatrists’ reports on the barriers using Stata
12 statistical software (StataCorp 2013). We used one-sample test of proportion to
estimate percentage of psychiatrists supporting each identified belief. We also coded the
rank-ordered data reported by psychiatrists.

Results
Emergent themes from focus groups
Two major themes emerged from focus groups with students and counsellors: (1)
structural barriers and (2) attitudes and beliefs.

Theme 1 – structural barriers

One of the significant themes that surfaced during focus groups related to participants’
perceptions of how the mental health system is currently organized. The following six
areas emerged during focus groups that relate to structural barriers: (1) availability of
services, (2) inconvenient location, (3) time, (4) finances/cost of services, (5) helping
skills of professionals and (6) confidentiality.
Student participants of this study mentioned that the availability of mental health
services was a crucial problem. According to Svitlana (all names were altered for
confidentiality), ‘the university is not involved in any way’ in helping the students.
Oksana added that ‘at the university they … smile and say, “go to a private clinic and get
some treatment there”’. Ivan commented that he has ‘not heard about professional
psychological assistance specifically for students’. Andriy ‘heard that other universities
have their own psychologists. But unfortunately we don’t have one’.
Many participants described that community-based psychological services were rare
and that students would seek help from Psychology Department faculty, which was
problematic because as Svitlana noted, ‘rendering paid services by teachers to their
students is against the law’. She further explained that it is ‘very hard to conduct therapies
and consultations for free after work’. Although most students in our study mentioned
that they have not heard about existence of university-based counselling services, such
services were in fact provided at one university participating in our study. In that
university, there were 17,000 students and four clinical psychologists who worked in a
poorly maintained room. Iryna, one of psychologists of this service, described that
treatment was provided in ‘a small room, where four people sit at four desks’ with ‘a
174 V. Burlaka et al.

ramshackle bookcase with a broken glass … When one person is having his therapy, three
have to leave the room’. She added that another issue is scheduling appointments,
because ‘we do not have a … landline phone number’. For therapeutic group sessions,
therapists and students with mental health problems ‘have to go and look for other places
wherever you can, even under the open sky’. Vasyl, commented that as a result, ‘young
people have nowhere to turn’.
In addition to being understaffed and provided with little resources, the counsellors
were placed in a building that was ‘very uncomfortable for students to walk to’ (Rita).
Psychology student Svitlana thinks that ‘most students have never been’ to this building
since it is located ‘separately from all of the others’. Maria commented that ‘there are
only two departments in this building, so only students from these two departments come
there’ while students from other departments ‘do not even know where it is’ (Valeriy).
Iryna believed that the psychological service needs to have ‘a greater access to it –
otherwise no one will go through half the town to see a psychologist’. Living in the rural
area was another barrier mentioned by focus group participants. For example, Petro
talked about psychological services in rural areas and commented that ‘I know for sure …
that no help is provided there’.
In this study, students mentioned that scheduling the appointment is an important
barrier to service utilization, because ‘a time should be set – a time that suits both you and
her’ (Natalya). Ivan told that he does not like to stand in line with other students waiting
to receive mental health care, therefore ‘when I enter … and there’re many people waiting
in line, I just say “no, everything is fine. Besides I don’t have much time because my
class starts very soon”’. Additionally, students are reluctant to professional help because it
entails significant commitment of time. Natalya explained that students ‘don’t go to see a
psychologist’ because ‘they don’t see the time frame in which the problem may be
solved’ and this ‘uncertainty … deters people’.
Many focus group participants mentioned that receiving quality professional help
depends on clients’ ability to pay for it. For example, Vika said that ‘you can’t go to a
good specialist unless you have your parents’ financial support’. Many participants –
students as well as psychologists – agreed that ‘very few students can afford [therapy] –
it’s not cheap’. Alla mentioned a ‘psychotherapeutic clinics operating on a commercial
basis’ which she believed are ‘sure not for students who don’t have any income other
than a small stipend, and maybe some allowance from their parents’. Valentyna pointed
out that ‘the government doesn’t fund young people talking with a psychologist’.
Participants commonly mentioned that mental health practitioners are ‘incompetent’,
‘unqualified’ and such who ‘have no experience and are only book-smart’. In addition to
being ‘pointless’ and ‘useless’, counselling is ‘not pleasant’ (Anatoliy). Halyna perceived
it to be ‘very frustrating to have somebody search for your problems, pull them out’. And
Oksana reflected on her visit: ‘if I say something “wrong” [psychiatrist] at once goes
“click!” “Got you!” … So without my consent or my desire she intrudes into my identity
and interprets it in her own way’. Andriy ‘found it impossible to seek help from some
staff psychologists because … they don’t give a damn about [students]’. Mykola
suggested that ‘students are not treated as people. Even in the [student’s] clinic, no one
will examine you properly’. Many students expressed the idea of treatment being not
helpful. For example, Maria shared that she ‘does not like government-funded clinics and
doctors in these clinics’ and asked rhetorically ‘What help can you get from a
psychologist who works at a public clinic?’
 European Journal of Higher Education 175

Serhiy described specialists at students’ health clinic he personally met as ‘over-

driven, tortured, suffering from having to constantly keep notes in voluminous notebooks
or from other bureaucratic requirements’ and told that ‘there’s a psychotherapist there
who knocks his hammer on your knees, checking all those reflexes. That’s all you can get
there’. Olexiy suggested that the ‘incompetent’ psychologist is one who ‘learned about
one illness and tells you “that’s what you have” or often sends you to another shrink –
“let’s see what that [doctor] says – and then you come back to me’”. For Anna, the notion
of being not helpful meant that psychologists use ‘a bunch of smart words that are not
going to help’. Participants perceived that professionals tend to favour the pharmacolo-
gical approach over talk therapy. Alyona noticed that ‘What matters to [a psychiatrist] is
reporting the diagnosis, prescribing medicine and referring you to the pharmacy’.
A number of focus group participants mentioned that receiving services from
Ukrainian professionals is not confidential. For example, Valentyna perceived it to be
‘very wrong’ when her sister’s psychologist shared details of her sister’s sessions: ‘neither
my mother nor my father nor my sister can stand this psychologist because he’s aired our
dirty laundry in public’. Ivanna thought that ‘Ukrainian psychologists can’t keep secrets’,
because her psychologist ‘retold girls about other girls’ sessions’. There seems to be a
lack of understanding of the need to keep treatment-related information secret across
helping professions in Ukraine as health care providers may even report students’ health
information to the departments. Olena described that ‘not just psychologists … disclose
information to the university’ but also ‘gynaecologists from a student clinic’. A person’s
health then becomes something that ‘the entire department is buzzing about’. Ihor added
that ‘university services are perceived this way: what if [service provider] tells someone
about it?’ After all, Valentyna believed that professionals were subordinated to the
university and therefore were encouraged to disclose private information, ‘staff
psychologist at the university is required to report which of the students have problems’.
For that reason, ‘some sort of free service that is neutral towards the University’ would be
‘much more useful’ (Alla).

Theme 2 – attitudes and beliefs

The following six areas emerged during focus groups that relate to the attitudes and
beliefs: (1) stigma, (2) acceptance, (3) empathy, (4) trust, (5) usefulness and (6) need.
The idea of going to a specialist brings a range of negative reactions, which are
associated with being stigmatized (by others) regarding being mentally ill or having a
weak personality. For example, Olesya thought that ‘seeking help from a psychologist is
embarrassing’. Alyona perceived that ‘there’s a certain stigma. If people discover you go
to a psychologist, they will avoid you as if you were mentally ill’. Oksana acknowledged
that ‘sometimes I find it difficult to express my problem, because it seems to me that I am
a weak person’. Therefore students ‘are ashamed to express their own problem’ (Vasyl).
Boris described that ‘if you go to a psychologist … your peers are going to say that
you’re really sick in your head. And what happens is that they’ll begin to mock you, poke
their fingers at you’.
Olesya described how her university department asked a student: ‘why did you go to
a psychologist to embarrass us?’ Alexander talked about ‘a stereotype’ in society: ‘if you
go to a psychologist, you’re a psycho’. Ihor thought that it is a ‘public reprimand that
scares people off’ because ‘if you go to see a psychologist – yeah, something’s wrong
with you’.
176 V. Burlaka et al.

Another significant barrier that was often discussed by students was that professional
treatment was not a commonly accepted choice for students with mental health problems.
In fact, students ‘do not even know where to look for [psychotherapy]’ (Natalya). Only
students at the Department of Psychology seemed to know where counselling was
offered, while ‘students from other departments are unlikely to know about it … because
it is not advertised in any way’ (Olga). Maria said she does not ‘know much about
psychotherapy’ and that the only ideas she has ‘come from American movies’. Other
students described that ‘in villages going to a psychologist wouldn’t occur to [people].
They simply don’t understand that it’s possible’ (Maryna). And Valentyna considered
‘those people who don’t know what a psychologist is and even what he does. They have
no such notion. Therefore they will never turn to a psychologist’ as opposed to those who
‘study psychology and know what it is about’. Inna commented on ‘fear, anxiety and …
unwillingness’ about ‘seeing a psychologist’ that comes from people not being
‘accustomed’. Maria agreed with this point by suggesting that ‘in Ukraine, the occupation
of a psychologist is not widespread’.
Many participants expressed their concern about the possibility of not being
understood by the faculty, service providers or dean’s office personnel when they try to
share their problem. For example Alyona ‘would not go to the dean’s office to say that I
have depression, or some emotional condition … Because they would never understand’.
And Alla suggested that a person with a mental condition such as schizophrenia ‘will not
go to the university service’ because ‘nobody will take it in a serious manner’. Petro
described that during his visit ‘[a psychologist] wants neither to hear me nor to
understand me’ therefore he felt like ‘I’m talking to an idiot’. Natalya felt ‘it is unlikely
that it will be the kind of attention you would like to receive or the kind of words you
would like to hear’. However, the fear of not being understood can be partly explained in
terms of differences in external attributes, such as clothes and communication styles
between the older generation (professionals) and younger generation (students). Olha
mentioned that ‘Ukrainian psychologists like to wear business suits, it’s too much!’ and
‘have very serious facial expression and never smile’, which made students feel ‘tense’
and ‘nasty’.
Students mentioned that lack of trust in providers is a common barrier to seeking help
for mental health problems. Mykola perceived a psychologist as spending life ‘in his
office’ and not in the student’s environment and therefore he wondered, ‘how can he
know about our lives?’ Denis also commented on distance between students and service
providers saying that ‘both faculty and psychologists see us as strangers’. Vika shared her
own experience during a visit to a psychologist: ‘I thought it was pointless to talk about
my problems. Because he was a very adult man, I could not trust him’. Vadym
commented that ‘people trust their friends’ and do not trust psychologists, who are
perceived as a ‘nonsense’ or a ‘humbug’. Tetyana perceived professionals as ‘outsiders’
who do not ‘know anything about my life’ and therefore cannot ‘help with solving my
problem’. She added that ‘this occupation hasn’t earned people’s trust’.
Some focus group participants were doubtful about the usefulness of mental health
interventions and perceived that other methods may be more advantageous: ‘The first
way is to go to a friend and have a drink and a talk with him. That’s how problems are
being solved – without going to a psychologist’ (Alla). Valentyna related to this by
describing that rather than ‘lying down on a … couch’ and talking in a psychotherapist’s
office and having to pay for that one chooses to ‘lay down on my own couch at home’,
ask ‘next door neighbours’ to come over to ‘talk everything over and [it] will be solved’.
 European Journal of Higher Education 177

Iryna asked: ‘Why would you go to a psychologist? Nowadays people turn to Google’.
Lubov listed ‘a hierarchy of methods people use if they have some personal
psychological problems’, which included ‘a friend and a bottle between the two of you
… church … various healers … [and] … a psychologist at the very end of this hierarchy’.
Roman thought that ‘people drink and smoke instead of going to a psychologist’. Other
students added that it is also common ‘to do nothing’, ‘waiting and hoping that a problem
just go away by itself’. Oleh thought that healers ‘have been there for centuries’ thus it
seemed to be more natural to ‘go to a healer rather than a psychologist’. And Ihor thought
that people ‘do go to those healers because they trust them more than others. They have a
better reputation’.
A number of participants felt that there was little need to seek help because the
problem could improve on its own. For example, Vitalyi believed that ‘a person himself is
capable of anything’. And Mykola thought that professional help is for ‘older people with
more serious problems’ rather than for students who ‘think they can solve anything by
themselves’. Iryna explained that people ‘wholly rely on God. And thus they live hoping
that things will get better’.

Survey results
Table 2 illustrates means and standard deviations of rank-ordered psychiatrist beliefs
about barriers that prevent students from seeking professional help.
The results of one-sample test of proportion suggest that the proportion of
psychiatrists who supported a belief that students avoided professional help hoping that
the problems will disappear on their own was equal to .66. With z = 1.7, we can reject the
null hypothesis that p = 0.5 at the p < 0.05 level. This result is in the direction expected,
namely, that more than a half of the psychiatrist sample supported this belief. Also, the
proportion of psychiatrists who believed that students avoid seeking services for fear of
being hospitalized was .76 while the proportion of professionals who believed that
anonymity concerns were a significant barrier to seeking professional help was .72. With
z = 2.8 and z = 2.4, respectively, we can reject the null hypothesis that p = 0.5 at the p <

Table 2. Means and standard deviations of psychiatrist beliefs about barriers preventing students
from seeking professional help.

Categories affecting help-seeking Mean SD

Fear of hospitalization 0.76** 0.44

Anonymity concerns 0.72** 0.45
Hope to manage on one’s own 0.66* 0.48
Feeling of shame 0.59 0.50
Lack of empathy 0.57 0.50
Provider attitudes 0.41 0.50
Costs of treatment 0.38 0.49
Student shortage of time 0.21 0.41
Inconvenient location of services 0.14 0.35
Poor provider skills 0.14 0.35
Inconvenient work hours 0.07 0.26
Note: *Significant one-sample test of proportion, p < .05; **Significant one-sample test of proportion, p < .01.
Psychiatrists assigned ranks from 1 to 3 (1 = highest endorsement of a barrier, 3 = lowest endorsement).
178 V. Burlaka et al.

0.01 level. Both of these beliefs are in expected direction, meaning that more than a half
of psychiatrists in the study supported these beliefs.

Discussion
This research examined barriers to utilization of mental health services using a two-step
mixed-method sequential exploratory study, which explored perspectives of students,
psychologists and psychiatrists. After coding the data, two major themes emerged
pointing to the barriers that were associated with the resources available to the students
and the barriers that were associated with the attitudes towards mental health problems
and seeking help for those problems. Consistent with prior research, this study identified
the attitudes and beliefs theme that has an internal common attribute, which refers to what
one feels that he or she has control over in life, as well as the structural barriers theme
with an external attribution, which refers to one’s perception of what one lacks control
over (Rotter 1966).
We thought about structural barriers as such that were related to organizational
problems and a lack of treatment resources in the university or community. These are the
barriers that students have no capacity to influence. One reason why students identified
these barriers perhaps relates to the way health care system has been set up historically
and also how it exists now. Structural barriers included students’ perceived frequent
inability to find services within the community or at their university, inconveniency
related to location and operation hours of mental health service providers, high costs of
professional treatment, students’ beliefs that professionals were missing essential helping
skills or allowed breeches of confidentiality. Another category of barriers was not related
to the existing service systems as much as it was related to the way students thought and
felt about engaging in seeking help for mental health problems. Barriers that belong to
this category include stigma, not accepting professional help as a viable option, the lack
of trust in professionals, lack of perceived usefulness of the treatment and the low level of
perceived need for treatment. These barriers were also found in previous studies with the
Western student populations (Eisenberg et al. 2009; Gulliver, Griffiths, and Christensen
2010; Mojtabai et al. 2011).
Ukrainian college students experienced a lack of services in their immediate
environments, their schools. They approached psychology professors or their advisors
as an alternative to the non-existent health services. But university faculty were
discouraged from providing paid services for students while feeling reluctant to perform
these services free of charge in the after-work hours. By banning such services, school
administrators perhaps wanted to avoid conflict of interests and as a result, they referred
students to treatment services outside of the university, for example, to private clinics.
However, publically funded mental health services often were not available in the
community while services from private providers were expensive. Lack of university-
based treatment solutions is a significant structural barrier that has not been identified in
prior research with the US students (Eisenberg, Golberstein, and Gollust 2007). This is
not to say that mental health services are not available on any college campus within
Ukraine though. One out of eight universities that participated in this study reported
having mental health professionals available to the students. Although this indicates a
potentially positive trend reflecting increasing realization of the importance of mental
health services to students, in that particular university the actual availability of these
services was limited, as the ratio of service providers to a total number of students was
 European Journal of Higher Education 179

4:17,000. The few service providers working in that university were further limited by
available space, inconvenient location and inability to use telecommunication means to
facilitate scheduling and provision of care.
Furthermore, the hours offered to students taking full-time classes were not always
convenient. Students also reported standing in long lines that interfered with class
attendance. Besides, students felt that being in the line to a mental health service provider
was disturbing because of stigma and confidentiality issues.
Students were reluctant to seek help when the services cost more than they, or their
parents, can afford to pay. Economic factor made professional help even more
unattainable, especially when alternative methods were cheaper. This barrier in particular
separated help-seekers by social class, suggesting that only those from a higher social
class with more financial resources were likely to seek professional help. These findings
are consistent with those of Bruffaerts et al. (2011) who also found that financial
considerations inhibited service use. Stepurko et al. (2013) research suggested that private
health insurance could be a way to help people with lower income to pay for health care
services. Our study supports this argument, given the lack of public funding and
insufficient support from the universities.
Students expressed the sheer disappointment with the quality of services they
received. Mental health professionals were widely described as being unhelpful, showing
little to no interest in building a rapport and making the treatment process uncomfortable
for the students. Students perceived service providers as being more preoccupied with
bureaucratic concerns than taking the time to help them. While this is certainly not the
case with all mental health professionals in Ukraine, it creates a large problem because
word-of-mouth advertising is very influential to those considering professional help, and
when students tell others of their bad experience, it dissuades many from even attempting
to seek help from professionals.
Not only did students not trust that they would receive the help they were seeking, but
they also questioned the ethics of the professionals. Since mental health is a very
stigmatized subject, confidentiality is very important to those seeking help for a mental
health problem. When this confidentiality is questioned, it presents a huge barrier to
seeking help. Both the students and the service providers interviewed in this study
reported the lack of confidentiality. Some students assumed that anything they say in a
school psychologist’s office would not be kept confidential. This disturbing violation of
professional ethics may contribute to the negative reputation of mental health profes-
sionals. Introducing licensure could help address this barrier. For example, licence
revocation or suspension could be a useful mechanism to maintain and safeguard
professional ethics. Raising awareness about ethical issues in community health services
would be another significant contribution to decreasing the structural barriers to
seeking help.
Besides the structural barriers, students reported that certain attitudes and beliefs
could impact seeking mental health services. Our results suggest that in Ukraine, mental
health problems are often affected by stigma. Additionally, seeking professional help for
these problems is often seen as a manifestation of the personal weakness. The stigma was
reported as a barrier to seeking treatment services in previous studies (Bruffaerts et al.
2011; Eisenberg et al. 2009). With Ukrainian students, stigma manifested itself at
multiple levels. On an individual level, students reported not seeking help out of
embarrassment and fear of being ‘labelled’. They felt embarrassed to admit to having a
problem that they could not fix independently. High self-efficacy was widely regarded
180 V. Burlaka et al.

across the focus groups to be a necessary personal trait. Talking about personal problems,
even to a trained psychologist, is seen as being weak. Furthermore, many students were
afraid of appearing weak to their peers, as they thought that this would result in social
exclusion or rejection. Students, who revealed to the university that they have some form
of mental illness, were judged negatively by the administration. These findings indicate
that beliefs about stigma may interfere with seeking help at individual, group and society
levels.
Main categories of the barriers to mental health services were supported by
psychiatrists. However, only three categories, including fear of hospitalization, anonymity
concerns and a belief that students hoped to manage on one’s own received significant
support from majority of psychiatrists. Interestingly, focus group participants had not
mentioned that they were avoiding mental health services because of a fear of being
hospitalized. This barrier may have been very important before the new Law of
Psychiatric Help was adopted in Ukraine (Verkhovna Rada of Ukraine 2000). This law
gave additional rights to people with suspected or diagnosed mental illnesses, including
the right to not be institutionalized against their will. It is possible that because
psychiatrists in our study were employed for 16 years, many of them still believe that
students choose not to seek professional help because they are afraid of being placed at a
mental hospital.
The results of this study display striking cross-national similarity of the barriers to
seeking help for mental health problems. In Ukraine, like in the USA, Canada or the
Netherlands, barriers were found to be either of structural or attitudinal nature (Mojtabai
et al. 2011; Sareen et al. 2007). Still, the services linked to the higher educational
institutions are not as common in Ukraine as they are in the West. The Government of
Ukraine should consider initiating health insurance system to cover costs of mental health
care. Finally, standards of care need to be improved through staff training and
introduction of the licensure mechanism.
When interpreting the results of this study, some limitations should be kept in mind.
First, these results come from participants who are mainly women. This imbalance does
not necessarily reflect the proportion of Ukrainian female and male students experiencing
mental health needs. Although the results were analysed with no gender distinction
between participants, it should be noted that the male perspective was underrepresented
compared to the female perspective. Results of this exploratory study are not general-
izable inasmuch as they reflect opinions of students from 8 out of the total of over 800
universities in Ukraine (UkrStat 2013) and may differ from beliefs of students studying at
other Ukrainian universities. Likewise, mental health practitioners and the faculty who
participated in this study may have expressed opinions that differ from opinions of their
colleagues in Ukraine. Future studies should have larger samples and incorporate
opinions of other professionals working at hospitals, student and general polyclinics,
churches and local authorities.
The strength of this study is that it contributes to the very limited knowledge of
barriers to help-seeking behaviours among young adults with mental health problems in
Ukraine. It does so by including perspectives of those who provide services and those
who need these services. The study provides new insights that can be utilized to improve
quality of education of students through improved mental health research, education of
practitioners, programming and policy-making in Ukraine and in other countries in the
region that have similar history and socio-economic foundation.
 European Journal of Higher Education 181

Notes on contributors
Viktor Burlaka is a joint PhD student at the University of Michigan School of Social Work and
Department of Psychology in Ann Arbor, Michigan. He is a member of the Child Violence and
Trauma Laboratory (Principal Investigator: Sandra Graham-Bermann, Ph.D.). Viktor uses qualit-
ative and quantitative methods to understand the intersection between substance use, mental health,
violence and family systems, and their effect on child behavior outcomes.
Iuliia Churakova is a research assistant at the University of Michigan Child Violence and Trauma
Laboratory (Principal Investigator: Sandra Graham-Bermann, Ph.D.). Her research interests include
children and youth behavior problems. She is particularly interested in parenting children with
externalizing behavior problems.
Olivia A. Aavik is an undergraduate psychology student at the University of Michigan in Ann
Arbor, Michigan. She is involved in the international research focusing on mental health literacy
and service utilization.
Dani Goldstein is an undergraduate psychology student at the University of Michigan in Ann
Arbor, Michigan. Her research interests include access to and utilization of mental health resources
as well as the impact of mental health on the family system.

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