In March of 2018, Dr. Hammer was recommended by the UK College of Education Faculty and Student Recognition Committee to receive $7500 from the Research and Creative Activity proposal fund distributed by the UK Vice President of Research to fund a research project entitled “Mental Healthcare Disparities: A Longitudinal Test of Barriers to Seeking Behavioral Healthcare from Primary Care Physicians.”

The proposed project sought to determine how the key barriers of stigma and lack of trust interact to stop people from seeking behavioral healthcare from a primary care physician when they are psychologically distressed.   Data from this project will provide pilot data to facilitate the pursuit of external funding that can support a full-scale version of this project.

This webpage and its subpages will provide key information about the nature of the project, preliminary findings, and published final findings in a format tailored to different audiences.

To learn more about this Mental Healthcare Disparities project, click on the link below that matches your background:

Information for Members of the Scientific Community

Statement of Problem

People with stigmatized mental illness (e.g., depression, schizophrenia) often refrain from seeking behavioral/mental healthcare when they need it (Wang et al., 2007).  In fact, only 37% of people with mental illness seek behavioral help in a given year (Nakash et al., 2014). Given that untreated mental illness is a significant cause of the world’s disease burden (Patel et al., 2015), it is imperative that barriers to treatment be identified and removed.  The proposed study seeks to determine how the key barriers of stigma and lack of trust interact to stop people from seeking behavioral healthcare when they are psychologically distressed.  Because most people seek behavioral healthcare from their primary care physician (PCP), but most of the help seeking literature focuses on factors influencing seeking help from mental health specialists rather than from PCPs, there is an integral need to understand what influences behavioral healthcare seeking from PCPs.  Vulnerable and underserved populations will receive special attention, given documented disparities in behavioral healthcare participation across race/ethnicity, income, gender, and geographic residence lines (e.g., Cook et al., 2014; Cook et al., 2007; Pattyn et al., 2015).


Scientists have identified myriad barriers to behavioral healthcare.  Interestingly, the average person with mental illness reports that psychosocial barriers (e.g., perceived need, attitudes) are more important than structural barriers (e.g., transportation, cost) to initiating behavioral healthcare (Andrade et al., 2013).  The most cited barrier is stigma (Corrigan, 2004), which manifests in several forms.  The self-stigmas (i.e., internalized shame from applying negative stereotypes to oneself) of mental illness, and of seeking help for it, are additive barriers to seeking behavioral healthcare (Lin et al., 2017; Rüsch et al., 2009; Tucker et al., 2013).  The anticipated stigma (from others) of seeking help has been identified as an additional barrier to proper behavioral healthcare (Pescosolido et al., 2007; Verhaeghe & Bracke, 2011; Vogel et al., 2009).  In sum, having mental illness and seeking help for this illness can come at an intra- and inter-personal cost.  While the impact of these stigmas on reduced behavioral healthcare participation has been established, the mediators that explain the causal mechanisms at work are still being identified.

Patient trust is one promising mediator. Trust in one’s primary care physician, the medical profession, health insurers, and mistrust of healthcare organizations have all been identified as barriers to healthcare participation (LoCurto & Berg, 2016; Müller et al., 2014; Ozawa & Sripad, 2013).  When patients don’t trust the medical establishment, they feel unsafe seeking help from medical organizations.  However, the impact of mental health stigmas on trust and behavioral healthcare participation is unknown.  Two studies (Pescosolido et al., 2007; Verhaeghe & Bracke, 2011) have examined stigmas’ relationship with trust and healthcare outcomes, but neither study measured actual behavioral healthcare participation or examined trust as a mediator. Both studies were cross-sectional, precluding causal conclusions about impact (Jose, 2016).

Therefore, the proposed study will utilize a longitudinal survey design with a national sample to elucidate the interactive influence of stigma and trust on behavioral healthcare participation.  Results could inform how to build trust for vulnerable patients in the health care system by establishing, for which populations, mental health stigma damages trust. Given the availability of empirically-supported interventions for reducing mental health stigma (e.g., Lannin et al., 2013), these results could directly inform what forms of stigma and trust should be targeted with interventions, which can enhance patient trust in health practitioners and systems to help overcome health disparities related to behavioral healthcare participation.


The proposed study will utilize a longitudinal survey design with a national sample (N = 500) to answer four unanswered research questions: (Q1) What is the impact of mental health stigmas on trust/mistrust? (Q2) What is the influence of mental health stigmas on prospective behavioral healthcare participation? (Q3) To what degree does trust/mistrust mediate the stigma-participation relationship? (Q4) How do these direct and indirect effects operate across privileged and vulnerable racial/ethnic, income, gender, and geographic residence populations? See Figure 1 for a visual representation of the theorized model, featuring a direct pathway from stigma to participation and an indirect path from stigma to participation via the mediator of trust.

Figure 1. Theorized Stigma, Trust, Healthcare Participation Model



We utilized Qualtrics Targeted Online Samples service to recruit 500 U.S. Citizens from across the country who varied across gender, racial/ethnic, income, and geographic residence lines to take the Time 1 survey, which measured the different forms of stigma and trust discussed above, as well as information on past help seeking behavior and demographic details.  Participation was restricted to those who (a) scored above the cutoff for “moderate psychological distress” on the K6 (Kessler et al., 2002), (b) had a PCP, and (c) have not sought professional help for mental illness in the last three years.  Three weeks later these same participants were contacted to complete the Time 2 survey, which included most of the same items as the Time 1 survey and also asked if the respondent had sought behavioral healthcare from their PCP since the Time 1 survey (the key dependent variable of interest).  About 150 respondents opted to participate at Time 2.


We are currently analyzing the data to determine the relationship between trust and stigma at Time 1 and subsequent help seeking behavior as reported at Time 2.  Preliminary findings indicate substantial inter-group differences in the presence and strength of these associations.

Information for Healthcare Practitioners

(coming soon)

Information for Healthcare Administrators/Policymakers

(coming soon)

Information for General Public

(coming soon)