HEALTH INFORMATION RIGHTS AWARENESS, PERCEIVED STIGMATIZATION, PERSONAL FACTORS AND WILLINGNESS TO USE MENTAL HEALTHCARE SERVICES AMONG LIBRARIANS IN PRIVATE UNIVERSITIES IN SOUTHWEST, NIGERIA

ABSTRACT

Mental health is a desirable state globally and a requirement for optimum performance in any area of human endeavour. Studies have shown that a lot of people have one mental challenge or the other and that most people are unwilling to use mental healthcare services.  There are indications that librarians in private universities may not be immune to factors that predispose to mental health challenges. Moreover, previous studies have focused on the factors that determine people’s willingness to use mental healthcare services without adequate consideration for health information rights awareness, perceived stigmatization and personal factors. The study examined the extent to which Health Information Rights Awareness (HIRA), Perceived Stigmatization (PS) and Personal Factors (PF) predict Willingness to use Mental Healthcare Services (WMHS) among librarians in private universities in South-West, Nigeria.

The survey design was used for the study. The population comprised 349 librarians in 22 private universities in South-west, Nigeria. The census was used to include the entire population in the study. The instrument was a validated questionnaire. The reliability test of the variables ranged between α = 0.63 - 0.74. Data were analysed using binary logistic and multiple regression.

The findings showed that health information rights awareness significantly predicted willingness to use mental healthcare services among the respondents (R² = 0.334, p<.05). Also, perceived stigmatization significantly influenced the use of mental healthcare services (R² = 0.176, p<.05). Furthermore, personal factors significantly predicted willingness to use mental healthcare with females less likely to use mental healthcare services (β = -0.043, p<.05). Respondents below 40 years (β = -0.172, p<.05);those with salary below N100, 000 (β= -0.020, p<.05) and those with higher education (β= -0.505, p<.05) were more willing to use mental healthcare services.

The study concluded that although health information rights awareness is high among academic librarians in South-West, Nigeria. Perceived stigmatization and personal factors such as education, age and gender could prevent them from using mental healthcare services. The study recommended that government should formulate and enforce anti-stigma policies and ensure strict adherence to ethical guidelines in management of health information by mental healthcare providers. Also, promotional efforts for mental healthcare services utilization should target women, youth and people with low level of education. Finally, libraries should create awareness on the need for mental health services utilization.

CHAPTER ONE

INTRODUCTION

1.1       Background to the Study

Information is data that is collected and organized for users in specific contexts. Information empowers people to make reasonable decisions; hence, it is an important resource for health professionals who make decisions that have implications on the physical and mental well-being of others.  Health facilities such as hospitals, healthcare centers, medical nursing homes, medical laboratories, pharmacies and drug stores require information to manage patients’ health and provide them with the best possible treatments (Friedman, 2011). Health information can be described as any information collected in relation to health, disability or health service received by a patient. It includes patients’ genetic information, notes of symptoms or diagnosis and treatment, specialist’s reports and test results, appointment and billing details, prescriptions, pharmaceutical purchases and other information relating to patient’s race, sexuality or religion (Office of the Australian Information Commissioner [OAIC], 2015).

Enlightening people with health information rights in hospital is much more problematic than preventing associated risk such as hackers, identity theft and unauthorized access. Although health information may be useful to assess patient’s state of health, it also has the potential to appraise performance of health services. For instance, overreliance on the security of health information can lead to grievous errors if a patient information contains false information.Making health information rights understood to remote people necessarily makes them more reachable and available to amend their information. People need to be educated and be aware, just like healthcare professionals,of health information rights in any preferable format for efficient and effective health information use. Both patients and guardians need health information to adhere to treatment that will make healthcare service more productive. Similarly, health insurers, government health agencies, the National Health Insurance Scheme (NHIS) and other agencies need to be aware of health information rights in order to properly process claims and pay for healthcare.

Personal health information is not utilized to its full potential to support effective and efficient care due to low level of health information rights awareness among people. A lot of factors in the society underscore the need for intervention addressing low health information rights awareness. We are a mobile population requiring access to vital personal health information in different locations. Personal health information is of sensitive nature and must be managed with care. However, this information often has to be shared among healthcare providers or disclosed to others outside health services for the patient’s benefit. For example, many Nigerians receive treatment in very different locations seasonally, and increasingly prevalent mental health challenges, like schizophrenia, personality disorder, depression, stress disorder, can only be managed by mental healthcare services. Many obvious patient safety and quality issues arise in the handover of patients among providers that fail to share necessary information. Natural disasters displace individuals to locales with unfamiliar providers and can destroy or render inaccessible existing health information repositories. Securing patients’ health information and protecting their rights to privacy and confidentiality thus becomes a major challenge for healthcare providers especially as medical information is increasingly accessible in electronic form. The loss, misuse, modification or unauthorized access to sensitive health information can adversely affect the welfare of an individual and this is particularly true of health information related to a person’s mental health status.

Today, people are plagued by anxiety, depression and crippling self-admiration. With this on the rise is an enormous proportion of Nigerians likely to fit the criteria for a mental disorder at some point during their lifetimes. But the questions are, is the state of mental health in Nigeria truly worse, or are we simply diagnosing disorders that were once unknown or is the millennial generation actually more depressed than the generations that lived through two world wars? The answers aren’t exactly simple.One problem with quantifying the change in the incidence of mental health problems or challenges over time comes from simply defining mental health. Mental health is not merely the absence of disease or infirmity, but a state of well-being in which an individual realizes his or her own abilities to cope with the normal stresses of life (WHO, 2014). Mental health and well-being are fundamental to our collective and individual ability as humans to think, emote, interact with each other, earn a living and enjoy life. The level of mental health of a person at any point in time can be determined by multiple social, psychological and biological factors. For example in academic setting, persistent socio-economic pressures of greater job insecurity, constant demand for results and an increasingly marketised higher education system are recognized risks to mental health challenges. University counselling staff and workplace health experts have seen a steady increase in numbers seeking help for mental health problems over the past decade, with research indicating nearly half of academics show symptoms of psychological distress in UK (Shaw & Ward, 2014). In addition to psychological distress is personality factors and prolonged stress. Stressors can be in the form of heavy workload, speed of work, working conditions, poorly designed environment, interpersonal discord with supervisors, colleagues, and discrimination based on age, sex and frustration related to the social organization of the workplace (Aldwin, 2007). Excessive job demands can result in excessive stress. Also, the interference of the home front with work place demands sometimes constitutes stress for employees especially where the staff concerned is not able to manage both effectively.

Mental health challenge is not confined to certain geo-polities or social strata.It is an issue that has the potential to affect anyone, male or female, young or old, rich or poor (Steel, Marnane, Iranpour, Chey, Jackson, Patel & Silove, 2014). It is indeed everyone’s business. This fact validates mental health challenge as a complex, yet current and important issue for people and the workplace in its entirety. This is because universities do not exist in a vacuum, workers are not recruited from outer space, but from the environment within which institution exist. Hence, the indices of mental health pertaining to Nigeria, should be of concern to Nigerian workplaces. Beyond this, the workplace itself is an environment that poses significant impact on mental health (World Health Organization and International Labour Organization, 2012). Furthermore, it is becoming clear through research that most mental health challenges, including depression, stress disorders, social phobia, schizophrenia, eating disorders, personality disorders and addictive behaviours are caused by a combination of biological, psychological and environmental factors (Neil, 2010). Environmental stressors, such as death of loved ones, divorce, a dysfunctional family life, feelings of inadequacy, low self-esteem, anxiety, anger, loneliness, changing jobs or schools, midlife job crisis, work-related stress, technology, socio-cultural expectations and substance abuse can trigger mental health challenges. In most cases, symptoms can be managed with a combination of medications and counseling otherwise known as psychotherapy (Jack-Ide, Uys & Middleton, 2012). 

In Nigeria, mental healthcare services are mostly provided in Federal Neuro-Psychiatric Hospitals. Currently, mental healthcare services are offered at eight dedicated facilities in Abeokuta, Benin, Calabar, Enugu, Kaduna, Lagos, Maiduguri and Sokoto by a multidisciplinary team comprising psychiatrists, psychologists, occupational therapists, physiotherapists, social workers and counsellors and nursing practitioners. Treatments offered include evidence-based drug therapy, individual psychiatric consultations and psychotherapy, group therapy and, where needed, physical therapy (Jack-Ide, Makoro & Azibiri, 2013). Unfortunately, studies have shown that most people with mental health challenges do not use mental healthcare services because of their cultural sensitivity, religious beliefs, lack of funds, coverage of mental healthcare services and stigmatization (Jack-Ide & Uys, 2013).

Mental health stigma is even widespread across the world, at least in part, because it is given a low priority (Wallace, 2010). Perhaps surprisingly, stigmatizing beliefs about individuals with mental health challenges are held by a broad range of individuals within society, regardless of whether they know someone with a mental health challenge, have a family member with a mental health challenge, or have a good knowledge and experience of mental health problems (Moses, 2010; Wallace, 2010). Mental health stigma can be divided into two distinct types: social stigma is characterized by prejudicial attitudes and discriminating behaviour directed towards individuals with mental health challenges as a result of the psychiatric label they have been given. In contrast, perceived stigma or self-stigma is the internalizing by the mental health sufferer of their perceptions of discrimination (Link, Cullen, Struening & Shrout, 2009), and perceived stigma can significantly affect feelings of shame and lead to poorer treatment outcomes (Perlick, Rosenheck, Clarkin, Sirey et al., 2011).

In relation to social stigma, studies have suggested that stigmatizing attitudes towards people with mental health challenges are widespread and commonly held (Bryne, 2007; Heginbotham, 2008). In a survey of adults in the Niger Delta region, Jack-Ide, Makoro and Azibiri (2013) found that the most commonly held belief was that people with mental health challenges were dangerous  (especially those with schizophrenia, alcoholism and drug dependence), were self-inflicted (people with eating disorders and substance abuse), and were generally hard to talk to. People tended to hold these negative beliefs regardless of their age, regardless of what knowledge they had of mental health challenges, and regardless of whether they knew someone who had a mental health challenge. Stigma embraces both prejudicial attitudes and discriminating behaviour towards individuals with mental health challenges, and the social effects of this include exclusion, poor social support, poorer subjective quality of life, and low self-esteem (Livingston & Boyd, 2010). As well as it’s affect on the quality of daily living, stigma also has a detrimental effect on treatment outcomes, and so hinders efficient and effective recovery from mental health challenges (Perlick, Rosenheck, Clarkin, Sirey et al., 2011). In particular, self-stigma is correlated with poorer vocational outcomes (employment success) and increased social isolation (Yanos, Roe & Lysaker, 2010). These factors alone represent significant reasons for attempting to eradicate mental health stigma and ensure that social inclusion is facilitated and recovery can be efficiently achieved.

Individuals who are shamed, bullied or discriminated against based on preconceived judgments of their appearance, disabilities or lifestyles are victims of stigmatization.Stigmatized individuals fall outside the society definition of "normal." Examples include prostitutes, mentally ill patients, drug addicts or people with physical deformities. Stigmatization is generally measured as stereotypes, prejudice and discrimination (Collins, Wong, Cerully, Schultz & Eberhart, 2012). Stigmatization can prevent people from properly seeking knowledge, advice, treatment and care that can enhance their mental health.

Another factor that could affect the use of mental healthcare service is low awareness of health information rights. Although, health information rights is not specifically defined under any of the laws that apply to the health sector, however, the National Health Act (NHA) 2014 makes reference to health information rights of users of healthcare institutions. The NHA is the first law that provides obligations of healthcare personnel and health information rights of users of healthcare services in Nigeria (Federal Ministry of Health, 2015). This Act requires every healthcare provider to give users of healthcare services relevant health information, keep and attach confidentiality to users’ health information, impose restrictions on the disclosure of users’ health information and set up control measures for preventing unauthorized access to users’ health information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) of The United States also provides important rights that everybody need to know about their health information. In addition, the International Human Rights Law imposes two obligations with respect to health information rights, which are: (i) states must not only refrain from actions that would interfere with people’s rights to health information, but also affirmatively take steps to ensure that individuals are provided with health information, and (ii) must ensure that health information is accessible and available to all on a non-discriminatory basis (Institute for Information, Law and Policy, 2012).

Health information rights of people are enshrined in the laws of countries. In Nigeria, consideration is given in NHA that users of healthcare services should be given relevant information pertaining to their health in a language that the user understands and in a manner which takes into account the user's level of literacy. People need to be educated to understand their health information rights, ask questions about them and file a complaint if they think their rights are being denied or not being protected (Afolayan, 2009). Having adequate awareness of health information rights will empower people to be more in control of decisions regarding their health and well-being.  For example, individuals who know their right to access or amend their health information are better able to monitor chronic conditions, adhere to treatment plans, find and fix errors in their health information and can track progress in wellness or disease management programmes.

Health information rights includes confidentiality and privacy of health information. Confidentiality is the right of an individual to have personal identifiable information kept private (Osundina, 2014). Confidentiality implies that the use, disclosure or release of personal health information must be with the knowledge and consent of the individual. Confidentiality ensures that personal health information given to a healthcare provider is not disclosed to others unless the individual owner has given specific permission for such release. Privacy is the right of an individual to be let alone, free from observation or intrusion into personal private affairs and the right to exercise control over certain personal health information. In Nigeria, every healthcare institution, including mental healthcare facilities have ethical and legal responsibilities to uphold the privacy and confidentiality of people’s health information obtained while providing care (Ukachi, 2007).

Incidentally, a large proportion of people using healthcare services are not aware of this health information rights (Ogunrin, Ogunrin & Akerele, 2007). According to United Nations, Department of Economic and Social Affairs(2015) and Sotubo (2015), about 21million people out of 182million population of Nigeria suffer mental health challenges that could have been prevented in mental healthcare services with simple medications and healthy lifestyles (Acho, 2005). The situation however, can be different if the populace are aware of their health information rights and take advantage of it.

Librarians in academic institutions are not exempted from stress. They are responsible for developing library collections, providing access to information, and providing training on information retrieval and use to students and faculty. Interestingly, these roles are constantly evolving with technological advancements and the librarians are expected to adapt their skills to meet the changing educational, social and technological needs of their users (Bunge, 2010). In particular, librarians in private universities are often expected to perform optimally in order to beat the stiff competition in the higher educational sector even with minimal financial and human resources. Private universities are established by Act of government through the National Universities Commission. Private universities are owned, funded and managed by participating individuals, agencies, and corporate bodies other than government. The corporate bodies are mostly religious organizations. Besides, private universities have to justify their existence through high employee productivity and high quality students’ output. This result-orientation invariably translates to increased demand for high quality performance from their staff. These combination of role expectations, has helped to hype up the stress levels of academic librarians in private universities (Al-Qallaf, 2006). Furthermore, the emergence of information communication technology (ICT) in university libraries has brought unprecedented changes to the roles of librarians with increasing demand on the mental and emotional resources of librarians, which in turn result to technostress. Technostress is a state of mental and physiological arousal observed in people who are heavily dependent on technology to perform their work, and that occurs when people find their work stimulating, but feel they do not have the necessary skills to cope with the technology (Yuvaraj & Singh, 2015).

Laspinas (2015) stressed the two major consequences of technostress which are frequently suffered by librarians, these are brain drain and information overload. Thus, librarians can only overcome mental health challenge that may be caused by technostress when they are ready and willing to use mental healthcare services.

Willingness to use mental healthcare services is a state of preparedness or readiness to seek the professional assistance and support provided by mental healthcare providers in solving mental health challenges (Chandra& Minkovitz, 2006). The willingness of a person to seek help is dependent on three elements: recognition of the need for external assistance, readiness for self-disclosure, and willingness to relinquish at least some degree of control to an expert helper (Segal, Coolidge, Mincic & O’Riley, 2005). Studies have established the various factors that determine people’s willingness to use mental healthcare services, these are: stigma, proximity or nearness to mental healthcare services, cost, expertise of care givers, ease of access, type of services, severity of illness, poor awareness, insufficient facilities and personal factors (Sellars, Garza, Fryer & Thomas, 2010; Vanagas, 2011; Ohaeri & Fido, 2010).

Personal factors such as, gender, age, marital status, low income status, low education and religion affiliation, play considerable roles on people’s willingness to use mental healthcare services, thereby making the mental health interventions and responses greatly different across the country(Oladipo, 2015; Sellars, Garza Fryer & Thomas, 2010). Gender role is perceived as masculine and feminine. Females are known to be more mentally inactive than males (Shehu, Yahaya, Onasanya, Ogunsakin & Oniyangi, 2011). Gender differences in the use of mental healthcare services are a long-standing concern for the Nigerian mental healthcare system, and such differences have been documented in many studies. For example, research has shown that women are more willing to use healthcare services than men, but the willingness to use mental healthcare services by women and men may differ according to the mental health challenge for which care is required(Azuh, Fayomi & Ajayi 2015). Differences in age and marital status also play considerable role on people’s willingness to use mental healthcare. Older adults today encounter a number of mental health challenges as they age and, on average, use a relatively large volume of mental healthcare services. However, the older adult population is quite heterogeneous, with individual members displaying an array of health statuses and needing a variety of healthcare services. Therefore, older adults are more willing and exhibit favourable intentions to use mental healthcare services than younger adults (Abdulrahem, 2007). Older adults are more willing to use mental healthcare services than younger groups. Although older adults vary greatly in their demographic characteristics, which leads to differences in their demand for and willingness to use of mental healthcare services. Furthermore, marital status includes single, married, divorced, separated and widowed. The widowed and divorced are more susceptible to have mental health challenges due to the loss and hurtful experiences of their loved ones. Also, individuals with less-educational qualification and low income earners are more likely to have mental health challenges; they tend to be less willing to use mental healthcare services (Kessler, Chiu, Demler & Walters, 2005). From experience religion is also conceived as a factor that influences people’s willingness to use mental healthcare services. The three most recognized religions in Nigeria today are Christianity, Islam, and Traditional religions. In many religious belief systems, mental health challenges are perceived as due to ancestors or by bewitchment and religious advisors are viewed as having expertise in these areas, thereby making many people not to use mental healthcare services.

Thus, the role of these aforementioned personal factors together with health information rights awareness and perceived stigmatization on willingness to use mental healthcare services require scholarly attention. Therefore, this current study examined the extent to which health information rights awareness, perceived stigmatization and personal factors influence willingness to use mental healthcare services among librarians in private universities in South-West,Nigeria.

1.2       Statement of the Problem

Mental health is a desirable state globally and a requirement for optimum performance in any area of human endeavor. However, various biological, physical or environmental variables can predispose people to mental health challenges that could undermine their ability to meet up with expectations. Job-related stress has been indicated as the major cause of mental health challenges in the academic environment.While most studies focused on stress among the faculty, there are indications that academic librarians may not also be immune to the mounting stress levels in the academia. Perhaps, maintaining mental health is more challenging for librarians in the performance-driven academic environment, because there is constant demand for results and minimal resources are expected to yield optimum results(Shaw & Ward, 2014).  Besides, the constant need to keep up with the fast pace of technological change, publish and present academic papers and acquire multiple competencies pose a major threat to the mental health of librarians. Unfortunately, the literature has established that most people are not willing to use mental healthcare services for fear of being stigmatized as crazy and unfit. Also, personal factors such as gender, age, marital status, income status, educational status and religious affiliation have been found to influence the decision to seek mental healthcare treatment among various groups. Therefore, this study investigates the influence of health information rights awareness,perceived stigmatization and personal factors on willingness to use mental healthcare services among librariansin private universities in South-West, Nigeria.

1.3       Objective of the Study

The main objective of the study is to ascertain the predictive ability of health information rights awareness, perceived stigmatization and personal factors on willingness to use mental healthcare services among librarians in private universities in South-West, Nigeria.  The specificobjectives are to:

1. find out the factors that can predispose librarians to mental health challenges in private universities in South-West, Nigeria;
2. ascertain the experience of mental health challenges among librarians in private universities in South-West, Nigeria;
3. ascertain level of health information rights awareness among librarians in private universities in South-West, Nigeria;

4.      find out the extent to which librarians in private universities in South-West, Nigeria believe that mentally ill people are stigmatized;

5. find out the attitude of librarians towards the use of mental healthcare services;
6. find out the possible hindrances to the use mental healthcare services among librarians in private universities in South-West, Nigeria;
7. ascertain the willingness of librarians in private universities in South-West, Nigeria to use mental healthcare services;
8. determine the extent to which health information rights awareness predicts willingness to use mental healthcare services by librarians in private universities in South-West, Nigeria;
9. determine the extent to which perceived stigmatization  predictswillingness to use mental healthcare services by librarians in private universities in South-West, Nigeria and
10. find out how personal factors such as gender, age, marital status, income status, educational status and religion affiliation predict willingness to use mental healthcare services by librarians in private universities in South-West, Nigeria.

1.4       Research Questions

This research is guided by the following questions:

1. What are the factors that predispose librarians to mental health challenges in private universities in South-West, Nigeria?
2. What are the experiences of librarians in private universities in South-West, Nigeria towards mental health challenges?
3. What is the level of health information rightsawareness among librarians in private universities in South-West, Nigeria?
4. How is stigmatization of mentally ill people perceived by librarians in private universities in South-West, Nigeria?
5. What is the attitude of librarians in private universities in South-West, Nigeria towards the use of mental healthcare services?
6. What are the possible hindrances to the use of mental healthcare services among librarians in private universities in South-West, Nigeria?
7. How willing are librarians in private universities in South-West, Nigeria to make use of mental healthcare services?

1.5       Hypotheses

The following null hypotheses were tested at α = 0.05 level of significance:

Ho₁:Health information rightsawareness will not predict willingness to use mental healthcare services among librarians in private universities in South-West, Nigeria.

Ho₂:   Perceived stigmatization cannot predict willingness to use mental healthcare services among librarians in private universities in South-West, Nigeria.

Ho₃:   Personal factors will not predict willingness to use mental healthcare services among librarians in private universities in South-West, Nigeria.

1.6       Scope of the Study

This study investigates the influence of information rights awareness, perceived stigmatization and personal factors on librarians’ willingness to use mental healthcare services in private universities in South-West, Nigeria. In this study, health information rights was considered as right to access personal health information, right to privacy, right to confidentiality and right to amend/correct personal health information; perceived stigmatization was considered as stereotype, prejudice and discrimination; while personal factors was considered as gender, age, marital status, income status, education status and religion affiliation. Unlike most studies on health information rights awareness, this study focused on non-patients, that is people who are not necessarily registered users of any mental healthcare service or institution. The study was conducted among professional and para-professional librarians working in private universities in South-West, Nigeria.

1.7       Significance of the Study

This study is important as it emphasized the need for Nigerian Library Association, Nigerian Medical Association and healthcare professionals to enlighten people, both young and old, on health information rights through intensified awareness programs on media such as television, radio and social media. Findings of this study will also educate librarians and mental healthcare experts to knowmost conditions such as depression, job-related stress and stressful life situation that contribute tomental health challenges.This study would assist government to develop anti-stigma policies that will ensure effective utilization of mental healthcare services. The findingsthat emerged from this study will help Nigeria Medical Association to know the need to design health information policies and strategies toincrease people’s willingness to use mental healthcare services.Finally, the findings of the study would serve as useful reference study for students, academia, psychiatrists, information professionals, health record officers and future research endeavours.

1.8       Operational Definition of Terms

Librarians:Librariansare professionals and para-professionals employed to develop library collections, provide access to information and provide training on information retrieval and use to students and faculty in private universities in South-West, Nigeria.

Confidentiality: This refers to the right of an individual to have personally identifiable information kept private and not disclosed to others unless the individual owner has given specific permission for such release.

Health information: This refers to any data about patients that is in verbal, written or electronic form that conveys meaning and which could be used in diagnosis, treatment or medical prescription.

Health Information Rights: This refers to patients’ access, right to privacy, right to confidentiality and right to amend/correct personal health information.

Health Information Rights Awareness: This refers to the level of knowledge or enlightenment that librarians have about the right to access personal health information, right to privacy, right to confidentiality and right to amend/correct their personal health information.

Mental Healthcare Services: These are the provisions meant to take care of mental illness and other related mental health challenges.

Mental Health Challenge: This refers to mental health conditions that negatively affect people’s mood, feelings, thinking and behaviour.

Personal Factors:In this study, it refers to individual factors such as age, gender, marital status, income status, educational status and religion affiliation that influence individual’s willingness to use mental healthcare services

Stigmatization: This is defined in terms of stereotype, prejudice and discrimination against people that seek mental healthcare services.

South-West, Nigeria: This is one of the six geopolitical zones in Nigeria. It comprises six states namely: Ekiti, Lagos, Ogun, Ondo, Osun and Oyo. It is a Yoruba language speaking zone. It has the highest concentration of Universities and other tertiary institutions in Nigeria; and it is the study area for this research.

Willingness to use mental healthcare services: This refers to the readiness of librarians to inquire about their mental state of health or seek treatment in mental healthcare facilities. 

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