Development and validation of the help-seeking motivation scale for patients with schizophrenia(HSMS)

Abstract

Objective

Schizophrenia is one of the mental disorders with the longest delay in treatment. Motivation for help-seeking is an important factor in getting professional treatment. There is no instrument to measure help-seeking motivation in schizophrenia. We aim to develop a scale to provide a valid measurement tool for assessing help-seeking motivation in this population.

Methods

A literature review and semi-structured interviews were used to construct the dimensions and item pool. Then, the scale was adjusted according to the results of Delphi study, cognitive interviews and pilot survey. Next, we screened the items and determined the potential structure via item analysis and exploratory factor analysis. Lastly, we tested the reliability and validity.

Results

Exploratory factor analysis and confirmatory factor analysis showed that the 21-item scale comprised three factors (autonomous motivation, controlled motivation and amotivation). The results of exploratory factor analysis showed the factor loading ranged from 0.602 to 0.888. Three factors explained 60.462% of the total variance. The results of confirmatory factor analysis showed an adequate model fit (χ²/df = 1.932, GFI = 0.908, AGFI = 0.885, NFI = 0.907, NNFI = 0.946, CFI = 0.952, IFI = 0.953, RMR = 0.048, RMSEA = 0.052). The Cronbach’s α for the scale was 0.903. The item-level content validity index (I-CVI) was 0.890 ~ 1.000, scale-level content validity index (S-CVI) was 0.983.

Conclusion

The help-seeking motivation scale for patients with schizophrenia has excellent psychometric properties. This scale may be a reliable measure for assessing help-seeking motivation in schizophrenia.

Clinical trial number

Not applicable.

Introduction

The global prevalence rate of schizophrenia is 0.5-1% [1], and it is characterized by high disability rate and heavy economic burden [2]. Early identification, diagnosis and timely treatment play an important role in the prognosis of schizophrenia. Delayed diagnosis and treatment of patients can lead to a certain degree of brain volume loss and brain function impairment, and poor prognosis in terms of mental symptoms, cognitive and social function [3]. At present, the delay in diagnosis and treatment of schizophrenia remains a worldwide problem. Addington J et al. found in a study of American community patients with schizophrenia that 68% of patients had a delay in diagnosis and treatment for more than 6 months [4]. Promoting early diagnosis and treatment of patients with mental disorders has always been a key concern in the field of mental health.

Delay behavior in the diagnosis and treatment of schizophrenia is caused by multiple systematic factors, of which patient delay is the main reason, and help-seeking motivation is the key factor in whether patients seek professional help [5, 6]. Help-seeking motivation refers to the internal psychological process of inspiring and maintaining individuals to seek help from professionals under the guidance of the goal of solving mental problems or relieving pain [7]. It is not only the direct cause of help-seeking behavior, but also the driving force behind it, which can determine to a large extent whether patients will adopt help-seeking behavior and maintain treatment [8].

Lack of motivation is the core of the treatment process of schizophrenia. A study investigating the incidence of early motivational impairment in schizophrenia showed that 15.1% of patients experienced severe motivational defects, and 76.5% had varying degrees of motivational disorders [9]. It is suggested that there may be a certain degree of deviation and lack of help-seeking motivation in most patients with schizophrenia [10], which may lead to delays in professional help-seeking behavior or passive treatment [11]. Therefore, it is necessary to accurately measure the level of help-seeking motivation in patients with schizophrenia to both accurately identify the presence of a clinical problem and to promote them receive treatment as early as possible.

A review of the literature found that methods for measuring help-seeking motivation in patients with schizophrenia were still lacking [12, 13]. Current measurement content related to help-seeking motivation mainly focuses on motivation and professional psychological help-seeking attitude, and is usually assessed by scales or questionnaires. Among those that measure motivation include Intrinsic Motivation Inventory For Schizophrenia Research(IMI-SR) [14], Treatment Self-Regulation Questionnaire(TSRQ) [15], Motivational Trait Questionnaire(MTQ) [16], etc., which are mostly used to assess the patient’s internal motivation, behavior management motivation or motivational traits, and cannot be used to assess the patient’s motivation for seeking help. Assessments of professional help include The Attitudes Toward Seeking Professional Psychological Help Scale(ATSPPH) [17], The Attitudes Toward Seeking Professional Psychological Help Scale-Short Form(ATSPPH-SF) [18], Intention of Seeking Counseling Inventory(ISCI) [19], etc., most of them focus on professional help-seeking attitudes, and the research subjects are mostly students or community groups, so there are certain limitations in the scope of application. At the same time, some of the above-mentioned measurement tools lack evaluation of their content validity or structural validity, the reliability of some questionnaires is not high, and the content of the questionnaires is not comprehensive enough. In summary, there is currently no suitable measurement tool for help-seeking motivation.

Self-determination theory (SDT) is an important organizational framework for motivation research in schizophrenia [20]. Its branch, organic integration theory, divides motivation into three categories: amotivation, extrinsic motivation and intrinsic motivation. Their degree of self-determination ranges from low to high, and gradually becomes stronger. Our conceptual model, in conjunction with the Self-determination theory, supports the above three domains as a multidimensional construct of help-seeking motivation: amotivated patients do not recognize the connection between professional help-seeking behavior and behavioral outcomes, and therefore lack the idea and intention to seek professional help. Extrinsic motivation occurs when patients seek help in exchange for external rewards or because of pressure. Intrinsic motivated patients have a correct understanding of mental illness and professional treatment due to their own values, beliefs and perceived benefits of professional help, and they seek professional help independently under the drive of their own will. The goal of this study is to produce a self-report questionnaire of help-seeking motivation for patients with schizophrenia based on the self-determination theory as a theoretical framework, that is, Help-Seeking Motivation Scale for patients with schizophrenia(HSMS), so that it can be used in clinical services and research. It also provides a reliable quantitative tool for evaluating the help-seeking motivation of patients with schizophrenia and fills the gap in the field of schizophrenic help-seeking motivation measurement.

Fig. 1

Flowchart for the development and validation phases of the HSMS

Methods

Our research team followed the recommendations of best practices in scale development [21], that is, to develop and validate the HSMS through three phases (Fig. 1). The methods used in each phase are described in detail below. And in determining the steps for the validation study design, we used the COSMIN checklist [22] to select the appropriate criteria to scrutinize the quality of measure development. In phase 1, we initially formed the item tool of the scale through literature analysis, semi-structured interviews, Delphi study and cognitive interviews. After content validity was tested by experts, a pilot survey of the items was conducted with patient samples. In phase 2, a main survey was conducted by applying the HSMS to patients, and item screening was conducted through item analysis and exploratory factor analysis (EFA) [21]. In phase 3, the reliability and validity of the scale were tested.

Phase 1: item development

Literature review

Two independent authors conducted an electronic database search of Cochrane Library, PubMed, Web of Science, Ovid MEDLINE, PsycINFO, Embase from inception to September 2022. The search terms used were: “schizophrenia” OR “schizophrenic disorders” AND “seek help” OR “help-seeking behavior” OR “motivation” OR “help-seeking motivation”. A search was conducted on Google Scholar using the same keywords to identify any additional relevant articles. Reviewed the retrieved literature related to the help-seeking motivation of patients with schizophrenia, and extracted and summarized the content related to the research topic.

Semi-structured interviews

Purposive sampling method was used to select 20 patients with schizophrenia who were admitted to a psychiatric hospital in Daqing, China, for face-to-face semi-structured interviews. The inclusion and exclusion criteria for participants are presented in Table 1. An interview guideline(Document S1)was developed based on self-determination theory, research purpose and literature review. The interview lasted 30 to 60 min. Within 24 h after the interview, the researcher transcribed the audio recording into text, analyzed and summarized the data.

Table 1 Inclusion and exclusion criteria of the participants

Item generation

The theoretical framework of this study was based on Self-determination theory (SDT), whose branch of organic integration theory divides motivation into three categories: amotivation, external motivation and internal motivation [20]. After literature review and semi-structured interviews, a bilingual collaborative research team first generated a list of items via two brainstorming sessions and then revised the items after discussion with subject experts; Each session lasted 2–3 h and were chaired by the author. All researchers and experts were psychiatrists and/or public mental health specialists. The process of item generation was done in two languages simultaneously (English, Chinese) according to a dual-focus approach to encompass an ethical concern and avoid a cultural bias [23]. The representation of each component of help-seeking motivation was then independently evaluated and compared by two researchers, to allow each item could cover one or more components of help-seeking motivation.

Delphi study

Following established procedures of previous studies, the Delphi method was used to screen and assess the generated dimensions and items [21]. Since the inquiry questions in this study belong to the field of mental psychology, the number of experts can range from 5 to 15 [24]. The experts were purposively sampled based on the following criteria: (1) possessed at least an undergraduate degree; (2) have at least 10 years of experience in their field and intermediate or above professional titles; (3) willing to participate in this study. Eventually, expert reviews of the scale items from nine psychiatric medical experts were obtained via a two-round Delphi study.

The item pool was compiled and sorted to form the first round of expert consultation questionnaire. The questionnaire consisted of an introduction to the consultation content, basic information about the experts, and an expert evaluation form on the HSMS. It was sent to each expert’s mailbox via email. Experts used the Likert 5-level scoring method to score the importance of scale dimensions and items, and provided comments or suggestions for modifications to the content of the items. The item selection criteria were based on the mean of importance assignment > 3.500 and the coefficient of variation < 0.300. Experts relied on the overall analysis of this study to determine the basis for their judgment (Ca) and familiarity (Cs). On the basis of sorting and summarizing the expert opinions from the first round of expert consultation, some items were deleted and modified after discussion by the research team. The revised items were compiled into the second round of expert consultation questionnaire, which was sent to all experts for further adjustment of the items, and then assessed the content validity of the scale. At the same time, we also calculated the effective questionnaire recovery rate, authority coefficient, Kendall’s W, and coefficient of variation to evaluate the objectivity of the expert judgment results in the two rounds of expert consultation.

Tests of content validity

This study invited nine experts who engaged in clinical psychology, behavioral medicine, and nursing psychology to assess the content validity. Experts were required to rate the relevance between the content described in each item and the measurement dimensions and concepts (1–4 points for “not relevant” to “very relevant”) and to propose modifications to the items. Content validity was assessed using the item-level content validity index (I-CVI) and scale-level content validity index (S-CVI).

Cognitive interviews

In order to test the target population’s understanding of the meaning of the items, improve the quality of the scale, and ensure the accuracy of survey data collection. From December 2022 to January 2023, we used the maximum difference sampling method to select 30 patients with schizophrenia with different education levels, ages and genders in a psychiatric hospital with the inclusion and exclusion criteria of semi-structured interviews for cognitive interviews. The interview guideline(Document S1)was formulated based on the research purpose, Tourangeau cognitive theory [25], relevant literature review, and expert opinions. Cognitive interviews should be conducted at least 3 rounds, with the number of interviewees in each round ranging from 5 to 15. Once the data was saturated, the interview would be stopped. The researchers transcribed the interview content and related information word by word, and made an Excel spreadsheet item by item to form an independent document about each survey question. Then, the doubtful items were modified based on the coding results of the Question Appraisal System(QAS-99) [26] and the opinions of the expert group.

Pilot survey

According to the inclusion and exclusion criteria of semi-structured interviews, purposive sampling method was used to select 25 patients with schizophrenia who were admitted to a psychiatric hospital, and a small sample pilot survey was conducted on them using the scale modified by cognitive interviews. Based on the results of patient feedback, the research team adjusted the language expression and order of items after discussion to form the initial HSMS.

Phase 2: scale development

From February to May 2023, convenience sampling method was used to select patients with schizophrenia admitted to two psychiatric hospitals for investigation. The inclusion and exclusion criteria for participants were the same as for semi-structured interviews. Considering that the sample size of factor analysis is 5 ~ 10 times the number of items [27], and considering the lost follow-up rate of 10%, the initial version of HSMS in this study had 26 items, so a total of 572 samples were recruited. The final sample was randomly divided into two parts, 286 samples were used for scale development (item analysis and exploratory factor analysis), and 286 samples were used for scale validation (reliability and validity testing and confirmatory factor analysis).

Item analysis

The scale item analysis used five methods: the discrete trend method, critical ratio method, correlation coefficient method, reliability test method and factor analysis method to test the appropriateness or reliability of the scale or individual items, so as to screen the items. The results can be used as the basis for item selection or modification.

Exploratory factor analysis (EFA)

We used SPSS23.0 to perform EFA to identify the factor structure of HSMS. In order to ensure the validity of factor analysis, we conducted the Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test of sphericity. The principal component analysis method was used to extract common factors, correlation matrix analysis was performed, and the choice of the rotation axis mode was determined according to the correlation coefficient between the factors. If the correlation coefficient between the factors is greater than 0.3, the oblique rotation method is used for rotation, otherwise the orthogonal rotation axis is used. The criteria for deleting items are: the loading value on multiple factors is > 0.400 or the loading value on any factor is < 0.400. The results of the scree plot and parallel analysis were used as a reference to determine the number of retained factors.

Phase 3: scale validation

Confirmatory factor analysis (CFA)

CFA was performed to evaluate the fitness of the model via Amos 24.0 and help find the most plausible solution on the testing sample. The chi-square degree of freedom ratio (x²/df), goodness-of-fit Index (GFI), adjusted goodness-of-fit index (AGFI), root mean square residual (RMR), root mean square error of approximation (RMSEA), incremental fit index (IFI), Tucker-Lewis index (TLI), canonical fit index (NFI) and comparative fit index (CFI) were used to determine the overall fitness of the model [28, 29]. If some indexes did not reach the fit criteria, the confirmatory factor analysis was performed again after correction according to the modification indicators prompted by the Modification Indices function in Amos 24.0, and the best fitting model was finally determined.

Convergent and discriminant validity

The combination reliability (CR) and average variance extracted (AVE) were used as the indicators to evaluate the convergence validity. It is generally considered that CR > 0.7, AVE > 0.5, and the convergence validity is good. If the square root of the corresponding AVE is higher than the correlation coefficient between factors, it indicates that CFA model of HSMS has a good discrimination validity [30].

Tests of reliability

Cronbach’s α coefficient, test-retest reliability, and split-half reliability were used to calculate the internal consistency reliability of the scale. Scale measurement was considered to have high reliability when the Cronbach’s α coefficient, the test-retest reliability, and the split-half reliability larger than 0.7 [31].

Results

A total of 635 questionnaires were collected (295 in phase2 and 340 in phase3), of which 309 (48.66%) were male and 326 (51.34%) were female. Most of the participants were aged 31 to 50 (56.69%), unmarried (51.18%) and with secondary education (59.37%). Table 2 shows the details of participants’ demographic characteristics.

Table 2 Demographic characteristics for participants

Phase 1: item development

Item development

Based on the self-determination theory, combined with the results of literature review and semi-structured interviews, the research team finally generated a pool of 75 items with four dimensions of autonomous motivation, introjected regulation, external regulation, and amotivation, which were back-translated from English to Chinese by four bilingual researchers.

Delphi study

A total of 9 authoritative experts linked to the subject of the study and the field of specialization were interrogated. The effective questionnaire recovery rate in both two rounds of expert consultation were 100%, the overall average authority coefficient of the experts was 0.928, the Kendall’s W of the two rounds of consultation were 0.587 and 0.673 (P < 0.001) respectively, and the coefficient of variation were 0.064 and 0.031 respectively, indicating that the reliability of the consultation results and the concentration and coordination of expert opinions are relatively high. See Table 3 for specific results. According to experts’ opinions, 30 items were deleted, such as “I thought I need treatment when I was sick” and “I felt responsible for my own health”. A total of 8 items were modified, such as changing item “I knew that seeking professional help was important to me” to “Going to a psychiatrist was very important to me”. There were 28 items were combined, such as combining item “I wanted to improve physical symptoms” and “I wished to improve mood or sleep problems” with “I went to a psychiatrist to improve my symptoms”. Following the revision of two rounds of expert consultation, 27 items were retained.

Table 3 Expert reliability

Tests of content validity

The experts who took part in the content validity test were the same as the experts who participated in Delphi study. Based on the calculation of the experts’ scores, the I-CVI of item 27 was 0.67, lower than the recommendation standard of 0.78, and the expert considered that this item was not closely associated with “professional help-seeking” and should be deleted. The I-CVI of the remaining 26 items after deleting item 27 was 0.89 to 1.00, and the S-CVI was 0.98, greater than 0.900, indicating that the content validity of the scale is good.

Cognitive interviews

Three rounds of cognitive interviews were conducted in 30 cases of patients with schizophrenia. The results of the first round of cognitive interviews showed that respondents felt that 11 items contained ambiguous terms and expressions, and we revised some problematic items after discussion, such as the item “Going to a psychiatric clinic would not delay illness” was revised to “I went to a psychiatrist to prevent my condition from getting worse”. In the second round of interviews, respondents thought the item “I had not considered this (go to the psychiatrist) and should seek other help” was an inappropriate assumption. After some deliberation, it was revised to “I would not consider going to a psychiatrist”. In the third round of interviews, the respondents thought that no items needed to be changed, and the interviews were stopped.

Pilot survey

A small-scale pilot survey was conducted in 25 patients with schizophrenia with the scale modified by cognitive interviews. According to the feedback of the patients, the research team revised some items after discussion. The item “I would feel guilty if I did harm or burden my family because of mental illness” was revised to “I would feel guilty if I didn’t go to a psychiatrist”, as well as the item “I did something bad (abnormal speech or behavior at the time of onset) because didn’t go to a psychiatrist” was revised to “If I didn’t go to a psychiatrist, I would feel regretful”, the item “I did not think about it (go to a psychiatrist) ” was revised to “I would not consider going to a psychiatrist”. The reason for the revision was that the sentence patterns of the above items were not consistent with other items of the scale, and some patients needed to spend more thinking time to answer, which was easier for patients to understand after the revision. After a slight modification of the items via the pilot survey, the initial HSMS with four dimensions and 26 items were developed. Likert 5-point scoring method were used with 1 representing “Strongly disagree” and 5 representing “Strongly agree”. A higher score indicated a higher level of help-seeking motivation.

Phase 2: scale development

Item analysis

The results of the discrete trend method showed that the standard deviation of items 1, 2, 13, and 14 were less than 1.000, indicating that these items had poor discriminative ability. The results of the critical ratio method showed that the CR values of items 1 and 14 were less than 3.000, indicating that the discriminative ability of these items was poor. The results of the correlation coefficient method showed that the correlation coefficients between items 1, 2, 13 and 14 and the total score of the scale were less than 0.300, indicating that their homogeneity was low. The results of reliability test method showed that the Cronbach’s α coefficient of the scale increased after items 1, 2, 13 and 14 were deleted. The results of the factor analysis method showed that the commonality of items 1, 2, 13, 14 and 25 was less than 0.200 and the factor loading was less than 0.450, indicating that these items were less representative. Based on the item analysis results, items 1, 2, 13, 14 and 15 were deleted, leaving 21 items. See Table 4 for specific results.

Table 4 Item analysis of the HSMS

Exploratory factor analysis

Results of the EFA showed that the KMO was 0.914, the Bartlett’s Test of Sphericity was significant (χ²=3413.806, P < 0.001). Three common factors were extracted by principal component analysis, and factor rotation by orthogonal rotation with maximum variance, explaining 60.462% of the total variance. It was observed from the scree plot (Document S2) that the curve changed from steep to gentle after the third factor. Therefore, a factor number of 3 is the maximum number of factors that can be retained for this study. Compared with the scree plot, parallel analysis (Document S2) found that random eigenvalue curve and actual eigenvalue curve intersected between 3 and 4, so this study finally selected the number of three factors as the composition dimension of the scale. The dimensions of the scale formed by exploratory factor analysis were renamed in combination with existing knowledge of schizophrenia, relevant theories and initial dimensions of the scale. Factor one was named autonomous motivation, including 8 items; factor two was controlled motivation, including 8 items; factor three was named amotivation, including 5 items. The factor loading of each item was more than 0.5, as shown in Table 5.

Table 5 The loaded factor matrix of items of explorative items analysis of the HSMS

Phase 3: scale validation

Confirmatory factor analysis

340 survey data were collected to conduct two rounds of confirmatory factor analysis on the three-factor structure formed by exploratory factor analysis. Results of the first-round CFA showed that χ²/df = 2.088 (Fit criteria < 3.000), GFI = 9.010 (Fit criteria > 0.900), AGFI = 0.877 (Fit criteria > 0.800), RMR = 0.048 (Fit criteria < 0.100), RMSEA = 0.056 (Fit criteria < 0.080), CFI = 0.944 (Fit criteria > 0.900), NFI = 0.899 (Fit criteria > 0.900). To sum up, some indicators had not yet reached the fit criteria. According to the modified indicators prompted by the Amos software, we established a bidirectional correlation between the residuals 18 and 19, and found that the chi-square value of the overall model fit will decrease by at least 27.445. Therefore, CFA was conducted again after establishing a bidirectional correlation between residuals 18 and 19. Results of the second-round CFA after correction showed that, χ²=357.495 (P < 0.001), df = 185, χ²/df = 1.932, GFI, AGFI, NFI, NNFI, CFI, IFI all >0.900, RMSEA < 0.080, RMR < 0.100. All indicators were within the acceptable range. The modified CFA model results (Document S3) showed that the non-normalized estimates for all items ranged from 0.716 to 0.991 (P < 0.01). See Table 6 for details.

Table 6 Confirmatory factor analysis model modified fit results

Convergent and discriminant validity

The three-dimensional CR for autonomous motivation, controlled motivation and amotivation were 0.802, 0.786 and 0.822, respectively. The AVE were 0.506, 0.503 and 0.624, respectively, indicating that the structural dimension of the HSMS had good convergent validity (Table 6). Table 7 also shows that the square root of AVE under the dimension of autonomous motivation was 0.711, and the correlation coefficients between this dimension and controlled motivation and amotivation were 0.474 and 0.406 respectively; the square root of AVE under the dimension of controlled motivation was 0.710, and the correlation coefficients between this dimension and autonomous motivation and amotivation were 0.474 and 0.256 respectively; the square root of AVE under the dimension of amotivation was 0.790, and the correlation coefficients between this dimension and autonomous motivation and controlled motivation were 0.406 and 0.256 respectively. We found the square root of the corresponding AVE was higher than the correlation coefficient between factors, indicating that CFA model of HSMS has a good discrimination validity.

Table 7 Convergent and discriminant validity of the HSMS

Tests of reliability

Table 8 shows the Cronbach’s α of the overall HSMS was 0.903 and that of each sub-factor ranged from 0.888 to 0.896; The split-half reliability for the overall HSMS was 0.747 and that for each sub-factor ranged from 0.828 to 0.919; 30 subjects were selected from the previous study and retested two weeks later. The results showed that the test-retest reliability of the overall HSMS and that of each sub-factor were all larger than 0.900.

Table 8 Reliability of the HSMS

Discussion

At a time when timely medical care is increasingly valued, the level of help-seeking motivation is an essential determinant of patients’ health outcomes [32]. Consequently, we aimed to describe the process of developing and validating a conceptual model of help-seeking motivation among patients with schizophrenia, to assess levels of self-reported help-seeking motivation within this population. Overall, three domains were identified in the conceptualization of help-seeking motivation among patients with schizophrenia, namely, autonomous motivation, controlled motivation and amotivation. The results of this study shows that the scale has a moderate number of items, the language expression is simple and easy to understand, and the patients have good feedback in the process of investigation, which indicates that the HSMS has high clinical application value.

Our findings indicate that HSMS validly measured the intended construct according to contemporary research understanding. The three identified domains are largely consistent with the Self-determination theory. On the other hand, some conceptual distinctions were also revealed, such as extrinsic motivation and controlled motivation, intrinsic motivation and autonomous motivation. Given the continued subdivision of extrinsic motivation and intrinsic motivation, controlled motivation and autonomous motivation may be considered two important domains of help-seeking motivation in patients with schizophrenia [33]. This innovation means that the scale can not only reflect the patients’ motivation to seek medical treatment on their own, but also perceive the patients’ motivation to seek help due to external influences or pressure. In other words, HSMS takes into account the patients’ active and passive factors, ensuring the comprehensiveness of the assessed level of help-seeking motivation. Therefore, this novel conceptual model could a foundation for future research to develop relevant evidence-based help-seeking motivation interventions.

Up till the present moment, it is the first scale in the world to measure the self-reported help-seeking motivation level of patients with schizophrenia. It is crucial to identify the level of help-seeking motivation in patients with schizophrenia so that we can take timely and relevant intervention measures. To show you what I mean, low help-seeking motivation can affect the diagnosis and treatment process and have a negative impact on prognosis [34]. Patients with schizophrenia with inadequate help-seeking motivation tend to seek professional help less often, leading to a higher prevalence of delayed diagnosis and treatment [35]. Ultimately, the lack of motivation to seek help poses a great challenge for patients to receive timely and professional treatment, and greatly increases the burden on patients’ families and society. Nowadays, the HSMS can serve as a diagnostic tool to identify which domains of help-seeking motivation need intervention. If HSMS can be used regularly, they can easily identify patients who need additional support. Therefore, the HSMS not only enables the identification of vulnerable motivation within specific domains, but also effectively evaluate interventions’ effectiveness at all research stages, thereby facilitating the customization of personalised interventions.

Overall, the psychometric properties of the HSMS measure were satisfactory. The factor loading ranged from 0.602 to 0.888, indicating that each item of the scale is well correlated with its dimension [36]. After correction, the fitting indexes were all in line with the standard, indicating that the overall fitting degree of the model was good. The CR of all factors were greater than 0.7, the AVE of all factors were greater than 0.5, which indicated that the internal quality of the model is good and the structural dimension of the HSMS has good convergent validity. The square root of the corresponding AVE was higher than the correlation coefficient between factors, indicating that CFA model of HSMS has a good discrimination validity. Additionally, the Cronbach’s α of the overall scale was 0.903 and that of each sub-factor ranged from 0.888 to 0.896, which were higher than the recommended standard, indicating that the internal consistency of the scale is good [36]. The test-retest reliability coefficient of each dimension was 0.908 to 0.941, and the total test-retest reliability was 0.945. It showed the results of two measurements were relatively consistent, and the measurement tools were relatively stable. The split-half reliability for the overall scale was 0.747 and that for each sub-factor ranged from 0.828 to 0.919, indicating that the reliability of the scale is good.

It is worth noting that this new scale has unique and clinically informative psychometric properties over its traditional counterpart. Our results suggested that the HSMS challenged the traditional, unidimensional conceptualization of help-seeking motivation with its ability to assess three dimensions of motivation for seeking help, offering subscales of autonomous motivation, controlled motivation and amotivation. Autonomous motivation can reflect the patient’s willingness to seek medical treatment independently, controlled motivation can perceive the patient’s motivation level to seek help due to external influences or pressure, and amotivation can clearly distinguish whether the patient has the motivation to seek professional help. Also novel to our scale were subscales that showed evidence of stronger and unique relevance to motivation compared to a traditional self-report measure like the ATSPPH [13], while the ATSPPH reflected more help-seeking attitude and had not yet shown sensitivity to help-seeking motivation. Furthermore, The HSMS can assess the level of help-seeking motivation in patients with schizophrenia, while the ATSPPH has not been implemented in people with mental disorders. According to the overall findings, the HSMS is a valid and reliable scale for assessing help-seeking motivation among patients with schizophrenia.

Limitations

The limitations of this study are as follows: Firstly, due to time and space constraints, this study only sampled from two psychiatric hospitals, and in order to ensure the smooth progress of the interview process, the authenticity and reliability of the interview data, the interview subjects were patients with PANSS insight symptom severity being less than 4 and patients without intellectual deficits. Therefore, the intended usage and appropriate subjects of the scale is also for this group of people. In the future, the research site can be expanded and other types of samples can be increased to further test the scale. Furthermore, mental disorders are known to feature motivation difficulties but with separate etiological mechanisms. More research can be conducted in the future to explore the potential application of this scale for people with mental disorders other than schizophrenia. Secondly, due to the great difference in the measurement concept between the existing evaluation tools and the help-seeking motivation scale, this study did not carry out the criterion-related validity test. As a result, it makes sense to apply the scale to several distinct samples in order to check the standard’s validity. Lastly, the scale was developed in a Chinese social and cultural background, and further research is needed to evaluate its use of English and other language translations across cultures and settings.

Conclusions

This study strictly followed the scale development process and developed a help-seeking motivation scale for patients with schizophrenia. It has good reliability and validity and can be used as a reliable and accurate tool to assess the Help-seeking motivation of patients with schizophrenia. Moreover, the development of help-seeking motivation scale fills the gap in the field of research and application of help-seeking motivation in mental disorder groups, which is helpful for mental health workers to better understand the current situation of help-seeking motivation of patients with schizophrenia, and then formulate effective intervention measures to promote patients with schizophrenia to receive correct diagnosis and treatment as soon as possible.