Journal of Muslim Mental Health

Author Note

I am grateful for the support of all of my mentors, in particular the mentorship offered by Dr. Natalie Rasgon as I embarked on this work. I would also like to thank Dr. Stewart Agras and all of the NIMH T32 Fellows at Stanford for their feedback. I wish to convey much gratitude to the APA Minority Fellowship program under the then leadership of Dr. Annelle Primm for the support they provided throughout the entire length of this project.

Correspondence concerning this article should be addressed to Rania Awaad, Stanford Muslim Mental Health Lab, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd. Stanford, CA, 94305. Email: [email protected]

Abstract

Proper study of the perceptions and attitudes of mental health in minority populations depends on valid and reliable measurements that are customized for each population. Currently, no existing measure is tailored to the unique needs of Muslim women residing in the U.S. The Muslims’ Perceptions and Attitudes to Mental Health (M-PAMH) Scale was developed by adapting existing instruments in order to establish a psychometrically robust scale for the utilization in mental health care research when studying Muslim women. Scale validity was tested using data from 1,279 American Muslim women (mean age: 32.3) who anonymously completed a 40-item questionnaire hosted on a medical school website. The complete sample was randomly divided into roughly equivalent halves. The first half of the sample (n=623) was subjected to an exploratory factor analysis (EFA); a four-factor structure was indicated. The EFA pattern matrix was used to indicate the factor structure of a confirmatory factor analysis (CFA) with the remaining sample (n=656). Following this, 18 items indicated the proposed four-factor structure. The CFA demonstrated an excellent fit to the data, with small to moderate correlations between factors. The M-PAMH successfully assesses four important domains: rejection attitudes toward professional mental health care, cultural and religious beliefs about mental health, stigma associated with the usage of mental health services, and familiarity with formal mental health services.

Keywords: American Muslim Women, Perceptions and Attitudes, Psychometric Scales, Stigma, Islam, Muslim Mental Health, M-PAMH

Introduction

Recent scholarship recognizes that attitudes and perceptions toward mental health in minority populations require individualized attention in order to reduce stigma and increase service utilization (Gibbs & Huang, 1998; Herrick & Brown, 1998, Trinh, Rho, Lu & Sanders, 2009). The underutilization of mental health services by minorities is often attributed to beliefs about the origin and proper treatment of mental illness or beliefs that discourage the disclosure of problems to those outside of the family network (Gaw, 1993). Other theories of underutilization in minority groups include stigma (Corrigan & Kleinlein, 2005), lack of knowledge regarding available services (Aloud, 2004), and differences in values on the part of the clinician or counselor (Shafi, 1998; Ahmed & Reddy, 2007).

American Muslims are a growing minority group and a unique subset of the U.S. population with limited studies of their health and wellbeing (Sheridan & North, 2004; Maslim & Bjorck, 2009). This is regrettable considering the increased attention Muslims are receiving in the media and the steady growth of the number of Muslims making it the projected second largest religious group in the United States by 2040 (Mohamed, 2016).

The limits of existing research on attitudes and perceptions of mental health in American Muslims creates a disadvantage for both providers and potential patients; a more thorough exploration of such can lead to better utilization and tailoring of services. Progress has been hampered in part due to the lack of appropriate measures specific to the Islamic faith (Abu Raiya, Pargament, Mahoney & Stein, 2008; Bjorck & Maslim, 2011). The lack of insight into a minority population that is increasingly suffering from poor mental health (Amer, 2005; El-Khadiri Derose, 2009), is growing at a rapid rate (Pew, 2007), and represents the largest population of refugees and asylum-seekers entering the United States (Leonard, 2003) runs the risk of forming a persistent barrier that alienates Muslims from acculturation and integration into the social fabric of this country (Khawaja, 2016).

Even more pressing is the need for research on American Muslim women (Sheridan & North, 2004). Muslim women living in the United States are of particular interest in this regard because of the prominent roles they play in making family and community decisions. Muslim women traditionally engage in a caretaking role. In this regard, they are influential decision-makers within their family and in their Muslim communities (Wang, 2006). Muslim women are also a source of guidance and consolation within their family and extended community (Turkes-Habibovic, 2011). To this end, their attitudes toward mental health may influence the decisions of others in their lives about whether to seek mental health care services.

To help remedy this research gap, our study specifically recruited Muslim women. The aim of the proposed study is to develop a valid psychological measure that examines attitudes and perceptions of Muslim women as it relates to their understanding of mental illness and use of mental health services. This article describes the process of adapting existing scales to develop the Muslim Perceptions and Attitudes to Mental Health (M-PAMH) scale and validating its psychometric properties in a sample of American Muslim women; the validation of the M-PAMH scale was part of a larger study that focused on the mental health of Muslim women.

Method

Instrument Development

To fully understand the ways in which American Muslims view mental health, the catalysts of mental illness and attitudes toward treatment and help-seeking preferences in this population must first be explored. In order to do this, we conducted a literature review of scales that measure perceptions and attitudes toward mental health and help-seeking behaviors as it relates to minority communities. Our review indicated limited availability of such scales. In developing our study, the following scales by Fischer and Turner (1970) and Aloud (2004) were used and adapted:

The Attitude Toward Seeking Formal Mental Health Service (ATSFMHS; Aloud, 2004)

The most widely used scale to facilitate the exploration of help-seeking attitudes is the Attitudes toward Seeking Professional Psychological Help Scale (ATSPPH) by Fischer and Turner (1970). This scale was later adapted by Aloud (2004) who undertook a comprehensive revision to account for Islamic terms. An example of an Islamically sensitive modification by Aloud to the scale is adjusting the question, “A person with a strong character can get over mental conflicts by himself, and would have little need of a therapist” to instead read: “A person with strong Iman [faith] can get rid of a mental health or psychological problem without the need of professional help.” To capture the influence of religiosity and religio-cultural misconceptions on attitudes toward mental health, we developed five items as described in Table 1. These items were developed based on emerging concepts from the Muslim mental health literature (Ahmed & Amer, 2013; Ali, Milstein & Marzuk, 2005). The new scale was renamed the “Attitude Toward Seeking Formal Mental Health Service” (ATSFMHS) and yielded high reliability (Cronbach’s Alphas of 0.74; Aloud, 2004).

Cultural Beliefs about Mental Health Problems, their Causes, and Treatments (Aloud, 2004)

This scale was created by Aloud to examine the influence of cultural, traditional, and religious beliefs on perceptions of the causes and treatment of mental health problems by Arab Muslims. The scale is comprised of eleven Likert-type items; we only used seven items in order to limit redundancy in our survey. For example, Aloud’s subscale had three questions that asked about beliefs in superstition as a cause of mental illness. We only included one question because including the three would have made the subscale longer without additional utility. The decision to keep or remove items was made based on the important concepts that emerged from the literature review, the primary researcher’s clinical experience with Muslim clients, and discussions with the research team. Because of the important correlation between Islamic belief and a Muslim’s wellbeing (Padela et al. 2012), we developed two items that asked about the Islamic concept of fate (qadar) as it has particular influence on Muslim help-seeking behaviors (Ahmed & Amer, 2013). The two items developed are illustrated in table 1.

Table 1. The eight items developed by the authors
Familiarity with mental health services and conditionsHow familiar are you with the type of conditions that can be treated by professional mental health or psychological treatment (e.g. mental instability, depression, etc.)?
Attitudes Toward Mental Health ServicesI would be comfortable contacting a mental health care professional or using psychological services in the future.
The Islamic religion encourages Muslims to seek medical care for psychological and mental health difficulties.
I would rather be advised by a religious figure (e.g., a Shaykh) than by a mental health professional, even for serious psychological problems.
I admire an individual who is willing to cope with his/her conflicts without resorting to professional mental health care.
Even if I sought professional mental health care, I would also still seek help from a religious figure (e.g. Shaykh) for a psychological difficulty I was facing.
Cultural Beliefs About Mental Health ProblemsMental health or psychological problems are the result of Qadar (fate).
If it is in one’s Qadar (fate) to have a mental health or psychological problem, it can still be treated using professional mental health or psychological counseling services.

Knowledge and Familiarity with Formal Mental Health Services Instrument

This scale is used to explore the extent of familiarity with types of mental health problems treated by professional mental health workers, as well as familiarity with the mental health services offered in the community. Aloud’s scale is comprised of eleven Likert-type questions which we found to be lengthy. We used only two of the items after modifying them because we wanted to keep the survey simple; we were interested in generally assessing the familiarity of participants with psychological problems, their treatments and mental health resources in their communities without going into specific details. Since our study did not focus on Arab Muslims or a certain geographical area in the US, but rather was a national study that aimed at including Muslim women from different ethnicities who are living in the US, the item “The Arab and Muslim professionals who practice mental health or psychological counseling within your local community (Columbus, OH),” was modified to “The Muslim professionals who practice mental health or psychological counseling within your local community.” We developed a single item, “How familiar are you with the type of conditions that can be treated by professional mental health or psychological treatment (e.g., mental instability, depression, etc.)?” to replace the 5 items developed by Aloud that separately examined familiarity of the respondents with mental health problems, types of clinical interventions, and the role of clinical social workers, psychologists, and psychiatrists. The kept the item: “How familiar are you with the availability of mental health and psychological services in your community (e.g., location, phone #, type of services provided)?” The total eight items that we developed are illustrated in the Table 1.

The resulting survey was comprised of 40 questions divided into four sections: Section 1 included questions on attitudes toward professional mental health care, Section 2 evaluated cultural and religious beliefs as they relate to causes and treatments of disorders, Section 3 assessed the level of familiarity of mental health services, and Section 4 included demographic questions like age, education, and ethnicity. Questions in sections 1 and 2 were scored using a 4-item Likert-type scale that assesses the degree of agreement to each statement, for example, (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). Questions in section 3 are scored using a 4-item Likert-type scale but with different wording (0 = not at all, 1 = very little, 2 = somewhat, 3 = very familiar). The survey questions are attached in the appendix.

Sample and Data Collection

After receiving IRB approval, the survey was posted on Stanford University’s School of Medicine website with a cover letter highlighting the primary author’s interest in determining how Muslim women felt about mental health care and its practitioners. Consent information was also provided. The researchers then sent a weblink to colleagues and friends to help spread the word about their survey and its purpose. Specific online interest groups and listservs known to cater to Muslim women living in the U.S. were targeted and their moderators were asked to forward the link to their constituents. In this way, participants were recruited using a snowball technique. By the end of the 3-month period, 1279 American Muslim women had completed the online survey.

Statistical Analysis

SPSS version 20 (Statistical Package for Social Sciences software) was used in examining the data, and conducting the exploratory factor analysis (EFA). Confirmatory factor analysis (CFA) was performed using LISREL program (version 8.80; Joreskog & Sorbom, 2006).

Results

Characteristics of the Sample

A total of 1279 Muslim women participated in the study. The mean age was 32.3 ± 10.5 (range: 11-94) and the average duration of their stay in the United States was 24.2 ± 12.2 years (range: 0-69). Few missing values were identified and treated by listwise deletion. Frequencies and percentages of the demographic variables are summarized in Table 2.

Table 2. Participants Characteristics: Frequencies and Percentages
Participants characteristicsFrequencyPercentage
Age
<19705.5%
20-3993473.5%
40-6425920.4%
>6580.6%
Born in the U.S.
Yes53141.8%
No74058.2%
Ethnicity
Caucasian20115.8%
African American927.2%
American Indian60.5%
Arab33026%
African302.4%
South East Asian48237.9%
Asian/ Pacific Islander262%
Iranian110.9%
Turkish100.8%
European342.7%
Latin American362.8%
Other100.8%
Education
High school or less15111.9%
Undergraduate degree68954.2%
Graduate degree43133.9%
Occupation
Not working58045.6%
Professional66852.6%
Blue collar231.8%
Marital Status
Single33526.4%
Married84066.1%
Divorced836.5%
Widowed131%

Approach to Exploratory and Confirmatory Factor Analyses

The complete sample was randomly divided into two roughly equivalents halves. The first half of the sample (n=623) was subjected to an exploratory factor analysis (EFA). For cross-validation, the EFA pattern matrix was then used to indicate the factor structure of a confirmatory factor analysis (CFA) with the remaining sample (n=656). We determined a priori that items must have a minimum factor loading of .40 to be retained in the analysis.

Goodness of fit was assessed via the chi-square statistic and the following alternative fit indices: the comparative fit index (CFI), the non-normed fit index (NNFI), and the standardized root mean square residual (SRMR). The chi-square statistic can reflect poor model fit due to sample size and large correlations within the data. The CFI, in contrast to the chi-square, benefits from large correlations within the data (which are assumed a priori to exist within the present data). In addition, the NNFI corrects for the number of parameters in the model. Both of these indices reflect good model fit at values of .95 or greater. Finally, the SRMR, as opposed to the chi-square, benefits from larger sample sizes and represents the difference between the observed and predicted covariance. A value of zero reflects a perfect fit, and values less than .08 reflect a good model fit.

Exploratory Factor Analysis

A principal components analysis was first applied to the 25 items. Given that we assumed some degree of correlation within the factor structure, an Oblimin rotation was employed. Visual inspection of the scree plot revealed a four-factor structure. The analysis was constrained to four factors and rerun. Five items exhibited factor loadings below the .40 cut off (items 7, 15, 17, 19, and 23) and were removed. A complete list of the survey items is provided in the appendix. The pattern matrix for the four-factor solution of the remaining 20 items was then used for CFA.

Confirmatory Factor Analysis

In addition to the decision rule to retain only items exhibiting a standardized loading of ≥ .40, an additional decision rule was employed for CFA. Items cross-loaded at ≥ .40 on more than one factor were also discarded in order to be maximally conservative about the information embedded within a given latent factor.

A CFA was performed on the 20 remaining items with items 4, 6, 9, 12, 14, and 15 indicating rejection; items 16, 20, 21, 22, 24, 25, and 26 indicating beliefs; items 2, 3, 10, and 11 indicating stigma; and items 27, 28, and 29 indicating familiarity. This model exhibited an acceptable fit, χ 2 (164) = 508.21, p < .001, CFI = .94, NNFI = .93, SRMR = .056, however, one item (item 12, factor 1) exhibited a loading < .40 (loading = -.23), and inspection of the modifications indices revealed one item with a cross-loading of > .40 (item 3, factor 3). Thus, these two items were removed from the analysis and the remaining 18 items were rerun a final time. While this model maintained a non-significant chi-square statistic (χ 2 (129) = 376.68, p < .001), the alternative fit indices revealed a good (NNFI = .94) to excellent (CFI = .95, SRMR = .049) fit to the data. The final scale and factor loadings are shown in Table 3.

Table 3. Factor Structure and Factor Loading of the M-PAMH Scale
Factor Loadings
ItemsRejectionBeliefsStigmaFamiliarity
1. Most mental health and psychological problems can be solved by oneself without the assistance of professionals..56
2. I admire an individual who is willing to cope with his/her conflicts without resorting to professional mental health care..50
3. Mental health and psychological difficulties, like many things, tend to go away on their own..49
4. The idea of talking about my problems with a mental health professional is a poor way to solve mental health difficulties..54
5. Seeking psychological and mental health services should be the last resort after trying all other options (e.g., self-help, Shaykh, or friend counseling)..68
6. Mental health or psychological problems can be caused by Jinn (spirits)..77
7. Mental health or psychological problems can be caused by Ayn (evil eye)..72
8. Mental health or psychological problems can be treated using Ruqya (Quranic Recitation)..67
9. Even if I sought professional mental health care, I would also still seek help from a religious figure (e.g., Shaykh) for a psychological difficulty I was facing..48
10. There are certain mental health or psychological problems that CANNOT be treated using mental health or psychological treatment; rather they require Ruqya (Quranic Recitation)..57
11. Mental health or psychological problems can be treated using traditional medicine (e.g., black seed)..53
12. Mental health or psychological problems are the result of Qadar (fate)..49
13. I would feel embarrassed to seek mental health or psychological services because of others’ negative opinions..74
14. Using mental health or psychological services is more difficult than using other medical services because of the shame (societal stigma)..51
15. I would be comfortable contacting a mental health care professional or using psychological services in the future.-.65
16. Familiarity with the availability of mental health and psychological services in your community (e.g., location, phone #, type of services provided)..94
17. Familiarity with the type of conditions that can be treated by professional mental health or psychological treatment (e.g., mental instability, depression, etc.)..58
18. Familiarity with the Muslim professionals who practice mental health or psychological counseling within your local community..48

Discussion

Empirical findings indicate that religion has a driving role in the lives of Muslims affecting their attitudes toward mental illness, their help-seeking behaviors and hence their utilization of mental health services. In addition to the common religious values that Muslims share, they originate from different ethnic and cultural backgrounds that shape their worldviews and influence their behaviors. This interplay of religion and culture makes Muslim mental health a challenging phenomenon to study.

The aim of this study was to develop and validate a psychometric scale that evaluates the attitudes and perceptions toward mental health by Muslim women residing in the U.S. One of the strengths of this scale is its ability to examine the cultural and religious beliefs that can affect Muslims’ utilization of mental health care services. The scale also took into consideration attitudes that some Muslims might have toward professional mental health care, that in turn, can negatively influence their help-seeking behaviors. As discussed in the introduction, stigma can influence the decision to seek help, thus, we included a subscale that focused on measuring stigma as it relates to help-seeking behaviors. Another important domain that the scale successfully captured was familiarity of clients with mental health resources that could facilitate or hinder clients seeking mental health services. The resultant M-PAMH scale is comprised of 18 brief items that can be used independently or be easily added to an existing survey with minimal additional response burden. The M-PAMH scale provides future researchers with an easy and feasible method to assess four important mental health domains: rejection attitudes toward professional mental health care, cultural and religious beliefs about mental health, stigma associated with mental health services and familiarity with formal mental health services offered in the community. Understanding these domains will help researchers investigate the reasons for the underutilization of mental health services by Muslim women and explore the underlying factors affecting their help-seeking behaviors.

In regards to the psychometric properties of the scale, we performed an exploratory factor analysis on half of the sample which proposed a four-factor structure that was further validated by a confirmatory factor analysis that was performed on the second half of the sample. This statistical methodology afforded the M-PAMH scale stronger psychometric properties over other similar surveys found in mental health literature.

The M-PAMH scale also demonstrates methodological strengths. A limitation of many studies was their use of qualitative methodology and framework (Turkes-Habibovic, 2011). Such studies do not offer generalizable or quantifiable results about attitudes and perceptions of Muslims toward mental health. Similarly, when quantitative scales tailored to Muslims and demonstrated sound psychometric properties were available, they were focused on religious coping (Amer, Hovey, Fox, & Rezcallah, 2008; Khan & Watson, 2006), religious support (Bjorck & Maslim, 2011), or Muslim practice and belief (Almarri, Oei, & Al-Adawi, 2009) rather than on attitudes and perceptions as intended in the present work. The remaining studies, such as Aloud, were quantitative in nature but were limited by small sample sizes that do not permit rigorous validation of their scale (Bagasra, 2011). The present study had a sample size above the 1000-participant threshold needed to run factor analyses and produce a validated scale.

Another strength demonstrated by this study, is that the M-PAMH scale was created from an ethnically heterogeneous sample of Muslim women, unlike other studies that focused on one ethnically homogenous sample. Particular attention was also paid to ensuring that the M-PAMH scale was appropriate for the Muslim faith and culture.

There are some limitations to the M-PAMH scale. The online nature of the survey likely skewed the sample toward young, educated, tech-savvy, and English-speaking participants. This convenience sample is not representative of the entire population of Muslim women residing in the U.S. Volunteer bias is also plausible considering that those who were willing to volunteer their time were likely more interested in the subject matter. Thus, we cannot be sure to what extent the participants’ motivation influenced their answers. Additionally, it is possible that participants may have broadened their definition of mental health and therefore responded with more positive perceptions or attitudes without shifting actual behavior. Therefore, when using the M-PAMH scale, it might be useful to include a separate question concerning the definition and actual behaviors employed by participants in relation to mental health to anchor their responses.

Despite these limitations, the M-PAMH scale significantly improves on previous scales by offering the research community a brief, feasible, psychometrically robust, and culturally congruent measure that has been proven successful in researching Muslim women.

References

  • Ahmed, S., & Amer, M. M. (Eds.). (2013). Counseling Muslims: Handbook of mental health issues and interventions. New York, NY: Routledge. https://doi.org/10.4324/9780203893814
  • Ahmed, S., & Reddy, L. A. (2007). Understanding the mental health needs of American Muslims: Recommendations and considerations for practice. Journal of Multicultural Counseling & Development, 35(4), 207-218. https://doi.org/10.1002/j.2161-1912.2007.tb00061.x
  • Ali, O. M., Milstein, G., & Marzuk, P. M. (2005). The Imam's role in meeting the counseling needs of Muslim communities in the United States. Psychiatric services, 56(2), 202-205. https://doi.org/10.1176/appi.ps.56.2.202
  • AlMarri, T., Oei, T., & Al-Adawi, S. (2009). The development of the short Muslim practice and belief scale. Mental Health, Religion & Culture, 12(5), 415-426. https://doi.org/10.1080/13674670802637643
  • Aloud, N. & Rathur, A. (2009). Factors affecting attitudes toward seeking and using formal mental health and psychological services among Arab-Muslims population. Journal of Muslim Mental Health, 4(2), 79-103. https://doi.org/10.1080/15564900802487675
  • Amer, M. M. (2005). Arab American mental health in the post September 11 era: Acculturation, stress, and coping (Doctoral Dissertation). Retrieved from University of Toledo. (1403)
  • Amer, M., Hovey, J., Fox, C., & Rezcallah, A. (2008). Initial development of the brief Arab religious coping scale (BARCS). Journal of Muslim Mental Health, 3(1), 69-88. https://doi.org/10.1080/15564900802156676
  • Bagasra, A. B. (2012). Acculturation, religious commitment, and conceptualization of mental illness in the Muslim American community. Retrieved from https://books.google.com/books/about/Acculturation_Religious_Commitment_and_C.html?id=G7WIMAEACAAJ
  • Bjorck, J. P., & Maslim, A. A. (2011). The multi-faith religious support scale: Validation with a sample of Muslim women. Journal of Muslim Mental Health, 6(1), 62-80. https://doi.org/10.3998/jmmh.10381607.0006.105
  • Corrigan, P. W. (2005). On the stigma of mental illness: Practical strategies for research and social change. Washington DC: American Psychological Association. https://doi.org/10.1037/10887-000
  • Derose, M. -K. (2009). Factors affecting Arab Americans' psychological health: Culture, religion, acculturation, and experiences of discrimination (Doctoral dissertation). Retrieved from Roosevelt University.
  • Fischer, E. H., & Turner, J. I. (1970). Orientations to seeking professional help: Development and research utility of an attitude scale. Journal of Consulting and Clinical Psychology, 35(1), 79-90. https://doi.org/10.1037/h0029636
  • Gaw, A. (1993). Culture, ethnicity, and mental illness. Washington, D.C.: American Psychiatric Press.
  • Gibbs, J. T., & Huang, L. (1998). Children of color: Psychological interventions with culturally diverse youth. San Francisco, CA: Jossey-Bass.
  • Herrick, C., & Brown, H.N. (1998). Underutilization of mental health services by Asian Americans residing in the United States. Mental Health Nursing, 19(3), 225. https://doi.org/10.1080/016128498249042
  • Khan, Z. H., & Watson, P. J. (2006). Factorial complexity and validity of the Sahin–Francis attitude toward Islam scale among Pakistani university students. Journal of Beliefs & Values Journal of Beliefs & Values, 27(2), 231-235. https://doi.org/10.1080/13617670600850059
  • Khawaja, N. (2016). Acculturation of the Muslims Settled in the West. Journal of Muslim Mental Health, 10(1), 3-11. https://doi.org/10.3998/jmmh.10381607.0010.102
  • Leonard, K. (2003). American Muslim politics: Discourses and practices. Ethnicities, 3(2), 147-181. https://doi.org/10.1177/1468796803003002001
  • Maslim, A. A., & Bjorck, J. P. (2009). Reasons for conversion to Islam among women in the United States. Psychology of Religion and Spirituality, 1(2), 97-111. https://doi.org/10.1037/a0015735
  • Mohamed, B. (2016). A new estimate of the U.S. Muslim population. Retrieved from Pew Research Center website: http://www. pewresearch. org/fact-tank/2016/01/06/anew-estimate-of-the-us-muslim-population.
  • Padela, A. I., Killawi, A., Forman, J., DeMonner, S., & Heisler, M. (January 01, 2012). American Muslim perceptions of healing: Key agents in healing, and their roles. Qualitative Health Research, 22(6), 846-58. https://doi.org/10.1177/1049732312438969
  • Pew Research Center. (2007). Muslim Americans: No signs of growth in alienation or support for extremism. Retrieved from https://www.pewforum.org/2011/08/30/muslim-americans-no-signs-of-growth-in-alienation-or-support-for-extremism/
  • Raiya, H. A., Pargament, K. I., Mahoney, A., & Stein, C. (2008). A psychological measure of Islamic religiousness: Development and evidence for reliability and validity. International Journal for the Psychology of Religion, 18(4), 291-315. https://doi.org/10.1080/10508610802229270
  • Shafi, S. (1998). A study of Muslim Asian women's experiences of counseling and the necessity for a racially similar counselor. Counselling Psychology Quarterly, 11(3), 301-314. https://doi.org/10.1080/09515079808254062
  • Sheridan, L. P., & North, A. C. (2004). Representations of Islam and Muslims in psychological publications. International Journal for the Psychology of Religion, 14(3), 149-159. https://doi.org/10.1207/s15327582ijpr1403_1
  • Trinh, N., Rho, Y. C., Lu, F. G., & Sanders, K. M. (2009). Handbook of mental health and acculturation in Asian American families. Totowa, NJ: Humana Press. https://doi.org/10.1007/978-1-60327-437-1
  • Turkes-Habibovic, M. (2011). Social Context and Muslim Women’s Attitudes Towards Counseling (Doctoral dissertation). Retrieved from University of New Orleans. (1348)

Appendix

The Original 40-Item Questionnaire
SECTION IATMHS - Attitudes Toward Mental Health Services
4 = strongly agree3 = agree2 = disagree1 = strongly disagree
Question #NameQuestionLabel
1ATMHS1A person with strong Iman (faith) can get rid of a mental health or psychological problem without the need of professional help.strong faith can rid of psych prob
2ATMHS2I would feel embarrassed to seek mental health or psychological services because of others’ negative opinions.embarrassed to seek psych help
3ATMHS3If I believed I was having a psychological or mental health problem, my first step would be to seek professional mental health counseling.first step seek psych help
4ATMHS4The idea of talking about my problems with a mental health professional is a poor way to solve mental health difficulties.psych help poor way to solve prob
5ATMHS5I would rather live with certain mental health or psychological problems rather than going through the process of seeking professional help.live with psych prob than get psych help
6ATMHS6Seeking psychological and mental health services should be the last resort after trying all other options (e.g., self-help, Shaykh, or friend counseling).psych help is last resort after other options
7ATMHS7I would seek professional counseling services only if I was worried or upset for a long period of time.psych help only if upset for long time
8ATMHS8If I were experiencing a serious psychological problem at this point in my life, I would be confident that I could find relief by going to a mental health professional.If psych prob, confident in psych help
9ATMHS9Most mental health and psychological problems can be solved by oneself without the assistance of professionals.psych problems solved by oneself
10ATMHS10Using mental health or psychological services is more difficult than using other medical services because of the shame (societal stigma).social stigma for psych services
11ATMHS11I would be comfortable contacting a mental health care professional or using psychological services in the future.comfortable to use psych service in future
12ATMHS12The Islamic religion encourages Muslims to seek medical care for psychological and mental health difficulties.Islam encourages to get psych help
13ATMHS13I would rather be advised by a religious figure (e.g., a Shaykh) than by a mental health professional, even for serious psychological problems.rather be advised by religious figure
14ATMHS14I admire an individual who is willing to cope with his/her conflicts without resorting to professional mental health care.admire someone to cope w/o psych help
15ATMHS15Mental health and psychological difficulties, like many things, tend to go away on their own.psych problems go away on their own
16ATMHS16Even if I sought professional mental health care, I would also still seek help from a religious figure (e.g., Shaykh) for a psychological difficulty I was facing.psych help and religious figure help
17ATMHS17If I decide to seek mental health or psychological help, I would rather contact a Muslim professional than a professional from another background.Muslim psych professional
Section IICBMHP - Cultural Beliefs About Mental Health Problems
0 = False1 = probably false2 = probably true3 = true
Question #NameQuestionLabel
18CBMHP118Mental health or psychological problems can be caused by biological factors (e.g., genetic illness inherited from parents or grandparents).psych prob caused by biological factors
19CBMHP219Mental health or psychological problems can be caused by environmental factors (e.g., social stress, war experience, etc.).psych prob caused by environ factors
20CBMHP320Mental health or psychological problems can be caused by Ayn (evil eye).psych prob caused by ayn (evil eye)
21CBMHP421Mental health or psychological problems can be caused by Jinn (spirits).psych prob caused by Jinn (spirits)
22CBMHP522Mental health or psychological problems are the result of Qadar (fate).psych prob caused by Qadar (fate)
23CBMHP623If it is in one’s Qadar (fate) to have a mental health or psychological problem, it can still be treated using professional mental health or psychological counseling services.If it's in one's Qadar for psych prob, treated with psych help
24CBMHP724Mental health or psychological problems can be treated using traditional medicines (e.g., black seed)psych prob helped with traditional prescribed meds (blackseed)
25CBMHP825Mental health or psychological problems can be treated using Ruqya (Quranic Recitation).Psych problems can be treated with Ruqya (Quranic Recitation)
26CBMHP926There are certain mental health or psychological problems that CANNOT be treated using mental health or psychological treatment; rather they require Ruqya (Quranic Recitation).Certain psych prob cannot be treated with psych help, need Ruqya
Section IIIKFMHS - Knowledge about and Familiarity with Formal Mental Health Service
0 = not at all1 = very little2 = somewhat3 = very familiar
Question #NameQuestionLabel
27KFMHS127The type of conditions that can be treated by professional mental health or psychological treatment (e.g., mental instability, depression, etc.)?Types of conditions treated by psych help
28KFMHS228The availability of mental health and psychological services in your community (e.g., location, phone #, type of services provided)?Availability of psych help in community
29KFMHS329The Muslim professionals who practice mental health or psychological counseling within your local community?Muslim Professionals doing psych help
Section IVDIS - Demographic Information Sheet
Question #NameQuestionLabel
30DIS130How old are you?age
31DIS231Were you born in the U.S.A.?born in US?
32DIS332

How many years/months have you lived in the U.S.?

  Year/s ____  Month/s____

Number of years in US
33DIS433

How do you describe your ethnic background (if you are from a mixed background, please select your father’s ethnic origin)?

  ☐ American Indian  ☐ Caucasian American

  ☐ African American  ☐ African

  ☐ Hispanic American  ☐ Arab

  ☐ Iranian  ☐ Turkish

  ☐ South East Asian (Indian, Pakistani, Afghani)

  ☐ Asian/Pacific Islander (Chinese, Japanese, Korean, Filipino)

  ☐ Other

Ethnic Background
34DIS534

What is your marital status?

  ☐ Single  ☐ Married

  ☐ Divorced  ☐ Widowed

Marital Status
35DIS635

What is your highest (or current) level of education?

  ☐ Less than high school  ☐ High school

  ☐ Associate degree  ☐ Bachelor’s degree

  ☐ Master degree

  ☐ PhD degree (or other Graduate degree)

Highest level of education
36DIS736

In the past three years, approximately how many times have you visited a mental

health professional (psychiatrist, psychologist, or a social worker) for a

mental health or psychological concern?

  ☐ Never  ☐ 1 or 2 times

  ☐ 3 to 5 times  ☐ More than 5 times

How many times gone to psych professional
37DIS837Which of the following describes your occupation?Occupation
  Housewife
  Professional
  Student
  Business OwnerBusiness Owner
  Office EmployeeOffice Employee
  Store EmployeeStore Employee
  Manual WorkerManual Worker
  Unemployed
  V45
  Other (Please Specify)Other (Please Specify)
38DIS938To whom would you go first if you were to consider seeking help for a mental health/psychological problem (select only one)?Who is the FIRST person you'd consider
39DIS1039To whom would you go second if you were to consider seeking help for a mental health/psychological problem (select only one different from question # 38)?Who is the SECOND person you'd consider
40DIS1140To whom would you go third if you were to consider seeking help for a mental health/psychological problem (select only one different from question # 38 and 39)?Who is the THIRD person you'd consider