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Abstract
Introduction Athletes are not immune to mental health issues but are less likely to seek help than non-athletes and experience barriers including lack of access to services, lack of knowledge as to how to access services and negative past experiences for help-seeking. Formal (eg, university counsellors, general practitioners and psychologists) and semi-formal (eg, academic tutor, sports coach and physiotherapist) sources of support provided in healthcare, the sport context and higher education are key places for athletes to seek help for mental health, and there is a need to synthesise the evidence on athletes’ access, attitudes to and experiences of these services, to understand how to improve these services specific to athletes’ mental health needs. This protocol outlines a scoping review that will be used to map the evidence, identify gaps in the literature and summarise findings on athletes’ access, attitudes to and experiences of help-seeking for their mental health.
Methods and analysis The methodological frameworks of Arksey and O’Malley (2005), Levac et al (2010) and the Joanna Briggs Institute (2020 and 2021) were used to inform this scoping review protocol alongside the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols checklist and published scoping review protocols within sport and health. The six stages of Arksey and O’Malley’s (2005) framework have been used for this scoping review. The searches were conducted between 30 March 2022 and 3 April 2022 in the following databases: APA PsycINFO (via OVID), Embase (via Ovid), MEDLINE (via Ovid), APA PsycArticles Full Text (via OVID), Web of Science Core Collection, SPORTDiscus (via EBSCO), CINAHL (via EBSCO), Scopus, ProQuest (Education Database), ProQuest (Education Collection), ProQuest (Health & Medical Collection), ProQuest (Nursing & Allied Health database), ProQuest (Psychology Database), ProQuest (Public Health Database) and ProQuest (Sports Medicine & Education). The main inclusion criteria of this review are: papers that focus on past help-seeking behaviour, attitudes towards help-seeking and future behavioural intentions, papers that refer to formal and semi-formal sources of support and peer-reviewed literature, primary research articles, systematic or scoping reviews and interventions. During title and abstract screening and full-text review, at least two reviewers will be involved. Data to be extracted from studies includes: details of the study population, whether the paper focuses on formal and/or semi-formal sources of support and whether the focus is on access, attitudes or experiences to help-seeking for mental health.
Ethics and dissemination The evidence will be mapped numerically and through content analysis to describe studies and highlight key concepts, themes and gaps in the literature. The published scoping review will be disseminated to relevant stakeholders and policymakers including those in healthcare, the sporting context and the higher education system. The resulting outputs will be in the form of both peer-reviewed and non-peer reviewed publications (eg, multimedia in the form of a blog post and at conferences). The dissemination plan will be informed by patient and public involvement. Ethics approval was not required for this study.
- Sport
- well-being
- mental illness
- help-seeking behavior
- treatment-seeking
- mental health service
- formal support
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- Sport
- well-being
- mental illness
- help-seeking behavior
- treatment-seeking
- mental health service
- formal support
Strengths and limitations of this study
Informed by best practice methodological frameworks to ensure rigour.
Patient and public involvement will be involved in the analysis and dissemination of the results of this scoping review.
Lack of quality assessment of papers.
The review will only focus on formal and semi-formal sources of help-seeking (eg, healthcare, the sporting context and higher education) and will not include research on informal or self-help sources.
Introduction
Despite a common narrative suggesting otherwise (eg, across the media and broader society as well as the sport context), athletes are not immune to mental health issues. It is well recognised within the literature that athletes do experience mental ill health, however barriers such as stigma reduce help-seeking within this population.1 2 For example, in samples of French and Australian athletes, the most common disorders included anxiety, depression and eating disorders with overall prevalence rates of a mental health issue of 17% and 46%, respectively.3 4 Despite these rates being similar or higher to those found in the general population, athletes have comparatively lower rates of help-seeking for mental health.5 6
The mismatch between prevalence of mental health issues and rates of help-seeking in athletes is of concern. Help-seeking is ‘the process of actively seeking out and utilising social relationships, either formal or informal, to help with personal problems’ (Rickwood et al, p.8).7 In a 2014 report of the UK population, 15.7% of adults had symptoms of a common mental health disorder (generalised anxiety disorder, depression, phobias, obsessive compulsive disorder, panic disorder and common mental disorders (CMD) not otherwise specified) (p.44). It was reported that 12.1% of adults were receiving mental health treatment at that time (McManus et al, p.80).8 Although there is a gap between prevalence and help-seeking in the general population, this gap may be larger in athletes because of the unique aspects of the sporting context (eg, greater stigma).1
In a study comparing student-athletes and non-athlete students in the USA, of those who had received a mental health diagnosis, treatment seeking rates were significantly lower in athletes than non-athletes. A total of 52.4% of Varsity athletes and 64.3% of club/intramural athletes received treatment compared with 73.4% of non-athletes.9 Thus, a significant proportion of athletes are likely not getting the help required. As recognised by Uphill et al2, contextual factors (eg, stigma, sport culture) mean that at an athlete is less likely to seek help for their mental health, which may increase the difficulty to recognise mental health issues in sport.2 A scoping review is needed to map the literature on athletes’ attitudes towards and experiences of help-seeking, including how they access and use different forms of mental health services, and identify where evidence gaps exist.
There is a lack of an agreed definition of help-seeking within the mental health literature, and the use of conceptual or theoretical frameworks to explain help-seeking behaviour is limited and varied.7 10 However, Rickwood et al7 and Rickwood and Thomas10 have proposed two complimentary help-seeking frameworks which have informed the background to this scoping review and the inclusion/exclusion criteria as will be discussed. The first framework suggests a 4-step process: (1) ‘awareness and appraisal of problems’ (eg, aware that your mental health symptoms may require an intervention), (2) ‘expression of symptoms and need for support’ (eg, being able articulate your mental health difficulties to others), (3) ‘availability of sources of help’ (eg, if sources of help are accessible to the individual) and (4) ‘willingness to seek out and disclose to sources’ (eg, if the individual is willing to disclose their difficulty to the source of help available to them) (Rickwood et al, p.8).7 The second framework proposed five main components: (1) process (‘the part of the behavioural process that is of interest’), (2) time frame (when the action occurs), (3) source (where the assistance for help is sought from), (4) type (‘the form of actual support that is sought’) and (5) concern (‘the type of mental health problem for which help is being sought’) (Rickwood and Thomas, p.180–182).10 Further details on these frameworks are provided in online supplemental appendix 1. For the purposes of this scoping review protocol, the background will be mapped onto step 2 (expression of symptoms and need for support), step 3 (availability of sources of help) and step 4 (willingness to seek out and disclose to sources), and the process and source components of Rickwood and colleagues’ frameworks.7 10
Supplemental material
Expression of symptoms and need for support (step 2): athletes expression of symptoms to sources of support7
The second step in Rickwood et al’s framework is expression of symptoms and need for support.7 Research shows that athletes seek support from a variety of sources for their mental health including friends, family, clinical psychologists, counsellors, academic support staff, strength and conditioning staff, coaches and medical doctors.11–13 It is important to map the literature on the formal and semi-formal sources that athletes express their symptoms to, and the gaps that may exist.
Availability of sources of help (step 3): athletes and coaches perceived access to services7
As noted above, the third step in Rickwood et al’s framework is availability of sources of help.7 A barrier to young people and students seeking help for their mental health includes a lack of physical access to services and knowledge of how to access services.14–16 Similar results have been found in athlete populations.17 18 In a sample of Canadian athletes, 47.3% chose not to seek services for mental health when desired, with lack of available services as the main reason.17 In contrast, 98% of US collegiate sport coaches in Sudano and Miles’19 study stated that student-athletes can access mental healthcare services.19 Therefore, views on access to mental health services may differ between coaches and athletes as well as between contexts, highlighting the need for a scoping review to map and better understand athletes’ access to services.
Willingness to seek out and disclose to sources (step 4): past experiences7
Step four in Rickwood and colleagues’ framework is willingness to seek out and disclose to sources.7 Another key barrier for athletes seeking help for mental health is negative past experiences whereas a comparative facilitator is positive past experiences.1 18 This suggests that athletes do have experiences of mental health services, but there is a need to review the literature on athletes’ experiences of mental health help-seeking beyond the facilitators and barriers.
General orientation or attitude toward obtaining assistance, and observable behaviour (process): preferences for help-seeking10
When athletes do seek help, they are more likely to go outside the sport environment, and least likely to seek help from coaches.17 20 This maps onto the process component in Rickwood and Thomas’ framework10; that is, where athletes seek help from can be understood as an observable behaviour. Additionally, their preferences for help-seeking can be understood as a general orientation or attitude toward obtaining assistance. Existing literature has found that athletes express preferences for sport psychologists, counsellors, physiotherapists and clinicians and place importance on these professionals understanding sport demands or just having the ability to value the role of sport in the athletes’ life.13 21–24 It is now well established that the therapeutic relationship/alliance between a patient and service provider impacts treatment outcomes.25–28 It is important to consider athletes’ preferences for who to seek help from to ensure an optimal therapeutic alliance, and therefore treatment outcomes are achieved. However, there is yet to be a review that maps evidence on athlete preferences for a provider and their experiences of interacting with them, which is important to understand.
Formal and semi-formal sources of help (source): for example, healthcare, the sporting context and the higher education system10
Aligning with Rickwood and Thomas’ third component (source), help-seeking within primary care is a formal source of help due to the ‘specified role in delivery of mental healthcare’ (Rickwood and Thomas et al, p.181).10 Within UK primary care, sport psychiatry is not yet widely available.29 Similarly, in Canada there is only one centre for providing athlete-specific mental health services: The Canadian Centre for Mental Health in Sport.30 31 Therefore, athletes are likely using mental health services provided for the general population.
Institutions and clinicians have been identified as key areas to address and improve athlete mental health.32 However, it is still unclear which types of formal and semi-formal sources of support are most used by athletes struggling with their mental health. Within higher education, for example, both formal (eg, counsellors) and semi-formal sources (eg, academic tutors) of help are available. Similarly, there are both formal (eg, general practitioner, psychologist and psychiatrist) and semi-formal (eg, physiotherapist and dietician) sources of support in healthcare. In the sporting context, a coach and manager can be understood as semi-formal sources of support. It is important to map the existing literature on athlete interactions and experiences with formal and semi-formal sources of support for their mental health such as those within healthcare, the sporting context and the higher education system. Mapping this literature will show where an athlete is most likely to seek help, areas that require further investigation and will help to inform recommendations on how formal and semi-formal sources of help can best interact with athletes to ensure they have a positive experience.
Aims of this scoping review
In sum, there is a need to synthesise the literature on athletes’ mental health help-seeking in the form of a scoping review to improve their help-seeking experiences and mental health outcomes. By understanding athletes’ attitudes to seeking help and their past experiences, recommendations can be produced as to how to support an athlete when they seek help. This in turn will improve their experience of help-seeking for their mental health and consequently their mental health outcomes. This paper outlines the protocol for a scoping review that will aim to assess and map: (1) The literature on athlete access, attitudes to and use of semi-formal and formal sources of mental health support, (2) The literature on athlete experiences of mental health help-seeking from semi-formal and formal sources of support, (3) Current gaps in the literature and (4) What the literature recommends as further research. A scoping review is appropriate for addressing these aims because athlete mental health within sport psychology is a relatively new yet growing area of research, with evidence continually emerging.33
Methods and analysis
At the time of original submission, we had completed stage 1. However, at the point of resubmission additional stages had been completed. Therefore, we have updated the protocol to reflect this. Stages completed are in past tense and those yet to be completed are in future tense.
Frameworks to inform the scoping review
As is common practice in scoping reviews, a number of methodological frameworks and recommendations have been used to inform this protocol, alongside published scoping review protocols within sport and health.33–42 The five-stage framework proposed by Arksey and O’Malley35 was the predominant framework used.35 This was enhanced by Levac and colleagues33 who have provided further recommendations based on each stage of this framework.33 Additionally, the Joanna Briggs Institute (JBI) (2020 and 2021) framework and recommendations were used to ensure that this scoping review meets their stated purpose as well as providing the Person-Concept-Context (PPC) to inform the title.36 37 To ensure rigour the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist also informed this protocol and will inform the scoping review.38
Rickwood and Thomas’10 framework informed the inclusion and exclusion criteria.10 Both of Rickwood and colleagues’ frameworks will aid the data analysis and discussion.7 10
Stage 1: identifying the research question
To identify the research question (ie, athletes’ access to, attitudes towards and experiences of help-seeking for mental health) and the inclusion and exclusion criteria, JBI’s PCC framework was applied alongside the help-seeking frameworks.7 10 36 Table 1 shows how these frameworks were used to inform the research question. Further details on the two conceptual frameworks provided by Rickwood and colleagues, and how it maps onto the research question are provided in the appendix (see online supplemental appendix 1: tables 1 and 2).
Research question and how it maps onto conceptual frameworks7 10 36
Stage 2: identifying relevant studies
As recommended, the inclusion and exclusion criteria were initially predetermined.33 35 As the scoping review has been carried out, and the literature assessed, the criteria has been reassessed and modified as required. Details of how the criteria has been modified through conducting the review will be provided in the published paper. The decisions on inclusion and exclusion criteria has involved a research team,33 consisting of three individuals (KRB, MLQ and JC) with experience in conducting systematic reviews.
Primarily the inclusion criteria was:
Athletes from any sport (person).36
Athletes aged 16+ (person).36
All genders of athletes (person).36
Process:
Observable mental health help-seeking behaviour (in the past). For example, going to see a primary care clinician for mental health concerns.
General orientation or attitude toward obtaining assistance. For example, preference for the source of help for a mental health concern.
Future behavioural intention to gaining support. For example, where the athlete with gain support for a mental health concern in the future.10
Time frame: ever (eg, past behaviours and future intentions).10
Source: formal and semi-formal sources of mental health support.10
For example, university counsellors and welfare officers in higher education, and a general practitioner, psychologist and psychiatrist in healthcare (formal).
For example, university lecturer, academic tutor and sports coach in higher education and physiotherapist and dietician in healthcare (semi-formal).
For example, sports coach and manager in the sporting context (semi-formal).
Type: emotional support, treatment/health service provision and informational support.10
Concern: any mental health concern: specific symptoms and general distress.10
Primary research, reviews of any type (eg, systematic, scoping) (this is a scoping review of the peer-reviewed published literature).
Papers in English.
The exclusion criteria was as follows:
Source: informal, or self-help.10
To limit the scope of the review to ensure feasibility of completion within the time frame it was decided that only formal and semi-formal should be focused on. Given the results returned from initial searches it was decided that there would be a significant amount of literature from these two sources.
Type: instrumental support and affiliative support10
Instrumental support is to be excluded because this focuses on financial assistance and transport which is not specific in relation to help-seeking for mental health.
Affiliative support is to be excluded because this is peer support which is informal support which is not included in the review.
Opinion pieces, magazine articles, grey literature and newspaper articles.
To limit the scope, it was decided that only peer-reviewed literature would be included to ensure it was feasible to complete.
Papers in languages other than English
We did not have the resources or ability within the team of reviewers to translate papers from other languages.
Stage 2a: initial preliminary searches
Initial searches were carried out using relevant terms including: athlete, help-seeking experiences, attitudes to help-seeking, access to mental health services, support in education and mental health. Relevant search strategies from similar systematic and scoping reviews were used.18 43 44 Following an assessment of literature, and a discussion between the authors, other colleagues within the research group and with a research librarian, key words were identified.
Stage 2b: identification of key words and terms
Following the initial searches, discussions and review of the papers, a detailed search strategy was produced. The search strategy used the Boolean operators of AND and OR. Truncations were also be applied where appropriate. A draft search strategy for the OVID platform is provided in the appendix (see online supplemental appendix 2).
Once the search strategy was developed the databases searched were: APA PsycINFO (via OVID), Embase (via Ovid), MEDLINE (via Ovid), APA PsycArticles Full Text (via OVID), Web of Science Core Collection, SPORTDiscus (via EBSCO), CINAHL (via EBSCO), Scopus, ProQuest (Education Database), ProQuest (Education Collection), ProQuest (Health & Medical Collection), ProQuest (Nursing & Allied Health Database), ProQuest (Psychology Database), ProQuest (Public Health Database) and ProQuest (Sports Medicine & Education). The searches of these databases were conducted between 30 March 2022 and 3 April 2022.
Stage 3: study selection
Stage 3a: title and abstract screening
First, the titles and abstracts of all identified studies were reviewed. Similar to the protocol published by Griffin and colleagues,39 the lead author/reviewer (KRB) reviewed all titles and abstracts. The second reviewer (MLQ) reviewed a random selection of 30% of the titles and abstracts. Reviewers met throughout the beginning, midpoint and end of the abstract review33 35 36 to discuss the eligibility of studies where a conflict may have arisen, and any changes to the inclusion criteria they would like to make. If disagreements occurred on the eligibility of a study or changed the inclusion criteria, then the third reviewer (JC) was involved.
If full texts were not available, then authors were contacted to obtain the article or via an interlibrary loan request.
Stage 3b: review of full articles for inclusion
Following title and abstract screening, the full articles were reviewed. The lead reviewer (KRB) reviewed all of the full texts, and the second reviewer (MLQ) reviewed 20%. Again, authors met frequently and the third reviewer (JC) was involved to resolve any disagreements. In the case that an agreement could not be reached, then the article was excluded from the review.
If further information from included studies was required, then authors were contacted to obtain supplementary material or clarification.
Stage 4: charting the data
To collect the relevant data, a data charting form was created in Covidence.35 45 This form was updated as the research process and data extraction occurred through discussion between the reviewers.33
Stage 4a: testing the data charting form
In line with recommendations by Levac and colleagues,33 this data charting form was tested by two reviewers (KRB and JC). They independently extracted data from five studies and put it onto the data charting form in Covidence. All reviewers (KRB, JC and MLQ) met to discuss the data charting form, and made any changes required.
Stage 4b: charting the data from all included studies
Once the initial data charting form was agreed on, the data extraction process commenced. Data was extracted and charted from all included studies by the lead author (KRB) and then 20% was independently extracted by the second reviewer (JC). Disagreements in the charting of data was discussed by all three reviewers (KRB, JC and MLQ) to resolve conflicts.39
Based on other scoping reviews and the frameworks used to inform this review,33 35–37 39–42 we decided to extract the following information onto the data charting form. An example of the data extraction form as it appeared on Covidence is displayed in the appendix (see online supplemental appendix 3).
Title.
Authors (including corresponding author details).
Year of publication.
Location in which the study was conducted (country, city, institution).
Type of study (systematic review, scoping review, primary article or grey literature).
Size of study population.
Study population (eg, age, gender, sport, level of competition).
Inclusion and exclusion criteria.
Gap in the literature that the study fills.
Aims of the study.
Method of recruitment of participants (eg, phone, email, poster).
Data collection method (quantitative, qualitative or mixed methods).
Details of data collection (eg, questionnaires used for quantitative).
Intervention (if appropriate).
Details of intervention (eg, duration of intervention, outcome).
Key findings that relate to the aims of the scoping review (eg, is the focus on access/attitudes/experiences).
Gaps identified (eg, source of support sought).
Future directions identified (eg, recommendations for a systematic review).
The reference lists of included studies have been searched for any additional papers that are relevant, and these will be included if appropriate.
Stage 5: collating, summarising and reporting the results (data analysis plan)
The data analysis plan collates, summarises and reports the results in two main steps: (1) Descriptive numerical analysis, and (2) Content analysis.
Stage 5a: descriptive numerical
This is a descriptive and numerical analysis of all studies included.33 35 36 This description will include steps such as: the overall number of studies, the type of the studies, the year of publications, characteristics of study population and the number of studies from particular countries.
Stage 5b: content analysis
The data will also be analysed using directed content analysis, where existing theory and research will be used to identify the key concepts that are in the original research question (formal, semi-formal, access, attitudes and experiences).46 47 This content analysis will inform the protocol for a qualitative study which will be designed in collaboration with the patient and public involvement (PPI) group. The pre-planned directives for analysis were informed by the definitions of access, attitudes and experiences that were underpinned by Rickwood and colleagues help-seeking frameworks,7 10 the theory of planned behaviour,48 from results of included studies and from discussions with the PPI group.
Stage 5c: presentation of the data
As recommended by the JBI we will first describe the search strategy and selection process, and provide a PRISMA diagram.36
Descriptive numerical
We will present this data in tables,36 which will show overall descriptive statistics (eg, frequency counts of concepts and frequency of country studies).
Content analysis
There will be a table showing which studies looked at access, attitudes and/or experiences, and those that looked at formal and semi-formal sources of support.
More detailed results on the studies will be provided in the appendix.
The two conceptual frameworks by Rickwood et al and Rickwood and Thomas will aid the presentation of the data, themes and the overall discussion within the scoping review.7 10
Patient and public involvement:
Arksey and O’Malley suggest an optional stage of consultation and stakeholder involvement.33 35 Levac and colleagues stress the importance of this step and provide further recommendations on how to best involve stakeholders.33 At the point of writing this protocol, we have conducted the first PPI focus group to gain feedback on the conceptual help-seeking frameworks. A further two focus groups will be conducted to understand the results extracted from papers, to inform the main discussion points in the write up of the scoping review, and the dissemination of the results.
Ethics and dissemination
The findings of this scoping review will be presented to the PPI group involved with this research, who will inform the dissemination plan. The results will then be published in peer-reviewed journals, presented at conferences and summarised in non-academic formats (eg, in the form of a blog). Ethics approval was not required for this study.
Ethics statements
Patient consent for publication
Acknowledgments
We would like to thank Lynne Harris from the University of Birmingham library services who provided feedback on the search strategy, and selection of databases. We would like to thank our patient and public involvement group in advance for assisting in dissemination plans for the results of this scoping review.
References
Supplementary materials
Supplementary Data
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Footnotes
Twitter @kirstykrb, @Mary_q6, @jenncumming
Contributors KRB conceived the research question for the scoping review with supervision from MLQ and JC who approved and refined the idea. KRB conducted literature searches and drafted the entire manuscript with input from all coauthors. MLQ, GT and JC provided feedback on the manuscript. All authors reviewed and approved the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: that the Article Processing Charges will be covered by the University of Birmingham if accepted for publication; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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