13 1 GENERAL INTRODUCTION disorders, and depressive symptoms (34, 35). It should be noted that military personnel do not necessarily experience more MHI compared to civilians. The prevalence of MHI among military personnel differs between countries, and there are mixed findings when comparing the prevalence of MHI among civilians and military personnel. Some studies found that military personnel experienced less MHI compared to civilians (36), some showed that military personnel experienced more MHI compared to civilians (37, 38), and some found a similar prevalence among military personnel and civilians (36). The mental health stigma can be expected to be even stronger in the military, compared to civilian populations. For example, a study in the Canadian army showed that military personnel were 1.7 times more likely to have perceived stigma compared to a civilian sample (39). This is likely caused by the military culture. In the military, there is a general focus on being strong and tough, which enhances the negative opinions about those who have a MHI, as they might not be able to do the same tasks as they were once able to do (40, 41). Mental health stigma can influence two important decisions that military personnel with MHI face, namely (1) the decision to seek treatment (42) and (2) the decision to disclose a MHI to a supervisor (43). Both these decisions can affect health, sustainable employment, and well-being at work (see figure 2) (9, 14, 43, 44). Therefore, the current thesis will focus on these two decisions within the military context. The decision to seek treatment Worldwide, there is a treatment gap for MHI, which means that there is a mismatch between the proportion of people who could benefit from treatment and those who seek treatment (45). This is partly caused by (affordable) treatment not being available, but also because people do not seek treatment (46). Especially in high-risk occupations, such as the military, workers find it difficult to seek treatment (9, 47, 48). A recent systematic review showed that about 60% of military personnel who experienced MHI did not seek help, whereas many could benefit from professional treatment (49). Leaving MHI untreated poses a threat to sustainable employment through a higher risk of sick leave and unemployment (5, 9). Besides negative consequences that affect well-being at an individual level, there are high economic and social costs involved when leaving these conditions untreated (4, 50).The international literature reports different factors that determine whether military personnel seek treatment or not. They are related to (1) stigma and discrimination, (2) sociodemographic factors, (3) characteristics of the healthcare environment, and (4) treatment and MHI beliefs. All four factors will be considered in the present thesis.
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