Understanding Tolerance Towards Individuals with Non-suicidal Self-Injury: Predictors and Changes Over Six Months in a University Student Sample

Understanding Tolerance Towards Individuals with Non-suicidal Self-Injury: Predictors and Changes Over Six Months in a University Student Sample | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding Tolerance Towards Individuals with Non-suicidal Self-Injury: Predictors and Changes Over Six Months in a University Student Sample Rosie James, Elin Lundgren, Daiva Daukantaité, Magnus Nilsson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6168456/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Non-suicidal self-injury (NSSI) is increasingly prevalent yet remains heavily stigmatised. While research focuses on healthcare professionals’ tolerant attitudes, public attitudes – especially among friends and family – are underexplored. However, these groups are often the first to receive NSSI disclosures, making their tolerant attitudes towards individuals with NSSI crucial for encouraging help-seeking. This study investigates predictors of tolerance towards individuals with NSSI and examines changes over six months, specifically in those newly aware of friends or family with NSSI. Methods A survey of 1,430 Swedish university students was conducted, and 721 participated in the six-month follow-up. A correlation analysis examined relationships between four variables related to tolerance towards those with NSSI, and a multiple regression analysis assessed their individual and combined predictive strength. Changes over time were measured using a paired samples t-test. Results Gender, personal experience with NSSI, personal experience with mental health problems, and awareness of NSSI among friends or family significantly predicted more tolerant attitudes, together accounting for 16% of the variance in tolerance scores. Personal experience with NSSI was the most robust predictor. Tolerance scores increased significantly in participants who had become aware of friends or family with NSSI at follow-up (n = 67). Conclusions The study identified key predictors of tolerance towards individuals with NSSI and the novel finding that awareness of NSSI among friends and family is associated with greater tolerant attitudes. We propose a model to explain this interaction and discuss promoting awareness of NSSI within personal networks to foster tolerance, thereby informing stigma-reducing interventions. Non-suicidal self-injury tolerance stigma university students NSSI attitudes Figures Figure 1 Introduction Poor mental health among students is a globally recognised concern [ 1 – 4 ], with one in four undergraduates experiencing depression and one in six reporting suicidal ideation [ 3 ]. Despite Sweden’s significant investment in mental healthcare [ 5 – 7 ], this trend is no exception there. Of particularl concern, likely exacerbated by the COVID-19 pandemic [ 5 , 8 ], is the rise in non-suicidal self-injury (NSSI), defined as the deliberate harm of one’s body without the intention to die [ 9 ]. NSSI is associated with severe mental illness and increased risk of suicide [ 10 – 12 ], with international prevalence rates for NSSI in university students reaching up to 39% [ 13 – 16 ]. Seeking support for NSSI is therefore of utmost importance. However, due to barriers such as stigma and shame, many are hesitant to seek help [ 17 – 19 ] and for those who disclose their NSSI, the quality of their initial experience strongly influences their likelihood of seeking help again [ 20 , 21 ]. This highlights the importance of the tolerant attitudes of those receiving NSSI disclosures on future help-seeking behaviours. Tolerance towards individuals who self-harm, a construct encompassing empathy, respect, and understanding of differences that one may not personally endorse [ 22 ], could play a pivotal role in shaping disclosure experiences. Research on this topic has largely focused on healthcare professionals’ attitudes, demonstrating that greater knowledge and experience with NSSI are associated with increased tolerance towards those engaging in it [ 23 , 24 ]. However, most individuals with NSSI prefer seeking help from friends and family [ 19 , 25 , 26 ] over professional help [ 2 , 27 – 29 ]. To our knowledge, no large-scale quantitative studies have investigated the factors influencing public tolerance towards individuals engaging in NSSI, particularly among friends and family who receive disclosures. Qualitative studies suggest that receiving an NSSI disclosure can foster greater sympathy, awareness, and understanding of the behaviour’s underlying motivations [ 30 – 34 ]. These findings align with the Intergroup Contact Theory of stigma, which posits that supportive interactions between stigmatised and non-stigmatised groups can reduce stigma [ 35 ]. In this context, receiving an NSSI disclosure within a supportive environment may promote greater tolerance towards those who engage in it, thus reducing stigma. However, research on tolerance towards those with NSSI is limited, and the recent development of a quantitative measure of this construct provides an opportunity to investigate contributing factors on a larger scale [ 36 ]. Present study This study is the first to quantitatively explore variables associated with tolerance towards those with NSSI, with the aim of understanding how this can support intervention efforts. Variables including gender and personal experience with mental health problems have support in the literature as being related to an individual’s tolerance towards those with NSSI. For example, higher tolerance towards those with NSSI is found in women [ 23 , 37 ] and in those with personal experience with mental health [ 38 ]. Additionally, we examine awareness of friends or family with NSSI and personal experience of NSSI, based on the qualitative findings presented above. As far as we are aware, this has only qualitative support, and the present study will thus test and extend previous findings quantitatively to explore generalisability as well as if existing findings hold in the Swedish context. By exploring how well these variables predict tolerance towards those engaging in NSSI, this study can inform interventions aimed at fostering tolerance, reducing stigma, and encouraging help-seeking. Aims This paper has three primary aims: (1) to investigate the relationship between four factors – gender, personal experience with NSSI, personal experience with mental health problems, and having family or friends who engage in NSSI – and tolerance towards individuals with NSSI. Based on existing research, we hypothesise that tolerance is higher among women, individuals with a history of NSSI or mental health problems, and those who have family or friends who engage in NSSI; (2) to explore the predictive power of these four factors in explaining tolerance towards individuals with NSSI and to identify the most robust predictor; (3) to test whether becoming aware of family or friends with NSSI is associated with increased tolerance towards individuals with NSSI. As a secondary aim we provide an updated cross-sectional overview of the lifetime prevalence and frequency of NSSI, lifetime prevalence of mental health problems, and the proportion of individuals aware of family or friends engaging in NSSI within a Swedish university population, examining potential gender differences. Materials and methods Sample collection and ethics In February 2022, a comprehensive survey in Swedish was distributed via email to all students at Lund university, Sweden, as part of a broader data collection effort examining self-harming behaviour and attitudes. The baseline survey yielded a convenience sample of 1,500 responses, which was reduced to 1,430 after data cleaning [mean (SD) age 26 (7.33); 68.6% female]. Participants were excluded if they answered incorrectly on a control question or demonstrated signs of “straightlining” (i.e., repetitive answers across measures), indicating a lack of attention [ 39 ]. At the six-month follow-up, 721 participants [mean (SD) age 26.3 (8.00); 68.4% female] completed the same questionnaire. To enhance participation across both data collection periods, follow-up reminder emails were sent [ 40 ]. The study was approved by the Swedish Ethics Review Authority (Dnr 2021–05102), ensuring adherence to ethical standards. Participation was voluntary, without compensation, and written informed consent was obtained from all participants before completing the surveys at both time points. Each participant was assigned a unique, anonymised code to ensure data confidentiality, while still allowing baseline and follow-up data matching. Data was securely stored using LUSEC, the approved data-storage service at the Medical Faculty of Lund University. Measurements Lifetime prevalence of NSSI and mental health problems Participants were asked two separate questions about their personal experience with NSSI and mental health problems. They reported the recency of these experiences using four response options: “Earlier in life, but not during the last six months”, “Within the last six months but not before”, “Both within the last six months and earlier”, and “Neither within the last six months nor before”. For lifetime prevalence calculation, responses were collapsed into two categories: 1 (Personal experience of NSSI/mental health problems) or 0 (No personal experience of NSSI/mental health problems). Participants also reported the frequency of their NSSI in the last six months and more than six months ago, using a scale from 0 (no times) and 6 (more than 5 times). Lund Tolerance Towards Self-Harm (LUTOSH [ 36 ] ). Tolerance towards individuals who engage in NSSI was measured using the LUTOSH scale, which includes five statements assessing individuals’ tolerance towards self-harm in others. Responses were rated on a 10-point Likert scale ranging from 1 ( Completely disagree ) to 10 (C ompletely agree ), with total scores ranging from 5 to 50. Items 3 and 4 were reverse-coded, and higher scores indicated greater tolerance. An example item is: “People who self-harm shouldn’t be blamed” . The LUTOSH scale has demonstrated convergent validity and moderate internal consistency (Cronbach’s α = .72) in Swedish populations [ 36 ]. In this study, Cronbach’s α was .66. To our knowledge, the LUTOSH is the only scale specifically designed to measure public tolerance towards those who self-harm. Awareness of Friends or Family with NSSI. Participants were asked whether they were aware of a friend or family member who engages in NSSI, with response options of 1 ( Yes ) or 0 ( No ). They also indicated how they learned about the NSSI, choosing from the following options: “The person told me themselves”, “I received information about the self-harm through another person”, “I received information via social media”, and “Other”, with a free-text option for clarification. Responses categorised as “Other” were reviewed, and misclassifications were corrected. Many participants in this category described observing signs of NSSI in others, leading to the inclusion of this as an additional answer when analysing the results. Symptom Checklist - Core Depression (SCL-CD6; [ 41 ] ). Depressive symptoms were assessed using the Swedish version of the SCL-CD6, which includes items such as, “feeling blue/sad” and “blaming yourself”. Participants rated how much they were affected by these feelings on a 5-point Likert scale ranging from 1 (Not at all) to 5 (Extremely). A cutoff score of ≥ 17 was used to create a binary outcome, indicating clinical depression [ 41 ]. The measure has shown good internal reliability, and Cronbach’s α for the current sample was .90. Generalised Anxiety Disorder (GAD-7; [ 42 ] ). Anxiety symptoms were measured using the translated version of the GAD-7, which includes seven items assessing the frequency of symptoms over the last two weeks. Responses were recorded on a four-point Likert scale ranging from 0 ( Not at all ) to 3 ( Daily ). Example items include “feeling nervous, anxious and on edge”. While the original scale has been well validated [ 42 ], validation studies of the Swedish translation are limited despite its frequent use [ 43 ]. Cronbach’s α for the current sample was .91. Statistical analyses All analyses were run using IBM SPSS Statistics 28.0 [ 44 ]. We initially conducted an attrition analysis to ensure the trustworthiness of results by performing between-group comparisons of responders and non-responders. Independent samples t-test for continuous variables and Chi-square test for categorical variables were used. As part of the main analyses, we first generated a correlation matrix to explore relationships between all factors of interest, with dummy values in place for categorical variables. Then we conducted a multiple regression analysis on the baseline data to identify the relative robustness of four predictors of scores representing tolerance towards those engaging in NSSI. Assumptions of homogeneity of variance, normality, linearity, and absence of multicollinearity were met. The forced-entry method was selected due to the absence of strong evidence suggesting any predictor was more influential than the others in explaining tolerance scores. Thereafter, we ran a paired samples t-test comparing tolerance scores at baseline and follow-up on a subset of individuals, aiming to further explore the hypothesised association between tolerance scores and learning about friends or family who engage in NSSI. The subset included individuals who initially reported not being aware of friends or family engaging in NSSI but reported being aware at follow-up. Lastly, for the secondary aim, we conducted descriptive analyses to examine the prevalence of NSSI, mental health problems, and awareness of NSSI in friends or family in the total baseline sample and across genders. Where applicable, scales were categorised using established cutoff values. Results Attrition analysis The attrition analysis compared individuals who answered the follow-up after six months (N = 721) and those that did not (N = 709), on all measured variables in the present study. Participants with a history of NSSI were significantly more likely to respond to the follow-up (46.2%) than those without (53.8%), χ 2 (1) = 4.11, p < .05, Cramer’s V = .054. However, the small effect size suggests a limited practical significance of this association. Using baseline values, no significant differences were found for gender, age, tolerance towards those with NSSI, depression, anxiety, awareness of friends or family with NSSI, and personal experience of mental health problems. Correlation analyses In line with the first primary aim, a Pearson’s Correlation analysis was conducted to identify correlations between LUTOSH, gender (0 = male, 1 = female), prevalence of NSSI (0 = no, 1 = yes), prevalence of mental health problems (0 = no, 1 = yes) and lastly awareness of friends or family with NSSI (0 = no, 1 = yes). Results indicate significant positive correlations varying in strength between tolerance scores and being a woman ( r = .245, p <. 05), having engaged in NSSI at some point ( r = .314, p < .05), having had mental health problems at some point ( r = .243, p < .05), and being aware of friends or family with NSSI ( r = .158, p < .05). A summary of the results is presented in Table 1 . Predicting tolerance towards individuals with NSSI In line with the second primary aim, a multiple regression analysis was conducted to examine whether tolerance towards those with NSSI could be predicted by the same variables as used in the correlation analysis. The regression model accounted for 16.1% of the variance in tolerance scores, R 2 = .161, F (4,1376) = 65.94, p < .001. As presented in Table 2 , all four variables significantly predicted tolerance scores, with lifetime prevalence of NSSI being the most robust ( β = 0.21, p < .001) compared to lifetime prevalence of mental health problems ( β = 0.15, p < .001) and being female ( β = 0.18, p < .001). Awareness of friends or family with NSSI also significantly predicted tolerance, though to a lesser extent than the other predictors ( β = 0.09, p < .001). Change in Tolerance After Becoming Aware of Friends or Family with NSSI In line with the third primary aim, a paired samples t-test was conducted to explore whether becoming aware of friends or family with NSSI was associated with an increase in tolerant attitudes over a six-month period. A subset of 67 participants, who reported not being aware of friends or family with NSSI at baseline (M = 37.65; SD = 7.47) but reported awareness at follow-up (M = 38.87; SD = 7.76), were analysed. A small but significant increase of 1.22 points in tolerance scores was observed, t (67) = -1.58, p < .05. The effect size, Cohen’s d = 0.21, indicated a small effect [ 45 ]. Table 1 Pearson’s correlation matrix for tolerance towards individuals with NSSI score, gender, lifetime prevalence of NSSI, lifetime prevalence of mental health problems. LUTOSH total Gender Lifetime prevalence of NSSI Lifetime prevalence of mental health problems LUTOSH total Gender Lifetime prevalence of NSSI Lifetime prevalence of mental health problems Awareness of friends or family with NSSI - .245 .314 .243 .158 - - .217 .117 .129 - - - .326 .193 - - - - .063 Note. Gender 0 = male,1 = female; lifetime prevalence of NSSI 0 = no, 1 = yes; Lifetime prevalence of mental health problems 0 = no, 1 = yes; Know someone with NSSI 0 = no, 1 = yes. All correlations are significant, p < .05. Number of cases contributing to each correlation (N = 1381). Table 2 Linear model of predictors of tolerance towards individuals with NSSI, with 95% confidence intervals reported in parentheses. Explanatory variable B SE B β t Significance ( p ) (Constant) Gender Lifetime prevalence of NSSI Lifetime prevalence of mental health problems Awareness of friend or family with NSSI 30.60 (29.41, 31.80) 3.41 (2.47, 4.36) 3.72 (2.78, 4.65) 3.26 (2.13, 4.39) 1.50 (.62, 2.37) .61 .48 .48 .58 .45 - .18 .21 .15 .09 50.32 7.09 7.78 5.65 3.35 < .001 < .001 < .001 < .001 < .001 Note. R 2 = .16 for Model 1 ( p < .001). Prevalence of NSSI and Mental Health Issues In line with the secondary aim, NSSI prevalence and frequency, prevalence of mental health problems, and the proportion of individuals aware of NSSI in friends and family in a Swedish university population are summarised in Table 3 , along with statistics looking at gender differences. Results indicated an NSSI lifetime prevalence of 38.7%, with significantly fewer men (21.3%) reporting lifetime NSSI compared to women (44.4%) and those with non-specified gender (72.2%), χ 2 (2) = 82.11, p < .001. Mental health problems were reported by 82% of the sample, with again significantly fewer men (74.3%) reporting these problems than women (84.3%) and those with non-specified gender (100%), χ 2 (2) = 27.52, p < .001. These gender categories were also significantly more likely to be above the cut-off for severe anxiety compared to men, χ 2 (2) = 16.10, p < .001 and were significantly more likely to be aware of friends or family with NSSI than men, χ 2 (2) = 28.24, p < .001. No significant differences were found between the genders and whether the depression scores were above or below the clinical cutoff or the frequency of NSSI within the last six months. Table 3 Prevalence rates of lifetime NSSI and estimated frequency, mental health problems, knowledge of friends or family with NSSI, and depression and anxiety indicators by gender. Variable Total (n = 1430) Men (n = 400) Women (n = 981) Non-specified (n = 36) Significance ( p ) Lifetime prevalence of NSSI No Yes 876 (61.3%) 554 (38.7%) 315 (78.8%) 85 (21.3%) a 545 (55.6%) 436 (44.4%) a 10 (27.8%) 26 (72.2%) a 5 times n = 167 104 (62.3%) 63 (37.7%) n = 27 13 (48.1%) 14 (51.9%) a n = 130 84 (64.6%) 46 (35.4%) b n = 9 7 (77%) 2 (22.2%) c .172 Lifetime prevalence of mental health problems No Yes 258 (18%) 1172 (82%) 103 (25.8%) 297 (74.3%) a 154 (15.7%) 827 (84.3%) a 0 (0%) 36 (100%) a < .001 Know friends or family with NSSI No Yes 536 (37.5%) 894 (62.5%) 191 (47.8%) 209 (52.3%) a, b 333 (33.9%) 648 (66.1%) a 7 (19.4%) 29 (80.5%) b < .001 SCL-CD6 Below cutoff Above cutoff 1100 (76.9%) 330 (23.1%) 322 (80.5%) 78 (19.5%) a 746 (76%) 235 (24.0%) b 24 (66.7%) 12 (33.3%) c .066 GAD7 Below cutoff Above cutoff 966 (68.2%) 451 (31.8%) 300 (75%) 100 (25%) a, b 648 (66.1%) 327 (33.9%) a 18 (50%) 18 (50%) b < .001 Notes. SCL-CD6 = Symptom Checklist - Core Depression; GAD7 = Generalized Anxiety Disorder; Numbers of individuals in each gender group do not add up to the total number because those who did not disclose their gender (n = 13) have been excluded from these categories however, they are included in the total score. P values of < .001 show that there is a significant difference between the gender groupings according to a Pearson's Chi-square test. Post-hoc comparisons using a Bonferroni correction are reported in subscript letters where use of the same letter indicates a significant difference ( p < .05) between the genders in each factor. Discussion This study addressed three primary aims, identifying significant correlations between the four predictors of tolerance towards individuals with NSSI. Our findings suggest that tolerance towards those with NSSI is shaped by a combination of personal experience, social exposure, and demographic factors. Additionally, we extended qualitative literature by quantitatively demonstrating that gender, personal experience with NSSI, personal experience with mental health problems, and awareness of friend or family with NSSI significantly predict tolerance towards those with NSSI. Follow-up analyses further indicated that becoming aware of a friend or family member’s NSSI may have a small but positive effect on an individual’s overall tolerance towards those with NSSI. This finding highlights the potential for social exposure to play a role in shaping attitudes and reducing stigma. Tolerance towards those with NSSI The strongest predictor of tolerance towards others with NSSI was personal experience with the behaviour itself, likely due to the projection of cognitive empathy and experiential knowledge [ 46 ]. This may also explain why personal experience with mental health problems predicted greater tolerance towards those with NSSI among individuals who do not engage in NSSI. Gender differences in tolerance could be attributed to societal expectations of emotional expression and empathy in Western European cultures that are imposed on women [ 47 ], as well as their greater propensity to adopt caregiving roles [ 48 ]. Although awareness of friends or family engaging in NSSI was the weakest predictor, it remained significant when controlling for the other three variables. While the effect size was small, even minor increases in tolerance can have meaningful real-world implications when applied at the population level [ 49 , 50 ] (see Application of these results ). The six-month follow-up data further supports the hypothesis that awareness of friends and family engaging in NSSI can increase tolerant attitudes. However, it remains unclear whether direct interpersonal engagement is necessary or if simply knowing someone with NSSI is sufficient to increase tolerant attitudes. Qualitative studies suggest that disclosure experiences can promote empathy, understanding, and tolerance among friends and family [ 31 , 34 ], potentially encouraging recipients to seek information about NSSI and enhancing their ability to provide support. However, while disclosures can strengthen social connectedness and facilitate personal growth, they may also be overwhelming for recipients who feel ill-equipped to respond [ 34 ]. Our large-scale study does not account for the contextual factors that influence whether disclosures have a positive impact. This context is highlighted in the framework of Intergroup Contact Theory, which posits that supportive interactions between stigmatised and non-stigmatised groups can reduce stigma and enhance tolerance [ 51 , 52 ]. Cross-sectional prevalence statistics In our sample, 62.5% of participants reported being aware of friends or family who engage in NSSI. To our knowledge, this is the first study to estimate this prevalence. Women and those with non-specified gender reported awareness more frequently than men, possibly due to higher NSSI rates in these groups or a greater likelihood of disclosure within the same gender. A better understanding of individuals who receive NSSI disclosures and their role in fostering tolerance and reducing stigma could strengthen future interventions. Our findings suggest that university populations may be particularly valuable targets for such initiatives. Additionally, we found a lifetime NSSI prevalence of 38.7%, aligning with one prior study reporting a similar rate of 39% [ 13 ]. The literature on NSSI prevalence exhibits considerable variation, highlighting the influence of methodological factors [ 14 ]. For instance, our findings contrast greatly with a recent international meta-analysis, which reported a 20% lifetime prevalence among first-year university students [ 53 ]. However, our higher prevalence estimates may reflect regional differences, as the meta-analysis did not include Swedish universities. Moreover, national statistics have documented an increase in NSSI among Swedish adolescents over the past decade, making the present higher rates in university students more predictable [ 54 ]. While our opt-in approach is likely to have contributed to a degree of overreporting, the high NSSI incidence observed in our sample, consistent with some other studies, warrants further investigation. Our prevalence estimates of one in four for depression and one in three for generalised anxiety are however consistent with global estimates of depression in university students [ 3 ], Swedish national data [ 8 ], and European regional data [ 55 ]. Applications of these results The prevalence rates observed highlight the growing mental health crisis among Swedish university students and underline the need for targeted interventions. We have chosen to conceptualise our findings on what predicts tolerance towards those with NSSI in a cyclic framework (see Fig. 1 ). Strategic interventions at various points in this cycle could stimulate the development of tolerance towards those with NSSI and thus help-seeking in a cumulative manner [ 50 ]. For instance, implementing supportive interventions at Point 1 that encourage positive contact between individuals with and without NSSI, could increase awareness of friends or family who engage in NSSI. This, in turn, may foster more tolerant attitudes, eliciting supportive responses to disclosures, and facilitating help-seeking behaviours, in line with the principles of Intergroup Contact Theory [ 20 , 21 ]. Evidence from interventions such as the College Toolbox Project, which successfully improved attitudes towards mental illness and increased interactions between affected and unaffected groups, demonstrates the potential for applying this approach to NSSI [ 49 ]. However, to date, no large-scale interventions have specifically applied this framework to NSSI [ 51 ]. Anti-stigma campaigns at Point 2 could further enhance public understanding of NSSI, encourage open communication, and promote help-seeking behaviours, thereby reinforcing the cycle. Future initiatives aimed at increasing tolerance towards individuals with NSSI should also incorporate support mechanisms for those receiving disclosures to ensure positive interactions. As disclosures can be distressing for recipients [ 30 ], failing to provide adequate support may undermine the creation of a supportive environment, an essential condition for the effectiveness of the proposed theory and model. Strengths and limitations This study has several strengths, including its large sample size, quantitative design, and the university-wide approach. While the response rate of 4.7% is relatively low, it aligns with other large-scale online surveys conducted without compensation [ 56 ]. However, the generalisability of the findings is limited by the selection bias inherent in survey studies, which is difficult to control for. The slight overrepresentation of women is not necessarily a limitation, as women constituted a higher percentage of students at Lund University during the study period [ 57 ]. However, the sample’s homogeneity in age restricts conclusions about whether tolerance towards those with NSSI varies with age. Additional limitations include the length of the questionnaire and the small effect sizes observed in the regression analysis and t-test. Regarding the follow-up results, it is possible that participants who reported awareness of friends or family with NSSI at follow-up but not baseline were already aware but did not initially recall that person. A more specific question at follow-up could have improved the interpretation of these findings. Further research While this study provides an initial analysis of tolerance towards those with NSSI among those with family or friends who engage in NSSI, much of the variance in tolerance scores remains unexplained. A qualitative follow-up would also be warranted to complement the present findings. Future studies could explore interventions that use personal disclosure to foster tolerant attitudes while equipping individuals with strategies to support those engaging in NSSI. Additionally, examining whether different forms of disclosure (e.g., direct conversation vs. social media) impact tolerance differently could be valuable. Conclusion This study highlights the high prevalence of NSSI among Swedish university students, emphasising the potential risk of more severe mental health problems if left unaddressed. Our findings indicate that personal experience with NSSI, personal experience with mental health problems, female gender, and awareness of friends or family engaging in NSSI significantly predict tolerance towards individuals with NSSI. Notably, individuals who became aware of a friend or family member’s NSSI exhibited a small but significant increase in tolerance over six months. While these insights help identify factors contributing to tolerance towards those with NSSI, a substantial portion of variance remains unexplained. Given that two-thirds of students reported awareness of a friend or family member with NSSI, this population offers a valuable opportunity to further research into attitudes towards NSSI and their underlying influences. Our findings have practical implications for stigma-reduction campaigns and interventions that leverage interpersonal connections to foster greater understanding and encourage further help-seeking. Declarations Declaration of Interest statement The authors report there are no competing interests to declare. Acknowledgments We extend our sincere gratitude to the individuals who participated in the surveys, whose valuable input made this research possible. We also wish to thank Sofie Westling and Reid Lantto for their support in dissemination efforts. This work was supported by grants from Fonden för Psykisk Hälsa [The Fund for Mental Health], Stiftelsen O.M. Perssons Donationsfond [the O.M. Persson Foundation donation], and Stiftelsen Ellen och Henrik Sjöbrings minnesfond [the Foundation in memory of Ellen and Henrik Sjöbring]. Author Contributions statement M.N. and D.D. were involved in the conception and design; R.J., D.D. and E.L. were involved in the analysis and interpretation of the data; R.J. and E.L. were involved in the drafting and revising of the paper; all authors are provided final approval and are accountable for all aspects of the work. Data Availability statement The data are generally not available due to Swedish data regulations, but upon reasonable request and subsequent approval by the Swedish National Ethics review board, exceptions may be made. In this case, please make the request via the corresponding author – Rosie James. References Bruffaerts R, Mortier P, Kiekens G et al (2018) Mental health problems in college freshmen: Prevalence and academic functioning. J Affect Disord 225:97–103. https://doi.org/10.1016/j.jad.2017.07.044 Ebert DD, Franke M, Kählke F et al (2019) Increasing intentions to use mental health services among university students. Results of a pilot randomized controlled trial within the. Int J Methods Psychiatr Res 28. https://doi.org/10.1002/mpr.1754 . World Health Organization’s World Mental Health International College Student Initiative Sheldon E, Simmonds-Buckley M, Bone C et al (2021) Prevalence and risk factors for mental health problems in university undergraduate students: A systematic review with meta-analysis. J Affect Disord 287:282–292. https://doi.org/10.1016/J.JAD.2021.03.054 Whitlock J, Muehlenkamp J, Purington A et al (2011) Nonsuicidal Self-injury in a College Population: General Trends and Sex Differences. J Am Coll Health 59:691–698. https://doi.org/10.1080/07448481.2010.529626 CSN (2020) Studerandes hälsa 2020 UHR (2020) Studiesituationen för studenter med psykisk ohälsa Wang B, Feldman I, Chkonia E et al (2022) Mental health services in Scandinavia and Eurasia: comparison of financing and provision. Int Rev Psychiatry 34:118–127. https://doi.org/10.1080/09540261.2022.2065190 Folkhälsomyndigheten (2023) Psykisk hälsa och suicid i Sverige – Statistik om nuläge och utveckling fram till 2022 Nock MK, Favazza AR (2009) Nonsuicidal self-injury: Definition and classification. Understanding nonsuicidal self-injury: Origins, assessment, and treatment. American Psychological Association, Washington, pp 9–18 Fox KR, Franklin JC, Ribeiro JD et al (2015) Meta-analysis of risk factors for nonsuicidal self-injury. Clin Psychol Rev 42:156–167. https://doi.org/10.1016/J.CPR.2015.09.002 Whitlock J, Muehlenkamp J, Eckenrode J et al (2013) Nonsuicidal self-injury as a gateway to suicide in young adults. J Adolesc Health 52:486–492. https://doi.org/10.1016/j.jadohealth.2012.09.010 Ribeiro JD, Franklin JC, Fox KR et al (2016) Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychol Med 46:225–236. https://doi.org/10.1017/S0033291715001804 Cerutti R, Presaghi F, Manca M, Gratz KL (2012) Deliberate Self-Harm Behavior Among Italian Young Adults: Correlations With Clinical and Nonclinical Dimensions of Personality. Article Am J Orthopsychiatry. https://doi.org/10.1111/j.1939-0025.2012.01169.x Cipriano A, Cella S, Cotrufo P (2017) Nonsuicidal self-injury: A systematic review. Front Psychol 8:282818. https://doi.org/10.3389/FPSYG.2017.01946/BIBTEX Kiekens G, Claes L, Hasking P et al (2023) A longitudinal investigation of non-suicidal self-injury persistence patterns, risk factors, and clinical outcomes during the college period. Psychol Med 53:6011–6026. https://doi.org/10.1017/S0033291722003178 Sivertsen B, Hysing M, Knapstad M et al (2019) Suicide attempts and non-suicidal self-harm among university students: prevalence study. BJPsych Open 5:e26. https://doi.org/10.1192/BJO.2019.4 Mirichlis S, Hasking P, Lewis SP, Boyes ME (2022) Correlates of disclosure of non-suicidal self-injury amongst Australian university students. J Public Ment Health 21:70–81. https://doi.org/10.1108/JPMH-07-2021-0089 Rosenrot SA, Lewis SP (2020) Barriers and responses to the disclosure of non-suicidal self-injury: a thematic analysis. Couns Psychol Q 33:121–141. https://doi.org/10.1080/09515070.2018.1489220 Simone AC, Hamza CA (2020) Examining the disclosure of nonsuicidal self-injury to informal and formal sources: A review of the literature. Clin Psychol Rev 82:101907. https://doi.org/10.1016/J.CPR.2020.101907 Park Y, Ammerman BA (2020) How should we respond to non-suicidal self-injury disclosures? An examination of perceived reactions to disclosure, depression, and suicide risk. Psychiatry Res 293:113430. https://doi.org/10.1016/J.PSYCHRES.2020.113430 Toste JR, Heath NL (2010) School response to non-suicidal self-injury. Prev Researcher 17:14–17 Hjerm M, Eger MA, Bohman A, Fors Connolly F (2020) A New Approach to the Study of Tolerance: Conceptualizing and Measuring Acceptance, Respect, and Appreciation of Difference. Soc Indic Res 147:897–919. https://doi.org/10.1007/s11205-019-02176-y Pintar Babič M, Bregar B, Drobnič Radobuljac M (2020) The attitudes and feelings of mental health nurses towards adolescents and young adults with nonsuicidal self-injuring behaviors. Child Adolesc Psychiatry Ment Health 14:1–10. https://doi.org/10.1186/S13034-020-00343-5/TABLES/3 Muehlenkamp JJ, Claes L, Quigley K et al (2013) Association of Training on Attitudes Towards Self-Injuring Clients across Health Professionals. Archives Suicide Res 17:462–468. https://doi.org/10.1080/13811118.2013.801815 Ammerman BA, Mccloskey M, Drabick D et al (2018) Characteristics and consequences of non-suicidal self-injury disclosures. https://doi.org/10.34944/DSPACE/666 Armiento JS, Hamza CA, Willoughby T (2014) An Examination of Disclosure of Nonsuicidal Self-injury among University Students. https://doi.org/10.1002/casp.2190 Gouveia-Pereira FSV, Simões M, Duarte B E (2023) Young adults who self-harm: Barriers to and facilitators of seeking help. Psychiatry Res 327:115390. https://doi.org/10.1016/J.PSYCHRES.2023.115390 Lloyd B, Blazely A, Phillips L (2018) Stigma towards individuals who self harm: impact of gender and disclosure. J Public Ment Health 17:184–194. https://doi.org/10.1108/JPMH-02-2018-0016/FULL/PDF Rowe SL, French RS, Henderson C et al (2014) Help-seeking behaviour and adolescent self-harm: A systematic review. 48:1083–1095. https://doi.org/10.1177/0004867414555718 . http://dx.doi.org/101177/0004867414555718 Fisher K, Fitzgerald J, Tuffin K (2017) Peer Responses to Non-Suicidal Self-Injury: Young Women Speak About the Complexity of the Support-Provider Role. NZ J Psychol 46 Gayfer BL, Mahdy JC, Lewis SP (2020) Peer reactions to non-suicidal self-injury disclosures: a thematic analysis. Couns Psychol Q 33:79–99. https://doi.org/10.1080/09515070.2018.1536647 Law GU, Rostill-Brookes H, Goodman D (2009) Public stigma in health and non-healthcare students: Attributions, emotions and willingness to help with adolescent self-harm. Int J Nurs Stud 46:108–119. https://doi.org/10.1016/j.ijnurstu.2008.08.014 Nielsen E, Townsend E (2018) Archives of Suicide Research Public Perceptions of Self-Harm: Perceived Motivations of (and Willingness to Help in Response to) Adolescent Self-Harm Public Perceptions of Self-Harm: Perceived Motivations of (and Willingness to Help in Response to) Adolescent Self-Harm. Archives Suicide Res 22:479–495. https://doi.org/10.1080/13811118.2017.1358223 Simone AC, Yu S, Hamza CA (2023) Understanding experiences of disclosing and receiving disclosures of nonsuicidal self-injury amongst peers in university: A qualitative investigation. Couns Psychol Q 36:615–637. https://doi.org/10.1080/09515070.2022.2144807 Tajfel H, Turner JC (1979) An integrative theory of intergroup conflict. In: Austin WG, Worchel S (eds) The social psychology of intergroup relations. Brooks/Cole, Monterey, CA, pp 33–37 Nilsson M, Hellström C, Albin V et al (2020) Measuring Tolerance Toward Self-Harm: Introducing the Lund Tolerance Toward Self-Harm Scale (LUTOSH). Stigma Health 5:315–322. https://doi.org/10.1037/SAH0000199 Muehlenkamp J, Brausch A, Quigley K, Whitlock J (2013) Interpersonal Features and Functions of Nonsuicidal Self-injury. Suicide Life Threat Behav 43:67–80. https://doi.org/10.1111/J.1943-278X.2012.00128.X Stuber JP, Rocha Ann Christian Bruce Link AG (2014) Conceptions of Mental Illness: Attitudes of Mental Health Professionals and the General Public. Psychiatric Serv 65:490–497. https://doi.org/10.1176/appi.ps.201300136 Kim Y, Dykema J, Stevenson J et al (2019) Straightlining: Overview of Measurement, Comparison of Indicators, and Effects in Mail–Web Mixed-Mode Surveys. Soc Sci Comput Rev 37:214–233. https://doi.org/10.1177/0894439317752406 Manzo AN, Burke JM (2012) Increasing Response Rate in Web-Based/Internet Surveys. Handbook of Survey Methodology for the Social Sciences. Springer New York, New York, NY, pp 327–343 Magnusson Hanson LL, Westerlund H, Leineweber C et al (2014) The Symptom Checklist-core depression (SCL-CD 6 ) scale: Psychometric properties of a brief six item scale for the assessment of depression. Scand J Public Health 42:82–88. https://doi.org/10.1177/1403494813500591 Spitzer RL, Kroenke K, Williams JBW, Löwe B (2006) A Brief Measure for Assessing Generalized Anxiety Disorder. Arch Intern Med 166:1092. https://doi.org/10.1001/archinte.166.10.1092 Ahlqvist Lindqvist E, Ljungvall H, Zetterberg L et al (2021) Psychometric assessment of the Swedish version of the injustice experience questionnaire among patients with chronic pain. Scand J Pain 21:732–742. https://doi.org/10.1515/SJPAIN-2020-0187 Corp IBM (2021) IBM SPSS Statistics for Windows Cohen J (2013) Statistical Power Analysis for the Behavioral Sciences. Routledge Maunder RD, White FA (2019) Intergroup contact and mental health stigma: A comparative effectiveness meta-analysis. Clin Psychol Rev 72:101749. https://doi.org/10.1016/j.cpr.2019.101749 Chaplin TM (2015) Gender and Emotion Expression: A Developmental Contextual Perspective. Emot Rev 7:14–21. https://doi.org/10.1177/1754073914544408 Eagly AH, Koenig AM (2021) The Vicious Cycle Linking Stereotypes and Social Roles. Curr Dir Psychol Sci 30:343–350. https://doi.org/10.1177/09637214211013775 Pescosolido BA, Perry BL, Krendl AC (2020) Empowering the Next Generation to End Stigma by Starting the Conversation: Bring Change to Mind and the College Toolbox Project. J Am Acad Child Adolesc Psychiatry 59:519–530. https://doi.org/10.1016/j.jaac.2019.06.016 Götz FM, Gosling SD, Rentfrow PJ (2022) Small Effects: The Indispensable Foundation for a Cumulative Psychological Science. Perspect Psychol Sci 17:205–215. https://doi.org/10.1177/1745691620984483 Manago B, Krendl AC (2023) Cultivating contact: How social norms can reduce mental illness stigma in college populations. Stigma Health 8:61–71. https://doi.org/10.1037/sah0000363 Svensson B, Hansson L (2016) How mental health literacy and experience of mental illness relate to stigmatizing attitudes and social distance towards people with depression or psychosis: A cross-sectional study. Nord J Psychiatry 70:309–313. https://doi.org/10.3109/08039488.2015.1109140 Kiekens G, Hasking P, Bruffaerts R et al (2023) Non-suicidal self-injury among first-year college students and its association with mental disorders: results from the World Mental Health International College Student (WMH-ICS) initiative. Psychol Med 53:875–886. https://doi.org/10.1017/S0033291721002245 Zetterqvist M, Jonsson LS, Landberg Å, Svedin CG (2021) A potential increase in adolescent nonsuicidal self-injury during covid-19: A comparison of data from three different time points during 2011–2021. Psychiatry Res 305:114208. https://doi.org/10.1016/J.PSYCHRES.2021.114208 Li W, Zhao Z, Chen D et al (2022) Prevalence and associated factors of depression and anxiety symptoms among college students: a systematic review and meta-analysis. J Child Psychol Psychiatry 63:1222–1230. https://doi.org/10.1111/jcpp.13606 Cho YI, Johnson TP, VanGeest JB (2013) Enhancing Surveys of Health Care Professionals. Eval Health Prof 36:382–407. https://doi.org/10.1177/0163278713496425 Lund U (2022) Årsredovisning 2021. Lund Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6168456","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":425921715,"identity":"d8bdb52c-bd4b-45dc-bd7a-8c3267e6e6ce","order_by":0,"name":"Rosie James","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYNACHhDBfICBgY1BhhQtbAkgLTwkWWVAnBbz9vaHDxhk7KL5+c983fChDKjxADtQBA+QOXPG2ICBJzl35ozcbTdnnANp4QGK4AESEjlsEgw8zLkbbvBuu83bBtYCFMGrJf35Dwae+tz95888u/0XrIUdKIJXS4IZ0OeHczcw5LDdZgRrYTDDp4NBgueMsUQCz/HcGTfSzG72nJPgkTzMY4zfYeztDz987KnO7e8//OzGjzIbOb7jQBG81oBAYg/CCGAqIKgeBPB6dxSMglEwCkY8AADcPkTFCdgNXwAAAABJRU5ErkJggg==","orcid":"","institution":"Lund University","correspondingAuthor":true,"prefix":"","firstName":"Rosie","middleName":"","lastName":"James","suffix":""},{"id":425921716,"identity":"f4174477-578f-4722-b101-cc7bb4ed1864","order_by":1,"name":"Elin Lundgren","email":"","orcid":"","institution":"Skåne University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Elin","middleName":"","lastName":"Lundgren","suffix":""},{"id":425921717,"identity":"c61549c1-25d3-4b6a-823b-49a902e088e2","order_by":2,"name":"Daiva Daukantaité","email":"","orcid":"","institution":"Lund University","correspondingAuthor":false,"prefix":"","firstName":"Daiva","middleName":"","lastName":"Daukantaité","suffix":""},{"id":425921718,"identity":"ffcb637d-c1bd-4293-9744-1ee578e2eeb2","order_by":3,"name":"Magnus Nilsson","email":"","orcid":"","institution":"Lund University","correspondingAuthor":false,"prefix":"","firstName":"Magnus","middleName":"","lastName":"Nilsson","suffix":""}],"badges":[],"createdAt":"2025-03-06 08:23:12","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6168456/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6168456/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78236675,"identity":"bd995e03-fc7a-4c66-a3d5-5bcabad46981","added_by":"auto","created_at":"2025-03-11 08:30:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35449,"visible":true,"origin":"","legend":"\u003cp\u003eThe hypothesised cycle for encouraging tolerance towards individuals with NSSI in the general population.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6168456/v1/b96fa5b49ba051c2fa60250f.png"},{"id":78985196,"identity":"4103099d-239f-4e63-9a58-0642bb4aeb8d","added_by":"auto","created_at":"2025-03-21 17:46:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1018202,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6168456/v1/b18dabf3-9a76-4b1d-8ed8-0bc52457f581.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding Tolerance Towards Individuals with Non-suicidal Self-Injury: Predictors and Changes Over Six Months in a University Student Sample","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePoor mental health among students is a globally recognised concern [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], with one in four undergraduates experiencing depression and one in six reporting suicidal ideation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite Sweden\u0026rsquo;s significant investment in mental healthcare [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], this trend is no exception there. Of particularl concern, likely exacerbated by the COVID-19 pandemic [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], is the rise in non-suicidal self-injury (NSSI), defined as the deliberate harm of one\u0026rsquo;s body without the intention to die [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. NSSI is associated with severe mental illness and increased risk of suicide [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], with international prevalence rates for NSSI in university students reaching up to 39% [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Seeking support for NSSI is therefore of utmost importance. However, due to barriers such as stigma and shame, many are hesitant to seek help [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and for those who disclose their NSSI, the quality of their initial experience strongly influences their likelihood of seeking help again [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This highlights the importance of the tolerant attitudes of those receiving NSSI disclosures on future help-seeking behaviours.\u003c/p\u003e \u003cp\u003eTolerance towards individuals who self-harm, a construct encompassing empathy, respect, and understanding of differences that one may not personally endorse [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], could play a pivotal role in shaping disclosure experiences. Research on this topic has largely focused on healthcare professionals\u0026rsquo; attitudes, demonstrating that greater knowledge and experience with NSSI are associated with increased tolerance towards those engaging in it [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, most individuals with NSSI prefer seeking help from friends and family [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] over professional help [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. To our knowledge, no large-scale quantitative studies have investigated the factors influencing public tolerance towards individuals engaging in NSSI, particularly among friends and family who receive disclosures.\u003c/p\u003e \u003cp\u003eQualitative studies suggest that receiving an NSSI disclosure can foster greater sympathy, awareness, and understanding of the behaviour\u0026rsquo;s underlying motivations [\u003cspan additionalcitationids=\"CR31 CR32 CR33\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. These findings align with the Intergroup Contact Theory of stigma, which posits that supportive interactions between stigmatised and non-stigmatised groups can reduce stigma [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In this context, receiving an NSSI disclosure within a supportive environment may promote greater tolerance towards those who engage in it, thus reducing stigma. However, research on tolerance towards those with NSSI is limited, and the recent development of a quantitative measure of this construct provides an opportunity to investigate contributing factors on a larger scale [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePresent study\u003c/h3\u003e\n\u003cp\u003eThis study is the first to quantitatively explore variables associated with tolerance towards those with NSSI, with the aim of understanding how this can support intervention efforts. Variables including gender and personal experience with mental health problems have support in the literature as being related to an individual\u0026rsquo;s tolerance towards those with NSSI. For example, higher tolerance towards those with NSSI is found in women [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and in those with personal experience with mental health [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Additionally, we examine awareness of friends or family with NSSI and personal experience of NSSI, based on the qualitative findings presented above. As far as we are aware, this has only qualitative support, and the present study will thus test and extend previous findings quantitatively to explore generalisability as well as if existing findings hold in the Swedish context. By exploring how well these variables predict tolerance towards those engaging in NSSI, this study can inform interventions aimed at fostering tolerance, reducing stigma, and encouraging help-seeking.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAims\u003c/h2\u003e \u003cp\u003eThis paper has three primary aims: (1) to investigate the relationship between four factors \u0026ndash; gender, personal experience with NSSI, personal experience with mental health problems, and having family or friends who engage in NSSI \u0026ndash; and tolerance towards individuals with NSSI. Based on existing research, we hypothesise that tolerance is higher among women, individuals with a history of NSSI or mental health problems, and those who have family or friends who engage in NSSI; (2) to explore the predictive power of these four factors in explaining tolerance towards individuals with NSSI and to identify the most robust predictor; (3) to test whether becoming aware of family or friends with NSSI is associated with increased tolerance towards individuals with NSSI. As a secondary aim we provide an updated cross-sectional overview of the lifetime prevalence and frequency of NSSI, lifetime prevalence of mental health problems, and the proportion of individuals aware of family or friends engaging in NSSI within a Swedish university population, examining potential gender differences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSample collection and ethics\u003c/h2\u003e \u003cp\u003eIn February 2022, a comprehensive survey in Swedish was distributed via email to all students at Lund university, Sweden, as part of a broader data collection effort examining self-harming behaviour and attitudes. The baseline survey yielded a convenience sample of 1,500 responses, which was reduced to 1,430 after data cleaning [mean (SD) age 26 (7.33); 68.6% female]. Participants were excluded if they answered incorrectly on a control question or demonstrated signs of \u0026ldquo;straightlining\u0026rdquo; (i.e., repetitive answers across measures), indicating a lack of attention [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. At the six-month follow-up, 721 participants [mean (SD) age 26.3 (8.00); 68.4% female] completed the same questionnaire. To enhance participation across both data collection periods, follow-up reminder emails were sent [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The study was approved by the Swedish Ethics Review Authority (Dnr 2021\u0026ndash;05102), ensuring adherence to ethical standards. Participation was voluntary, without compensation, and written informed consent was obtained from all participants before completing the surveys at both time points. Each participant was assigned a unique, anonymised code to ensure data confidentiality, while still allowing baseline and follow-up data matching. Data was securely stored using LUSEC, the approved data-storage service at the Medical Faculty of Lund University.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eLifetime prevalence of NSSI and mental health problems\u003c/h2\u003e \u003cp\u003eParticipants were asked two separate questions about their personal experience with NSSI and mental health problems. They reported the recency of these experiences using four response options: \u0026ldquo;Earlier in life, but not during the last six months\u0026rdquo;, \u0026ldquo;Within the last six months but not before\u0026rdquo;, \u0026ldquo;Both within the last six months and earlier\u0026rdquo;, and \u0026ldquo;Neither within the last six months nor before\u0026rdquo;. For lifetime prevalence calculation, responses were collapsed into two categories: 1 (Personal experience of NSSI/mental health problems) or 0 (No personal experience of NSSI/mental health problems). Participants also reported the frequency of their NSSI in the last six months and more than six months ago, using a scale from 0 (no times) and 6 (more than 5 times).\u003c/p\u003e \u003cp\u003e \u003cem\u003eLund Tolerance Towards Self-Harm (LUTOSH\u003c/em\u003e [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTolerance towards individuals who engage in NSSI was measured using the LUTOSH scale, which includes five statements assessing individuals\u0026rsquo; tolerance towards self-harm in others. Responses were rated on a 10-point Likert scale ranging from 1 (\u003cem\u003eCompletely disagree\u003c/em\u003e) to 10 (C\u003cem\u003eompletely agree\u003c/em\u003e), with total scores ranging from 5 to 50. Items 3 and 4 were reverse-coded, and higher scores indicated greater tolerance. An example item is: \u003cem\u003e\u0026ldquo;People who self-harm shouldn\u0026rsquo;t be blamed\u0026rdquo;\u003c/em\u003e. The LUTOSH scale has demonstrated convergent validity and moderate internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.72) in Swedish populations [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In this study, Cronbach\u0026rsquo;s α was .66. To our knowledge, the LUTOSH is the only scale specifically designed to measure public tolerance towards those who self-harm.\u003c/p\u003e \u003cp\u003e \u003cem\u003eAwareness of Friends or Family with NSSI.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants were asked whether they were aware of a friend or family member who engages in NSSI, with response options of 1 (\u003cem\u003eYes\u003c/em\u003e) or 0 (\u003cem\u003eNo\u003c/em\u003e). They also indicated how they learned about the NSSI, choosing from the following options: \u0026ldquo;The person told me themselves\u0026rdquo;, \u0026ldquo;I received information about the self-harm through another person\u0026rdquo;, \u0026ldquo;I received information via social media\u0026rdquo;, and \u0026ldquo;Other\u0026rdquo;, with a free-text option for clarification. Responses categorised as \u0026ldquo;Other\u0026rdquo; were reviewed, and misclassifications were corrected. Many participants in this category described observing signs of NSSI in others, leading to the inclusion of this as an additional answer when analysing the results.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSymptom Checklist - Core Depression (SCL-CD6;\u003c/em\u003e [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eDepressive symptoms were assessed using the Swedish version of the SCL-CD6, which includes items such as, \u0026ldquo;feeling blue/sad\u0026rdquo; and \u0026ldquo;blaming yourself\u0026rdquo;. Participants rated how much they were affected by these feelings on a 5-point Likert scale ranging from 1 (Not at all) to 5 (Extremely). A cutoff score of \u0026ge;\u0026thinsp;17 was used to create a binary outcome, indicating clinical depression [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The measure has shown good internal reliability, and Cronbach\u0026rsquo;s α for the current sample was .90.\u003c/p\u003e \u003cp\u003e \u003cem\u003eGeneralised Anxiety Disorder (GAD-7;\u003c/em\u003e [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAnxiety symptoms were measured using the translated version of the GAD-7, which includes seven items assessing the frequency of symptoms over the last two weeks. Responses were recorded on a four-point Likert scale ranging from 0 (\u003cem\u003eNot at all\u003c/em\u003e) to 3 (\u003cem\u003eDaily\u003c/em\u003e). Example items include \u0026ldquo;feeling nervous, anxious and on edge\u0026rdquo;. While the original scale has been well validated [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], validation studies of the Swedish translation are limited despite its frequent use [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Cronbach\u0026rsquo;s α for the current sample was .91.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eAll analyses were run using IBM SPSS Statistics 28.0 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. We initially conducted an attrition analysis to ensure the trustworthiness of results by performing between-group comparisons of responders and non-responders. Independent samples t-test for continuous variables and Chi-square test for categorical variables were used.\u003c/p\u003e \u003cp\u003eAs part of the main analyses, we first generated a correlation matrix to explore relationships between all factors of interest, with dummy values in place for categorical variables. Then we conducted a multiple regression analysis on the baseline data to identify the relative robustness of four predictors of scores representing tolerance towards those engaging in NSSI. Assumptions of homogeneity of variance, normality, linearity, and absence of multicollinearity were met. The forced-entry method was selected due to the absence of strong evidence suggesting any predictor was more influential than the others in explaining tolerance scores.\u003c/p\u003e \u003cp\u003eThereafter, we ran a paired samples t-test comparing tolerance scores at baseline and follow-up on a subset of individuals, aiming to further explore the hypothesised association between tolerance scores and learning about friends or family who engage in NSSI. The subset included individuals who initially reported not being aware of friends or family engaging in NSSI but reported being aware at follow-up. Lastly, for the secondary aim, we conducted descriptive analyses to examine the prevalence of NSSI, mental health problems, and awareness of NSSI in friends or family in the total baseline sample and across genders. Where applicable, scales were categorised using established cutoff values.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAttrition analysis\u003c/h2\u003e \u003cp\u003eThe attrition analysis compared individuals who answered the follow-up after six months (N\u0026thinsp;=\u0026thinsp;721) and those that did not (N\u0026thinsp;=\u0026thinsp;709), on all measured variables in the present study. Participants with a history of NSSI were significantly more likely to respond to the follow-up (46.2%) than those without (53.8%), \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (1)\u0026thinsp;=\u0026thinsp;4.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, Cramer\u0026rsquo;s \u003cem\u003eV\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.054. However, the small effect size suggests a limited practical significance of this association. Using baseline values, no significant differences were found for gender, age, tolerance towards those with NSSI, depression, anxiety, awareness of friends or family with NSSI, and personal experience of mental health problems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation analyses\u003c/h2\u003e \u003cp\u003eIn line with the first primary aim, a Pearson\u0026rsquo;s Correlation analysis was conducted to identify correlations between LUTOSH, gender (0\u0026thinsp;=\u0026thinsp;male, 1\u0026thinsp;=\u0026thinsp;female), prevalence of NSSI (0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;yes), prevalence of mental health problems (0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;yes) and lastly awareness of friends or family with NSSI (0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;yes). Results indicate significant positive correlations varying in strength between tolerance scores and being a woman (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.245, \u003cem\u003ep\u003c/em\u003e \u0026lt;. 05), having engaged in NSSI at some point (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.314, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), having had mental health problems at some point (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.243, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), and being aware of friends or family with NSSI (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.158, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). A summary of the results is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePredicting tolerance towards individuals with NSSI\u003c/h2\u003e \u003cp\u003eIn line with the second primary aim, a multiple regression analysis was conducted to examine whether tolerance towards those with NSSI could be predicted by the same variables as used in the correlation analysis. The regression model accounted for 16.1% of the variance in tolerance scores, \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.161, \u003cem\u003eF\u003c/em\u003e (4,1376)\u0026thinsp;=\u0026thinsp;65.94, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. As presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, all four variables significantly predicted tolerance scores, with lifetime prevalence of NSSI being the most robust (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.21, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) compared to lifetime prevalence of mental health problems (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.15, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and being female (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Awareness of friends or family with NSSI also significantly predicted tolerance, though to a lesser extent than the other predictors (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eChange in Tolerance After Becoming Aware of Friends or Family with NSSI\u003c/h2\u003e \u003cp\u003eIn line with the third primary aim, a paired samples t-test was conducted to explore whether becoming aware of friends or family with NSSI was associated with an increase in tolerant attitudes over a six-month period. A subset of 67 participants, who reported not being aware of friends or family with NSSI at baseline (M\u0026thinsp;=\u0026thinsp;37.65; SD\u0026thinsp;=\u0026thinsp;7.47) but reported awareness at follow-up (M\u0026thinsp;=\u0026thinsp;38.87; SD\u0026thinsp;=\u0026thinsp;7.76), were analysed. A small but significant increase of 1.22 points in tolerance scores was observed, \u003cem\u003et\u003c/em\u003e (67) = -1.58, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05. The effect size, Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.21, indicated a small effect [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePearson\u0026rsquo;s correlation matrix for tolerance towards individuals with NSSI score, gender, lifetime prevalence of NSSI, lifetime prevalence of mental health problems.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLUTOSH total\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLifetime prevalence of NSSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLifetime prevalence of mental health problems\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLUTOSH total\u003c/p\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eLifetime prevalence of NSSI\u003c/p\u003e \u003cp\u003eLifetime prevalence of mental health problems\u003c/p\u003e \u003cp\u003eAwareness of friends or family with NSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e.245\u003c/p\u003e \u003cp\u003e.314\u003c/p\u003e \u003cp\u003e.243\u003c/p\u003e \u003cp\u003e.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e.217\u003c/p\u003e \u003cp\u003e.117\u003c/p\u003e \u003cp\u003e.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e.326\u003c/p\u003e \u003cp\u003e.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e.063\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote. Gender 0\u0026thinsp;=\u0026thinsp;male,1\u0026thinsp;=\u0026thinsp;female; lifetime prevalence of NSSI 0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;yes; Lifetime prevalence of mental health problems 0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;yes; Know someone with NSSI 0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;yes. All correlations are significant, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05. Number of cases contributing to each correlation (N\u0026thinsp;=\u0026thinsp;1381).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLinear model of predictors of tolerance towards individuals with NSSI, with 95% confidence intervals reported in parentheses.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExplanatory variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSignificance (\u003cem\u003ep\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Constant)\u003c/p\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eLifetime prevalence of NSSI\u003c/p\u003e \u003cp\u003eLifetime prevalence of mental health problems\u003c/p\u003e \u003cp\u003eAwareness of friend or family with NSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.60 (29.41, 31.80)\u003c/p\u003e \u003cp\u003e3.41 (2.47, 4.36)\u003c/p\u003e \u003cp\u003e3.72 (2.78, 4.65)\u003c/p\u003e \u003cp\u003e3.26 (2.13, 4.39)\u003c/p\u003e \u003cp\u003e1.50 (.62, 2.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.61\u003c/p\u003e \u003cp\u003e.48\u003c/p\u003e \u003cp\u003e.48\u003c/p\u003e \u003cp\u003e.58\u003c/p\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e.18\u003c/p\u003e \u003cp\u003e.21\u003c/p\u003e \u003cp\u003e.15\u003c/p\u003e \u003cp\u003e.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.32\u003c/p\u003e \u003cp\u003e7.09\u003c/p\u003e \u003cp\u003e7.78\u003c/p\u003e \u003cp\u003e5.65\u003c/p\u003e \u003cp\u003e3.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote. R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.16 for Model 1 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of NSSI and Mental Health Issues\u003c/h2\u003e \u003cp\u003eIn line with the secondary aim, NSSI prevalence and frequency, prevalence of mental health problems, and the proportion of individuals aware of NSSI in friends and family in a Swedish university population are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, along with statistics looking at gender differences. Results indicated an NSSI lifetime prevalence of 38.7%, with significantly fewer men (21.3%) reporting lifetime NSSI compared to women (44.4%) and those with non-specified gender (72.2%), \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;82.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Mental health problems were reported by 82% of the sample, with again significantly fewer men (74.3%) reporting these problems than women (84.3%) and those with non-specified gender (100%), \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;27.52, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. These gender categories were also significantly more likely to be above the cut-off for severe anxiety compared to men, \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;16.10, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001 and were significantly more likely to be aware of friends or family with NSSI than men, \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;28.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. No significant differences were found between the genders and whether the depression scores were above or below the clinical cutoff or the frequency of NSSI within the last six months.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence rates of lifetime NSSI and estimated frequency, mental health problems, knowledge of friends or family with NSSI, and depression and anxiety indicators by gender.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;1430)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen (n\u0026thinsp;=\u0026thinsp;400)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWomen (n\u0026thinsp;=\u0026thinsp;981)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNon-specified (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSignificance (\u003cem\u003ep\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLifetime prevalence of NSSI\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e876 (61.3%)\u003c/p\u003e \u003cp\u003e554 (38.7%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e315 (78.8%)\u003c/p\u003e \u003cp\u003e85 (21.3%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e545 (55.6%)\u003c/p\u003e \u003cp\u003e436 (44.4%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (27.8%)\u003c/p\u003e \u003cp\u003e26 (72.2%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNSSI frequency in last 6 months\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026le;\u0026thinsp;5 times\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;167\u003c/p\u003e \u003cp\u003e104 (62.3%)\u003c/p\u003e \u003cp\u003e63 (37.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;27\u003c/p\u003e \u003cp\u003e13 (48.1%)\u003c/p\u003e \u003cp\u003e14 (51.9%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;130\u003c/p\u003e \u003cp\u003e84 (64.6%)\u003c/p\u003e \u003cp\u003e46 (35.4%) \u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003cp\u003e7 (77%)\u003c/p\u003e \u003cp\u003e2 (22.2%) \u003csub\u003ec\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.172\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLifetime prevalence of mental health problems\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e258 (18%)\u003c/p\u003e \u003cp\u003e1172 (82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103 (25.8%)\u003c/p\u003e \u003cp\u003e297 (74.3%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e154 (15.7%)\u003c/p\u003e \u003cp\u003e827 (84.3%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e36 (100%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnow friends or family with NSSI\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e536 (37.5%)\u003c/p\u003e \u003cp\u003e894 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e191 (47.8%)\u003c/p\u003e \u003cp\u003e209 (52.3%) \u003csub\u003ea, b\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e333 (33.9%)\u003c/p\u003e \u003cp\u003e648 (66.1%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (19.4%)\u003c/p\u003e \u003cp\u003e29 (80.5%) \u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSCL-CD6\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBelow cutoff\u003c/p\u003e \u003cp\u003eAbove cutoff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1100 (76.9%)\u003c/p\u003e \u003cp\u003e330 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e322 (80.5%)\u003c/p\u003e \u003cp\u003e78 (19.5%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e746 (76%)\u003c/p\u003e \u003cp\u003e235 (24.0%) \u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (66.7%)\u003c/p\u003e \u003cp\u003e12 (33.3%) \u003csub\u003ec\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGAD7\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBelow cutoff\u003c/p\u003e \u003cp\u003eAbove cutoff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e966 (68.2%)\u003c/p\u003e \u003cp\u003e451 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e300 (75%)\u003c/p\u003e \u003cp\u003e100 (25%) \u003csub\u003ea, b\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e648 (66.1%)\u003c/p\u003e \u003cp\u003e327 (33.9%) \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (50%)\u003c/p\u003e \u003cp\u003e18 (50%) \u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNotes. SCL-CD6\u0026thinsp;=\u0026thinsp;Symptom Checklist - Core Depression; GAD7\u0026thinsp;\u003cb\u003e=\u003c/b\u003e\u0026thinsp;Generalized Anxiety Disorder; Numbers of individuals in each gender group do not add up to the total number because those who did not disclose their gender (n\u0026thinsp;=\u0026thinsp;13) have been excluded from these categories however, they are included in the total score. P values of \u0026lt;\u0026thinsp;.001 show that there is a significant difference between the gender groupings according to a Pearson's Chi-square test. Post-hoc comparisons using a Bonferroni correction are reported in subscript letters where use of the same letter indicates a significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) between the genders in each factor.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study addressed three primary aims, identifying significant correlations between the four predictors of tolerance towards individuals with NSSI. Our findings suggest that tolerance towards those with NSSI is shaped by a combination of personal experience, social exposure, and demographic factors. Additionally, we extended qualitative literature by quantitatively demonstrating that gender, personal experience with NSSI, personal experience with mental health problems, and awareness of friend or family with NSSI significantly predict tolerance towards those with NSSI. Follow-up analyses further indicated that becoming aware of a friend or family member\u0026rsquo;s NSSI may have a small but positive effect on an individual\u0026rsquo;s overall tolerance towards those with NSSI. This finding highlights the potential for social exposure to play a role in shaping attitudes and reducing stigma.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTolerance towards those with NSSI\u003c/h2\u003e \u003cp\u003eThe strongest predictor of tolerance towards others with NSSI was personal experience with the behaviour itself, likely due to the projection of cognitive empathy and experiential knowledge [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. This may also explain why personal experience with mental health problems predicted greater tolerance towards those with NSSI among individuals who do not engage in NSSI. Gender differences in tolerance could be attributed to societal expectations of emotional expression and empathy in Western European cultures that are imposed on women [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], as well as their greater propensity to adopt caregiving roles [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough awareness of friends or family engaging in NSSI was the weakest predictor, it remained significant when controlling for the other three variables. While the effect size was small, even minor increases in tolerance can have meaningful real-world implications when applied at the population level [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] (see \u003cem\u003eApplication of these results\u003c/em\u003e). The six-month follow-up data further supports the hypothesis that awareness of friends and family engaging in NSSI can increase tolerant attitudes. However, it remains unclear whether direct interpersonal engagement is necessary or if simply knowing someone with NSSI is sufficient to increase tolerant attitudes.\u003c/p\u003e \u003cp\u003eQualitative studies suggest that disclosure experiences can promote empathy, understanding, and tolerance among friends and family [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], potentially encouraging recipients to seek information about NSSI and enhancing their ability to provide support. However, while disclosures can strengthen social connectedness and facilitate personal growth, they may also be overwhelming for recipients who feel ill-equipped to respond [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our large-scale study does not account for the contextual factors that influence whether disclosures have a positive impact. This context is highlighted in the framework of Intergroup Contact Theory, which posits that \u003cem\u003esupportive\u003c/em\u003e interactions between stigmatised and non-stigmatised groups can reduce stigma and enhance tolerance [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCross-sectional prevalence statistics\u003c/h2\u003e \u003cp\u003eIn our sample, 62.5% of participants reported being aware of friends or family who engage in NSSI. To our knowledge, this is the first study to estimate this prevalence. Women and those with non-specified gender reported awareness more frequently than men, possibly due to higher NSSI rates in these groups or a greater likelihood of disclosure within the same gender. A better understanding of individuals who receive NSSI disclosures and their role in fostering tolerance and reducing stigma could strengthen future interventions. Our findings suggest that university populations may be particularly valuable targets for such initiatives.\u003c/p\u003e \u003cp\u003eAdditionally, we found a lifetime NSSI prevalence of 38.7%, aligning with one prior study reporting a similar rate of 39% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The literature on NSSI prevalence exhibits considerable variation, highlighting the influence of methodological factors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. For instance, our findings contrast greatly with a recent international meta-analysis, which reported a 20% lifetime prevalence among first-year university students [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. However, our higher prevalence estimates may reflect regional differences, as the meta-analysis did not include Swedish universities. Moreover, national statistics have documented an increase in NSSI among Swedish adolescents over the past decade, making the present higher rates in university students more predictable [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. While our opt-in approach is likely to have contributed to a degree of overreporting, the high NSSI incidence observed in our sample, consistent with some other studies, warrants further investigation. Our prevalence estimates of one in four for depression and one in three for generalised anxiety are however consistent with global estimates of depression in university students [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], Swedish national data [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and European regional data [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eApplications of these results\u003c/h2\u003e \u003cp\u003eThe prevalence rates observed highlight the growing mental health crisis among Swedish university students and underline the need for targeted interventions. We have chosen to conceptualise our findings on what predicts tolerance towards those with NSSI in a cyclic framework (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eStrategic interventions at various points in this cycle could stimulate the development of tolerance towards those with NSSI and thus help-seeking in a cumulative manner [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. For instance, implementing supportive interventions at Point 1 that encourage positive contact between individuals with and without NSSI, could increase awareness of friends or family who engage in NSSI. This, in turn, may foster more tolerant attitudes, eliciting supportive responses to disclosures, and facilitating help-seeking behaviours, in line with the principles of Intergroup Contact Theory [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Evidence from interventions such as the College Toolbox Project, which successfully improved attitudes towards mental illness and increased interactions between affected and unaffected groups, demonstrates the potential for applying this approach to NSSI [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. However, to date, no large-scale interventions have specifically applied this framework to NSSI [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnti-stigma campaigns at Point 2 could further enhance public understanding of NSSI, encourage open communication, and promote help-seeking behaviours, thereby reinforcing the cycle. Future initiatives aimed at increasing tolerance towards individuals with NSSI should also incorporate support mechanisms for those receiving disclosures to ensure positive interactions. As disclosures can be distressing for recipients [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], failing to provide adequate support may undermine the creation of a supportive environment, an essential condition for the effectiveness of the proposed theory and model.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths, including its large sample size, quantitative design, and the university-wide approach. While the response rate of 4.7% is relatively low, it aligns with other large-scale online surveys conducted without compensation [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. However, the generalisability of the findings is limited by the selection bias inherent in survey studies, which is difficult to control for.\u003c/p\u003e \u003cp\u003eThe slight overrepresentation of women is not necessarily a limitation, as women constituted a higher percentage of students at Lund University during the study period [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. However, the sample\u0026rsquo;s homogeneity in age restricts conclusions about whether tolerance towards those with NSSI varies with age.\u003c/p\u003e \u003cp\u003eAdditional limitations include the length of the questionnaire and the small effect sizes observed in the regression analysis and t-test. Regarding the follow-up results, it is possible that participants who reported awareness of friends or family with NSSI at follow-up but not baseline were already aware but did not initially recall that person. A more specific question at follow-up could have improved the interpretation of these findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eFurther research\u003c/h2\u003e \u003cp\u003eWhile this study provides an initial analysis of tolerance towards those with NSSI among those with family or friends who engage in NSSI, much of the variance in tolerance scores remains unexplained. A qualitative follow-up would also be warranted to complement the present findings. Future studies could explore interventions that use personal disclosure to foster tolerant attitudes while equipping individuals with strategies to support those engaging in NSSI. Additionally, examining whether different forms of disclosure (e.g., direct conversation vs. social media) impact tolerance differently could be valuable.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the high prevalence of NSSI among Swedish university students, emphasising the potential risk of more severe mental health problems if left unaddressed. Our findings indicate that personal experience with NSSI, personal experience with mental health problems, female gender, and awareness of friends or family engaging in NSSI significantly predict tolerance towards individuals with NSSI. Notably, individuals who became aware of a friend or family member\u0026rsquo;s NSSI exhibited a small but significant increase in tolerance over six months.\u003c/p\u003e \u003cp\u003eWhile these insights help identify factors contributing to tolerance towards those with NSSI, a substantial portion of variance remains unexplained. Given that two-thirds of students reported awareness of a friend or family member with NSSI, this population offers a valuable opportunity to further research into attitudes towards NSSI and their underlying influences. Our findings have practical implications for stigma-reduction campaigns and interventions that leverage interpersonal connections to foster greater understanding and encourage further help-seeking.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Interest statement \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report there are no competing interests to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to the individuals who participated in the surveys, whose valuable input made this research possible. We also wish to thank Sofie Westling and Reid Lantto for their support in dissemination efforts. This work was supported by grants from Fonden f\u0026ouml;r Psykisk H\u0026auml;lsa [The Fund for Mental Health], Stiftelsen O.M. Perssons Donationsfond [the O.M. Persson Foundation donation], and Stiftelsen Ellen och Henrik Sj\u0026ouml;brings minnesfond [the Foundation in memory of Ellen and Henrik Sj\u0026ouml;bring].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.N. and D.D. were involved in the conception and design; R.J., D.D. and E.L. were involved in the analysis and interpretation of the data; R.J. and E.L. were involved in the drafting and revising of the paper; all authors are provided final approval and are accountable for all aspects of the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are generally not available due to Swedish data regulations, but upon reasonable request and subsequent approval by the Swedish National Ethics review board, exceptions may be made. In this case, please make the request via the corresponding author \u0026ndash; Rosie James.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBruffaerts R, Mortier P, Kiekens G et al (2018) Mental health problems in college freshmen: Prevalence and academic functioning. J Affect Disord 225:97\u0026ndash;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2017.07.044\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2017.07.044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEbert DD, Franke M, K\u0026auml;hlke F et al (2019) Increasing intentions to use mental health services among university students. Results of a pilot randomized controlled trial within the. Int J Methods Psychiatr Res 28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/mpr.1754\u003c/span\u003e\u003cspan address=\"10.1002/mpr.1754\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. World Health Organization\u0026rsquo;s World Mental Health International College Student Initiative\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheldon E, Simmonds-Buckley M, Bone C et al (2021) Prevalence and risk factors for mental health problems in university undergraduate students: A systematic review with meta-analysis. J Affect Disord 287:282\u0026ndash;292. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.JAD.2021.03.054\u003c/span\u003e\u003cspan address=\"10.1016/J.JAD.2021.03.054\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitlock J, Muehlenkamp J, Purington A et al (2011) Nonsuicidal Self-injury in a College Population: General Trends and Sex Differences. J Am Coll Health 59:691\u0026ndash;698. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/07448481.2010.529626\u003c/span\u003e\u003cspan address=\"10.1080/07448481.2010.529626\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCSN (2020) Studerandes h\u0026auml;lsa 2020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUHR (2020) Studiesituationen f\u0026ouml;r studenter med psykisk oh\u0026auml;lsa\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang B, Feldman I, Chkonia E et al (2022) Mental health services in Scandinavia and Eurasia: comparison of financing and provision. Int Rev Psychiatry 34:118\u0026ndash;127. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09540261.2022.2065190\u003c/span\u003e\u003cspan address=\"10.1080/09540261.2022.2065190\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFolkh\u0026auml;lsomyndigheten (2023) Psykisk h\u0026auml;lsa och suicid i Sverige \u0026ndash; Statistik om nul\u0026auml;ge och utveckling fram till 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNock MK, Favazza AR (2009) Nonsuicidal self-injury: Definition and classification. Understanding nonsuicidal self-injury: Origins, assessment, and treatment. American Psychological Association, Washington, pp 9\u0026ndash;18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFox KR, Franklin JC, Ribeiro JD et al (2015) Meta-analysis of risk factors for nonsuicidal self-injury. Clin Psychol Rev 42:156\u0026ndash;167. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.CPR.2015.09.002\u003c/span\u003e\u003cspan address=\"10.1016/J.CPR.2015.09.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitlock J, Muehlenkamp J, Eckenrode J et al (2013) Nonsuicidal self-injury as a gateway to suicide in young adults. J Adolesc Health 52:486\u0026ndash;492. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jadohealth.2012.09.010\u003c/span\u003e\u003cspan address=\"10.1016/j.jadohealth.2012.09.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRibeiro JD, Franklin JC, Fox KR et al (2016) Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychol Med 46:225\u0026ndash;236. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0033291715001804\u003c/span\u003e\u003cspan address=\"10.1017/S0033291715001804\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCerutti R, Presaghi F, Manca M, Gratz KL (2012) Deliberate Self-Harm Behavior Among Italian Young Adults: Correlations With Clinical and Nonclinical Dimensions of Personality. Article Am J Orthopsychiatry. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1939-0025.2012.01169.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1939-0025.2012.01169.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCipriano A, Cella S, Cotrufo P (2017) Nonsuicidal self-injury: A systematic review. Front Psychol 8:282818. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/FPSYG.2017.01946/BIBTEX\u003c/span\u003e\u003cspan address=\"10.3389/FPSYG.2017.01946/BIBTEX\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiekens G, Claes L, Hasking P et al (2023) A longitudinal investigation of non-suicidal self-injury persistence patterns, risk factors, and clinical outcomes during the college period. Psychol Med 53:6011\u0026ndash;6026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0033291722003178\u003c/span\u003e\u003cspan address=\"10.1017/S0033291722003178\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSivertsen B, Hysing M, Knapstad M et al (2019) Suicide attempts and non-suicidal self-harm among university students: prevalence study. BJPsych Open 5:e26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1192/BJO.2019.4\u003c/span\u003e\u003cspan address=\"10.1192/BJO.2019.4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirichlis S, Hasking P, Lewis SP, Boyes ME (2022) Correlates of disclosure of non-suicidal self-injury amongst Australian university students. J Public Ment Health 21:70\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/JPMH-07-2021-0089\u003c/span\u003e\u003cspan address=\"10.1108/JPMH-07-2021-0089\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenrot SA, Lewis SP (2020) Barriers and responses to the disclosure of non-suicidal self-injury: a thematic analysis. Couns Psychol Q 33:121\u0026ndash;141. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09515070.2018.1489220\u003c/span\u003e\u003cspan address=\"10.1080/09515070.2018.1489220\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimone AC, Hamza CA (2020) Examining the disclosure of nonsuicidal self-injury to informal and formal sources: A review of the literature. Clin Psychol Rev 82:101907. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.CPR.2020.101907\u003c/span\u003e\u003cspan address=\"10.1016/J.CPR.2020.101907\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark Y, Ammerman BA (2020) How should we respond to non-suicidal self-injury disclosures? An examination of perceived reactions to disclosure, depression, and suicide risk. Psychiatry Res 293:113430. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.PSYCHRES.2020.113430\u003c/span\u003e\u003cspan address=\"10.1016/J.PSYCHRES.2020.113430\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToste JR, Heath NL (2010) School response to non-suicidal self-injury. Prev Researcher 17:14\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHjerm M, Eger MA, Bohman A, Fors Connolly F (2020) A New Approach to the Study of Tolerance: Conceptualizing and Measuring Acceptance, Respect, and Appreciation of Difference. Soc Indic Res 147:897\u0026ndash;919. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11205-019-02176-y\u003c/span\u003e\u003cspan address=\"10.1007/s11205-019-02176-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePintar Babič M, Bregar B, Drobnič Radobuljac M (2020) The attitudes and feelings of mental health nurses towards adolescents and young adults with nonsuicidal self-injuring behaviors. Child Adolesc Psychiatry Ment Health 14:1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/S13034-020-00343-5/TABLES/3\u003c/span\u003e\u003cspan address=\"10.1186/S13034-020-00343-5/TABLES/3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuehlenkamp JJ, Claes L, Quigley K et al (2013) Association of Training on Attitudes Towards Self-Injuring Clients across Health Professionals. Archives Suicide Res 17:462\u0026ndash;468. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13811118.2013.801815\u003c/span\u003e\u003cspan address=\"10.1080/13811118.2013.801815\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmmerman BA, Mccloskey M, Drabick D et al (2018) Characteristics and consequences of non-suicidal self-injury disclosures. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.34944/DSPACE/666\u003c/span\u003e\u003cspan address=\"10.34944/DSPACE/666\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArmiento JS, Hamza CA, Willoughby T (2014) An Examination of Disclosure of Nonsuicidal Self-injury among University Students. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/casp.2190\u003c/span\u003e\u003cspan address=\"10.1002/casp.2190\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGouveia-Pereira FSV, Sim\u0026otilde;es M, Duarte B E (2023) Young adults who self-harm: Barriers to and facilitators of seeking help. Psychiatry Res 327:115390. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.PSYCHRES.2023.115390\u003c/span\u003e\u003cspan address=\"10.1016/J.PSYCHRES.2023.115390\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLloyd B, Blazely A, Phillips L (2018) Stigma towards individuals who self harm: impact of gender and disclosure. J Public Ment Health 17:184\u0026ndash;194. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/JPMH-02-2018-0016/FULL/PDF\u003c/span\u003e\u003cspan address=\"10.1108/JPMH-02-2018-0016/FULL/PDF\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRowe SL, French RS, Henderson C et al (2014) Help-seeking behaviour and adolescent self-harm: A systematic review. 48:1083\u0026ndash;1095. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0004867414555718\u003c/span\u003e\u003cspan address=\"10.1177/0004867414555718\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. http://dx.doi.org/101177/0004867414555718\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFisher K, Fitzgerald J, Tuffin K (2017) Peer Responses to Non-Suicidal Self-Injury: Young Women Speak About the Complexity of the Support-Provider Role. NZ J Psychol 46\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGayfer BL, Mahdy JC, Lewis SP (2020) Peer reactions to non-suicidal self-injury disclosures: a thematic analysis. Couns Psychol Q 33:79\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09515070.2018.1536647\u003c/span\u003e\u003cspan address=\"10.1080/09515070.2018.1536647\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaw GU, Rostill-Brookes H, Goodman D (2009) Public stigma in health and non-healthcare students: Attributions, emotions and willingness to help with adolescent self-harm. Int J Nurs Stud 46:108\u0026ndash;119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijnurstu.2008.08.014\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnurstu.2008.08.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNielsen E, Townsend E (2018) Archives of Suicide Research Public Perceptions of Self-Harm: Perceived Motivations of (and Willingness to Help in Response to) Adolescent Self-Harm Public Perceptions of Self-Harm: Perceived Motivations of (and Willingness to Help in Response to) Adolescent Self-Harm. Archives Suicide Res 22:479\u0026ndash;495. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13811118.2017.1358223\u003c/span\u003e\u003cspan address=\"10.1080/13811118.2017.1358223\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimone AC, Yu S, Hamza CA (2023) Understanding experiences of disclosing and receiving disclosures of nonsuicidal self-injury amongst peers in university: A qualitative investigation. Couns Psychol Q 36:615\u0026ndash;637. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09515070.2022.2144807\u003c/span\u003e\u003cspan address=\"10.1080/09515070.2022.2144807\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTajfel H, Turner JC (1979) An integrative theory of intergroup conflict. In: Austin WG, Worchel S (eds) The social psychology of intergroup relations. Brooks/Cole, Monterey, CA, pp 33\u0026ndash;37\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNilsson M, Hellstr\u0026ouml;m C, Albin V et al (2020) Measuring Tolerance Toward Self-Harm: Introducing the Lund Tolerance Toward Self-Harm Scale (LUTOSH). Stigma Health 5:315\u0026ndash;322. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/SAH0000199\u003c/span\u003e\u003cspan address=\"10.1037/SAH0000199\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuehlenkamp J, Brausch A, Quigley K, Whitlock J (2013) Interpersonal Features and Functions of Nonsuicidal Self-injury. Suicide Life Threat Behav 43:67\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/J.1943-278X.2012.00128.X\u003c/span\u003e\u003cspan address=\"10.1111/J.1943-278X.2012.00128.X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStuber JP, Rocha Ann Christian Bruce Link AG (2014) Conceptions of Mental Illness: Attitudes of Mental Health Professionals and the General Public. Psychiatric Serv 65:490\u0026ndash;497. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1176/appi.ps.201300136\u003c/span\u003e\u003cspan address=\"10.1176/appi.ps.201300136\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim Y, Dykema J, Stevenson J et al (2019) Straightlining: Overview of Measurement, Comparison of Indicators, and Effects in Mail\u0026ndash;Web Mixed-Mode Surveys. Soc Sci Comput Rev 37:214\u0026ndash;233. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0894439317752406\u003c/span\u003e\u003cspan address=\"10.1177/0894439317752406\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManzo AN, Burke JM (2012) Increasing Response Rate in Web-Based/Internet Surveys. Handbook of Survey Methodology for the Social Sciences. Springer New York, New York, NY, pp 327\u0026ndash;343\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMagnusson Hanson LL, Westerlund H, Leineweber C et al (2014) The Symptom Checklist-core depression (SCL-CD \u003csub\u003e6\u003c/sub\u003e) scale: Psychometric properties of a brief six item scale for the assessment of depression. Scand J Public Health 42:82\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1403494813500591\u003c/span\u003e\u003cspan address=\"10.1177/1403494813500591\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpitzer RL, Kroenke K, Williams JBW, L\u0026ouml;we B (2006) A Brief Measure for Assessing Generalized Anxiety Disorder. Arch Intern Med 166:1092. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/archinte.166.10.1092\u003c/span\u003e\u003cspan address=\"10.1001/archinte.166.10.1092\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhlqvist Lindqvist E, Ljungvall H, Zetterberg L et al (2021) Psychometric assessment of the Swedish version of the injustice experience questionnaire among patients with chronic pain. Scand J Pain 21:732\u0026ndash;742. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1515/SJPAIN-2020-0187\u003c/span\u003e\u003cspan address=\"10.1515/SJPAIN-2020-0187\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorp IBM (2021) IBM SPSS Statistics for Windows\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen J (2013) Statistical Power Analysis for the Behavioral Sciences. Routledge\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaunder RD, White FA (2019) Intergroup contact and mental health stigma: A comparative effectiveness meta-analysis. Clin Psychol Rev 72:101749. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cpr.2019.101749\u003c/span\u003e\u003cspan address=\"10.1016/j.cpr.2019.101749\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaplin TM (2015) Gender and Emotion Expression: A Developmental Contextual Perspective. Emot Rev 7:14\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1754073914544408\u003c/span\u003e\u003cspan address=\"10.1177/1754073914544408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEagly AH, Koenig AM (2021) The Vicious Cycle Linking Stereotypes and Social Roles. Curr Dir Psychol Sci 30:343\u0026ndash;350. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/09637214211013775\u003c/span\u003e\u003cspan address=\"10.1177/09637214211013775\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePescosolido BA, Perry BL, Krendl AC (2020) Empowering the Next Generation to End Stigma by Starting the Conversation: Bring Change to Mind and the College Toolbox Project. J Am Acad Child Adolesc Psychiatry 59:519\u0026ndash;530. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaac.2019.06.016\u003c/span\u003e\u003cspan address=\"10.1016/j.jaac.2019.06.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026ouml;tz FM, Gosling SD, Rentfrow PJ (2022) Small Effects: The Indispensable Foundation for a Cumulative Psychological Science. Perspect Psychol Sci 17:205\u0026ndash;215. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1745691620984483\u003c/span\u003e\u003cspan address=\"10.1177/1745691620984483\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManago B, Krendl AC (2023) Cultivating contact: How social norms can reduce mental illness stigma in college populations. Stigma Health 8:61\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/sah0000363\u003c/span\u003e\u003cspan address=\"10.1037/sah0000363\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSvensson B, Hansson L (2016) How mental health literacy and experience of mental illness relate to stigmatizing attitudes and social distance towards people with depression or psychosis: A cross-sectional study. Nord J Psychiatry 70:309\u0026ndash;313. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3109/08039488.2015.1109140\u003c/span\u003e\u003cspan address=\"10.3109/08039488.2015.1109140\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiekens G, Hasking P, Bruffaerts R et al (2023) Non-suicidal self-injury among first-year college students and its association with mental disorders: results from the World Mental Health International College Student (WMH-ICS) initiative. Psychol Med 53:875\u0026ndash;886. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0033291721002245\u003c/span\u003e\u003cspan address=\"10.1017/S0033291721002245\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZetterqvist M, Jonsson LS, Landberg \u0026Aring;, Svedin CG (2021) A potential increase in adolescent nonsuicidal self-injury during covid-19: A comparison of data from three different time points during 2011\u0026ndash;2021. Psychiatry Res 305:114208. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.PSYCHRES.2021.114208\u003c/span\u003e\u003cspan address=\"10.1016/J.PSYCHRES.2021.114208\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi W, Zhao Z, Chen D et al (2022) Prevalence and associated factors of depression and anxiety symptoms among college students: a systematic review and meta-analysis. J Child Psychol Psychiatry 63:1222\u0026ndash;1230. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpp.13606\u003c/span\u003e\u003cspan address=\"10.1111/jcpp.13606\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho YI, Johnson TP, VanGeest JB (2013) Enhancing Surveys of Health Care Professionals. Eval Health Prof 36:382\u0026ndash;407. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0163278713496425\u003c/span\u003e\u003cspan address=\"10.1177/0163278713496425\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLund U (2022) \u0026Aring;rsredovisning 2021. Lund\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Non-suicidal self-injury, tolerance, stigma, university students, NSSI, attitudes","lastPublishedDoi":"10.21203/rs.3.rs-6168456/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6168456/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eNon-suicidal self-injury (NSSI) is increasingly prevalent yet remains heavily stigmatised. While research focuses on healthcare professionals\u0026rsquo; tolerant attitudes, public attitudes \u0026ndash; especially among friends and family \u0026ndash; are underexplored. However, these groups are often the first to receive NSSI disclosures, making their tolerant attitudes towards individuals with NSSI crucial for encouraging help-seeking. This study investigates predictors of tolerance towards individuals with NSSI and examines changes over six months, specifically in those newly aware of friends or family with NSSI.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA survey of 1,430 Swedish university students was conducted, and 721 participated in the six-month follow-up. A correlation analysis examined relationships between four variables related to tolerance towards those with NSSI, and a multiple regression analysis assessed their individual and combined predictive strength. Changes over time were measured using a paired samples t-test.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGender, personal experience with NSSI, personal experience with mental health problems, and awareness of NSSI among friends or family significantly predicted more tolerant attitudes, together accounting for 16% of the variance in tolerance scores. Personal experience with NSSI was the most robust predictor. Tolerance scores increased significantly in participants who had become aware of friends or family with NSSI at follow-up (n\u0026thinsp;=\u0026thinsp;67).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe study identified key predictors of tolerance towards individuals with NSSI and the novel finding that awareness of NSSI among friends and family is associated with greater tolerant attitudes. We propose a model to explain this interaction and discuss promoting awareness of NSSI within personal networks to foster tolerance, thereby informing stigma-reducing interventions.\u003c/p\u003e","manuscriptTitle":"Understanding Tolerance Towards Individuals with Non-suicidal Self-Injury: Predictors and Changes Over Six Months in a University Student Sample","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-11 08:30:38","doi":"10.21203/rs.3.rs-6168456/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"941c43dd-8955-4f6d-a48a-ca3e0d50cfff","owner":[],"postedDate":"March 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-21T17:38:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-11 08:30:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6168456","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6168456","identity":"rs-6168456","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}