Depression Literacy and its Relationship with Depression Stigma and Attitude Toward Seeking Help in Iranian Women

Document Type : Descriptive & Survey

Authors
Z. Saboohi 1
M. Solhi 2
M. Hajihashemi 3
R. Nouri 1
M. Nazarnia 4
1 Department of Health Services, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
2 Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran
3 Department of Health Education and Health Promotion, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
10.58209/hehp.12.2.231
Abstract
Aims: Depression, anxiety, and psychiatric symptoms are more prevalent among women than men. Given the significance of depression literacy and its associated factors, this study aimed to explore the level of depression literacy and its correlation with depression stigma and attitudes toward seeking help among Iranian women attending health centers in Saveh City.

Instrument & Methods: This cross-sectional study assessed 280 women aged 18-65 selected through cluster sampling from September 2023 to December 2023 in Saveh County, Iran. Reliable and validated tools, including the D-Lit Questionnaire, Attitude Toward Seeking Professional Psychological Help Scale, and DSS-Personal Subscale were utilized for data collection. Data analysis was conducted using independent samples t-test and one-way ANOVA. Predictors were identified through hierarchical linear regression analysis.

Findings: The lowest correct answer rate was associated with knowledge of available treatment methods (15.4%). The mean scores for D-Lit, attitude toward seeking help, and personal depression stigma were 41.36±4.83, 23.63±3.69, and 25.39±4.36, respectively. Education level, consultation with a psychologist, attitude toward seeking help, and depression stigma collectively accounted for approximately 23% of the variance in depression literacy.

Conclusions: The level of depression literacy among Iranian women is insufficient.

Keywords

Subjects

Introduction
As per the World Health Organization (WHO), the global incidence of mental disorders is on the rise, especially in low-income nations. Depressive disorders are the most common mental health issues, affecting 322 million individuals worldwide [1]. A meta-analysis focusing on medical students in China unveiled a depression prevalence rate of 32.74% [2]. Among Iranians, the prevalence of depression was reported at 49%, with rates of very severe, severe, moderate, and mild depression standing at 5%, 19%, 33%, and 38%, respectively, as per a meta-analysis [3]. Depression contributes to increased mortality, morbidity, unemployment, interpersonal challenges, family and societal disabilities, suicide, and elevated risks of heart disease, diabetes, and hypertension [4-7].
Gender is recognized as a crucial factor that influences health, encompassing mental health and mental illness. Mental health indicators reveal varying patterns of psychiatric disorders and psychological distress between men and women. Symptoms of depression, anxiety, and psychiatric disorders are more commonly observed in women than in men [8]. Depression, being one of the most prevalent mental health conditions among women, might exhibit higher prevalence rates in women [9]. In cases where a woman experiences a mental illness, she might seek services infrequently or face blame and social exclusion from her family and spouse [10].
Depression literacy (DL), a specific component of Mental Health Literacy (MHL), pertains to the ability to recognize symptoms and beliefs associated with depression, aiding in its management and prevention [11]. Various countries, including Australia [12], Canada [11], and the US [13], have conducted studies on DL, reporting a moderate level of understanding. Moreover, a recent study focusing on Iranian teenage girls indicated low depression literacy levels among this demographic [14-16].
Depression stigma reflects an individual’s negative attitudes and behaviors towards depression [17]. It is commonly categorized into personal stigma and perceived stigma. Perceived depression stigma involves the devaluation and rejection of individuals experiencing depression by others [18]. Stigma associated with depression serves as a significant obstacle for individuals with depression seeking professional help [19]. Research involving 1,312 adults highlighted that stigmatizing beliefs about depression could diminish the likelihood of seeking assistance from professionals like general practitioners, psychiatrists, and psychologists [20]. However, studies examining the link between depression knowledge and attitudes are limited, and existing findings often present conflicting results [21].
Attitudes towards mental health services play a pivotal role in determining whether individuals with mental health concerns, including depression, seek appropriate treatment. Positive attitudes can facilitate help-seeking behaviors and enhance treatment outcomes, whereas negative attitudes can pose barriers to accessing necessary support [22]. Previous studies have predominantly explored the correlation between mental health literacy and attitudes towards mental health services [23]. Research on the association between depression literacy and attitudes towards mental health services is limited.
Given the prevalence of depression and the significance of depression literacy and its related factors, this study aimed to investigate the level of depression literacy and its association with depression stigma and attitudes toward mental health services among Iranian women attending health centers in Saveh City.

Instrument and Methods
Study design and participants
This cross-sectional study was carried out from August to September 2023 involving 280 women receiving routine prenatal care at health centers in Saveh City. Using G-power, the sample size was initially estimated to be 138 (p=0.05 (two-tailed), power=95%, and correlation coefficient=0.3). Considering the utilization of cluster sampling, the sample size was adjusted to 207 by incorporating a design effect of 1.5. Furthermore, accounting for a projected 10% attrition rate, the final sample size was determined to be 228.
Inclusion criteria comprised having a health center file, a reachable phone number, and a basic level of education (i.e., reading and writing skills). Exclusion criteria included lack of cooperation and incomplete questionnaire completion.
Initially, the www.random.org website was utilized to select five health centers in Saveh, representing a quarter of all health centers. The researcher accessed Iran’s Integrated Health System (SIB) to obtain the list of women registered under the specified health centers along with their contact numbers. Subsequently, participants were randomly selected in proportion to the number of women served by each center. The researcher then contacted the participants via telephone to explain the study’s objectives and procedures and assess their eligibility based on the inclusion and exclusion criteria. If participants agreed to take part and met the criteria, the questionnaires were sent electronically (via platforms, like Telegram, WhatsApp, Ita, and Shad).
Data collection was done using the following questionnaires:
1) The socio-demographic questionnaire: This questionnaire was developed by the authors and validated by ten academics from the Iran University of Medical Sciences and included inquiries about respondents’ age, level of education, occupation, income, number of children, and other relevant details.
2) Depression Literacy Questionnaire (D-Lit): This questionnaire was developed and validated by Griffiths et al. and comprises 22 items aimed at assessing depression literacy status [24]. Responses to these questions are graded on a three-point scale (true, false, or I don’t know), with a scoring range of 22 to 66 points. Each correct answer is assigned a score, with higher scores indicating a better depression literacy status. In Griffiths et al.'s study, Cronbach’s alpha and the three-month test-retest reliability were reported to be 0.70 and 0.71, respectively [24]. In Tehrani’s study, the validity and reliability of the Persian version of the D-Lit questionnaire were examined. Through exploratory factor analysis, five factors with eigenvalues exceeding one were identified, explaining 56.30% of the variance (knowledge of psychological symptoms, knowledge of treatment method effectiveness, knowledge of cognitive-behavioral symptoms, knowledge of medication usage and side effects, and knowledge of disease severity) [3]. Confirmatory factor analysis validated these five factors, resulting in the elimination of one question and confirming a final questionnaire with 21 items and a scoring range of 21 to 63. The Cronbach’s alpha coefficient for the whole scale was 0.89 [3].
2) Attitude Toward Seeking Professional Psychological Help (ATSPPH) Scale: This scale was employed to assess attitudes toward seeking help. It consists of ten questions rated on a Likert scale from “1” (completely disagree) to “5” (completely agree). Participants with higher scores on the questionnaire demonstrate a positive attitude towards seeking help [25]. Sharifi et al. [26] conducted psychometric testing on this questionnaire. In Iran, factor analysis results indicated the validity of the ATSPPH-S model. Additionally, we obtained a Cronbach’s alpha value of 0.84.
3) The DSS-Personal Subscale: This tool comprises nine items rated on a five-point Likert scale (0=strongly disagree, 4=strongly agree) [24]. The total score (ranging from 0 to 36) is obtained by summing the scores of each item, with higher scores indicating a higher level of stigma toward mental illness. It has been widely used in population surveys [27, 28]. The internal consistency within our sample was calculated to be 0.824. We combined the categories of agree and strongly agree for each item to determine if the respondent exhibited personal stigma. Individuals with fewer than six entries indicating personal stigma were identified as having a personal stigma toward mental disorders.
Statistical analysis
Using SPSS 21, the obtained data were analyzed. Using the Kolmogorov-Smirnov test, the normality of the quantitative data was analyzed. Using central and dispersion indicators and frequencies (percent), respectively, the quantitative and qualitative variables were evaluated. Spearman's rank correlation coefficient test was used to examine the correlation between self-care performance and perceived stress levels in the bivariate correlation analysis. Adjusting for the confounding effects of sociodemographic and obstetric variables, univariate and multivariate regression analyses were also conducted to determine the correlation between self-care performance and perceived stress levels.

Findings
All 228 studied participants were women, with the majority of them (48%) having a high school diploma or higher, and a significant portion (77.7%) being housewives. About 61% of the women reported having a moderate financial situation, and the vast majority (85%) were married (Table 1).

Table 1. Frequency of demographic variables and mean score of depression literacy according to general characteristics


Among the components of the D-Lit Questionnaire, the highest percentage of correct answers was related to knowledge of disease severity (58.5%), while the lowest correct response rate was linked to knowledge of available treatment methods (15.4%; Table 2).

Table 2. Participants' response to the D-Lit Questionnaire


The mean scores of the D-Lit Questionnaire subscales, attitude toward seeking help, and personal depression stigma is shown (Table 3).

Table 3. Mean scores of the D-Lit Questionnaire subscales


In step 1, demographic characteristics emerged as significant predictors of depression literacy scores. These factors accounted for 9% of the variance in depression literacy scores (F=2.39; p-value=0.03), signifying that demographic variables contribute to approximately 9% of the variation in depression literacy scores. Subsequently, in step 2, the inclusion of attitude toward seeking help explained an additional 5% of the variance (F=18.02; p-value=0.01). Furthermore, the incorporation of depression stigma in step 3 elucidated an additional 9% of the variance (F=17.24; p-value=0.001). Collectively, variables, such as education level, attitude towards seeking help, and depression stigma could account for approximately 23% of the variation in D depression literacy scores (Table 4).

Table 4. Hierarchical regression analysis for variables predicting depression literacy


Discussion
This study assessed the level of depression literacy and its association with depression stigma and attitudes toward mental health services among Iranian women in Saveh City. The study’s outcomes revealed that depression stigma stands out as the most influential predictor of depression literacy among the female participants. These findings align with those of Pruksarungruang et al. in Thailand, who highlight that there is a significant correlation between depression literacy and personal stigma [21]. The study underscored the necessity for comprehensive mental health literacy initiatives that extend beyond merely imparting knowledge about depression to actively challenging and reshaping societal attitudes and perceptions. In addition to focusing on the clinical facets of depression, educational efforts should also tackle the social determinants that fuel stigma, including stereotypes, discrimination, and misinformation. These results underscore the importance of adopting a multifaceted approach to enhance depression literacy. This approach involves not only disseminating accurate information but also confronting societal norms, fostering empathy, and fostering supportive environments for individuals grappling with depression. The attitude toward mental health services emerged as another predictor of depression literacy among the women involved in this study. This finding aligns with prior research exploring the connection between mental health literacy and attitudes toward seeking help [23, 29]. Negative perceptions of mental health services, often stemming from societal stigma, can act as barriers that hinder individuals from seeking the vital support they require [30]. It is crucial to address these adverse attitudes to promote early intervention and enhance mental health outcomes.
Consistent with previous research [31, 32], this study revealed that the highest percentage of correct responses was linked to understanding the severity of the disease, while the lowest proportion was related to knowledge of the effectiveness of available treatment methods. The study’s findings suggest that the awareness campaign in Iran prioritizes patient awareness over information about treatment options. Nearly half of the participants were informed that numerous well-known figures have faced challenges with depression. In line with a Korean study [33], following media coverage of a celebrity’s suicide attributed to depression, there is an increase in individuals seeking psychiatric treatment the subsequent month. Such celebrity news helps the public understand that depression can impact anyone and provides insights into prevention and treatment strategies.
The study’s results highlighted a deficiency in participants’ awareness of the effectiveness of available treatment methods. A significant portion of the participants demonstrated a lack of knowledge about cognitive behavioral therapy (CBT). Specifically, nearly all participants (94.3%) mistakenly perceived counseling to be as effective as CBT for depression, which is consistent with a previous study [34]. A meta-analysis of 409 clinical trials conducted in 2023 revealed that CBT is as effective as drug therapy in the short term and more effective than supportive therapy in the long term [35]. Moreover, the majority of participants exhibited a lack of understanding regarding drug therapy. Almost all participants (92%) incorrectly believed that various treatments for depression were more effective than antidepressants. These findings have substantial implications for mental health professionals and the healthcare community. The participants’ limited knowledge concerning depression treatment methods suggests that current efforts to educate individuals about these treatments have been ineffective. It is crucial to undertake efforts aimed at delivering thorough and precise information regarding the available treatments for depression. Furthermore, the findings of this study underscore the significance of enhancing communication between healthcare providers and the general public to guarantee that individuals seeking treatment for depression are adequately informed about their treatment alternatives and the potential advantages of different treatment methods.
The study unveiled that participants had inadequate knowledge concerning the cognitive-behavioral symptoms of depression. For example, approximately 77% of the women in the study identified irresponsible and foolish behavior as common symptoms of depression, while 83% recognized that having multiple personalities could indicate depression. Failing to distinguish depression symptoms from those of other mental health disorders can lead to the stigmatization of individuals with depression and impede their access to timely treatment [11]. To foster precise comprehension and prompt individuals to seek help for depression and related mental health concerns, mental health education, and awareness initiatives should address and rectify these misconceptions.
In the realm of knowledge therapy and its impacts, more than half of the women provided incorrect responses to the inquiries. For instance, around 70% of the women in this study believed that antidepressants were addictive and acted rapidly. Misunderstandings regarding the addictive nature of antidepressants and the speed of their effects could dissuade individuals from seeking treatment, leading to untreated depression. To address these misconceptions, efforts should focus on promoting the use of reliable sources of mental health information. Numerous studies have explored the link between folate, vitamin D, B vitamins, and depression. However, systematic reviews have revealed a lack of evidence regarding the role of vitamins in treating individuals with depression [36]. Despite these scientific findings, approximately 88% of our participants perceived vitamins as the most effective alternative and lifestyle treatment for depression, mirroring the findings of an audio-recording investigation involving hospital employees in Iran [31]. In Iran’s healthcare system, such misinformation can pose a significant obstacle.
In line with Reavley et al.'s study in Australia, this research indicated that factors, like higher education levels and a background of consulting with a psychologist or psychiatrist can impact depression literacy [37]. Education, exposure to the disorder, and receiving professional support can influence depression literacy among Sri Lankan students [38].
This study underscored the critical importance of addressing depression stigma as a primary predictor of depression literacy among the participants. Negative attitudes towards mental health services, often stemming from social stigma, must be addressed to ensure individuals seek the necessary support. There is a necessity for more effective dissemination of information regarding depression treatment and the advantages of various methods. Improving communication between healthcare providers and the public is essential to empower individuals seeking depression treatment with informed choices. Efforts should also focus on correcting misconceptions surrounding depression symptoms and dispelling myths about treatments, including the role of vitamins and alternative therapies. Promoting credible mental health information sources is crucial to combat these misconceptions. Also, there are significant knowledge gaps concerning depression treatment methods, cognitive-behavioral symptoms, and misconceptions about therapy options.
Our study had limitations. First, due to the cross-sectional study design, a causal relationship cannot    be established. Second, the measurement of depression literacy was evaluated by self-report method. Third, this study was conducted only on the women in Saveh City, which may limit the generalization of the findings to women throughout Iran. Sampling in this study was done from public health centers, and it is suggested to include private centers in future works.

Conclusion
The level of depression literacy among Iranian women is insufficient. Factors, such as education level and prior exposure to mental health services affect depression literacy, aligning with findings from other countries.

Acknowledgments: The authors appreciate all women who participated in this research and all those involved in this study.
Ethical Permissions: This study was conducted in compliance with the Helsinki Declaration and all relevant laws and received approval from the Ethics Committee of Iran University of Medical Sciences (IR.IUMS.REC.1401.713).
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Saboohi Z (First Author), Discussion Writer/Main Researcher (25%); Solhi M (Second Author), Statistical Analyst/Main Researcher (25%); Hajihashemi M (Third Author), Introduction Writer (20%); Nouri R (Forth Author), Methodologist (%15); Nazarnia M (Fifth Author), Assistant Researcher (15%)
Funding/Support: This project was funded by the National Agency for Strategic Research in Medical Education, Tehran, Iran (Grant No.: 960360).
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Health Education and Health Promotion
Volume 12, Issue 2
Spring 2024
Pages 231-241