Depression Literacy of Women and Girls in Terms of Prevention and Interventions.

Objective: Recognizing the status of mental health literacy among women and girls as effective and key individuals in family and society seem to be essential. Therefore, the present study was conducted to evaluate depression literacy among women and girls in Tehran on prevention and effective interventions for improving depression. Method : This study was part of a large mental health literacy project on residents of Tehran in 2017, with a sample size of 1023 girls and women aged 16-68 years. Random Digit Dialing (RDD) sampling was done using the Australian questionnaire, whose Persian version's validity and reliability was tested in our previous study. Data were analyzed by SPSS 21 software. In order to determine the effect of demographic variables on predicting depression literacy among participants, multiple regression analysis was performed.
Results: Receiving counseling, relaxation training, having physical activity, and studying self-help books were the most helpful items, respectively, from the participations' point of view. More than 70% of participants agreed with avoiding stressful situations and close relationship with family and friends, while only 49.8% agreed with coping skills learning. Based on the regression analysis, only higher education and the history of exposure to a person with similar Vignette problem were able to predict mental health literacy in the area of intervention and prevention.
Conclusion: Considering the effects of women's and girls' depression on individual, family, and even social life, more attention should be paid to improve depression literacy in this group.

Based on World Health Organization (WHO), the health of women and girls is of specific concern because they are disadvantaged by discrimination due to sociocultural factors (1). Gender is considered as a major influential factor for health, including mental health and mental illness (2). Improving mental health is an important strategy for achieving social indicators of development and can affect all aspects of people's lives (3). In addition, attention to the differences between women’s and men’s health risks, health status, and access to services will make the function of Universal Health Coverage (UHC) systems better. Without a clear focus on the comprehensive women’s health needs beyond their reproductive role, UHC goals will not be achieved (4). The stress of women’s multiple roles, gender discrimination, and related factors with poverty, hunger, malnutrition, high labor, domestic violence, and sexual abuse affect women's health (5). Analysis of mental health indicators shows that patterns of psychiatric disorder and psychological distress are different among women than men. Depression, anxiety, and psychiatric disturbances symptoms are more common among women than men (2). According to the World Health Organization, depression disorders in women account for almost 41.9% of disability due to psychiatric disorders, while this is 29.3% for men (5).

In addition, depression is not only the most common problem in women's mental health, but may be more resistant in women (5). On the other hand, mental health problems can have serious consequences, including insomnia, drug use, and alcohol consumption, conflict with family and friends, illness, and suicidal thoughts (6). When a woman becomes mentally ill, services may be rarely and lately sought or she may be blamed and rejected by the family and the spouse (7).

Many people, due to personal and structural problems, such as stigma, and concerns about confidentiality, lack of service awareness, the notion that mental distress reflects only a temporary crisis at a particular age, and the lack of appropriate responses from people around them, may not seek appropriate help for mental health problems (8-9). Some of these problems can be linked to limited mental health literacy (10). Mental health literacy is knowledge and beliefs about mental disorders that help prevent, diagnose, and manage these disorders (11). Mental health literacy includes identifying psychiatric disorders to facilitate quick search help, professional help knowledge, existing therapies, and effective self-help strategies, skills for giving first-aid psychology to others, and knowledge about how to prevent mental disorders (12).

Although mental health literacy is essential for having a healthy life, research shows that its level is not appropriate among people (13). Individuals with low level literacy are at risk of both physical and mental illnesses and are more likely to pay for treatment than those with a good mental health literacy level (14). Unfortunately, more than 70% of people with mental illness do not receive any treatment from health services around the world (15). Only about 40% of women with depression are diagnosed by health care providers, and a significant proportion of them do not receive proper treatment for their depression symptoms (16).

For preventing mental health problems in a society, paying attention to women and girls is highly important, and preventive measures such as education, support, and planning for these people are of high priority (17). Accordingly, considering the direct effect of mental health literacy on improving the community mental health and assessing the status of mental health literacy among women and girls as key and effective individuals in the family and society seem essential; then if necessary, focusing on its improvement could be considered.

Few studies have been published in the field of mental health literacy and women's depression literacy in Iran. Among these few studies, Bahrami determined the level of mental health literacy among limited number of high school girls in Chabahar (18). Noroozi studied the relationship between mental health literacy and health-promoting behaviors in adults in Bushehr (19). Therefore, considering the importance of mental health literacy among women and girls, the present study was conducted to evaluate girls’ and women’ depression literacy in Tehran regarding prevention and effective interventions for depression treatment.

Materials and Methods

This study was part of a large mental health literacy survey on residents of Tehran in 2017, with a sample size of 1023 girls and women aged 16-68 years. For various reasons such as the lack of free time, people do not fill out a questionnaire or participate in a face-to-face interview, and popularity of telephone interview is increasing day by day among people and researchers. Thus, in this study, Random Digit Dialing was used for sampling (20). Regarding the importance of observing the correct principles for a random sampling without bias, the telephone numbers were randomly selected using the Excel software from Tehran telephone numbers and telephone. To reduce the number of nonresponse rate, different methods, such as several time ringing and leaving message on answering machines were performed. Intended sample for the study was recruited by selection inside the household. From each household, after obtaining verbal consent, interview with all individuals in intended age range without any physical, mental or speech disorder was performed. At the time of sampling, questionnaires that were completed less than 80% were excluded. The interviewers received required training from the project managers before starting the study. A phone interview guide was provided to the interviewers.

In order to prepare data gathering tool, we first searched valid global questionnaires. Finally, the Australian questionnaire was selected that has been used in several national and international studies (21). Mental health literacy has been defined as “knowledge and beliefs about mental disorders, which aid their recognition, management or prevention” and was first defined by Jorm et al in Australia (22). The original version of the questionnaire was received from developers. The validity and reliability of the Persian version have been tested in our previous study (20). The validity was approved by experts with Content Validity Index (CVI) of 0.86. Total Alpha Cronbach's score was acceptable (0.84%) and removal of any of the subscale items would result in a decrease in Alpha value. Reliability was checked using pretest-posttest method on 20 individuals with 2-week interval, and internal-class correlation coefficient (ICC) was 0.83.

The fields of this questionnaire include recognition; intended actions to seek help and perceived barriers; beliefs and intentions about first aid; exposure to mental disorders; stigma; beliefs about preventions and interventions. In this study, after introducing a vignette of depression, the depression literacy of participants in the field of beliefs about prevention and interventions to improve depression was evaluated. Psychiatric disorder of vignette could be selected according to the researcher's opinion. For example, introduction of vignette with depression, which is one of the most common psychiatric problems in public, is as follows:

“Maryam/Ali is a … years old person who unusually feels sad and miserable in the last few weeks. She / He is always tired and hardly sleeps at night. Maryam/Ali is not interested in eating and is suffering from weight loss. She/ He cannot concentrate on the study and has dropped in academic level. She/ He cannot make a decision, and even doing his daily routines is beyond his / her ability. Her/ his parents and friends are very worried about her/ him.”

The gender and age of the person introduced in the vignette were matched to the contact group.

For asking about socioeconomic status, due to the large number of questions and considering experts' opinion in the field of questionnaire design, a single question that was most likely to be objective was selected. The identity of participants was kept confidential, and the information was entered into SPSS by code instead of participants' names. This study was approved by the Ethics Committee of Tehran University of Medical Sciences and Health Services (IR.TUMS.REC.1394.1991).

Data were entered into SPSS 21 software for analysis. The descriptive findings were reported and statistical tests were used based on the type of variables. In order to determine the effect of demographic variables on predicting depression literacy among participants in the field of prevention and intervention, multiple regression analysis was performed. For this purpose, the correct and incorrect answers were recoded into 1 and 0, respectively. The total scores were 0 to 13 according to the number of items. The presumptions of multiple regression were observed. In this regard, independent variables were dummy coding. This study was performed on 1023 samples, so statistically, the dependent variable distribution can be assumed as normal. In addition, the number of samples was more than 10 times of the number of desired variables. Descriptive variables were independent. Age was classified into 2 groups higher and lower than the mean age of 35. P value less than 0.05 was considered statistically significant.

Results

Finally, 1023 completed questionnaires were analyzed. The mean age of participants was 34.5 ± 12.5 years. The participants’ demographic information is presented in Table 1.

Table    1 

Participants' Age, Marital Status, Education, Occupation, Socioeconomic and Exposure Characteristics

Variable		Number	Percent
Age	<35 years	550	53.8
	=>35 years	473	46.2
Marital status	Married	369	36.2
	Single (not married, divorced or widowed)	651	63.8
Education	=<diploma	395	38.6
	>diploma	628	61.4
Occupation	Employed	314	30.7
	Non employed	472	46.1
	Student	237	23.2
Socioeconomic level (monthly)	=< 2.5 * 107 (rials)	531	51.9
	> 2.5 * 107 (rials)	491	48.1
Exposure (Has anyone in your family or close circle of friends ever had a problem similar to vignette?	Yes	603	58.9
	No	420	41.1

Most of participants were single (63.8%) and older than 35 years (53.8%) with education degree above diploma (61.4%). Of them, 41.6% was unemployed with monthly income equal or lower than 25 million Rials. Also, 58.9% of participants expressed that they have had exposure to someone in their family or close friends with a problem similar to vignette.

The results of depression literacy about interventions and prevention are presented in Table 2.

Table    2 

Participants' Beliefs and Knowledge about Depression Prevention and Related Interventions

		Number	Percent
People who could possibly help vignette	GP or family doctor	432	42.2
	Psychologist or psychiatrist	644	63.1
	Close family member	605	59.1
	Close friend	620	60.7
The items that are likely to be helpful for vignette	Getting relaxation training	813	79.6
	Receiving counseling	834	81.5
	Reading a self-help book on (his/her) problem	565	55.4
	Joining a support group of people with similar problems	426	41.9
	Looking up a web site giving information about (his/her) problem	453	44.5
	Going to a local mental health service	477	46.9
	Being admitted to a psychiatric ward of a hospital if necessary	370	36.3
	Becoming more physically active	798	78
The item would reduce the risk of developing a problem like vignette	learning to avoid becoming stressed in the first place and taking actions to decrease stress when it occurs	839	82.7
	Keeping regular contact with friends	766	74.9
	Keeping regular contact with family	862	84.3
	Learning coping skills	509	49.8
Duration required for treatment	If vignette does not feel any tangible improvement after 5 days using prescribed meditation, which action do you consider appropriate? (Need to continue treatment answers)	564	55.2

In the area of people who could possibly help vignette, "psychologist or psychiatrist" and then "close friend" were the most popular individuals.

Based on findings "getting relaxation training" (79.6%) and "receiving counseling" (81.5%) were 2 items with the most number of positive points regarding their helpfulness.

Considering the items that would reduce the risk of developing a problem like vignette, most participants mentioned "keeping regular contact with family" and "learning to avoid becoming stressed in the first place and taking actions to decrease stress when it occurs."

As seen in Table 3, in multiple regression analysis among the variables studied, age, higher education, and history of exposure to a person with a similar problem to vignette were significantly able to predict mental health literacy in the field of intervention and prevention. Adjusted R square for the obtained model was 0.11 (P < 0.001).

Table    3 

Predictors of Scores on Depression Intervention/ Prevention Beliefs Scale Using Multiple Regression

Variable		Subgroup score (Means ± SD)	Unstandardized Coefficients (Standard Error)	Standardized CoefficientsBeta	P value	95% Confidence Interval for B
(Constant)			7.1 (0.3)		<0.001	6.5 - 7.8
Age	<35 years*	7.8 ± 2.3	0.3 (0.2)	0.07	0.032*	0.03 – 0.7
	=>35 years	8.6 ± 2.3
Marital status	Married	7.9 ± 2.3	0.05 (0.2)	0.01	0.75	-0.3 – 0.4
	Notmarried (Single, divorced or widowed)*	8.4 ± 2.3
Education	=<diploma*	7.8 ± 2.3	0.3 (0.2)	0.07	0.031*	0.03 – 0.6
	>diploma	8.3 ± 2.3
Occupation	Employed	8.3 ± 2.3	0.02 (0.1)	0.005	0.8	-0.2 – 0.2
	Non employed	8.3 ± 2.3
	Student*	7.5 ± 2.3
Socioeconomic level (monthly)	=< 2500 * 1000 (rials)	8.2 ± 2.3	-0.07 (0.1)	-0.02	0.53	-0.3 – 0.2
	> 2500 1000 (rials)	8.0 ± 2.3
Exposure	Yes	8.7 ± 2.2	1.3 (0.1)	0.3	<0.001*	1.0 – 1.6

Discussion

This study assessed the depression literacy in girls and women in Tehran regarding prevention and effective interventions for improving depression.

Mental health literacy studies in different countries have been conducted with different tools, the general findings of which are discussed below. Nonetheless, some studies have been done with the same tools as ours, which allowed for detailed comparison of results.

Bahrami conducted a study on 65 high school girls in the city of Chabahar in Iran, which examined the relationship between mental health literacy and general health. This study showed that high school girls had moderate levels of mental health literacy and emphasis was placed on improving mental health literacy in all societies, but there was no relationship between general health and mental health literacy in students (18).

Noroozi studied the relationship between mental health literacy and health-promoting behaviors in a study of 378 adults aged in Bushehr, Iran. This study showed that mental health literacy was slightly higher in women than in men, and there was a significant relationship between mental health literacy level with educational level and history of mental illness (19).

Arafat examined depressive literacy in 306 students in Bangladesh who reported poor literacy levels (23). Arafat in another study showed that there was no significant difference between depressive literacy of male and female students in Bangladesh (24).

Ram in a study on 339 health care professional students in India studied depression literacy and suicide literacy and showed that depressive literacy scores were higher in females (25).

The present study showed that answering to the question about a helpful person who can help in the event of a psychiatric disorder, most participants believed that psychologists or psychiatrists could be helpful, a friend and family were next ranked, and the general practitioner or family doctor was the last.

In Sayarifard study, friends and then the family were introduced as the best helper, followed by psychiatrists and psychologists, and general practitioners (20). However, based on Reavley study, students in Australia believed that the most effective interventions are delivered by general practitioners, followed by friends and family, counselors, psychologists, and psychiatrists (26).

Also, Australians believed that general practitioners are the most effective (27). Considering the presence of general practitioners or family physicians in the first level of providing health services, including mental health.

In the case of actions which could be helpful, in this study, receiving counseling, relaxation training, physical activity, and studying self-help books were the most items mentioned by participants, respectively, similar to those found in Sayarifard and Ravley studies among students (20, 26). In Australians and the Japanese, increased physical activity and relaxation were identified as helpful interventions by participants (27, 28).

Concerning the issue of joining to groups with similar problems, less than half of the participants agreed on the helpfulness of this approach, while in the Reavley study, this item was considered by the public in Australia as an effective intervention (27). The reason for this contradiction may be the lack of Iranian women’s and girls’ awareness about this treatment, which in any case needs to be further investigated. Using educational websites, informing about valid and relevant sites can be helpful.

Regarding the agreement of the majority of participants on the unhelpfulness of hospitalization, it seems that there is still stigma among Iranian women and girls. Therefore, it is necessary to plan and perform appropriate interventions for reducing stigma in this group. However, studies from other countries revealed that most people, almost similar to current study, prefer to use general and informal interventions rather than professional interventions and services (29). Therefore, it seems that designing interventions for improving health literacy at the community level are preferred.

Considering the helpful items on preventing depression, more than 70% of participants agreed with avoiding stressful situations and close contact with friends and family, while less than half agreed with learning coping skills. Results were consistent with the study by Holubova et al in Czech Republic in which participants with depression tended to use negative coping strategies such as strategies to escape stressful situations (30).

The results of Moghanibashi et al in Iran showed that coping skills training for female students had a positive effect on reducing depression and increasing well-being (31). Therefore, education and emphasis on the necessity of learning coping skills among public, especially women and girls, is of great importance. Using coping skills properly can greatly contribute to the prevention of mood disorders, especially depression.

About half of the participants declared that medication consumption should not continue. The results of this study were similar to those of Ram et al, in which patients had poor knowledge about physiological and medical treatment for depression (32). Given the availability and cost-effectiveness of antidepressant medications, according to the World Health Organization, only one-third of depressed people use appropriate medical treatments, which could be due to factors such as patients’ mistrust in antidepressants and public negative attitudes toward depression and medication therapy (33). This view can hinder the correct use of antidepressants and bring up doubt about medical treatment for psychiatric disorders. Thus, necessary training on medication therapy, its specific characteristics and considerations, such as late advent of the therapeutic effects, will be useful.

Findings of this study showed that factors such as age, higher education, and history of depression can affect depression literacy, which was similar to Reavley study in Australia (21). Amarasuriya study also revealed that gender, education, exposure to disorder, receiving help, and stigma can affect depression literacy in Sri Lankan students (34).

In response to the question "Have you or your relatives ever had a similar problem?" more than half of responses was positive. Although in this study depressive disorders of participants’ relatives were not assessed, this finding reflected the prevalence of psychiatric disorders from participants’ point of view and indicated the importance of further investigation, and if necessary, performing preventive measures for all people in the society.

Limitation

Participation in the study was voluntary, it was likely that people with a greater awareness and interest in mental health issues have participated in the study. In addition, the study was conducted in Tehran and may not be generalizable to the whole country.

Conclusion

In general, depression literacy of women and girls in Tehran needs to be improved. Based on the findings of this study, increased age, higher education, and previous exposure are predictors of higher depression literacy among women and girls in the field of prevention and effective interventions. Given that mental health problems, such as depression, are more common among women and girls, and the consequences of these problems may affect their individual, family, and social life, promoting depression literacy in this target group is inevitable.