Mental Health Literacy: knowledge and beliefs of an adolescent population

INTRODUCTION

Health literacy has been gaining prominence in the last few decades and is currently a key concept tin health prevention and promotion and in disease management. The World Health Organization (WHO) defines it as the achievement of a level of knowledge, personal skills and confidence to take action to improve health.¹

In fact, several studies reveal that inadequate health literacy levels have profound repercussions on health, quality of life, morbidity and mortality as well as the inappropriate use of health are resources, which ultimately has a negative economic impact on health care systems (estimated at approximately 5% of the total cost in a region).¹ In contrast, high levels of health literacy are associated with positive outcomes. More specifically, there is evidence of improvements in health indicators, population welfare, use of health services and active and informed participation of citizens, as well as reductions in health risk behaviours, health care expenditures and health inequities, with increased resilience of communities against challenges and crises and social enrichment.¹

While the importance of health literacy for physical health is widely acknowledged, the area of mental health literacy has been comparatively neglected.

In the mental health field, in 1997, Jorm et al. defined mental health literacy (MHL) as knowledge and beliefs about mental disorders which aid their recognition, management or prevention. In the most recent definition, it also encompasses the ability to provide first aid for individuals that are developing a mental health disorder or who are in crisis.^2-4

An aspect that is particularly relevant as regards MHL is the high incidence and prevalence of mental health disorders in the general population. Based on some studies, practically every person will experience mental illness or have close contact with someone with a mental illness.⁴

In this study, our aim was to assess and characterised the MHL level of a population of adolescents enrolled in secondary school in an inland city.

An additional objective was to assess whether close contact with mental illness had an impact on the level of MHL in this area.

MATERIAL AND METHODS

We conducted a cross-sectional study in a sample of adolescents enrolled in secondary education in a group of schools in the city of Guarda, Portugal.

At the outset, the parents/legal guardians received informed consent forms for participation containing a detailed description of the study. After obtaining informed consent, the questionnaire was distributed to the students to be completed anonymously in the classroom.

The inclusion criteria were being enrolled in secondary education, authorization from the parents for participation and normal cognitive development. The exclusion criteria were absence of parental/guardian consent and incomplete or incorrect completion of the questionnaire.

We administered the standardised version of the Mental Health Literacy Questionnaire (MHLq) adapted for the Portuguese population. It is a questionnaire comprised by 29 items rated on a 1-5 Likert scale (1: strongly disagree; 5: strongly agree). Items were organised in 4 subscales: knowledge of mental health disorders (subscale 1); beliefs/stereotypes (subscale 2); first-aid skills (subscale 3) and self-help strategies (subscale 4). In addition to the score in the subscales, there is a global score obtained from adding the answers for all the items. Higher scores are indicative of greater knowledge in mental health.

In addition to completing the questionnaire, we obtained information from the adolescents on their age, sex, year of school and presence of mental health illness in the family.

The statistical analysis was performed with the software SPSS for Windows® version 27. In the inferential analysis, we considered p <0.05 statistically significant. We compared the mean values in the different subscales with the Student t test.

RESULTS

A total of 485 informed consent forms were given out (to every secondary education student of the Afonso Albuquerque school group, Guarda). Of this total, only 185 were completed by parents/legal guardians authorising students to participate in the study.

To this group, we administered the Portuguese adaptation of the MHLq in the classroom. We obtained a total of 179 correctly completed questionnaires.

The average age of students in the sample was 16 years (minimum, 15; maximum, 20), and 54% were female. The 12^th year had the most students participating. Forty-three respondents (24%) reported mental illness in the family. In the analysis of the scores obtained in the MHLq, we found a mean score of 122 (standard deviation, 8) out of the possible maximum score of 145.

When we compared student sex to the global score and subscale scores, we found a statistically significant difference between male and female students in the score of subscale 2 (male: 55.92; female: 57.34; p = 0.02) (Table 1).

SD: standard deviation.

Table 1. Differences in questionnaire scores based on sex and presence of mental illness in the family (Student t test for independent samples, statistical significance defined as p <0.05)
	Sex			Presence of mental illness in the family
	Male	Female	p	No	Yes	p
Total score. Mean ± SD	121.57 ± 7.88	123.43 ± 8.15	0.126	122.01 ± 7.50	124.49 ± 9.48	0.079
Subscale 1. Mean ± SD	70.54 ± 5.52	71.33 ± 5.47	0.343	70.54 ± 5.29	72.40 ± 5.92	0.053
Subscale 2. Mean ± SD	55.92 ± 4.03	57.34 ± 3.98	0.02	56.13 ± 4.04	58.56 ± 3.53	0.001
Subscale 3. Mean ± SD	36.97 ± 4.18	37.48 ± 4.21	0.425	37.29 ± 3.16%	37.14 ± 4.93	0.834
Subscale 4. Mean ± SD	38.38 ± 3.04	38.35 ± 3.3	0.951	38.31 ± 2.87	38.53 ± 4.04	0.686

On the other hand, when it came to the association between mental illness in the family and questionnaire scores, we found a statistically significant difference in the scores in subscale 2 based on the presence or absence of mental illness in the family (absent: 56.13; present: 58.56; p = 0.001) (Table 1).

Another salient finding was that adolescents that reported mental illness in the family had higher global scores in the questionnaire compared to those who did not (p = 0.079). It is also worth noting that when it came to knowledge of mental health disorders (subscale 1), adolescents that reported mental illness in the family scored better than adolescents that did not, with a p-value that neared the threshold of significance (absence of mental illness: 70.54; presence of mental illness: 72.40; p = 0.053) (Table 1).

DISCUSSION

The study included 179 youth aged 15 to 20 years, with a majority of female students, enrolled in years 9 to 12 of compulsory education in Portugal. Although the sample was not large, there was a certain proximity to mental health problems (about ¼ of respondents reported contact with mental illness), which was consistent with the high prevalence of mental health disorders in the general population described in the international literature.⁵

Several previous studies have sought to analyse the impact on MHL of variables like sex or proximity to mental health problems.

The first nationwide mental health survey conducted in Portugal, coordinated by the psychiatrist Caldas de Almeida in the framework of a global initiative led by Harvard University and the WHO, revealed that Portugal had the highest prevalence of mental health disorders in Europe, with an annual prevalence of mental health disorders of 22.9%, a prevalence of anxiety disorders of 16.5% and of mood disorders of 7.9%.

As regards the paediatric age group, the WHO estimates that approximately 20% of children and adolescents suffer mental health disorders (chiefly anxiety, depression, suicidal ideation/risk and substance disorders) and that approximately half of this group go on to have mental health disorders in adulthood. However, in most cases, adolescents receive help late or do not receive it at all.⁴

The synthesis report on health literacy in Portugal of the Fundação Calouste Gulbenkian (2016) describes a level of health literacy that is slightly lower compared to the mean in the European Union, and below what would be desirable.⁶ As regards MHL in particular, the observed lack of knowledge and skills on the subject is not only a barrier to the detection of a potential problem, but also fosters negative and discriminatory attitudes and behaviours that contribute to personal and social stigmatization.

Loureiro et al. (2013) propose that adolescence is a decisive stage for acquiring knowledge and behaviours that will persist in adulthood. Thus, there are multiple reasons why early intervention to promote mental health in youth is important: the high prevalence of mental health problems in adolescence (keeping in mind that, even if they are treated later, they do start at a young age), the fact that the stigma associated with mental health problems seems to emerge from age 5 years, and the low MHL level, which has an impact on seeking professional help.^7,8

In the sample under study, we found a statistically significant association between female sex and subscale 2 (beliefs/stereotypes about mental health disorders), several studies in youth conducted in the past decade have reported similar results, specifically with higher levels of MHL in female participants, which may be partly explained by the greater prevalence of mental health disorders in female adolescents described in the previous literature (such as depression or anxiety disorders) or because female individuals may be more willing to seek help for mental health problems, while male individuals may tend to deny or hide them.^2,5,9

We also found a statistically significant association between proximity to mental health disorders and the mental health disorder beliefs/stereotypes dimension, and a marginally significant difference between the total score in the MHLq and the presence of mental illness in the family. These results were consistent with the existing evidence, as previous studies have also shown that individuals exposed to mental illness in family members had significantly higher levels of MHL, and another relevant aspect in this dimension is the potential impact that close proximity to a family member with mental illness may have in adolescents, as it may lead to greater communication and learning about mental health.⁵

We also found that a high proportion of the informed consent forms distributed to all eligible students in the population of interest were not completed (62% of the total), which may be associated with the social stigma associated with mental illness.

CONCLUSION

Mental health literacy is an evolving field in health that is growing in importance.

A better understanding of MHL is possible using instruments like the MHLq, which allow objective evaluation of the knowledge of a given population on this particular area, overall and in its specific components, to develop targeted interventions at the individual and population levels.

The sample under study exhibited an adequate mental health literacy level, and proximity to mental illness in the family had a positive impact on the MHLq results.

The chief limitations of the study are its relatively small sample size and it being limited to a single geographical region, which precludes extrapolation of the findings to the national level.

Using the findings of the study, we intend to hold mental health literacy workshops in every school in the health district of Guarda, seeking to improve knowledge in this area, as today’s adolescents are tomorrow’s adults.

In the future, it would be important to carry out a nationwide study to determine the level of MHL in adolescents throughout Portugal.

CONFLICTS DE INTEREST

The authors have no conflicts of interest to declare in relation to the preparation and publication of this article.

ABREVIATURAS

MHL: mental health literacy · MHLq: mental health literacy questionnaire · WHO: World Health Organization.

REFERENCES

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