Rural Australians' Mental Health Literacy: Identifying and Addressing their Knowledge and Attitudes

David Pierce^1* and Clare Shann²

¹Rural Health Academic Centre, The University of Melbourne, 806 Mair Street, Ballarat, Victoria 3350, Australia

²Beyondblue, PO Box 6100, Hawthorn West, Victoria 3122, Australia

Corresponding Author:

David Pierce
Rural Health Academic Centre
The University of Melbourne
806 Mair Street, Ballarat
Victoria 3350, Australia
Tel: +61 3 4301 6810
Fax: +61 3 5332 4519
E-mail: d.pierce@unimelb.edu.au

Received Date: March 12, 2012; Accepted Date: April 09, 2012; Published Date: April 11, 2012

Citation: Pierce D, Shann C (2012) Rural Australians’ Mental Health Literacy: Identifying and Addressing their Knowledge and Attitudes. J Community Med Health Educ 2:139. doi: 10.4172/jcmhe.1000139

Copyright: © 2012 Pierce D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Keywords

Mental health; Rural; Depression; Mental health literacy

Introduction

The health burden of depression and related disorders is well established, with one in twenty adults experiencing major depression in any twelve month period [1]. Whilst local variation may occur the overall prevalence of depression in urban and rural areas is similar [2]. However, the experience of depression and its impact may differ in rural and urban areas. Depression may have a greater impact in rural areas. Limited availability of mental health professionals [3], less likely treatment of a mental health condition [4] and lower levels of mental health literacy compared to major cities [5] may result in greater impact of depression in rural communities. Other related factors that may increase the impact of depression in rural areas include mental health stigma. Addressing the impact of depression in rural areas may require initiatives that focus on the dual barriers of limited awareness of mental health conditions and pathways to seek effective help and limited access to health care when a mental health need is recognised.

Mental health literacy has been defined as knowledge and beliefs about mental health disorders which aid recognition, management and prevention [6]. It includes: capacity to recognise specific psychological distress e.g. depression; knowledge and beliefs about causes, risk factors, self and professional help; and attitudes which support recognition and help-seeking behaviour [7]. Mental health literacy has been described as an essential prerequisite for early recognition and consequently early intervention in mental health conditions [8]. Increased mental health literacy may result in empowerment to respond to mental health difficulties with increased confidence to help someone experiencing mental health problems [9]. Access to mental health services may be enhanced through greater understanding of mental health issues and how to access available services. A recent review of mental health literacy approaches identified the need for research focused on the best ways to achieved enhanced mental health knowledge and help-seeking behaviours [10].

A range of approaches to address mental health literacy have been reported including whole of community campaigns, training for individuals and targeted approaches for young people [10]. One such approach, undertaken in Australia since 2004 by Beyondbluea, is the National Workplace Program. This evidence-based program provides mental health awareness messages to individuals, employers, managers and staff in the workplace. It is an awareness and early intervention program promoting mental health literacy and is delivered by facilitators with a mental health qualification and experience. Evaluation of this program suggests it is associated with increased understanding of common mental health problems including what depression is like, reduced stigma towards those experiencing depression and increased confidence in assisting someone experiencing depression, anxiety or related disorder [11].

[^aBeyondblue is a national, independent, not-for-profit organisation working to address issues associated with depression and anxiety in Australia]

The paper reports research, undertaken during 2008/09 in rural Australia that was informed by the experience of the National Workplace Program. The research aimed to investigate the knowledge and views about depression of those expressing interest in attending a depression information workshop. A secondary aim was to identify any changes in mental health literacy following such a workshop and investigate the experience of those who attended such a workshop. Investigation of potential participants’ knowledge and beliefs about depression may allow more precise targeting of future rural depression literacy initiatives. The research also tested the application of the National Workplace Program by presenting the workshops used in this program in a new setting, i.e. with rural community groups rather than as previously in the workplace.

A number of rural community groups had requested information about depression for their members. Project participants were drawn from these existing community groups. Workshops were offered in response to those requests and aimed to promote increased knowledge about depression, earlier recognition of depression, greater understanding of how to seek help for depression especially where resources are limited and improved knowledge of evidence based treatment options. Equally they intended to promote positive attitudes to depression. Approaches promoting behaviour change to adopt helpful responses to depression in self or others are likely to be most effective if they target barriers to helpful responses [12]. Barriers may include limitations of knowledge about and/or attitudes to depression. This research aimed to investigate potential knowledge and attitudinal barriers in a group of rural residents expressing interest in depression workshops. The findings of this research may inform the planning of future depression literacy initiatives by facilitating targeting of identified barriers to helpful responses to depression in self and others.

Method

The project was undertaken by Beyondblue, The University of Melbourne and a Victorian rural Primary Care Partnership (PCP). It aimed to investigate the knowledge about and attitudes to depression and those experiencing depression of rural residents who had expressed interest in knowing more about depression. A secondary aim was to assess the expectations and experience of rural participants in a depression information workshop. This PCP had links to 32 health, education and human service agencies. Using the resources of the PCP, a convenience sample of members of small rural community groups who had expressed interest in an information workshop about depression for their members was recruited.

A mixed method was used providing data from questionnaires and from focus groups. Initial data collection, before workshop participation, utilised a questionnaire and focus groups. Immediately, following workshop participation, additional limited survey data about workshop experience were collected. Finally, four to six months after workshop participation final data were collected using the same questionnaire as used at the initial data collection. The questionnaire was developed from and similar to one used in the Beyondblue Workplace Program. It assessed: participant personal mental health experience, views on depression risk, impact of depression with comparison to other conditions, attitudes to depression and those experiencing depression, views on a range of depression treatments, and participants’ self reported depression knowledge and confidence in responding to depression. Demographic data were collected only in the initial questionnaire.

To assist utilisation of project findings in planning of future mental health literacy initiatives it was felt important to investigate participants’ views of depression before those views may have been influenced by workshop participation. Focus groups were therefore, conducted before workshop participation. Focus group data were collected to complement data obtained in the initial questionnaire. Two focus groups were held before the workshops. Each lasted one hour, was planned to have between five and eight participants, and was facilitated by a member of the research team. Key questions used to initiate discussion in the focus groups included: what depression is; where people get information about depression; why people might want to participate in a depression workshop and issues about depression that may be specifically important to rural residents.

Following initial data collection using questionnaires and focus groups, participants were invited to attend a depression information workshop using material previously developed for the Beyondblue National Workplace program. The workshops included information about depression and related disorders, and promoted less stigmatising attitudes to depression and those experiencing depression, and confidence in adopting evidence supported responses to depression. Workshop facilitators were experienced mental health professionals who were trained and credentialed by Beyondblue to undertake this role.

The project received ethics approval from The University of Melbourne. Participants consented in writing before data collection commenced. Data analysis was undertaken using SPSS version 18. Prepost comparisons between initial and follow-up were undertaken using Wilcoxon signed rank test on matched pairs. Spearman’s rho was used for correlation analysis. Statistical significance was set as p<0.05. Focus group interviews were transcribed. These transcripts were read and reread. Data analysis focused on participants’ views of depression and those experiencing depression, views on obtaining information about depression, and expectations of a depression workshop. In addition, specific issues about depression in rural areas were noted.

Results

Data presented below were obtained from both questionnaires and focus groups. Focus group data were collected at the beginning of the project only, before participation in a depression information workshop. All other data originated from questionnaires. Findings that compare initial and final questionnaire data are indicated. Otherwise data may be assumed to be from the initial questionnaire before participation in a depression information workshop.

Demographics

Individuals from five established community groups, including a land care group, a school parent support group, a women’s wellbeing group and community house support group were recruited to the project. All participants had expressed interest in learning more about depression through an information workshop. Two of the groups included health promotion in their activities. The population of the communities in which the five participating groups were located varied greatly as indicated below in Table 1.

Table 1: Community population of participating group location.

Four of the five groups were located in small population rural communities which had recently experienced prolonged drought. The group from the largest population centre was located on the edge of a provincial city, immediately adjacent to and linked to surrounding drought affected rural areas.

A total of 38 individual participants took part; participant group size varied from 6-10. Local issues prevented all six members of one group from participating in a workshop. Initial questionnaire data were available from all 38 participants and follow-up (post workshop) data from 25 of the 32 who attended a workshop. In addition, 13 individuals participated in two focus groups held before the workshops, with 5 and 8 participants respectively.

Participants were mostly female, (30/38; 79%), over the age of 40 (29/38; 76%), married or living with a partner (27/38; 71%) and well educated with (26/38 - 68%) having completed some post secondary education. Most (27/38; 71%) were working either full time or part time with smaller numbers being unemployed (5/38; 13%) or retired (5/38; 13%).

Most (31/37; 84%) felt well supported by their family and/or friends. Similarly most (32/38; 84%) rated their personal health as good, reporting a 4 or 5 point score on a 5 point scale.*

* [scale ranged from 1: most negative to 5: most positive]

Experience of depression

Slightly more than one in ten (4/38; 12%) of participants reported experiencing current depression, with almost one in three (12/38; 32%) reporting previous treatment for depression. In addition, most participants (27/38; 71%) reported that a family member or close friend had been treated for depression.

Risk and impact of depression

Most participants markedly underestimated the proportion of Australians who will experience depression during their life. Little change in this estimate was reported following workshop participation. In both, the initial and follow up surveys four out of ten identified the most accurate response (1 in 5) (Table 2). Following the workshops more than half of the participants underestimated the lifetime experience of depression by a factor of at least four fold.

Table 2: Participant estimate of life-time depression risk.

The perceived importance and impact of a number of health problems, including depression, cancer, heart disease, obesity and diabetes was measured using linear scale, with 1 designated as not important at all and 10 designated as extremely important. Mean participant responses, for the importance of each of the listed conditions, were at the important end of the scale, ranging from 7.38 - 9.40 / 10. Depression was rated at 9.0. Minimal change in responses was reported following participation in the workshops. When asked about the impact, as distinct from the importance of a number of common health conditions, using a similar scale mean responses were generally lower ranging from 5.29 – 8.57 / 10. Depression was rated as the condition with the greatest impact (8.57). Minimal change from initial responses was reported in the follow-up data by those completing the workshops.

A weak correlation was found between perception of lifetime depression risk and depression importance (r=0.25 p=0.14) and a moderate correlation between perception of lifetime depression risk and depression impact (r=0.44 p=0.008)

Attitudes towards depression and those experiencing depression

Focus groups were conducted before the workshops. Participants’ views of how they understood depression were investigated. Generally, depression was referred to in descriptive terms, both symptomatically and functionally as illustrated below:

low self esteem ID25

unmotivated ID24

sad all the time, poor thinking patterns, stinking thinking,

the whole negative thought patterns, instead of being occasional

becoming chronic and continuous ID23

Some expressed views about the cause of depression, with external factors, such as significant life stressors, most prominently reported as perceived causes:

sickness, change of life ID25

medical conditions ID24

life circumstances ID22

may be reactive to life for others it may be a chemical imbalance ID39

Participants were asked to respond using a four point Likert scale* to a number of negative statements about depression, its cause and impact, and about people who may be experiencing depression. Results are reported in Table 3.

Table 3: Attitudes to depression and those experiencing depression- initial and follow-up surveys.

*[Scale ranged from strongly disagrees to strongly agree. No neutral position was offered]

Most of the above statements were not associated with statistically significant change in response between the initial and follow-up measures, except for ‘Depression and stress are much the same things’. It was associated with a marked decrease in the number agreeing with the statement following workshop participation (p=0.03).

The view that those experiencing depression never fully recover, was expressed by four out of ten participants before the workshops and three out of ten after workshop participation. Similar negative views about recovery from depression were reported by focus group participants as illustrated in the following quotes:

I think with depression it takes so much time, I don’t even know if it ever gets cured from the different people I know with depression ID32

People who are depressed in my experience withdraw, they don’t want to talk about it. And they don’t want to seek help... ID23

In dealing with depression, stigma is seen as an important barrier, influencing people’s attitudes and responses. As indicated in the following focus group comment rural residents may not respond because of stigma and lack of social anonymity:

In rural areas it is about lack of staff, with waiting lists ...... there is such a stigma they don’t want to be seen talking to a counsellor ID 31

Attitudes towards social engagement with those experiencing depression were measured. Most respondents were willing to make friends or socialise with someone experiencing depression. However, one in four was unwilling to have that person marry into their family, a situation that may involve a significant degree of social exposure (Table 4).

Table 4: Unwillingness to participate in a range of social interactions with people experiencing depression.

Follow-up responses to the questions after workshop participation were only minimally changed from the above pre- workshop measures, except for “Unwillingness to go to them at a party”. A statistically significant decrease in support for this statement was found (p=0.02).

Obtaining help for depression, including treatments options

Participants were asked to rate a range of depression treatments on a 1-10 scale (1: not at all helpful to 10: extremely helpful). Treatments rated as very helpful (mean >7.5) were talking to a friend, being part of a social group, meditation, regular exercise and psychological therapy (CBT). Tranquilizer medications and painkiller medication were perceived as not helpful by many (mean <5.0). Antidepressant medication, which was described in the workshops as an effective treatment option, was rated as 7.3/10 before the workshops and 7.0/10 in the follow-up survey. In addition, participants were asked to rate how helpful they felt a range of social interactions may be to those experiencing depression. A number of approaches including keeping out of their way, taking them to the pub and sharing your worries with them to provide perspective were seen by most as unhelpful. Including those experiencing depression in social activities, talking with them about their experience and encouraging them to focus on positive things were seen by many as helpful (Table 5).

Table 5: Pre-workshop attitudes to helping options for those experiencing depression.

No statistically significant changes in the items reported in Table 5 were recorded between responses from the pre-workshop and post workshop follow-up measures.

Participant views about what may help those experiencing depression were further investigated in focus group discussion. Some participants felt the need for specific approaches to help those experiencing depression, rather than just talking about it.

Just talking about it, won’t solve the depression ID39

Others commented on the value of communication and more information as helpful approaches in addressing depression.

Take away on holiday and have a big talk to her ID25

Learn a little bit more about it, because it is so common I think it would be reassuring to know they are not alone. Find out more about treatment ID21

Knowledge and confidence

Participant self-reported level of knowledge about depression and confidence in dealing with depression in self or in helping a friend experiencing depression was measured using a 1 to 10 scale (1: no knowledge/confidence to 10: extremely knowledgeable/confident). Change in these responses was measured with most participants reporting an increase in knowledge and confidence (Table 6).

Table 6: Before and after workshop self reported level of knowledge about depression and confidence in responding to depression expressed using a 1- 10 and number of participants increasing and decreasing level of knowledge or confidence.

More than two out of three participants felt their knowledge of depression and confidence to respond to depression in them increased between the beginning of the workshops and four-six months later. Slightly more than half felt their confidence in responding to depression in a friend had increased over the same period.

Participants’ needs and workshop expectations

As noted above, more than two out of three participants reported experience of depression themselves or in a close family member or friend. Many wanted to know more about depression; some wanted specific detail.

Early indications, how you can see it in someone else earlier…..

I have a husband with a farm….how do you tell if he is depressed ID25

…and then the interventions; how do you intervene ID23

For a number of participants their concerns and questions about depression related to their job. They hoped the information workshops would help them develop skills that may be relevant to those they encounter in their work.

I think as a local country hairdresser I am think I going to get some tools because where I come from was a bit affect by the bushfires last Monday, it has brought up peoples vulnerability and I am going to start seeing people come in with depression, all of a sudden they have got no control over their lives, ID32

Often I am the person’s first port of call when they come into the agency [with depression] and often then they don’t want to be referred to anyone else, but it is about having some of those tools. ID31

The research was undertaken in rural Australia. Some issues were seen as being specific to rural areas with different attitudes and behaviours being relevant compared to the large cities as illustrated in the following quotations:

Different reasons for it here [rural]. They [in the city] would not be stressing about the weather ID24

Statistically male Australian farmers particularly have the highest suicide rate of any age group or any occupation so that you would think that the common link is their life style and financial pressures and the drought ID23

People are a lot more proud…farmers don’t go to doctors ID21

Immediately following each workshop participants were asked to rate the degree they felt their expectation and needs had been met by the workshop using a five point Likert scale (scale ranged from not met at all to completely meet). Almost all participants felt the workshop had met their expectations, (52% completely and 41% mostly). Similarly almost all felt the workshop had met their needs (30% completely and 63% mostly).

Discussion

This research reports on the knowledge and attitudes to depression of rural residents who expressed interest in a depression information workshop and on the experience of those who participated in such a workshop.

Participants in this research were from established community groups, avoiding the need for new community structures and organisations being developed to support rural mental health literacy promotion. This approach has been previously identified as appropriate especially in rural areas that may be resource limited in terms of social capital [9]. This approach may more efficiently use limited community resources but may also, as was found in this research, not include many participants with less well developed mental health literacy such as males and younger people. These groups were significantly underrepresented in this project, reinforcing the need in future similar initiatives to include targeted recruitment of underrepresented groups. Sports clubs and other organisations with a significant number of male members, and youth clubs may be appropriate to target in future recruitment. Greater participant knowledge and attitudinal change may have occurred if participants from these groups, with initially less well developed mental health literacy, were included.

Most participants reported having a family member or close friend who had experienced depression or having experienced depression themselves. This may have been an important factor motivating participation. Such participants may come with specific questions related to their own experience rather than more general questions about depression. The approach of this project, using experienced mental health professionals as facilitators with the capacity to address unexpected mental health questions from participants, is therefore suggested for similar initiatives.

The concept of ratio (e.g. 1:5) was used to promote understanding the life-time risk of depression. Despite the risk of depression being discussed in the workshops this was not translated into more accurate post-workshop responses by participants. It is of concern that in the post workshop data more than half of the participants underestimated this risk by between 400% and 1000%. Possible explanations for this observation include difficulty understanding the concept of ratio. Communication of this concept may benefit from use of a range of approaches including visual representations and non-numerical descriptive approaches. Not surprisingly, in a group expressing interest in a depression information workshop, depression was reported as being both important and with substantial impact. The association between perceived lifetime risk of depression and impact of depression reported in this research suggests potential benefits of communicating depression risk in a clearly understood way. This research did not address the question of behaviour change that may develop from a more accurate understanding of depression risk. Further research may be appropriate to investigate not only the best ways to communicate depression risk but also ways in which a change in understanding of depression risk influences perception of the impact of depression and response to that risk in self and others.

The research highlighted some negative views of depression and those experiencing depression that may inform the information about depression that is provided to rural communities. Almost four out of ten participants felt that those with depression never fully recover. Following the workshop three out of ten still held this view. (This change was not statistically significant.) Higher suicide rates have been reported among some groups in rural and remote areas [13]. A number of specific stressors related to climate, depopulation and limited healthcare workforce may have greater impact in rural areas. This suggests that it may be appropriate to more clearly communicate the generally positive outcome of depression treatments, especially in rural areas.

Attitudes towards those experiencing depression may not always match with expressed views on the value of depression treatments. All participants described including those experiencing depression in social activities and talking to them about their experience as helpful. However, when personal social space is impacted upon by going up to them at a party, spending an evening socialising with them, or having them marry into your family significantly less positive responses were reported. This suggests addressing the issue of personal responses to those experiencing depression as distinct from what is perceived as being helpful in a more abstract way may be a valuable additional component of future depression information workshops. Depression information sessions provided to smaller rural communities may require more focus on this issue. It is reassuring that unhelpful responses to depression such as taking the person to the pub to forget about their worries or telling them about your problems to give them perspective were seen by almost all participants as unhelpful.

Most of those recruited to this project expressing interest in learning more about depression participated in one of the depression information workshops. They reported that their needs and expectations were met, suggesting the content and format were appropriate for this group. Statistically significant increases in selfreported knowledge about depression and confidence in responding to depression was reported up to six months after the initial workshop. It is unclear if this reported increased level of confidence was reflected in a positive impact upon their local communities. However, the setting of this project, using existing groups which met regularly for another purpose may have assisted in maintaining participant knowledge and confidence after the workshops if members of the groups continued informal discussion of relevant issues in the following months.

Limitations and difficulties of the project

This research was undertaken in a number of rural locations. Most participants were female with many having achieved a higher level of education than that of the wider community. Males and young people were underrepresented in those participating in this project.

Notwithstanding the self reported increase in knowledge and confidence, other measures generally showed limited change in attitude and understanding of depression. This may have reflected good preworkshop knowledge and positive attitudes of many participants. Caution should be applied in considering the applicability of the study findings to other settings, especially with a different demographic mix and to individuals without the support of a community group that may have promoted the continuation of reported changes in knowledge and confidence six months after workshop participation.

One location recruited for this study was a small relatively isolated community. Participants from this location were unable to participate in a workshop, because of local harvesting needs and difficulties in travelling to an alternative location to participate in another workshop. This experience highlights the difficulties of addressing the needs of smaller rural communities. Innovative electronic solutions may need to be implemented to address such needs.

Conclusions

This paper discusses some of the depression knowledge and attitudes of rural residents expressing interest in a depression information workshop and their experience of such a workshop. This may inform future mental health literacy initiatives by highlighting a number of issues that may be appropriate to address including the need for active recruitment of typically underrepresented groups, difficulty communicating depression risk and negative outcome expectations with depression.

Acknowledgements

The research reported in this article was supported by Beyondblue Australia.

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