Depression literacy among Chinese stroke survivors

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  • This article was downloaded by: [Northeastern University]On: 19 November 2014, At: 23:35Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: MortimerHouse, 37-41 Mortimer Street, London W1T 3JH, UK

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    Depression literacy among Chinese stroke survivorsA.C.K. Lee a , S.W. Tang b , S.S.K. Leung a , G.K.K. Yu c & R.T.F. Cheung da Department of Nursing Studies , The University of Hong Kong , Hong Kong SAR, Chinab University of California , Irvine, California, United Statesc Department of Psychiatry , Queen Mary Hospital, Hong Kong , Hong Kong SAR, Chinad Department of Medicine , The University of Hong Kong , Hong Kong SAR, ChinaPublished online: 29 May 2009.

    To cite this article: A.C.K. Lee , S.W. Tang , S.S.K. Leung , G.K.K. Yu & R.T.F. Cheung (2009) Depression literacy amongChinese stroke survivors, Aging & Mental Health, 13:3, 349-356, DOI: 10.1080/13607860802636230

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  • Aging & Mental HealthVol. 13, No. 3, May 2009, 349356

    Depression literacy among Chinese stroke survivors

    A.C.K. Leea*, S.W. Tangb, S.S.K. Leunga, G.K.K. Yuc and R.T.F. Cheungd

    aDepartment of Nursing Studies, The University of Hong Kong, Hong Kong SAR, China; bUniversity of California, Irvine,California, United States; cDepartment of Psychiatry, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China;

    dDepartment of Medicine, The University of Hong Kong, Hong Kong SAR, China

    (Received 17 September 2007; final version received 14 March 2008)

    Objectives: Mental health literacy is fundamental to the pursuit of health. Little is known about patients literacylevels regarding depression even though it is common among elderly stroke survivors. This paper will report thelevel of mental health literacy and thematic constructs of depression interpreted by a group of stroke survivors.Method: Qualitative data on patients understanding of depression in Chinese were translated and analyzedby an academic and a researcher separately to identify emerging constructs using a thematic approach. Out of214 ischemic stroke older adults, aged 50, 85 were able to explain the term in their own words after their firststroke attack.Results: The majority of stroke patients (60%, 129 out of 214) had never heard of depression and only fourreferred to it as a medical disease. Only a third would like to learn more about depression. Older Chineseadults depicted depression mainly by using words in the cognitive and affective domains, but the descriptorsused were mostly non-specific and might not match the diagnostic criteria for depression or the commonly usedscreening tools.Conclusion: Low mental health literacy among older patients indicated that much more work needs to be done inhealth promotion and education on depression literacy.

    Keywords: depression literacy; depression after stroke; mental health; older adults

    Introduction

    This paper will report the level of mental healthliteracy and knowledge as regards the interpretationof depression in a group of older Chinese strokesurvivors. The concept of mental health being funda-mental to health has been widely publicised since themid 1990s (Kelly, Jorm, & Rodgers, 2006). Mentalhealth problems, in particular depression, are tremen-dous burdens locally (Woo et al., 1994) and globally(Murray & Lopez, 1997). Effective treatment verymuch depends on the recognition and diagnosisof depression in the population, which in turn is afunction of mental health literacy levels. The mentalhealth literacy of different target groups has receivedlittle attention, and the medical model of diagnosisrarely takes cultural factors into consideration, result-ing in different healthcare consequences (Skaer, Sclar,Robison, & Galin, 2000). It cannot be assumed that themanifestation of depression in all cultures is as clear asthat stated in the standard Western diagnostic tools.Mental health literacy in elderly depressed patients isparticularly important, but has not been extensivelystudied. In depression after stroke (DAS), aphasia andother disabilities of expression further complicaterecognition and diagnosis. We have very little infor-mation on patients literacy levels with respect todepression despite the fact that depression is known tobe common among older Chinese adults (Lee, 2003;Woo et al., 1994) and stroke survivors (Lee, Tang,

    Yu, & Cheung, 2007). In fact, the search for subjec-tive views on the situation of vulnerable groups,including those aged 65, mentally disabled or withlow literacy levels, has remained fruitless in the pro-fessional literature (Mika, Kelly, Price, Franquiz, &Villarreal, 2005).

    The World Health Organization (WHO) hasproposed a broad definition of health literacy: Healthliteracy represents the cognitive and social skills whichdetermine the motivation and ability of individuals togain access to, understand and use information in wayswhich promote and maintain good health (Nutbeam,1998). Baker (2006) presented the definition as: Healthliteracy is an achieved level of knowledge or proficiencythat depends upon an individuals capacity andmotivation to learn and use resources provided by ahealthcare system. Thus a triadic relationship betweenthe individual, healthcare professionals and the health-care system itself was proposed in the knowledgetransaction process. We have based our study onthese definitions of health literacy to explore depressionliteracy among older stroke patients.

    Background to the study

    In a highly developed country like the UnitedStates, studies report that 45% of US adults havevery low or only basic health literacy skills and that25% are in fact functionally illiterate (Weiss, Francis,

    *Corresponding author. Email: acklee@hkucc.hku.hk

    ISSN 13607863 print/ISSN 13646915 online

    2009 Taylor & FrancisDOI: 10.1080/13607860802636230

    http://www.informaworld.com

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  • Senf, Heist, & Hargraves, 2006). The situation isapparently even worse in the case of some ethnicgroups and those chronically ill (Mika et al., 2005). Inrecent years, evidence has become available to supportthe relationship between health literacy and healthcareoutcomes in both physical and mental health areas(Howard, Sentell, & Gazmararian, 2006; Schillinger,Grumback, & Piette, 2002; Wolf, 2005). It is particu-larly important to identify depression literacy amongolder patients, as inadequate health literacy has beenindependently associated with poorer physical andmental health among community-dwelling older adults(Gazmararian, Baker, Parker, & Blazer, 2000; Wolf,2005). More importantly, a low level of literacy isproportional to mortality as well as healthcare accessamong older people (Sudore et al., 2006).

    From the perspective of public health, the explora-tion of depression literacy levels is worthwhile. Healthliteracy as regards depression directly influences earlyrecognition of the condition, which is common inlater life (Lee, 2003; Murray & Lopez, 1997; Wooet al., 1994). Depression after stroke is estimated tooccur one among four to six first-ever ischemic strokesurvivors, as reported in the literature (Lee et al., 2007;Tang, Ungvari, Chiu, & Sze, 2004). Improvement indepression literacy fosters changes in attitude andhealth-seeking behavior (Lauber, Nordt, Falcato, &Rossler, 2003). For early diagnosis, the mentalhealth literacy of the population must be ascertained.If the health literacy of the target group is low atthe beginning, health promotion outcomes may bedeemed trivial or insignificant (Mika et al., 2005). Themismatch of message delivery and receipt will renderthe health education effort wasteful or even harmful.Indeed, previous studies have acknowledged a widegap in the understanding of depression between health-care professionals and patients/community residents(Lee, 2002). Therefore Mika et al. (2005) suggestedincreasing health literacy, as a means towards inter-vention research and improving health outcomes, asa research agenda. Mismatches between the healthliteracy levels expected by healthcare professionals andthose actually found in patients will result in undesir-able clinical outcomes and decreased use of preventiveservices (Vahabi, 2007). The logical step towardsdevising interventions in depression after stroke mayfollow from identifying the depression literacy amongtarget subjects, but this information has not yet beenmade available. The present paper aims to fill thisknowledge gap by reporting the level of mental healthliteracy and thematic constructs of depression asinterpreted by older Chinese stroke patients.

    Method

    The paper retrieved data regarding the literacy ofdepression from a full-scale study of depression afterstroke among older Chinese subjects (Lee et al., 2007).That study had sought ethical approval from the

    Institutional Review Board of the University of HongKong and of the hospital under study. It reported thatone out of every four stroke patients aged 50 amongfirst-ever ischemic stroke survivors at one month mayhave suffered from depression. Personal interviewswith questionnaires were used to collect both quanti-tative and qualitative data on depression. The quali-tative questions aimed to explore the meanings strokesubjects gave to depression and the experience thatwas of distinct value to them (Streubert & Carpenter,1999). The main study incorporated a long list ofquestions (four depression assessments, five domainsof predictor variables, socio-demographic and healthdata) and a period of nearly 45min was required tocomplete an interview. In view of possible physicalexhaustion and the short attention span of strokeparticipants, only essential qualitative questions wereincorporated, elaborated as follows:

    (1) All participants were asked at the end of theinterview: What is the meaning of depressionto you? and How will depression be inter-preted? Respondents were encouraged to giveany possible meaning to the term, and werereassured that they would not be judgedby their answers as there was no right orwrong answer but only their own perceptions.They were also asked if they would beinterested in learning more about depression.

    (2) The emotional status and expressions of thepatients were then observed and recorded. Inaddition, all retrievable medical records werestudied retrospectively for any documentationof mood status: the presence of depression,signs and symptoms such as emotional com-plaints or observation by nurses or relatives,sadness, loss of appetite, change in sleeppatterns, self-worthlessness, hopelessness,social withdrawal, frustration, self-pity, grief,guilt and shame, suicidal ideation (expressionof self-worthlessness, thoughts of death, con-crete plans for suicides, attempted suicide);screening instruments or diagnostic tools fordepression, the identity of the person reportingthe onset of depression (patient/relative/nurse/doctor); any prescription of treatment options(psychoactive medication including antidepres-sants, referral to psychiatrist/psychologist/med-ical social workers/nurse specialist/others)because of emotional needs after stroke onset;and treatment duration.

    The qualitative data was translated into English,and backward translation was also conducted by aprofessional translator and the researcher separatelyto align the original meaning posed by participants.One academic staff member and one researcher workedseparately to delineate and categorize the subjectsinterpretations of depression. After data immersionand analysis, thematic constructs emerged and corethemes on depression were identified.

    350 A.C.K. Lee et al.

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  • Results

    A total of 214 patients participated in the study onemonth after their first-ever ischemic stroke attack. Ofthese patients, 85 (38.9%) described depression intheir own words. This group was thereafter referredto as the Depression Literate group. The remainderof the patients, referred to as the DepressionIlliterate group, explicitly remarked the lack ofknowledge or understanding of the term depressionin Cantonese, which is the prevailing languageamong local Chinese. Slightly more than a third ofthe participants were female and widowed/single/divorced. One in six in this study sample was stillworking at the time (see Table 1). No significantgroup difference was identified in the above with therest of the participants demographic background,including age, as far as depression literacy was con-cerned. The only exception was noted in the case ofthe depression literate group, who had significantlylonger formal education (mean 6.1 years) than theircounterparts (mean 4.4 years, t 6.126, p 0.014,see Table 1).

    With regard to common clinical features amongstroke survivors, there was no significant differencebetween the depression literate and depressionilliterate groups. Study variables included depres-sion as assessed by DSM IV criteria, presence ofexpressive aphasia and receptive aphasia, dysarthria,hearing problems and memory problems (seeTable 2). Where help-seeking behavior was con-cerned, only about a third of the participants in bothgroups expressed an interest in knowing more aboutdepression.

    During analysis, the emerging themes of thedepression interpreted by...

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