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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
To link to this article: http://dx.doi.org/10.1080/13607860802636230
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Aging & Mental HealthVol. 13, No. 3, May 2009, 349–356
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 50þ, 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 65þ, 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 individual’s 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: [email protected]
ISSN 1360–7863 print/ISSN 1364–6915 online
� 2009 Taylor & Francis
DOI: 10.1080/13607860802636230
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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 50þ 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 subjects’interpretations of depression. After data immersionand analysis, thematic constructs emerged and corethemes on depression were identified.
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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 ‘depression’in 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 (mean¼ 6.1 years) than theircounterparts (mean¼ 4.4 years, t¼ 6.126, p¼ 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 the‘depression’ interpreted by participants were found tofall into three domains of expression: affective,behavioral and cognitive. Sixty participants in thedepression literate group (69.8%) described depres-sion using terms in the affective domain, 25 (29.1%) inthe behavioral and 39 (45.3%) in the cognitivedomains. Forty participants used descriptors in dualdomains: affective and behavioral (20.9%), affectiveand cognitive (19.8%), behavioral and cognitive(5.8%, see Table 3).
Themes in the affective domain
‘Unhappy’
There were 60 illustrations depicting the affectiveperspective on ‘depression’ – ‘unhappy’, ‘worries’,‘boredom’ and ‘keeping things to oneself’ were thecore mood-related descriptors. The most frequentword used by participants was ‘unhappy’, quoted 20times. Among them, six also included an intensifier,such as ‘very unhappy’ ([sc142F/66-0], [sc184F/56-0],[sc238F/71-0], [sc302M/66-6]) or ‘always unhappy orsad’ ([sc81F/69-6], [sc189M/79-0], [sc295M/51-15],[sc293M/71-1]).1 Some participants suggested thatthe unhappiness was generated by the sufferersthemselves: ‘Unhappy things locked in one’s heartcause illness’ ([sc164M/78-5]); ‘feeling unhappy byoneself; one confines oneself but one doesn’t feelcomfortable’ ([sc141F/72-2]). Five added ‘sulkiness/upset’ alongside an unhappy mood ([sc170M/67-1],[sc193F/79-12], [sc219M/76-15], [sc276M/78-6],[sc293M/71-1]).
Table 1. Demographics of the participants.
TotalDepressionilliterate
Depressionliterate
(n¼ 214) (n¼ 129) (n¼ 85)
n % n % n % �2 d.f.Significance(two-tailed)
GenderMale 135 63.1 81 62.8 54 63.5 0.012 1 0.913Female 79 36.9 48 37.2 31 36.5
Marital statusWidowed/single/divorced 78 36.4 51 39.5 27 31.8 1.336 1 0.248Married 136 63.6 78 60.5 58 68.2
OccupationRetired/housewife 35 16.4 20 15.5 15 17.6 0.172 1 0.678Working 179 83.6 109 84.5 70 82.4
Age,a mean, SD 72.3 9.4 72.4 9.7 72.1 9.1 0.046 1, 212 0.831
Years of formal education,a
mean, SD5.1 5.0 4.4 4.7 6.1 5.2 6.126 1, 212 0.014
Length of hospital stayin days,a mean, SD
17.2 15.4 16.3 15.4 17.9 15.4 0.564 1, 212 0.454
Pearson chi-square test was undertaken for the above variables.aStudent’s t-test conducted.
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‘Burying things in one’s heart’
Altogether 19 scripts mentioned a portrait of thedepressed subjects as ‘burying things within oneself’.Why were they acting in this way? Five suggested‘unhappiness’; four suggested problems they wantedto conceal; three mentioned ‘worries’. Quite a fewrespondents (n¼ 9) did not specify what exactly theissue/problem was that they had concealed. This wasparticularly the case with women, four out of five,with a low level of formal education (0–4 years).
‘Worry/anxiety’ and ‘bored/gloomy’
‘Worry/anxiety’ and ‘boredom’ were another twocommon descriptions of depression. Six had usedworries alone to interpret ‘depression’ ([sc101M/83-4], [sc102M/72-5], [sc132M/75-6], [sc145M/70-16],[sc226M/84-6], [sc240M/65-12]). Another six addedthe intensity and frequency of worries: ‘worry too
much’ ([sc185M/84-9], [sc289M/69-2], [sc302M/66-5]),‘always worry’ ([sc132M/75-6], [sc306M/63-6]) or‘worry about everything’ ([sc263F/70-10]). Eightscripts mentioned boredom, three separately withothers occurring in combination and/or specifying theintensity of the mood ([sc88M/62-15], [sc114M/64-10],[sc140F/87-2], [sc251F/68-12], [sc263F/70-10]).
‘Fidgeting/irritated’
After worry/boredom, ‘fidgeting/irritated’ was men-tioned five times to interpret depression. Such emotion,however, was seen to follow other descriptors ratherthan being posed at the beginning of the illustration.Examples were as follows:
. ‘Got to take medicine; always in a fidget,always feel sad’, [sc81F/69-6].
. ‘Unhappy; in a fidget’, [sc105M/64-15].
. ‘Patient very irritated; feeling sick in differentparts of the body’, [sc124M/75-1].
. ‘Don’t feel at ease all day; always in a fidgetand always blaming oneself for one’s badtemper’, [sc231M/69-12].
. ‘Feeling bored and throwing oneself into afidget’, [sc278M/81-20].
Non-specific descriptors
Some subjects (n¼ 19) were unable to describe depres-sion specifically, as shown by the use of vague termssuch as ‘in a bad mood’ ([sc89F/68-0], [sc269F/72-12]),‘a heavy heart’ ([sc166M/54-6], [sc220M/83-10],
Table 3. Domains of emerging themes on depressioninterpretation by 86 participants.
Domains of descriptors for depression n %
Affective 60 69.8Behavioral 25 29.1Cognitive 39 45.3Affective and behavioral 18 20.9Affective and cognitive 17 19.8Behavioral and cognitive 5 5.8
Table 2. Comparison of clinical status between of depression literate and illiterate groups.
TotalDepressionilliterate
Depressionliterate
(n¼ 214) (n¼ 129) (n¼ 85)
n % n % n % �2 d.f.Significance(two-tailed)
Clinical statusAssessment of depression No 153 71.5 95 73.6 58 68.2 0.735 1 0.391
Yes 61 28.5 34 26.4 27 31.8Presence of expressive aphasia No 180 84.1 106 82.2 74 87.1 0.916 1 0.338
Yes 34 15.9 23 17.8 11 12.9Presence of receptive aphasia No 212 99.1 128 99.2 84 98.8 0.089 1 0.765
Yes 2 0.9 1 0.8 1 1.2Presence of dysarthria No 169 79.0 100 77.5 69 81.2 0.413 1 0.521
Yes 45 21.0 29 22.5 16 18.8Presence of hearing problems No 189 88.3 113 87.6 76 89.4 0.164 1 0.686
Yes 25 11.7 16 12.4 9 10.6Presence of memory problems No 173 80.8 103 79.8 70 82.4 0.208 1 0.648
Yes 41 19.2 26 20.2 15 17.6
Help-seeking behaviorWish to learn more about depression No 141 65.9 85 65.9 56 65.9 0 1 0.999
Yes 73 34.1 44 34.1 29 34.1Wish to learn more about stroke No 101 47.2 67 51.9 34 40 2.93 1 0.087
Yes 113 52.8 62 48.1 51 60
Pearson chi-square test was undertaken for the above variables.
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[sc267M/83-6]), ‘feeling uncomfortable’ ([sc118M/73-4], [sc141F/72-2], [sc219M/76-15], [sc227F/81-4]),‘don’t feel at ease all day’ ([sc231M/69-12]), ‘want todie’ ([sc238F/71-0], [sc282F/80-15]), ‘feeling lonely’([sc284F/81-0]), ‘desire for something’ ([sc296F/71-2]),‘neurosis’ ([sc300F/71-5]), ‘it’s something to do withone’s personality’ ([sc88M/62-15], [sc251 F/68-12]),‘always fail to get what one wants’ ([sc84M/88-4]),‘feeling useless’ ([sc112M/78-14]).
Themes in the behavioral domain
Of the three domains, the behavioral was the leastelaborated. Some suggested that depressed peoplewould display obvious avoidance behavior such as‘confining oneself’ (n¼ 4); decreased/no verbalizationor avoiding people – family members, other peopleor a medical doctor (n¼ 13). Other behavioral cuesindicating depression were only mentioned once ortwice (n¼ 8), for example, ‘cry’ (2) ([sc246M/74-1],[sc283M/64-12]), ‘wear a sad face’ (n¼ 2) ([sc193F/79-12], [sc283M/64-12]), ‘can’t do lots of things’ ([sc90M/89-6]), ‘very lazy in taking care of myself’ ([sc231M/69-12]), ‘displaying bad temper’ ([sc276M/78-6]) or‘can’t sleep’ ([sc306M/63-6]).
Themes in the cognitive domain
Descriptors in the cognitive domain were the secondmost commonly cited by the interviewees. To delineatethe nature and content of their thoughts, specific andnon-specific descriptors could be identified, with someelaborated according to the intensity of these thoughtssuch as ‘always’ (n¼ 5) or ‘frequently’ (n¼ 5). It wasaltered thinking patterns like ‘taking things too hard’that were quoted most frequently (n¼ 8). Intervieweesalso cited ‘can’t take things in a relaxed manner’ (n¼ 4)or ‘can’t understand how things go’ (n¼ 4). Foursubjects noted that such emotional status could be adisease, such as the following:
. ‘This is a kind of morbidity; a kind ofpsychological problem’ ([sc87M/59-12]).
. ‘When one is introverted; one will be prone tothis illness’ ([sc251F/68-12]).
. ‘Mental disorder; but don’t know what it is’([sc272F/57-5]).
. ‘Thinking unhappy things and locking them inmy heart bring me this illness’ ([sc164M/78-5]).
Other specific descriptors included the following(n¼ 6): ‘to split hairs, think about things that arehard or bad’ ([sc139M/62-15]), ‘the world is grey andthere is no future’ ([sc134M/60-12]), ‘always deepin thought, brooding over something bad’ ([sc138F/79-0]), ‘negative things’ ([sc301M/71-0]), ‘thinkingfrom one single perspective’ (n¼ 2) ([sc118M/73-4],[sc146F/67-0]). Three related their cognition to self-worth. Nine participants emphasized the intensefrequency of such patterns of thought.
Discussion
While health literacy as regards depression directlyinfluences early recognition of depression, and improve-ment in depression literacy fosters changes in attitude,health-seeking behavior (Lauber et al., 2003) and healthoutcomes (Baker, 2006), little discussion of the con-struct ‘depression’ in the Chinese or Asian worlds was tobe found in the literature. Studies cautioned againstapplying the translated Western term ‘depression’ intothe local context, as the term could be interpreteddifferently among different ethnic groups (Patel, Abas,Broadhead, Todd, & Reeler, 2001). The answers to thetwo questions ‘What is depression?’ and ‘How willdepression be interpreted?’ among older Chinese strokepatients remain largely unknown. The results of thisstudy may help to inform the care of stroke victimswhen fosteringmental health literacy, particularly in thecase of depression (Howard et al., 2006; Weiss et al.,2006), and may be used to improve recognition anddetection of mental illness. Patients with low literacy arefrequently encountered in healthcare settings(Hendener & Vezeau, 2005). It is more challenging todifferentiate a non-depressed subject having a low levelof depression literacy from a depressed patient whodemonstrates withdrawal and psychomotor retarda-tion. Both clinicians and patients are unable to relateclients’ verbal cues to depression, thus making detectionor diagnosis a hurdle. The clinicians need to raise theindex of suspicion for depression when descriptors fallinto the affective–behavioral–cognitive domains asdescribed in the paper, if they are persistently reportedin consecutive follow-ups.
The results of our study lend some support to thesupposition that older adults might not have adequatemental-health literacy to give verbal cues for depres-sion assessment that might induce earlier diagnosis byclinicians (Robinson-Smith, 2004). We need to high-light that low formal education of the patients is theonly significant factor that is associated with depres-sion literacy in this study. The majority of strokepatients aged 50þ reported inadequate knowledge ofdepression, despite the fact that there was frequentcoverage of depression in local news media. Thiscertainly reflects the limitations of current health-education programmes in reaching or fulfilling theneeds of the illiterate target groups. Clinicians tend tobe unaware of or have unrealistic assumptions aboutpatients’ reading abilities in health education. Worsestill, none of the patient education material that wasstudied considered cultural sensitivity as an importantfactor (Wilson et al., 2003). Moreover, as shown inthis study, low depression literacy may also influencean individual’s motivation to learn more abouthealth promotion. One study has found that healthliteracy mediates the result between education andhealth outcomes among low-income diabetes patients(Schillinger, Barton, Karter, Wang, & Adler, 2006).Furthermore, the wide range of literacy levels withinthe same culture or among various diversified ethnic
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groups is seldom investigated before any health pro-motion attempts are made. In our study, the majorityof the interviewees (60%) were unable to describe‘depression’. Some said they had never heard of itat all. Some subjects could only use vague termssuch as ‘in a bad mood’, ‘a heavy heart’ or ‘feelinguncomfortable’. Most of these descriptors are notfound in the commonly used diagnostic or screeninginstruments – the fourth edition of the Diagnostic andStatistical Manual (DSM IV) (American PsychiatricAssociation, 1994), the Geriatric Depression Scaleshort form, Chinese version (Brink et al., 1982; Lee,Chiu, & Kwong, 1994) or the Centre of EpidemiologicStudies for Depression, Chinese version (Boey, 1999;Radloff, 1977), showing a low recognition of depres-sion among the older participants, in particular whenclinicians have to meet competing demands in theirduties (Lee, 2002). The use of descriptors/words bymost interviewees was very limited, with half of theillustrations falling into one of the three domains(affective, behavioral and cognitive) only. Someincorporated terms from two domains. However, theworry is that the most frequently cited descriptors,such as ‘unhappy’, ‘bored/in a fidget’, ‘irritation’ areunlikely to be indicative of depression as a medicaldisease when they are presented to clinicians. Infact, only four individuals related ‘depression’ to amedical disease.
The difficulty of detecting depression may becompounded by the patients themselves. Studies haveshown that older adults (65þ) are more resistant toseeking help from a healthcare worker (psychiatrist,psychologist or social worker) than younger agegroups. Older adults also consider such professionalsand their services unhelpful (Fisher & Goldney, 2003).Worse still, a very popular and commonly acceptedproverb reflects much of the Chinese belief patternsamong the elderly population: ‘Unsatisfactory out-comes are common, occurring nine out of ten times’.This common belief shared by a Chinese patient mightmask a depressed mood and might not alert the healthworker to the need for further medical attention.Chinese people also tend to be rather reserved in theirdisplays of emotion. They consider displaying sadnessor unhappiness in front of people outside the familycircle inappropriate because of the ‘loss of face’involved (Bond, 1991). This is supported by somereported avoidance behavior under the behavioraldomain in explaining ‘depression’. However, there isa contra-argument maintaining that ‘depression’ mayoccur as a result of a lack of people for patients toconfide in (Alexander, 2001). Indeed, a recent studyhas found two streams of lay opinion regardingdepression. One group has treated depression as a lifecrisis, implying that it might be considered a ‘normallife event’, while the other prefers a problem-solvingapproach to tackle any occurrence of depressivesymptoms (Lauber, Nordt, Falcato, & Rossler, 2001).A poor literacy level with respect to depression maythus further perpetuate belief in mood episodes and
favor the acceptance of persistent mood disturbanceamong the sufferers. The situation may also be morecommon among older people who are passive in healthdecision-making. This study also supports previousfindings regarding reluctance among older adults toseek help for their emotional needs (Fisher & Goldney,2003). Two-thirds of patients reported they were notinterested in knowing about depression as a medicaldisease. In this way, only four subjects remarkedthat the mood condition was or might turn into adisease. This is an important finding as patients’inclinations and views on mental health will affecttheir health decision-making and subsequent healthoutcomes. Studies have demonstrated that thosewho regard depression as a medical illness are morereceptive to psycho-pharmacology, while others per-ceiving the condition as a psychological matter wouldturn to psychotherapy as a natural remedy (Lauberet al., 2003).
Following the discussion above, we are justifiedin suggesting that mental health literacy among olderadults must be addressed as an important mentalhealth issue if depression and old age are recognizedas growing concerns in healthcare. The discussion ondepression literacy is particularly worthwhile fromthe healthcare professionals’ perspective. There is evi-dence of low literacy levels among both the generalpublic (Bartlett et al., 2006) and vulnerable patientgroups (Howard et al., 2006) regarding mental healthpresentation, such as common signs and symptoms,and this will obviously affect early prevention andtimely treatment.
To raise depression literacy, the joint efforts ofhealthcare authorities, clinicians and older adults areneeded to be effective. This is supported by findingsthat medical societies/associations and health politicsin some European countries are core factors thatcontribute to creating an adequate service to tackledepression in later life (Bramesfeld, 2003).
The current study shows that we may still need towork very hard towards such a goal, so as to promotedepression literacy among older people and theirfamilies, since their knowledge, skill and motivationto learn about depression are still relatively low.
Conclusion
According to the definitions, mental health literacy is afundamental requirement for the pursuit of health.Literacy studies will impact on wide areas of health,including those involving communication, educationand training in community, organizational and policydevelopment (Rootman & Ronson, 2005). As healthliteracy is critical to empowerment (Nutbeam, 1998)and the provision of information does not guaranteedesirable health literacy on depression to aid effectivedecisions, healthcare educators need to re-think care-fully the design of health communication strategies forolder adults in health promotion and education
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programmes (Vahabi, 2007). Depression/mental health
literacy should be the first entry point for meaningful
public health interventions – preventive measures,health promotion or health education programmes.
Future studies on mental health literacy should beculture-sensitive and may target those with a low
level of formal education, as our study demonstrates.The situation of low levels of depression literacy
applies not only to Caucasian samples but also toolder Chinese subjects. Whether this problem may also
extend to other cultures and ethnicities is a definitearea for future research.
Using older Chinese stroke patients as a study
population, our paper represents a preliminary explo-ration of mental health literacy levels and develops
a preliminary thematic framework to conceptualizethe expression of depressed moods under affective,
behavioral and cognitive domains. The direct applica-tion of this model in other cultures requires caution
as Chinese are known to moderate their emotionaldisplay. In this study, the definition of depression
provided by the stroke patients showed a mismatchwith that of clinicians and the only factor associated
with depression literacy is the low levels of formaleducation in this study. This finding may provide some
insight into future work in mental health promotionamong the older population, irrespective of ethnicity.
Future research may explore existing initiatives, andclarify the extent of problems in health literacy among
different target groups in culturally appropriatecontexts, in particular during the assessment and
planning phases of health promotion and educationprogrammes, in order to justify outcome-based, cost-
effective and culturally specific interventions.
Note
1. [scXXX¼ subject code no.; M¼male; F¼ female, fol-lowed by age; the last figure following a hyphen¼ yearsof formal education].
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