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This study aims to explore attitudes towards, complications of and preventive measures for depression and the barriers that result in delays in seeking help among the various ethnic groups in Penang, Malaysia. In June 2007 a questionnaire‐based survey was undertaken in Penang. Face‐to‐face interviews were conducted, and 1855 respondents were approached to participate in the study by adopting a cluster random sampling method. A 25‐item questionnaire was used to explore public attitudes towards, complications of and preventive measures for depression and delays in seeking help. A total of 1149 (61.94%) showed willingness to participate in the survey. Ethnically, 490 (42.6%) of the respondents who participated in the survey were Malay, while 413 (35.9%) were Chinese, 149 (13%) Indian and 97 (8.4%) from other ethnic minorities. The mean age of the respondents was 30 years (SD ± 11.5). In evaluating public attitudes, the majority (n = 910, 79.2%) agreed with the statement that family and friends can enhance the depression recovery process by providing more care and attention to the patient and this was found to be statistically significant (P ≤0.001). More than one‐third of the respondents (n = 437, 38.0%) perceived depression as a normal medical condition and believed that it subsides automatically. The majority (n = 830, 72.2%) stated that depression results in social problems, while some felt that it can lead to raised blood pressure (n = 518, 45.1%). In terms of prevention, most of the respondents indicated that one can prevent depression by maintaining a good social life. In evaluating the barriers to seeking professional help, the majority (n = 582, 50.7%) stated that they did not believe they were at risk, with the next largest group identifying a lack of awareness regarding the signs and symptoms. However, a positive attitude was observed towards the complications and prevention of depression. Initiatives to increase mental health literacy will prove fruitful in neutralising the negative public perceptions towards the treatment of depression and barriers to seeking professional help.
Mental disorders are a recurrent issue in the discussion of health significance in developed and developing countries. According to World Health Organization (WHO) statistics from 2001, mental disorders affect at least 25% of adults once during their lives. 1 Of all the mental disorders depression is the most prevalent; it was ranked as the fourth leading cause of global disease burden in 1990 and is expected to be second to ischaemic heart disease by the year 2020.2,3 One of the perceived causes of its high incidence is the low level of mental health literacy. Mental health refers to the symptoms and causes of mental disorders and ways to seek the appropriate professional help, while evaluation of an individual's knowledge of these is referred to as mental health literacy. 4 However, public attitudes towards the complications of mental disorders, preventive measures for depression and the barriers that result in delays in seeking help are neglected research issues that should be made the subject of further scientific investigation. 5–7 It has been observed that the majority of people have negative attitudes and beliefs towards depression.8,9 While the stigma towards schizophrenia may be greater, stigma is also associated with depression. 5–7 Elevation of public knowledge through mental health campaigns has brought some augmentation in public knowledge and changed the way the public thinks about mental disorders. 10 However, there still remains a need to change public beliefs regarding depression. In the context of mental health, most of the research to date has centred on the evaluation of public knowledge about depression and its causes. 9 In Malaysia, as well as internationally, no evidence is so far available on public attitudes towards depression, its complications, preventive measures for depression and the barriers that result in delays in seeking help. A previous finding has provided evidence of supernatural beliefs among Malaysians in relation to psychiatric problems and showed that the majority were willing to seek help from religious and traditional healers. 11 However, other studies have focused on the evaluation of public knowledge of the symptoms of, therapy for and beliefs about the causes of depression. 12
The main aim of this study is to rectify the lack of research and to advance knowledge in the area by exploring attitudes towards, complications of and preventive measures for depression and the barriers that result in delays in seeking help among various ethnic groups in Penang, Malaysia.
In June 2007 a questionnaire‐based survey was undertaken in Penang, Malaysia. Penang is one of the 13 states of Malaysia, and comprises two parts, i.e. Penang Island and Penang mainland, with a population of 1.5 million. The population of Penang comprises Malays (42.5%), Chinese (46.5%), Indians (10.6%) and other minorities (0.4%). 13
The research design encompasses a non‐experimental field research survey. Face‐to‐face interviews were conducted, and 1855 respondents were approached to participate in the study by adopting a cluster random sampling method. A 25‐item questionnaire was used to explore public attitudes towards, complications of and preventive measures for depression and delays in seeking help. The content and face validity of the questionnaire was approved by professionals in the discipline of social and administrative pharmacy at the University Sains Malaysia (USM) Department of Psychiatry and by the Department of Biostatistics, Penang General Hospital. A reliability scale was applied to estimate the internal consistency of the knowledge domain: it was estimated on the basis of Cronbach's Alpha (α = 0.80). Furthermore, to assure the validity of the contents, factor analysis was carried out. The content validity was estimated by using Bartlett's test of sphericity and the Kaiser–Meyer–Olkin measure of sampling adequacy. Bartlett's test of sphericity was significant at 0.0000, while the Kaiser–Meyer–Olkin measure of sampling adequacy was 0.790. According to Scheridan and Lyndall (2001), a measure of more than 0.6 reflects the adequacy of the contents of the questionnaire. 14 Thus the results provided considerable evidence of the reliability and validity of the sampling tool. Keeping in mind the language constraints in Penang, all the interviews were conducted by researchers with excellent proficiency in the Malay, Indian and Chinese languages.
The questionnaire comprised two parts; the demographic section and the section linked to the objectives of the study. The demographic variables considered in the study tool were race, age, religion, education, income and gender. The second part of the study, i.e. public attitudes towards complications of depression, was assessed using a six‐item scale. Moreover, an option was also given to the respondents to disclose their beliefs in other complications of depression not covered by these six items.
Public attitudes toward depression were explored by asking the respondents to respond to the four items or statements below:
The level of agreement with these items was measured by using a three‐item scale, i.e. agree (A), disagree (DA) and don't know.
Similarly, the following three items or statements were used to evaluate public belief that depression could be prevented:
Furthermore, an option was provided to the respondents to share their own views about the prevention of depression.
Public belief regarding the barriers to seeking help for depression was evaluated using the six items or statements below:
Potential respondents from Penang Island and the mainland were approached using a cluster random sampling method. Clustering was done on the basis of the four main racial groupings, i.e. Malay, Chinese, Indian and other ethnic minorities. 13 Ethical approval from the research ethics committee of the University Sains Malaysia and from the clinical research committee of the Ministry of Health, Malaysia was obtained for this study. Moreover, verbal consent was sought from the respondents after assurance that the information obtained from them would remain confidential.
For the purpose of data analysis, the Statistical Package for Social Sciences (SPSS13.0®) was used. The chi‐square test was used to test the difference between proportions. However, to analyse the multiple responses, e.g. agree, disagree and don't know, the Kruskal–Wallis test was applied: a P‐value of 0.05 or less is considered significant. Some of the questions had multiple items for the respondents to choose from; therefore the sum total of percentages, as shown in the tables, is not always 100%.
A total of 1149 (61.94%) of those approached showed a willingness to participate in the survey. Ethnically, 490 (42.6%) of the respondents who participated in the survey were Malay, while 413 (35.9%) were Chinese, 149 (13%) were Indian and 97 (8.4%) were from other ethnic minorities. The mean age of the respondents was 30 years (SD ± 11.5). Details of the socio‐demographic characteristics of the respondents are illustrated in Table 1.
In evaluating public attitudes, the majority (n = 910, 79.2%) agreed with the statement that ‘Family and friends can enhance the depression recovery process by providing more care and attention to the patient’ and this result was found to be statistically significant (P ≤ 0.001). More than one‐third of the respondents (n = 437, 38.0%) believed that ‘Depression is a normal medical condition and it subsides automatically’. Detailed responses with appropriate statistics are presented in Table 2.
Evaluating public beliefs regarding the complications of depression proved to be a difficult task. Six items were provided with ‘yes/no’ options. In addition, respondents were invited to share their beliefs about the complications of depression. The top ranked complication identified was social problems. The majority (n = 830, 72.2%) stated that depression results in social problems, while some felt that it can result in raised blood pressure 518 (45.1%). The detailed results are shown in Table 3, while the personal perceptions of the respondents regarding the complications of depression are described in Table 4.
Three options were given to the respondents to explore their beliefs about the prevention of depression. Most of the respondents felt that one can prevent depression by maintaining a good social life. Detailed responses are illustrated in Table 5.
Exploration of public beliefs in terms of seeking help for depression revealed three main barriers. Slightly more than half of the respondents (n = 582, 50.7%) believed that the most important hindrance in the help‐seeking process is that depressed people do not think that they are at risk of depression. Other barriers highlighted are that ‘They are not aware of the signs and symptoms’ followed by ‘They don't want to share their problems’. Their detailed responses are shown in Table 6.
Mental health had long been a neglected issue in Malaysia. However, in 2007, in a letter of intent, the Ministry of Health (MOH) of Malaysia stressed the need to explore the level of mental health literacy, and public attitudes towards, complications of and preventive measures for depression and the barriers that result in delays in seeking help. 15 In other words, this 2007 letter of intent by the MOH was the main motivation for this study.
A total of 1855 respondents were approached, of whom 61.94% showed a willingness to participate in this study. Demographic facts revealed that youths aged 18–30 years were more willing to participate. The majority of them were those with auniversity or other tertiary qualification. A possible reason for this may be the fact that students are often the victim of some type of depressive disorder during their academic life. 16 The findings of Sherina et al (2003) and Zaid et al (2007) provide evidence of a high prevalence of depression among students.17,18
Attitudes toward depression were assessed on the basis of four items. The majority (n = 870, 75.7%) disagreed with the statement that only women and children suffer from depression, although there is evidence that correlates prevalence of depression with gender. 19 However, this also reflects a positive insight on the part of the respondents that anyone can suffer from depression, regardless of age and gender.
In exploring public attitudes toward the treatment of depression, the majority (n = 910, 79.2%) stated that family and friends can enhance the depression recovery process by providing more care and attention to the patient. This attitude may be beneficial where the depression is caused by social relationship problems. Still, as many as 485 (42.2%) of the respondents believe that people suffering from depression should be treated with antidepressants. These findings provide evidence of a positive attitude towards the use of antidepressants and contradict the internationally reported finding of a negative attitude toward the use of antidepressants. However, a noticeable number (n = 437, 38.0%) agreed with the statement that depression is a normal medical condition that subsides automatically. This fact provides insight for future research to explore the reasons or factors that could account for such an attitude.
Though it is generally difficult to evaluate public beliefs regarding the complications of depression, an effort was made to obtain some preliminary data. Social problems were perceived to be a major complication of depression, followed by raised blood pressure, sexual disorders, loss of memory and heart attacks. In evaluating their personal beliefs, the respondents revealed suicide as one of the major complications, followed by job‐related problems, family tensions, mania, loss of relationships, lack of interest in work and headaches. After ethnical segregation of the responses, it was apparent that Malays tended to identify family and relationship problems; the Chinese, job‐related complications, lack of interest in work and mania; and the Indians, headaches as the main complications of depression.
Attitudes towards the prevention of depression can influence actual beliefs regarding depression. Overall, positive attitudes were observed towards the prevention of depression. A sizeable majority (n =1049, 91.3%) agreed that a change in lifestyle, such as maintaining a good social life, is one of the preventive measures. In addition, other preventive strategies involve maintaining a healthy diet and regular physical activity. About 893 (77.7%) of the respondents agreed with the statement that one can prevent depression by avoiding alcohol and drugs. We can assume that this reflects the respondents' knowledge of the side‐effects of alcohol and drug abuse.
The perception of a personal health risk is primarily influenced by general health values, which include interest and concern about health, specific beliefs about vulnerability to a particular illness and beliefs about the consequences of the illness, such as whether or not they are serious. 20 Recognised barriers to seeking help include social, professional and personal factors. Multiple responses were obtained in response to a question about why people are not willing to seek help or to be tested for depression. Slightly more than half of the respondents (n = 582, 50.7%) did not think that they were at risk of depression, while 575 (50%) stated that they were not aware of the signs and symptoms. In response to a question about treatment, 207 (18%) of the respondents mentioned that treatment of depression is expensive, and that this hinders patient access to proper mental health care. The response to this statement can be evaluated both negatively and positively. From a positive perspective, it can be interpreted to mean that mental health services provided by the private health sector are expensive. The negative interpretation may indicate the lack of awareness among the respondents that mental health care in the public hospitals of Malaysia is free for all Malaysians.
Other statements in this regard reflect the stigma‐related attitudes among the respondents towards seeking professional help. Slightly less than half (n = 544, 47.3%) agreed with the statement that depressed people do not want to share their problems, with a lower percentage agreeing that people do not want to know that they are depressed. Significant barriers to seeking help were; a lack of awareness of the signs and symptoms, costly treatment and the stigma associated with a diagnosis of depression. These findings are consistent with the findings of Outram et al (2004). 21 In fact, Outram et al claimed that a desire for privacy and confidentiality, fear of being judged by professionals, believing no one can help, pride and a desire to cope alone are the main barriers to seeking professional help. 21
Searle (1999) stated that the perceived stigma associated with mental illness and individuals' views about the illness itself play a vital role in compliance with treatment for depression. 7 Though the stigma of psychiatric illness influences its presentation, recognition and treatment adherence, public health campaigns can be beneficial in the eradication of misconceptions among the public with regard to mental disorders.22,23
Overall, positive attitudes were observed towards the complications and prevention of depression. However, there is a need to increase mental health literacy. Such initiatives will be effective in neutralising negative public perceptions regarding evidence‐based medical treatment options and removing barriers to seeking professional help.
It should be noted that the majority of the respondents in this study were young people and, more specifically, young females. This was not intentional: young female respondents were more willing to participate in the study by comparison with others. This limitation highlights the need for further studies that focus on the middle‐aged and the elderly to gauge whether their attitudes toward depression, prevention of depression and barriers to seeking help are significantly different.
In Malaysia there is scarcity of research in the field of mental health. It is hoped that these preliminary findings will prompt the Public Health Department to conduct more specific and methodologically sound studies to explore the ramifications of mental health illiteracy in this country, so as to create a more proactive and viable mental health delivery system.
Tahir M Khan, Postgraduate Fellow, School of Pharmaceutical Sciences, University Sains Malaysia, Pulau Penang and Lecturer, School of Pharmacy, Island College of Technology, Balik Pulau, Pulau Penang, Malaysia.
Syed A Sulaiman, Associate Professor, Dean, School of Pharmaceutical Sciences, University Sains Malaysia, Pulau Penang, Malaysia.
Mohamed A Hassali, Senior Lecturer, Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, Pulau Penang, Malaysia.
Humera Tahir, Postgraduate Fellow, School of Psychology, University of Punjab, Lahore, Pakistan.