Mental health first aid training for the Chinese community in Melbourne, Australia: effects on knowledge about and attitudes toward people with mental illness

Mental health literacy in Australia

"Mental health literacy" refers to knowledge and beliefs about mental disorders which aid their recognition, management or prevention. It includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking [7]. National surveys were done on Australian population on this area in the years 1995 and 2003. Considerable changes were found in the knowledge and beliefs about mental disorders and their treatment among the Australian public over this 8-year period. These changes involved better recognition of the disorder in a vignette and more positive beliefs about the helpfulness of a range of interventions. In general, these changes involve the public becoming more similar to mental health professionals in their beliefs [8]. Another study, with the South Australia population, examined mental health literacy regarding depression between 1998 and 2004. This research found that fewer respondents used non-specific terms such as psychological problems, nervous breakdown, or work-related problems to describe a person with depression. Instead, there was a greater recognition of depression or depressive symptoms in a vignette as well as in the respondents themselves, with a corresponding increase in treatment seeking and medication use [9].

Mental health literacy in Chinese community in Australia

Australia is a culturally diverse nation - 43% of Australians were born overseas or have at least one parent who was born overseas [10]. In addition to English, the most commonly spoken languages in the country are Italian, Greek, Cantonese, Arabic, Vietnamese and Mandarin [11]. Research on the mental health literacy of the immigrant population, however, is sparse.

People of Chinese-speaking background make up 3.4% (669,000) of the total Australian population. Overseas and Australian scholars have found that Asians, including Chinese, have a low rate of utilization of mental health services [12, 13]. Factors mentioned in the literature as associated with delays in accessing mental health services include knowledge of and beliefs surrounding mental illness and available mental health services [8, 14], cultural conceptions of the causes of mental illness [15, 16], public and self-stigma [17, 18], the tendency to rely on informal networks for support [19], and practical difficulties in accessing services [20].

Only a few studies have explored the mental health literacy of Chinese-speaking people. In studies conducted by Parker and colleagues of Chinese-speaking Australians, the researchers found that (1) Chinese tended to deny depression or express it somatically [21]; (2) Chinese prefer not to view a depressive episode as a disorder or to seek help for a psychological problem [22]; (3) most Chinese confided what they perceived to be private matters only to family members or close friends and (4) many Chinese expected Western medications to provide an instant cure to all kinds of worries, without need for explanation as to how such drugs work [23]. Those results reflect the poor mental health literacy among Chinese-speaking Australians and a study carried out by Wong et al[11] supports this claim.

There are also fewer studies exploring the schizophrenia literacy of Chinese-speaking Australian. Klimidis et al. [24] found that 47.4% of Chinese-speaking Australians were able to recognize a vignette as depicting schizophrenia when given multiple choice options. 50% of the respondents cited the condition as being related to emotional or mental problems and stress. By contrast, a study by Wong et al. [25] found that a much lower percentage of Chinese-speaking Australians (15.5%) was able to identify the vignette as a case of schizophrenia/psychosis when given an open-ended question. This study also found that Chinese-speaking Australians and Japanese were more likely to believe that close family members could be helpful compared to the general Australian population and also expressed more uncertainty about the usefulness or harmfulness of certain medications than the general Australian population.

Mental Health First Aid

In response to the inadequate mental health literacy in Chinese community in Australia, a suitable training program is required for improving the necessary confidence and skills to provide basic help. Mental Health First Aid (MHFA) training is such a program. It was developed on the basis that people with mental health problems can potentially be assisted by those in their social network [4, 26]. The MHFA program, which has now been implemented in many countries, aims to widen the base of people with the knowledge and skills to provide basic assistance to people in the community with mental health problems or in a mental health crisis. The 12-hour training course gives an overview of the major categories of mental health problems, introduces an MHFA Action Plan and applies those actions to problems of depression, anxiety disorders, psychosis and substance use disorders [27]. The course also covers the following mental health crisis situations: how to help a suicidal person, a person having a panic attack, a person who has experienced a traumatic event, a person with psychosis who is perceived to be threatening and a person who has overdosed. In the MHFA training program a structured response, consisting of five actions, is taught. Those actions are:

1) A ssess risk of suicide or harm

2) L isten non-judgmentally

3) G ive reassurance and information

4) E ncourage the person to get appropriate professional help

5) E ncourage self-help strategies

The initial letters of these actions constitute the mnemonic ALGEE. The MHFA program has more than 750 instructors delivering training across Australia and there are organizations in 14 countries that have adapted the MHFA Australia program for local use. The training course has been evaluated in various settings, with different samples using a range of methods, including randomized controlled trials, uncontrolled trials and qualitative studies. A review of evaluations of MHFA training has highlighted consistent positive benefits in knowledge, behavior, intentions and attitudes of participants [28].

The benefits of MHFA have been demonstrated in several studies with the general Australian community. However, there has been limited evaluation with immigrant communities. The only study to date has been an evaluation with Vietnamese Australians, which showed improvements in knowledge about mental disorders and reductions in stigmatizing attitudes [29]. There has, as yet, been no evaluation of training carried out in a Chinese immigrant community. The aim of this project is to investigate in members of the Chinese community in Melbourne the impact of MHFA training on mental health literacy of the participants' knowledge about appropriate first aid responses and stigmatizing attitudes. Our hypotheses are that at the end of the training participants will have increased knowledge of mental disorders and decreased negative attitudes towards people with mental disorders.

Design

The evaluation involved an uncontrolled pre-test post-test design with three training groups. This study was carried out between November 2008 and January 2009.

Participants

The participants were recruited through a convenience cluster sampling method in three major areas in metropolitan Melbourne where many Cantonese- and Mandarin-speaking Chinese people live: Box Hill and Doncaster, Monash, and Preston. The recruitment was carried out through social services organizations serving the Chinese population in these three areas. Posters in both traditional and simplified Chinese introducing the research were put up on the notice boards of these organizations. Interested potential participants approached the organizations to register for the program, which was delivered free of charge. Selection criteria included: being (1) aged 18 or above, (2) immigrants of Chinese-speaking background who were living in Melbourne, Australia, and (3) able to read and write basic Chinese.

Evaluation questionnaire

The participants were asked to complete a questionnaire on their own at the beginning of the program. Oral consent from participants was obtained prior to filling out the questionnaire, after the participants were made aware that participation in the study was voluntary and would not pose any barriers for them to join the program.

This questionnaire covered two categories of information: (1) mental health literacy regarding depression and schizophrenia, and (2) the sociodemographic characteristics of the respondents.

This instrument was adapted from that used by Jorm et al., [4] for the study of mental health literacy among Australian samples. This instrument is based around vignettes of a depression (the case of Mary) and one with schizophrenia (the case of John) that are written to satisfy the diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10).

The participants were asked, "From the information given, what, if anything, is wrong with Mary/John?" (open-ended question) and "Do you think Mary/John needs professional help?" (yes/no). These questions were followed by lists of professionals, treatments and actions that the person in the vignette might use, and participants were asked to rate each of the items as likely to be "Helpful" or "Harmful." "Neither" was also given as a response option.

For depression, there is a professional consensus that GPs, psychiatrists, clinical psychologists, antidepressants, counseling and cognitive behavior therapy are helpful, while for schizophrenia there is a professional consensus that GPs, psychiatrists, clinical psychologists, antipsychotics and admission to a ward are helpful [30]. Thus, for the depression vignette participants received a score from 0 to 6 according to the number of these interventions endorsed as helpful, while for the schizophrenia vignette they scored from 0 to 5. To equalize the range of scores for the two vignettes, they were then converted to percentages.

The questionnaire next assessed stigmatizing attitudes using a social distance scale. Social distance was measured by asking how willing the participant would be to: Move next door to Mary/John; Spend an evening socializing with Mary/John; Make friends with Mary/John; Have Mary/John start working closely with you on a job; Have Mary/John marry into your family. Each question was rated on the following scale: 1. Definitely willing, 2. Probably willing, 3. Probably unwilling, 4. Definitely unwilling. The post-test questionnaire was identical except that the socio-demographic information was excluded. The English version of the scale was translated into Chinese and back translated into English by an experienced professional translator.

Delivery of the training

The training was delivered by a qualified MHFA instructor, who is a mental health professional (holding both Social Worker and Occupational Therapist qualifications). The instructor was from Hong Kong and had 4 years experience in teaching MHFA there. The adapted MHFA manual was translated into Chinese by a Chinese psychologist. The training program was conducted in Cantonese and was instantaneously translated into Mandarin.

Statistical analysis

The McNemar test was used for analyzing change in the ability to recognize the disorder and in agreement that the person in each of the vignettes needs professional help. Answers to questions about the helpfulness of various types of intervention and about social distance were scored as scales and changes were evaluated by paired sample t-tests. Statistical data management and analyses of the data were carried out using Statistical Package for Social Sciences (SPSS 18.0 for Windows)