Dear Editor
Mental health literacy has been defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ (Jorm et al. Reference Jorm, Korten, Jacomb, Christensen, Rodgers and Pollitt1997). Although international research in the past decade has increased our understanding of the public's knowledge and beliefs about the recognition and management of mental illness (e.g. Angermeyer & Matschinger, Reference Angermeyer and Matschinger2005; Wang et al. Reference Wang, Adair, Fick, Lai, Evans, Perry, Jorm and Addington2007; Kermode et al. Reference Kermode, Bowen, Arole, Pathare and Jorm2009), there remains a dearth of understanding about the public's knowledge and beliefs about prevention. To date we are only aware of two studies that have examined this: a national survey of the German public aged 14 and over (Schomerus et al. Reference Schomerus, Angermeyer, Matschinger and Riedel-Heller2008) and a national survey of Australian youth aged 12–25 years and health professionals (Jorm et al. Reference Jorm, Morgan and Wright2010). However, despite substantial evidence about the importance of parenting as risk or protective factors in youth depression (Restifo & Bögels, Reference Restifo and Bögels2009), growing evidence suggesting that interventions to promote effective parenting can prevent youth depression (Sandler et al. Reference Sandler, Schoenfelder, Wolchik and MacKinnon2011), and public attributions of childhood depression to the way the child was raised (Perry et al. Reference Perry, Pescosolido, Martin, McLeod and Jensen2007), little is known about parents' knowledge and beliefs about their role in prevention. This is especially important given that the incidence of depression peaks in the first decades of life and is accompanied by serious long-term sequelae (Kessler, Reference Kessler2009).
In view of the limited research on this topic, we included questions about prevention as part of an Australian national survey of mental health literacy with youths and their parents. In particular, we examined parents' beliefs about three sets of parenting behaviors that evidence to date indicates are preventive against youth depression: (1) showing affection to their child, often conceptualized as parental warmth (e.g. see reviews by McLeod et al. Reference McLeod, Weisz and Wood2007; Restifo & Bögels, Reference Restifo and Bögels2009); (2) not keeping the child under tight control at all times, conceptualized as overcontrol (e.g. see reviews by McLeod et al. Reference McLeod, Weisz and Wood2007); and (3) avoiding parental conflict in front of the child, sometimes also conceptualized as marital discord (e.g. see reviews by Cummings & Davies, Reference Cummings and Davies2002; Restifo & Bögels, Reference Restifo and Bögels2009). To explore potential correlates of parental beliefs which can inform health promotion efforts, we also examined parental socio-demographic characteristics and their exposure to mental health problems and mental health information. Since child characteristics such as age and sex may influence parental beliefs (e.g. more affection for daughters v. more control for sons), we examined these variables as well.
Methods
Participants
In 2006, a national computer-assisted telephone survey was carried out via random digit dialing on a sample of 1873 young Australians aged 12–25 years (61.5% response rate). Of the 1466 youth respondents who lived with at least one parent, 982 (67%) had a parent who also completed a parent interview, 68% of whom were mothers (see Jorm et al. Reference Jorm, Wright and Morgan2007 for more details). This paper focuses on parent respondents only.
Survey interview
The national survey was conducted to investigate mental health literacy in Australian youth and their parents, and was based around a vignette of a young person (‘John’/‘Jenny’) with a mental disorder. Respondents were randomly assigned to one of four vignettes: depression, depression with alcohol misuse, social phobia or psychosis. Parents were read a vignette of the same gender and age group as their child, and then asked a series of questions based on the vignette (see Jorm et al. Reference Jorm, Wright and Morgan2007 for more details). This paper focuses only on the two depression vignettes because these have known parenting risk factors.
Prevention beliefs
Parents were asked: ‘The next few questions are about things a parent might do to reduce the risk of (John/Jenny) developing the problem in the first place. If a parent did the following, do you think it would reduce the risk of their child developing a problem like (John's/Jenny’s)?’. They were then read nine sets of parenting behaviors, which included three of interest in this paper due to their evidence base: ‘showing the child lots of affection’, ‘keeping the child under tight control at all times’, and ‘parents not having arguments in front of their child’. Possible responses were ‘Yes’, ‘No’, ‘Depends’, ‘Don't know’ and ‘Refused’. For the first and third behaviors, responses were coded ‘Yes’ = 1 and ‘No’ = 0. Responses for the second behavior were reverse coded such that ‘No’ = 1 and ‘Yes’ = 0. Hence all responses of ‘1′ indicate that the parent has accurate beliefs about prevention based on extant evidence. To avoid ambiguity in interpretation of findings, we excluded respondents who did not provide a ‘Yes’ or ‘No’ response in analyses examining the correlates of these beliefs.
Correlates of prevention beliefs
Child sex and age information were collected as part of the youth interview. During the parent interview, parents provided socio-demographic information including their sex, age, highest level of education completed, and whether they spoke a language other than English (LOTE) at home. Parental age was obtained as 20–29, 30–39, 40–49, 50–59, 60 or over or refused. For simplicity, the parental age variable was coded as 40–49 years (given that it was the most prevalent group), below 40 or above 50. Parental education was coded as tertiary v. other, consistent with past research (Griffiths et al. Reference Griffiths, Christensen and Jorm2008).
In addition, parents were asked about their exposure to mental disorders in themselves or someone close to them: ‘Have you ever had a problem similar to (John's/Jenny's)?’ and ‘Has anyone in your family or close circle of friends ever had a problem similar to (John's/Jenny's)?’.
Finally, parents were asked about their exposure to mental health information: ‘Have you seen, read, or heard any advertisements about mental health problems in the past 12 months?’; ‘Have you seen, read, or heard any news stories about mental health problems in the past 12 months?’; ‘Have you heard of beyondblue: the national depression initiative’?; ‘In the past 12 months, have you received any information about mental health problems from your child's school?’; and ‘In the past 12 months, have you received any information about mental health problems at your workplace?’. For the latter two questions, responses of parents who did not have a child at school or who were not in the workforce were coded as ‘No’ to maximize the sample size. All responses were coded ‘Yes’ = 1 and ‘No’ = 0.
Statistical analysis
Descriptive data on parent respondents' prevention beliefs and all correlates were analyzed using frequencies and percent frequencies. We then conducted three binary logistic regressions to explore whether the 14 abovementioned correlates predicted the accuracy of parental beliefs about each of the three parenting behaviors relative to research evidence. In these regressions, the prevention belief was the dichotomous-dependent variable, and all 14 correlates were entered simultaneously as predictors. All predictors were dichotomous except for parent age, which had three groups; and child age in years, which was a continuous variable. The p < 0.01 significance level was used to reduce Type 1 error given the large number of predictors examined. All analyses were performed using PASW version 18.
Ethics
Oral consent was obtained before commencing the interview. This study was approved by the University of Melbourne Human Research Ethics Committee.
Results
Of the 982 parents who completed the interview, one refused to provide their age and one refused to indicate whether they speak a LOTE at home. Hence they were excluded from further analyses, which gave a remaining sample of 980. However, given that we excluded respondents who did not respond with ‘Yes’ or ‘No’ to the prevention beliefs by list-wise deletion, the total sample for regression analyses predicting the affection, overcontrol, and parental conflict beliefs were 944, 911, and 928, respectively.
As summarized in Table 1, most parents correctly endorsed the parenting behaviors, especially showing lots of affection, although a significant minority did not believe that avoiding overcontrol and minimizing a child's exposure to parental conflict will reduce their risk of developing depressive disorders.
Table 1. Descriptive data for parent prevention beliefs and correlates of interest: number and percent of parent sample (N = 980)
*Child age is displayed here as two separate categories for ease of description, but child age in years is included as a continuous variable in regression analyses.
LOTE = language other than English.
As shown in Tables 2 and 3, four of the 14 correlates examined significantly predicted the affection and overcontrol beliefs. Parents who had received mental health information at work were more likely to correctly endorse the belief that showing the child lots of affection is preventive. Parents with tertiary education and those who speak English only at home, as well as those who had been exposed to mental health advertising, were more likely to correctly endorse that not exerting overcontrol is preventive. None of the correlates significantly predicted the belief about avoiding parental conflict.
Table 2. Summary of logistic regression analysis predicting the correct endorsement of ‘showing the child lots of affection’ as preventative (N = 944)
Nagelkerke R 2 = 0.13.
Significant effects (p < 0.01) are presented in bold. LOTE = language other than English.
Table 3. Summary of logistic regression analysis predicting the correct endorsement of not ‘keeping the child under tight control at all times’ as preventative (N = 911)
Nagelkerke R 2 = 0.13.
Significant effects (p < 0.01) are presented in bold. LOTE = language other than English.
Discussion
This study found that most parents believe that specific types of parenting behaviors have a role to play in preventing depression in young people. Parent education and LOTE status, as well as their exposure to mental health information through advertising and at their workplace, predicted some of these beliefs. There were no predictors of the belief about parental conflict, perhaps reflecting the fact that this has not been the target of depression awareness campaigns in Australia.
Overall, most parents believe that showing their child lots of affection is protective against depression in young people, although there is a minority who did not believe this, despite the strong evidence backing up its role in prevention of depression (Cummings & Davies, Reference Cummings and Davies2002; McLeod et al. Reference McLeod, Weisz and Wood2007; Restifo & Bögels, Reference Restifo and Bögels2009). Of greater concern are the findings that almost one in five parents did not believe in the important preventive role of not exerting tight control over their child at all times, and of parents not having arguments in front of their child. Interestingly, there were more parents indicating ‘Depends’ for the overcontrol belief than the other two. In line with the proposal raised in a recent review of family processes in the development of youth depression (Restifo & Bögels, Reference Restifo and Bögels2009), these views may reflect parents' belief that the broader social context (e.g. living in a high-crime neighborhood) and child characteristics (e.g. child temperament and peer selection) may be important in determining how much parental control is necessary for their child's safety and wellbeing. Nonetheless, taken together with the clear evidence that these parenting behaviors can be protective against youth depression, these findings of inadequate parental knowledge indicate the need to promote these prevention messages to parents, while being sensitive to the potential caveats and conditions in which such parenting behaviors could lead to different outcomes.
When considering ways to target the promotion of prevention messages, it is notable that parental socio-demographic factors seem to be important correlates of their prevention beliefs. In particular, parents with non-tertiary education and those with LOTE status may be important subgroups to target. These findings are generally consistent with extant evidence that lower education attainment (e.g. Kaneko & Motohashi, Reference Kaneko and Motohashi2007) and having a non-English-speaking background (e.g. Wong et al. Reference Wong, Lam and Poon2010) are associated with poorer mental health literacy. Relatedly, some studies have found that parenting is associated with parental ethnicity (e.g. Keller et al. Reference Keller, Borke, Yovsi, Lohaus and Jensen2005) and level of education (e.g. Simons et al. Reference Simons, Whitbeck, Conger and Wu1991), whereby Anglo- and European parents and those with higher levels of education are less likely to use authoritarian and harsh parenting. However, a meta-analysis of the association between parenting and child depression has found that these factors (especially ethnicity) are not important moderators of the effect size of this association (McLeod et al. Reference McLeod, Weisz and Wood2007). Nonetheless, evidence from these related fields of research should be taken together to inform policy and practice involving parenting programs and prevention and intervention efforts for depression in young people (Restifo & Bögels, Reference Restifo and Bögels2009). Our findings that parent sex did not influence their prevention beliefs are not consistent with some past research indicating that female adults in general have been found to have better mental health literacy (e.g. Griffiths et al. Reference Griffiths, Christensen and Jorm2008). However, as noted previously, less is known about prevention beliefs, and the limited literature to date (Schomerus et al. Reference Schomerus, Angermeyer, Matschinger and Riedel-Heller2008; Jorm et al. Reference Jorm, Morgan and Wright2010) has not reported adult or parent sex differences in these beliefs. It is noteworthy, nonetheless, that our sample of parents may not be representative of the general population, given that they were co-resident parents who were present with the youth respondent at the time of the survey and consented to being interviewed as well.
A personal history of mental health problems failed to influence parents' prevention beliefs, despite extant literature about the parenting deficiencies of parents with mental illness (Dozois et al. Reference Dozois, Seeds and Collins2009). This suggests that while parenting behaviors may be sensitive to parents' psychiatric history, broader parental characteristics like their education and LOTE status may be more important predictors of their beliefs about their role in protecting their child against depression. In addition, although 61% of parents knew someone in their close network with a history of mental health problems, this also failed to influence their prevention beliefs.
In terms of identifying potential avenues to reach parents effectively with prevention messages, it is notable that receiving mental health related information through advertisements and their workplace influenced parental beliefs, although awareness of beyondblue did not. Previous studies have found that such avenues can be important agents for improving mental health literacy in the general population (e.g. Jorm et al. Reference Jorm, Christensen and Griffiths2005). The current study suggests that mass media advertising and workplaces can be good avenues for promoting prevention messages to parents of young people. Although awareness of beyondblue has been found to predict other aspects of mental health literacy, prevention messages for parents of young people have not been a central focus in their campaigns to date, hence it is not surprising that it did not emerge as a significant predictor of parental prevention beliefs. Indeed, these findings highlight a need for future health promotion campaigns that focus on prevention messages for parents of young people, given evidence of the effectiveness of parenting programs which indicate that parenting behaviors are amenable to change (Sandler et al. Reference Sandler, Schoenfelder, Wolchik and MacKinnon2011), and the important role that parents play in the development of youth depression (Cummings & Davies, Reference Cummings and Davies2002; McLeod et al. Reference McLeod, Weisz and Wood2007; Restifo & Bögels, Reference Restifo and Bögels2009).
Strengths and limitations
This national survey is the first of its kind to examine the mental health literacy of young people and their parents. In particular, it is the only national survey to our knowledge that has examined parental beliefs about prevention, contributing to our limited knowledge about the prevention aspect of mental health literacy in the community.
Nonetheless, its findings should be interpreted in light of the study limitations. Firstly, our sample of parents may not be representative of all parents of young Australians given that they are a self-selected sample of co-resident parents who consented for interview along with their child. Future surveys with a more representative sample of parents are required to ascertain whether these findings are robust. In addition, we only assessed parental beliefs about parenting behaviors with reference to a vignette character, hence it is unclear how closely the reported beliefs reflect or translate into actual parenting behaviors with their own child. In this brief telephone survey, we were only able to assess parental beliefs using a closed-answer format. Future surveys should include open-ended responses to better evaluate parents' prevention beliefs qualitatively. It was also a challenge to frame the prevention beliefs in such a way that they accurately reflect research evidence without being so blatantly explicit as to encourage socially desirable responding. For example, when trying to tap into parental overcontrol, we avoided the term ‘overcontrol’ as it may carry a pejorative connotation. Hence, it is possible that parents may have interpreted these behaviors differently. Finally, it is worth noting that the correlates examined only accounted for a modest proportion of parental beliefs. It is possible that other factors, such as their own experience of parenting, as well as the beliefs of close others, may also be important influences.
Implications and conclusions
Findings from this study indicate that while most parents believe that certain parenting behaviors can protect young people from depression, a significant minority does not; highlighting the need to improve parents' understanding of their role in prevention. Importantly, these findings revealed various socio-demographic characteristics of parents that can facilitate the targeting the promotion of these evidence-based prevention messages. They also suggest that mass media advertising and providing prevention messages through the workplace may be good avenues for channeling promotion efforts.
Declaration of Interests
Funding for this study was provided by a National Health and Medical Research Council Program Grant, beyondblue: the national depression initiative, and the Colonial Foundation. The funding sources had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. The authors declare no conflict of interest related to the present paper.
