This study aimed to evaluate the Mental Health Literacy Scale (MHLS) in Iranian general people. There is no specified instrument for evaluating MHL in Iran, and no study was conducted on psychometrically the MHLS. One of the features of this instrument is measuring different aspects of MHL and can be efficiently measured with a short time and self-administered. In the present study, this instrument was completed by most participants without any problems in a short time. Therefore, this instrument seems to be useful for measuring the MHL of different age groups in society. Using this tool can be used to measure MHL and identify low literacy individuals in any attribute and design and implement intervention programs for them.
In the present study, this 35 items questionnaire was evaluated and modified. After evaluation of the questionnaire, 6 questions were finally omitted and the modified version of MHLS with 29 items and 6 attributes was approved. In the present study for asses the reliability of the instrument, McDonald’s omega coefficient, and Cronbach's alpha coefficient were used and calculated 0.797 and 0.789 respectively. McDonald’s omega coefficient similar to Cronbach's Alpha, but the omega coefficient provides a more accurate approximation of a scale’s reliability, and that the omega coefficient is almost always higher than Cronbach’s alpha coefficient [31]. Based on the many study results, McDonald’s omega coefficient is a more sensible index of internal consistency than Cronbach’s alpha and other alternatives [31, 33, 34]. Based on the results when developing a new measure, the value of the reliability coefficient above 0.70 is routinely considered acceptable[32].
In a study by Noroozi et al, the Cronbach’s alpha for total attributes of MHLS was 0.74 [35]. In a study conducted by O’Connor, the MHLS was designed based on other questionnaires in this field, and the 55-item questionnaire was evaluated, which after psychometric evaluation of the questionnaire, finally the MHLS with 35-item and six attributes were confirmed and Cronbach’s alpha of 0.879 and test-retest reliability of 0.797 was reported [22].
In a study conducted by Jung et al with the aim of development and reliability assessment of an instrument for evaluating MHL, the results of the exploratory factor analysis discovered three factors for the 26-item questionnaire. The results of CFA showed that the proposed model has a good fit in the stage of CFA. Also, Cronbach’s alpha for the first factor (knowledge-oriented MHL), the second factor (Beliefs-oriented MHL) and the third factor (resource-oriented MHL) were reported as 0.76, 0.77 and 0.84, respectively [36]. The results of a systematic review examined the tools available in the field of evaluation of MHL showed that the MHLS used in the present study is an acceptable tool for evaluating MHL in individuals [37].
The first attribute of this instrument was “the ability to recognize disorders”. This attribute was confirmed by 8 items, Omega 0.734, alpha 0.700 and factor loading 0.433 to 0.615. A study finding showed that many public people are not able to recognize specific disorders or different types of mental disorders [4]. The results of a study conducted by Jorm and et all in Australia showed that people had a better ability to recognize depression and schizophrenia were more likely to receive a wide range of interventions including assistance from mental health professionals, psychotherapy, medications, and psychiatric admissions [38]. Also, evidence showed that the ability to correctly recognize a mental disorder was related to less refer to informal sources for seeking help, increased preference to seek information/help from mental health professionals and mental health services [39].
The second attribute of this instrument was “knowledge of where to seek information”. This attribute was confirmed by 8 items, Omega 0.652, alpha 0.630 and factor loading 0.639 to 0.699. The results of a study in China showed that people have high intentions to seek mental health services but they have low knowledge about help sources and do not know where to seek potential help sources [40]. Based on the results a systematic review study, improved knowledge about mental disorders/mental health, where to seek help and treatment, improved the mental health outcomes and increase the use of mental health services by people [41].
The third attribute of this instrument was “knowledge of risk factors”. This attribute was confirmed by 8 items, Omega 0.601 alpha 0.600 and factor loading 0.270 to 0.422. Undoubtedly, one of the less well-regarded aspects of MHL has been prevention. We know more about the risk factors for other diseases than the risk factors for mental disorders, and people must know about the modifiable risk factors for mental disorders [42]. People who have more knowledge of risk factors and risk settings are better able to take preventative activities [43]. The results of a study in China showed that people who more learned about the mental disease had more knowledge about mental health [44].
The fourth attribute of this instrument was “knowledge of self-treatment”. This attribute was confirmed by 8 items, Omega 0.602, alpha 0.600 and factor loading 0.516 to 0.752. The ability to diagnose a mental disorder is useful, but the individual must have knowledge about evidence-based treatments available [42]. The results of the Thompson study in Australia showed that the most important reason for psychiatric patients to delay treatment was the lack of knowledge of available treatments [45].
The fifth attribute of this instrument was “knowledge of professional help available”. This attribute was confirmed by 8 items, Omega 0.643, alpha 0.640 and factor loading 0.354 to 0.731. Another important attribute of MHL is knowledge about professional help available in the community for the treatment of mental disorders [45]. Based on the results, most people with a mental disorder do not receive any treatment from health care service because they don’t know about how to access available treatment [46].
The sixth attribute of this instrument was “attitudes that promote recognition or appropriate help-seeking behavior”. This attribute was confirmed by 8 items, Omega 0.874, alpha 0.800 and factor loading 0.355 to 0.887. Results of a randomized controlled trial showed that the intervention of web-based depression literacy had a significant decrease in the stigmatizing attitudes of depressed patients with severe symptoms [23]. Study findings by Reynders and et all showed that people have more positive attitudes toward help-seeking and experience less self-stigma have fewer psychological problems and prevent these problems [47].
Strengths and Limitations
One of the strengths of this study is its conduction in the general population, with different age groups and social classes. The large sample size is another power of this study. Given the confirmation of the validity of the MHLS in this study and the applicability of this questionnaire to assess the level of MHL in different groups of society, it is recommended to use this questionnaire to assess the MHL of different target groups for educational, clinical and research purposes. Also, due to being new in this questionnaire, it is recommended that the psychometric of this questionnaire be evaluated in other studies and with various target populations.