Awareness, Attitudes, and Help-seeking Intention towards Perinatal Depression among Women from Different Ethnic Groups in Western Rural China

doi:10.21203/rs.3.rs-3230563/v1

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Awareness, Attitudes, and Help-seeking Intention towards Perinatal Depression among Women from Different Ethnic Groups in Western Rural China

https://doi.org/10.21203/rs.3.rs-3230563/v1

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Background Despite the high prevalence of perinatal depression in China, the underutilization of mental health services remains. This study aimed at understanding the awareness, attitudes, and help-seeking intentions towards perinatal depression among women from different ethnic groups in western rural China.

Methods A cross-sectional survey was conducted in a rural county of Yunnan Province in May 2022. Pregnant women and women within one year after childbirth were selected. Chi-square tests, Fisher's exact probability analyses and multiple logistic regression models were employed to investigate the determinants of women's help-seeking intentions concerning perinatal depression.

Results A total of 1,217 women participated in the survey and 1,152 were included for analysis, including 464 Hanwomen (40.28%), 498 Zhuang women (43.23%), and 190 from other ethnic minorities (16.49%). There were 12.67% of women detected with perinatal depressive symptoms, while 13.89% reporting they had experienced negative emotions for more than two weeks. Among women who had negative emotions history, just 4.38% had utilized mental health services. Over a quarter (26.91%)of women had never heard of depression, and nearly half were unawareof the available treatments (49.57%) or the facilities where they could seek treatment for depression (55.21%). The most participants (84.55%) reported that they would seek help for depression if needed. For those women who displayed a willingness to seek help, 75.36% prefer to seek support from interpersonal sources and 72.07% favored consulting professionals. Factors influencing help-seeking intentions differed across different ethnic groups. Hanwomen with beliefs about the preventability and curability of depression (OR=2.679, 95%CI: 1.329-5.401) were more likely to seek help from professionals. Zhuangwomen with stronger family support were associated with a greater likelihood of seeking help (OR=2.660, 95%CI: 1.087-6.508). Other ethnic minority women with salaried employment reflected a lower potential to seek help (OR=0.044, 95%CI: 0.005-0.403).

Conclusion Women from different ethnic groups in western rural China had a low level of awareness of perinatal depression and mental health services. It is of great necessity to implement educational campaigns and supportive interventions aimed at addressing the social and psychological vulnerabilities of women and attending to the unique needs of ethnic females.

Awareness

Attitudes

Help-seeking Intention

Perinatal Depression

Ethnic differences

Western China

Perinatal depression (PND) denotes the presence of depressive symptoms experienced by women during pregnancy and up to one year postpartum[1, 2]. Extensive reviews of recent literature indicate that the global prevalence of PND was approximately 12%, with a notably higher prevalence among women in low- and middle-income countries (13.1%) compared to those in high-income countries (11.4%)[3]. In China, the reported prevalence of PND has demonstrated a steady increase over the past decade, reaching 16.0% in recent years, particularly prevalent in less developed regions[2]. Empirical studies have confirmed that PND can significantly heighten the likelihood of complications during pregnancy and childbirth (e.g. gestational diabetes), exert substantially adverse effect on the physical and mental health of affected mothers, thereby disrupting family functioning and social relationships[2, 4–7]. Additionally, PND can detrimentally affect infants’ growth and their cognitive and emotional development[8, 9], and even pose potential risks of maternal suicide or infanticide[10]. Given the profound negative impact on maternal and infant well-beings, PND has become a predominant challenge in the realm of public health.

The existing body of evidence consistently supports the notion that the early assessment and provision of safe, effective, and accessible mental health care for women experiencing PND can significantly enhance the well-being of both mothers and infants[10–12]. Unfortunately, a substantial proportion of women suffering from PND either postpone health care-seeking or do not seek at all[13–15]. Merely 22% of women who were detected positively for PND utilized mental health services[16]. In the context of China, only 19% of pregnant women with depression or anxious symptoms had expressed their proactive intention to seek health services[17].

The reluctance to seek help can be attributed to three main categories of barriers: structural, sociocultural, and individual. Structural barriers primarily pertain to impediments in service accessibility, including inadequate availability of mental health providers or resources, geographical distances, and inadequate health insurance coverage[7, 14, 18]. Sociocultural barriers predominantly revolve around the passive role of stigma and discrimination towards mental health, which significantly contributes to the underutilization of mental health services among women[19–24]. Meanwhile, protective mechanisms such as social support and trust were identified as pushing factors, motivating help-seeking intentions and behaviors among women[13, 21, 25, 26]. Finally, at individual level, barriers encompass personal stigmatization towards mental health, lower educational attainment, limited health literacy, a diminished perceived necessity for mental healthcare, inadequate comprehension of the health system, as well as constrained leisure time and reduced household income[7, 10, 14, 27, 28].

Knowledge-attitude-practice theory posits that acquired knowledge and attitudes of women towards perinatal depression treatment play a pivotal role in mediating their help-seeking behaviors[7, 14, 26, 29]. In particular, women with more positive attitudes towards depression treatment are more likely to have stronger intentions to seek help and a higher likelihood of actually doing so[7, 21, 30]. While several studies have explored women's attitudes and help-seeking intentions towards perinatal depression in countries like the US and Portugal[15, 19], there remains a significant research gap in understanding these aspects in the context of China, particularly among ethnic minority women.

To date, only five studies have been conducted in China that specifically examined either women's attitudes towards perinatal depression or their help-seeking intentions, with two studies focusing on the urban area of Changsha City in eastern China[7, 21] and the remaining three encompassing nationwide online surveys and semi-structured interviews[17, 31, 32]. It is important to note that none of these five studies classified women based on their ethnicity. Therefore, further evidence is needed to understand Chinese women's attitudes towards perinatal depression treatment and their intentions to seek help, especially in less-developed western regions and among ethnic minorities.

The objectives of this study are to address the existing knowledge gap and pursue two primary goals: firstly, to investigate awareness, attitudes, and help-seeking intentions towards perinatal depression among women from diverse ethnic groups in a rural county with 11 ethnic minorities situated in western China; secondly to examine the influencing factors associated with their awareness, attitudes, and help-seeking intentions. The ultimate aim is to assist the development of effective public health strategies that positively impact their help-seeking behaviors.

Study Design and Participants

This cross-sectional survey was conducted in May 2022 in a rural county situated in Yunnan Province, China. By the end of 2021, the rural population in the county accounted for 72.0% of the total population, with ethnic minorities comprising 61.8%. The predominant ethnic groups are Zhuang and Han, constituting 42.6% and 38.2% of the total population, respectively. In addition, there are other ethnic minorities including Miao, Yi, Yao, Hui, Mongolian, Dai, Lahu, Buyi, and 11 other ethnic groups.

The study targeted women who were pregnant or within one year after childbirth as of May 2022, with a total surveyed participants of 1,217. Inclusion criteria required the participants to have resided in the county for at least three months and possess effective communication skills. Women with intellectual disabilities or those unwilling to participate were excluded from the study. The participants had the option to complete the questionnaire survey either independently or with the assistance of investigators. The investigation sites included the county maternal and child health hospital, county people's hospital, primary healthcare institutions, communities, villages, and the homes of the participating women.

Questionnaire

The questionnaire consists of two parts: a self-designed section and standardized scales. The self-designed section includes inquiries related to socio-demographic characteristics, negative emotions history, mental health service utilization, as well as awareness, attitudes, and help-seeking intentions towards perinatal depression. Standardized scales, developed by previous researchers, are employed to assess participants' perinatal depressive symptoms and the level of social support received from family, friends, and other sources.

Self-designed section

The socio-demographic information gathered included age, perinatal period (pregnant or postpartum), place of residence, marital status, ethnicity (Han, Zhuang, or other ethnic minorities), education level, employment status (unemployed, farmer, hourly employee, or salaried employee), medical insurance coverage, monthly household income (RMB), history of negative events within the past 12 months, satisfaction of relationship with husband or partner, family history of mental illness, spouse's ethnicity, spouse's employed status (yes or no), living arrangements with spouse, parents, or parents-in-law (yes or no).

Negative emotions history refers to experiences of negative emotions lasting more than two weeks prior to the initiation of the current study, including but not limited to symptoms of depression, anxiety, tension, fear, irritability, agitation, and low mood. Mental health service utilization includes utilization of formal mental health services (yes or no), the type of services sought from psychiatrists, psychological counselors, or non-professionals, online services or interpersonal interviews, the number of service utilized, and the cost of mental health services.

Regarding attitudes towards depression, the questionnaire covers the understanding of depression (yes or no), agreement on the preventability and curability of depression (yes or no), knowledge of available treatments for depression (yes or no), awareness of facilities for depression treatments (yes or no), agreement on the inclusion of mental services in health insurance coverage (yes, no, or unknown), satisfaction with current mental health services (yes, no, or unknown), and reasons for dissatisfaction with current mental health services.

Help-seeking intention towards perinatal depression encompasses three levels, including intention to seek help for depression when needed (yes or no), intention to seek help from other individuals when needed (yes or no), and intention to seek help from professionals when needed (yes or no). These professionals include psychiatrists or psychologists who work at general hospitals, psychiatric hospitals, or other institutions.

Standardized scales applied

The Edinburgh Postnatal Depression Scale (EPDS) was adopted to assess the perinatal depressive symptoms over the past seven days[33]. The EPDS questionnaire consists of 10 items, each scored on a 4-point Likert scale ranging from 0 ("never") to 3 ("often"). The total score of the EPDS ranges from 0 to 30, with higher scores indicating more severe depressive symptoms. In our study, a total score of ≥ 9 was considered an indicator of the presence of perinatal depressive symptoms[34]. The EPDS has previously demonstrated good internal consistency (Cronbach’s α was 0.87) in the study conducted by Cox et al[33]. The Cronbach’s α coefficient for this scale was 0.88 in our sample.

Social support was evaluated using the Multidimensional Scale of Perceived Social Support (MSPSS)[35], with the average score of the three subscales (family, friends, and others) being calculated. A score ranging from 1 to 5 was deemed low to moderate support, while a score from 5.1 to 7 represented strong support. The MSPSS has demonstrated good internal consistency and test-retest reliability[35]. The internal consistency of MSPSS in this study was sufficient (Cronbach’s α = 0.935).

Statistical Analyses

All analyses were conducted using Stata 15.1 software and a p-value of 0.05 was considered statistically significant. Categorical variables were described using frequency and percentage, while continuous variables (e.g. age) were described using median or interquartile range for statistical description. Chi-square test and Fisher's exact probability analysis were employed to explore the differences in awareness, attitudes, and help-seeking intentions towards perinatal depression among women from different ethnic groups and multiple logistic regression models were conducted to investigate the related factors. The models controlled for potential confounding factors, including age, place of residence, marital status, employment status, education level, monthly household income, family history of mental illness, spouse's ethnicity, spouse's employment status, history of negative events, relationship with husband or partner, level of social support, negative emotions history, utilization of mental health services, PND, and attitudes towards depression.

Demographic characteristics

A total of 1,217 women completed the questionnaires. After the exclusion of 65 incomplete questionnaires with missing key indicators, 1,152 validated questionnaires were included for analysis, resulting in a high effective response rate of 94.66%. The study sample comprised of 464 Han women (40.28%), 498 Zhuang women (43.23%), and 190 women from other ethnic minorities (16.49%). The average age of participants was 26.72 ± 5.58 years. Notably, significant differences (P < 0.05) were observed among these ethnic groups in terms of several factors, including age, education level, place of residence, monthly household income, employment status, and medical insurance.

Perinatal depression and negative emotions history

Among the participants, 12.67% were identified with perinatal depressive symptoms by the EPDS, while 13.89% self-reported experiencing negative emotions for more than two weeks. Zhuang women exhibited a higher detection rate of perinatal depression (14.46%) compared to Han women (10.78%) or women from other ethnic groups (12.63%). Conversely, women from other ethnic minorities had a higher prevalence of negative emotions history (16.32%) in comparison to Zhuang women (13.45%) or Han women (13.36%). However, statistical analysis did not reveal significant differences between these groups in terms of perinatal depression and negative emotions history (Table 1).

Table 1

Women's demographic characteristics, perinatal depression, and negative emotions history [n(%)]
Variables	Total 1152(100)	Ethnic Groups
Variables	Total 1152(100)	Han 464(40.28)	Zhuang 498(43.23)	Other ethnic minorities 190(16.49)	χ²/Fisher	P
Perinatal Period
Pregnant period	712(61.81)	297(64.01)	302(60.64)	113(59.47)	1.677	0.432
Postpartum period	440(38.19)	167(35.99)	196(39.36)	77(40.53)	1.677	0.432
Age (years)
<23	291(25.26)	88(18.97)	135(27.11)	68(35.79)	33.212	< 0.001
23–26	314(27.26)	115(24.78)	151(30.32)	48(25.26)
27–30	273(23.70)	128(27.59)	111(22.29)	34(17.89)
>30	274(23.78)	133(28.66)	101(20.28)	40(21.05)
Marital Status
Single/divorced/widowed	8(0.69)	3(0.65)	4(0.80)	1(0.53)	-	0.179^†
First-marriage	1019(88.45)	398(85.78)	449(90.16)	172(90.53)
Remarried	125(10.85)	63(13.58)	45(9.04)	17(8.95)
Place of residence
Rural	684(59.38)	234(50.43)	331(66.47)	119(62.63)	26.604	< 0.001
Urban	468(40.63)	230(49.57)	167(33.53)	71(37.37)	26.604	< 0.001
Education level
Junior high school or below	590(51.22)	225(48.49)	248(49.80)	117(61.58)	9.945	0.007
High school or above	562(48.78)	239(51.51)	250(50.20)	73(38.42)	9.945	0.007
Employment
Unemployed	453(39.32)	175(37.72)	192(38.55)	86(45.26)	13.591	0.035
Farmer	167(14.50)	58(12.50)	77(15.46)	32(16.84)
Hourly employee	184(15.97)	89(19.18)	67(13.45)	28(14.74)
Salaried employee	348(30.21)	142(30.60)	162(32.53)	44(23.16)
Monthly household income(in RMB)
<5000	527(45.75)	192(41.38)	246(49.40)	89(46.84)	6.332	0.042
≥ 5000	625(54.25)	272(58.62)	252(50.60)	101(53.16)	6.332	0.042
Holding medical insurance
No	31(2.69)	10(2.16)	10(2.01)	11(5.79)	8.362	0.015
Yes	1121(97.31)	454(97.84)	488(97.99)	179(94.21)	8.362	0.015
Perinatal depression ^a
No	1006(87.33)	414(89.22)	426(85.54)	166(87.37)	2.943	0.230
Yes	146(12.67)	50(10.78)	72(14.46)	24(12.63)	2.943	0.230
Negative emotions history ^b
No	992(86.11)	402(86.64)	431(86.55)	159(83.68)	1.122	0.571
Yes	160(13.89)	62(13.36)	67(13.45)	31(16.32)	1.122	0.571
^†Fisher's Exact test; ^a Edinburgh Postnatal Depression Scale (EPDS) score ≥ 9; ^b History of experiencing negative emotions
lasting more than two weeks prior to the start of the current study, including but not limited to symptoms of depression,
anxiety, tension, fear, irritability, agitation, and low mood

Utilization of mental health service

Only a small proportion of the participants (0.95%) reported having previously sought for mental health services. Among the 160 women who reported experiencing negative emotions, only seven (4.38%) sought out such services. They received services through face-to-face consultations (n = 5) or via telephone/internet (n = 2). The therapeutic interventions employed in the treatment encompassed medication therapy (n = 3), psychological counseling/guidance (n = 1), or therapeutic engagement with music/sports (n = 3). The cost for an individual session varied from 200 to 2,700 RMB, with free services availed to four women.

Awareness and attitudes towards depression

Among the participants, more than a quarter (26.91%) had demonstrated an absence of awareness regarding depression, 40.02% expressed disagreement with the idea that depression is amenable to prevention and cure. Moreover, a notable majority displayed a lack of knowledge concerning available treatment modalities (49.57%) or and healthcare facilities providing specialized care for depression (55.21%), and nearly 70% exhibited a lack of familiarity with mental health services in general.

It has been noted that 6.08% women expressed dissatisfaction with mental health services. The primary factors contributing to their discontent were identified as high costs (45.71%), geographical constraints in accessing medical facilities (30.00%), and perceived poor treatment outcomes (24.29%). However, a notable majority of the participants (63.98%) showed their support for the inclusion of mental health services, encompassing elements such as depression screening and early intervention, within the coverage provided by health insurance policies.

Further analyses revealed variations in attitudes towards depression and mental health services among different ethnic groups. Compared to Zhuang and Han women, women from other ethnic groups had lower levels of awareness regarding facilities available for depression treatments (47.59% vs 46.12% vs 34.21%, P = 0.005) and expressed greater uncertainty regarding the inclusion of mental health service costs under health insurance coverage (30.12% vs 30.17% vs 40.00%, P = 0.044). The findings above are list in Table 2.

Table 2

Women's awareness, attitudes, and help-seeking intention towards perinatal depression [n(%)]
Variables	Total 1152(100)	Ethnic Groups
Variables	Total 1152(100)	Han 464(40.28)	Zhuang 498(43.23)	Other ethnic minorities 190(16.49)	χ²	P
Have good understanding of depression
No	310(26.91)	121(26.08)	127(25.50)	62(32.63)	3.828	0.148
Yes	842(73.09)	343(73.92)	371(74.50)	128(67.37)	3.828	0.148
Agree that depression is preventable and curable
No	461(40.02)	185(39.87)	194(38.96)	82(43.16)	1.019	0.601
Yes	691(59.98)	279(60.13)	304(61.04)	108(56.84)	1.019	0.601
Know the treatments available for depression
No	571(49.57)	233(50.22)	238(47.79)	100(52.63)	1.420	0.492
Yes	581(50.43)	231(49.78)	260(52.21)	90(47.37)	1.420	0.492
Know the facilities available for depression treatments
No	636(55.21)	250(53.88)	261(52.41)	125(65.79)	10.511	0.005
Yes	516(44.79)	214(46.12)	237(47.59)	65(34.21)	10.511	0.005
Satisfied with the current mental health services
No	70(6.08)	27(5.82)	36(7.23)	7(3.68)	7.198	0.126
Unknown	800(69.44)	324(69.83)	351(70.48)	125(65.79)
Yes	282(24.48)	113(24.35)	111(22.29)	58(30.53)
Reasons for dissatisfaction with current mental health services^‡
High costs	32(45.71)	14(51.85)	15(41.67)	3(42.86)	-	0.737^†
Long distances	21(30.00)	7(25.93)	13(36.11)	1(14.29)	-	0.478^†
Poor treatment outcome	17(24.29)	7(25.93)	9(25.00)	1(14.29)	0.430	0.806
Long waiting time	12(17.14)	4(14.81)	7(19.44)	1(14.29)	-	0.897^†
Limited service options	4(5.71)	3(11.11)	1(2.78)	0	-	0.419^†
Short consultation times	4(5.71)	0	3(8.33)	1(14.29)	-	0.143^†
Poor service attitudes	3(4.29)	1(3.7)	1(2.78)	1(14.29)	-	0.328^†
Agree that mental services should be included into health insurance reimbursement
No	49(4.25)	22(4.74)	24(4.82)	3(1.58)	9.778	0.044
Unknown	366(31.77)	140(30.17)	150(30.12)	76(40.00)
Yes	737(63.98)	302(65.09)	324(65.06)	111(58.42)
Seek help for depression if needed
No	178(15.45)	69(14.87)	74(14.86)	35(18.42)	1.536	0.464
Yes	974(84.55)	395(85.13)	424(85.14)	155(81.58)	1.536	0.464
Seek help from other people if needed
No ^a	240(24.64)	106(26.84)	100(23.58)	34(21.94)	1.890	0.389
Yes	734(75.36)	289(73.16)	324(76.42)	121(78.06)	1.890	0.389
Seek help from professionals if needed ^b
No ^c	205(27.93)	79(27.34)	97(29.94)	29(23.97)	1.644	0.440
Yes	529(72.07)	210(72.66)	227(70.06)	92(76.03)	1.644	0.440
^† Fisher's Exact test; ^‡ Multiple responses to the question; ^a Not seeking help from anyone and only by consulting books or the internet; ^b Professionals include psychiatrists or psychologists employed at general hospitals, psychiatric hospitals, or other institutions; ^c Seeking help from non-professionals, such as family members or friends

Help-seeking intention towards depression

The most participants (84.55%) reported that they would seek help for depression if needed. For those women who displayed a willingness to seek help, a substantial portion (75.36%) prefer to seek support from interpersonal sources. Moreover, a significant majority (72.07%) of participants favored consulting psychological professionals. However, there were no significant differences across ethnic groups in terms of help-seeking intention (Table 2).

The logistic regression analysis revealed that women who had given birth within one year (OR = 1.559, 95%CI: 1.057–2.299), held the belief that depression is preventable and curable (OR = 1.746, 95%CI: 1.141–2.672), and possessed knowledge about available facilities for depression treatments (OR = 1.815, 95%CI: 1.111–2.965) were more inclined to seek help for depression when faced with such a need. Moreover, women with higher age were associated with lower help-seeking intentions for depression (OR = 0.535, 95%CI: 0.307–0.931). In addition, women with higher monthly household incomes (OR = 1.787, 95%CI: 1.294–2.468) were correlated with increased intention to seek help from other people. Furthermore, women who knew the facilities available for depression treatments were more willing to seek help from psychological professionals (OR = 1.936, 95%CI: 1.272–2.947), while those with PND were more likely to seek help from non-professionals such as family members or friends (OR = 0.550, 95%CI: 0.319–0.948).

Factors influencing help-seeking intentions differed across different ethnic groups. Among Han women, those who gave birth within one year (OR = 2.008, 95%CI: 1.038–3.883) and knew the facilities available for depression treatments (OR = 2.226, 95%CI: 1.019–5.034) exhibited a stronger intention to seek help. Women with higher education levels (OR = 2.440, 95%CI: 1.123–5.301) and beliefs about the preventability and curability of depression (OR = 2.679, 95%CI: 1.329–5.401) demonstrated a greater inclination to seek help from professionals, while women with a family history of mental illness expressed a stronger desire to seek help from non-professionals (OR = 0.023, 95%CI: 0.002–0.307).

Zhuang women with higher monthly household incomes (OR = 1.917, 95%CI: 1.034–3.554) and stronger family support (OR = 2.660, 95%CI: 1.087–6.508) were associated with a greater likelihood of seeking help, while those who were farmers (OR = 0.351, 95%CI: 0.154-0.800) and those with a family history of mental illness (OR = 0.146, 95%CI: 0.028–0.773) displayed an decreased tendency to seek help. Additionally, women with higher age (OR = 2.513, 95%CI: 1.001–6.310), higher monthly household incomes (OR = 2.157, 95%CI: 1.266–3.675), stronger family support (OR = 2.576, 95%CI: 1.110–5.980), employed spouses (OR = 2.426, 95%CI: 1.127–5.221), medical insurance coverage (OR = 11.180, 95%CI: 1.261–99.105), and living with their spouses, parents, or parents-in-law (OR = 3.206, 95%CI: 1.058–9.711) were more likely to seek help from other people. Specifically, women who knew the facilities available for depression treatments presented a greater possibility of seeking help from professionals (OR = 2.544, 95%CI: 1.304–4.963) while those women with employed spouses were found to be more inclined towards seeking help from non-professionals (OR = 0.198, 95%CI: 0.058–0.677).

Regarding other ethnic minority women, those who were salaried employees reflected a lower potential to seek help (OR = 0.044, 95%CI: 0.005–0.403). Women with senior age (OR = 9.969, 95%CI: 1.112–89.387) and higher monthly household incomes (OR = 3.312, 95%CI: 1.019–10.760) were more likely to seek help from others, while women who had experienced negative emotions were more inclined towards using self-help strategies such as web searching rather than seeking outside help (OR = 0.136, 95%CI: 0.027–0.687). Detailed information pertaining to these findings is presented in Table 3.

Table 3

Factors affecting women's help-seeking intention towards perinatal depression ^a [OR (95%CI)^†]
Help-Seeking Intention	Influence Factors	Total	Ethnic Groups
Help-Seeking Intention	Influence Factors	Total	Han	Zhuang	Other ethnic minorities
Seek help for depression if needed	Postpartum period (Ref: Pregnant period)	1.559(1.057,2.299)	2.008(1.038,3.883)	-	-
	Age > 30 years (Ref: ≤ 22 years)	0.535(0.307,0.931)	-	-	-
	Farmer (Ref: Unemployed)	-	-	0.351(0.154,0.800)	-
	Salaried employee (Ref: Unemployed)	-	-	-	0.044(0.005,0.403)
	Monthly household income ≥ 5000 RMB	-	-	1.917(1.034,3.554)	-
	Had family history of mental illness	-	-	0.146(0.028,0.773)	-
	Strong family support	-	-	2.660(1.087,6.508)	-
	Agree that depression is preventable and curable	1.746(1.141,2.672)	-	-	-
	Know the facilities available for depression treatments	1.815(1.111,2.965)	2.266(1.019,5.034)	-	-
Seek help from other people if needed	Age > 30 years (Ref: ≤ 22 years)	-	-	2.513(1.001,6.310)	9.969(1.112,89.387)
	Holding medical insurance	-	-	11.180(1.261,99.105)	-
	Monthly household income ≥ 5000 RMB	1.787(1.294,2.468)	-	2.157(1.266,3.675)	3.312(1.019,10.760)
	Spouse is employed	-	-	2.426(1.127,5.221)	-
	Living with spouse, parents, or parents-in-law	-	-	3.206(1.058,9.711)	-
	Strong family support	-	-	2.576(1.110,5.980)	-
	Negative emotions history	-	-	-	0.136(0.027,0.687)
Seek help from professionals if needed	High school education or above	-	2.440(1.123,5.301)	-	-
	Spouse is employed	-	-	0.198(0.058,0.677)	-
	Had family history of mental illness	-	0.023(0.002,0.307)	-	-
	Agree that depression is preventable and curable	-	2.679(1.329,5.401)	-	-
	Know the facilities available for depression treatments	1.936(1.272,2.947)	-	2.544(1.304,4.963)	-
	Perinatal depression	0.550(0.319,0.948)	-	-	-
^a The same logistic regression model was used in different ethnic groups, and only the model variables that reached significance after controlling for all other variables are displayed in this table; ^†Odds Ratios (95% Confidence Interval)

Although no significant difference in the risk of PND and negative emotions history had been found among women from different ethnicity, it is worth noting that the prevalence of PND (12.67%) in western rural China is relatively higher than certain eastern and central regions, such as Shanghai (12%), Jiangsu (11%), Hubei (9%), Jiangxi (9%)[2]. Furthermore, the prevalence of negative emotions history (13.89%) in western rural China is also higher than women in Changsha city, China (5.1%)[7]. Disparities in the prevalence of PND and negative emotions history across different regions of China can be influenced by factors such as variations in the utilization of depression screening scales, their cut-off score, and the social characteristics of the surveyed population. The findings from this study underscore the significance of providing prioritized mental healthcare to all women and their families living in less-developed areas, regardless of their ethnicity and personal background.

Women from different ethnic groups were found to exhibit a common low level of awareness concerning depression. More than a quarter of women had never heard of PND, and nearly half were unaware of the available treatments or relevant services delivery facilities. The results, to some extent, reflect the underutilization of mental health services in the area. Therefore, the health awareness campaign should be first in place to facilitate the participation of women in help seeking while simultaneously increasing their knowledge about PND. The reported reasons, such as high service costs, poor treatment outcomes, long distance from home to health facilities, long waiting time, and the dissatisfaction with current mental health services were highlighted by women for their reluctance to the use of mental health services. Meanwhile, over 60% of women believed that medical insurance coverage could alleviate the economic burden associated with using such services. These findings align with another study conducted in Changsha city, China[30]. In addition to awareness raising, we recommend addressing individual and sociocultural factors to support women in rural areas seeking quality mental health care.

Despite the lower level of awareness towards PND, a vast majority of women (84.55%) were willing to seek help when needed, and seeking help from professionals was the preferred way chosen by women (72.07%), which demonstrates a relatively positive intention in response to depression. Similar finding were also evident in the Ride J’s research conducted in Australia, which examined the willingness of women to utilize professional services for overcoming depression[36]. However, a noteworthy challenge arises when women's intentions remain high but do not always translate into improved health-seeking behaviors due to the presence of various barriers such as fear of being judged, and gender inequities in professional treatment[37]. Hence, gender-based elements should be considered in current educational campaign to empower women and make more consistent impacts on substantial behavior change[38, 39].

Factors influencing help-seeking intentions differed across different ethnic groups. Among Han women, those with a better awareness of depression exhibited a greater likelihood of seeking help from professionals, possibly indicating their higher confidence in help-seeking, and lower self-stigmatization related to mental illness[40]. Furthermore, Han women who have given birth within the past year exhibit a heightened inclination to seek assistance, potentially attributed to an increased susceptibility to postpartum depression. Previous investigations have revealed a rising prevalence of postpartum depression among Chinese women due to fluctuations in postpartum hormone levels, amplified infant care responsibilities, and elevated societal expectations placed upon new mothers[31, 41–44].

For Zhuang women, strong family support were associated with a higher likelihood of seeking help and sharing their depressive feelings with other people, which was similar to the finding of an online survey of Spanish-speaking women around the world[26]. This preference might be influenced by their culture norms emphasizing the centrality of family unit[45–47]. Conversely, Zhuang women with a family history of mental illness were less likely to seek help, likely due to the stigma attached to mental disorders an concerns about preserving family honor[48–52]. Accordingly, there is an urgent need for educational campaigns and policies that promote the reduction of pervasive stigma against individuals with mental disorders through various means such as utilizing mass media effectively and implementing awareness-raising interventions[53, 54].

Women from other ethnic minorities who in salaried employment displayed less willingness to seek help for depression. Again, the resistance to seeking assistance can be attributed to the prevailing stigma associated with both diseases and ethnic minorities[37]. It is noteworthy that ethnic minorities with higher incomes tend to harbor more unfavorable perceptions towards mental illness. Women with mental illness may suffer from multiple forms of discrimination resulted from a range of subordinative characteristics, such as age, socio-economic position, membership of a particular ethnic[37, 48]. Moreover, ethnic minority women in salaried employment may disregard or negate their potential mental health needs due to the conflict with their self-perception as healthy, employed and independent individuals. Furthermore, women from ethnic minorities who had experienced trauma in the past preferred self-help strategies like web searching rather than seeking external help, possibly due to the reluctance of family members and health professionals to respond to their emotional and practical needs[13]. Therefore, reliable online resources should be also included in mental health programs in rural areas to empower women with alternatives.

While this study has provided valuable insights into the awareness, attitudes, and help-seeking intentions towards depression among women from different ethnic groups in western China, it is important to note that the generalizability of the results is limited due to the fact that the study sample was drawn from only one county in Yunnan, China. Future studies should aim for a wider geographic spread to increase generalizability. Additionally, given the cross-sectional nature of this study, there is a possibility that reported help-seeking intentions may not necessarily translate into actual behaviors. Therefore, longitudinal research in future could offer a more comprehensive understanding of real-world behaviors over time.

By exploring women’s awareness, attitudes, and help-seeking intentions towards perinatal depression in western rural China, this study highlighted the prevailing low level of awareness of perinatal depression and mental health services among women from diverse ethnic groups in the region. Our findings substantiate the necessity for implementing educational campaigns and supportive interventions aimed at addressing the social and psychological vulnerabilities of women and attending to the unique needs of ethnic females.

PND Perinatal Depression

EPDS Edinburgh Postnatal Depression Scale

MSPSS Multidimensional Scale of Perceived Social Support

OR Odds ratio

US the United States

RMB Renminbi

Acknowledgements

The authors extend gratitude to the women who voluntarily participated in the survey and generously shared their valuable opinions and feedback.

Authors’ contributions

CYD and BY conceived the study. RD and YH supervised the data collection and managed the data, including quality control. XMD, YX,YL, SYL and FJ made their contributions to the acquisition, interpretation and analysis of the data. CYD and BY drafted the original manuscript. RD, YH and YX made their contributions to revision of the work, and all authors reviewed, edited, and approved the final manuscript. YH and RD takes responsibility for the paper as a whole.

Funding

This study was supported by the National Natural Science Foundation of China (71904069 and 72264020) and China Medical Board (CMB#19-338).

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was reviewed and approved by the Ethics Review Committee of the Kunming Medical University (NO. KMMU2022MEC013). At the beginning of the research, the researchers explain the project to the group of attendees and their spouses / accompanying person. The information included the aims of the study, potential advantages and disadvantages of participation, the expected benefits of carrying out the research, principle of privacy and confidentiality, and declaration of voluntary participation. Potential participants were also informed that they could withdraw from the study at any time. The study was performed in accordance with the Declaration of Helsinki and all included participants signed informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Authors details

¹ School of Public Health, Kunming Medical University, Kunming, China

² Department of Health Care, Guangnan County Maternal and Child Health Care Hospital, Wenshan, China

³ Department of Foreign Languages, Kunming Medical University, Kunming, China

⁴ Zhulin Town Central Hospital of Guangnan County, Wenshan, China

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No competing interests reported.

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Awareness, Attitudes, and Help-seeking Intention towards Perinatal Depression among Women from Different Ethnic Groups in Western Rural China

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Abstract

Background

Materials and Methods

Study Design and Participants

Questionnaire

Self-designed section

Standardized scales applied

Statistical Analyses

Results

Demographic characteristics

Perinatal depression and negative emotions history

Utilization of mental health service

Awareness and attitudes towards depression

Help-seeking intention towards depression

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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