Archives of Medicine and Health Sciences

: 2020  |  Volume : 8  |  Issue : 2  |  Page : 230--235

An observational study to assess mental health literacy among undergraduate students from Tamil Nadu

Robbin Bose1, B Sivaprakash2, Sukanto Sarkar2, Abu Backer3, S Eswaran2,  
1 Department of Mental Health, Geraldton Regional Hospital, Geraldton, Western Australia
2 Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to be University), Pondicherry, India
3 Department of Psychiatry, College of Medicine, Majmaah University, Saudi Arabia

Correspondence Address:
Dr. B Sivaprakash
Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to be University), Pondicherry - 607 402


Background and Aim: Misbeliefs regarding mental illness is a cause of concern and needs better understanding. There is a dearth in the literature highlighting the lack of knowledge regarding the basis of mental illness among educated individuals. Therefore, this study was designed to gauge the knowledge, beliefs, and attitude regarding the mental illness of final year undergraduate students of various courses at Tamil Nadu. The aim is to study mental health literacy and its determinants among undergraduate college students. Materials and Methods: This was a questionnaire-based observational study conducted on 527 final year undergraduate students from dental, nursing, engineering, arts, and science courses. A module containing ten close-ended questions was used to assess people's knowledge regarding the basis of mental illness. A vignette-based “Mental health literacy scale” was used, which described a case of depression and was used to evaluate the participant's knowledge, beliefs, and attitude regarding mental illness. The analysis was performed using Chi-square test and binary logistic regression model. Results: The association between opinion regarding the role of antidepressant and level of contact was statistically significant (P < 0.001). The course of the study was a significant predictor of recognition (P < 0.001). The nursing course had a 17 times more predictive value for recognizing the genetic cause as a perceived cause for mental illness (P < 0.001; odds ratio = 17.508; confidence interval = 7.106–43.136). Conclusion: The study tried to evaluate the knowledge, beliefs, and attitude of college students regarding mental illness, which can help to reduce the increasing burden of mental disorders by shedding light on the significance of mental health literacy toward curbing stigma associated with it. However, future research to create awareness and sensitization towards seeking medical help for curing these psychiatric problems is needed.

How to cite this article:
Bose R, Sivaprakash B, Sarkar S, Backer A, Eswaran S. An observational study to assess mental health literacy among undergraduate students from Tamil Nadu.Arch Med Health Sci 2020;8:230-235

How to cite this URL:
Bose R, Sivaprakash B, Sarkar S, Backer A, Eswaran S. An observational study to assess mental health literacy among undergraduate students from Tamil Nadu. Arch Med Health Sci [serial online] 2020 [cited 2021 May 6 ];8:230-235
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The World Health Organization (WHO) defines “Health” as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.[1] Mental health is an issue of major concern in both the developed and developing world.[2]

In recent years, mental disorders have led to disability and early death. According to the WHO, approximately 500 million people were reported to suffer from one form or the other mental disorder.[3] In a recent meta-analysis, the prevalence rates for all mental disorders in India were observed to be 65.4/1000 population.[4]

Major depressive disorder is the second leading cause, contributing to 8.1% of total years lived with disability.[5] The effort is being made through various studies to understand mental illness.

Mental illness is a health condition, like any other illness, and yet the illnesses of the mind is shrouded in fear and misunderstanding. Discrimination, abuse, and incarceration of people suffering from mental illness are all too common in countries throughout the world.[4],[5] Dissemination of the present understanding of mental disorders, dispelling deep-rooted beliefs and myths about mental illness, using science and reasoning to overrule shame and stigma toward people with mental illness are among the current challenges being faced by the world.[6]

Due to the current leap in scientific advancements, there are effective treatments and prevention strategies for mental disorders and ways to alleviate the suffering caused by them.[7] Many tools have been developed to study mental illness in various populations. However, it has been a challenge in India for researchers to embrace a standard and unified approach to measure awareness and attitude toward mental illness, owing to the unique and varied culture. Hence, there is a dearth of studies in the Indian literature depicting the same. It would be enlightening to gain a deeper and wider understanding of the community's knowledge, attitude, and beliefs regarding mental illness. These observations would serve to enhance the effective delivery of comprehensive mental health care to society. Therefore, this study was undertaken to investigate the knowledge, attitude, and beliefs as well as sociodemographic contact and level of contact to the mental illness of final year undergraduate students of various courses with regard to mental illness.

 Materials And Methods

Study design

This was a questionnaire-based observational study, carried out at a tertiary care hospital over a 1-year time-period. Before initiating the study, the institution's ethical committee clearance and prior consent form were procured from the participants willing to participate in the study.

By using purposive, convenience sampling, 527 final year undergraduate students from dental, nursing, engineering courses were included in the study. Of 527 participants, 323 students were from the engineering college, 59 from dental and 57 from the nursing college. For the objective of comparison, 88 participants (who did not have psychology as part of the curriculum) from the College of Arts and Science, within a radius of 10 km, were included using convenience sampling. The study excluded final year students who were absent on the day of the survey.

Data collection

A structured pro forma was employed to collect sociodemographic details such as age, gender, marital status, and domicile. This proforma also included items pertaining to socioeconomic status, score obtained from 'level-of-contact report' scale, response elicited by the module to evaluate the people's knowledge regarding the basis of mental illness, responses obtained from the mental health literacy scale.

The level-of-contact was evaluated based on the scale that was developed by Holmes et al.[8] It consists of 12 statements. These statements described situations of which the respondents had to choose the best statement to depict their exposure to persons with mental illness. These situations were adapted from other validated scales used in stigma research.[8]

The module to evaluate people's knowledge regarding the basis of mental illness consisted of ten close-ended questions.[9],[10] This was an extract from Gureje et al.'s adaptation of the questionnaire developed by the World Psychiatric Association. The original tool focused mainly on knowledge and attitude to schizophrenia.[11] Gureje et al. modified a part of the original questionnaire, substituting “mental illness” for “schizophrenia,” and deleted specific items related to schizophrenia. The modified questionnaire was to assess people's knowledge about causes of mental illness, among other aspects of mental health literacy.[11]

The knowledge, sensitivity, and attitude of these students toward mental health were established using vignette-based questionnaire developed by Jorm et al.[10] Mental health literacy was gauged as per a vignette-based questionnaire where the name in the vignette was substituted with a hypothetical person in the study setting who had been suffering from depression. The questionnaire comprised two open-ended questions, designed to assay the participant's acknowledgment of schizophrenia and their recommended source of help.[10]

Students were briefed about the study design and the tool and were given a data collection proforma. The estimated time for data collection was approximately 45 min, after which, a brief mental health awareness session was conducted to provide basic information regarding mental health and mental illness. Mental health awareness leaflets in the regional language (Tamil) were also distributed.

Statistical analysis

Statistical Package for Social sciences (version 22.0. SPSS Inc, Chicago, IL, USA) software. Association between course, recognition of mental illness, and use of anti-depressants with the level of contact was evaluated using Chi-square test. Binary logistic regression showing predictors of recognition, opinions, and attitude toward mental illness. P = 0.05 was considered statistically significant.


A total of 527 final year undergraduate students were enrolled for the study. The mean age of all the study participants was 20.83 years?. Of the 527 students, 270 (51.3%) were male and 257 (48.7%) were female. 229 (43.2%) participants were from rural and 298 (56.8%) were from urban areas [Table 1].{Table 1}

Ninety-two participants reported that their level of contact with mental illness has only been through a movie or a TV show in which a character depicted a person with mental illness, whereas 89 participants reported of having jobs that involved providing services/treatments for people with a severe mental illness [Table 2].{Table 2}

The students were asked to respond if they agreed or disagreed with each of the statements that described the possible reasons of mental illness. Stress was reported to be the possible cause of mental illness by 483 participants, whereas “possession by evil” was stated to be the least agreed-upon cause of mental illness [Table 3].{Table 3}

While correlating courses with level of contact, a statistically significant group difference was observed between the four groups (P < 0.001). With reference to the level of contact, there was a significant difference (P = 0.017) between the group that identified the case vignette as depression, mental illness, and others. Those who identified depression had a high mean rank (309.55) in comparison to others. The association between opinion regarding the role of antidepressant and level of contact was statistically significant (P < 0.001) between the groups that identified antidepressants as helpful, harmful, and others [Table 4].{Table 4}

Course of the study was a significant predictor of recognition (P < 0.001). Other predictors of recognition were gender (P = 0.021). Male gender was associated with 1.7 times more predictive value for recognition of mental illness (P = 0.021; odds ratio [OR] = 1.765; confidence interval [CI] = 1.089–2.858). Furthermore, higher level of contact shows a higher predictive value in recognition of mental illness (P = 0.042 OR = 1.076; CI = 1.003–1.155) [Table 5].{Table 5}

The course of the study was a significant predictor of the endorsement of genetic factors in the causation of mental illness (P < 0.001). Nursing course had a 17 times more predictive value for recognizing the genetic cause as a perceived cause for mental illness (P < 0.001; OR = 17.508; CI = 7.106–43.136) [Table 6].{Table 6}

The course was a significant predictor in the attitudes and beliefs (personal stigma) of the respondents (P = 0.004). In comparison to Arts and Science course, the dental course had a 5.3 times more predictive value in opining that the case in the vignette was not suffering from a mental illness (P = 0.002; OR = 5.137; CI = 1.872–15.097) [Table 7].{Table 7}


Jorm et al. introduced the term “mental health literacy” and have defined it as “knowledge and beliefs about mental disorders which aid their recognition, management, or prevention.” Mental health literacy consists of several components, including (a) The ability to recognize specific disorders or different types of psychological distress; (b) knowledge and beliefs about risk factors and causes; (c) knowledge and beliefs about self-help interventions; (d) knowledge and beliefs about professional help available; (e) attitudes which facilitate recognition and appropriate help-seeking; and (f) knowledge of how to seek mental health information.[10]

Mental health and its different aspects are not included in the school curriculum. Furthermore, there exists a huge stigma about mental illness and the mentally ill people. There are also wrong projections about mental illness and substance dependence in the media. Thus, there exists a low awareness of the mental illness and mental health literacy among students and public.[11]

The level of mental health literacy is variable for various disorders. Overall, the mental health literacy about recognition of psychosis and treatment interventions were lesser when compared to other mood and anxiety disorders. There is a better understanding of depression and suicide in the general population as these are frequently news that we encounter day in and day out. Furthermore, there is lots of discussion in social media about them. However, as told earlier Schizophrenia and other psychotic disorders are poorly understood, thus having a low mental health literacy.[11]

This study unveiled opinions of undergraduate final year students of various colleges and courses on mental illness.

The study depicted stress as an answer to the possible cause of mental illness, which was in contrast with the study by Gureje. et al. among caregivers, which concluded alcohol and drug abuse as the cause of mental illness.[11] Another study conducted in rural India revealed family tensions as the major cause of mental illness.[12] A study conducted by Arvaniti et al. among a group of 35 medical students showed that the majority of participants believed that evil spirits caused mental illness.[13] The plausible reason for these stark variations in findings could be attributed to the difference in the level of knowledge, attitude, and sensitization of people toward mental illness.

Studies on the ability to correctly label psychiatric symptoms have yielded different results. Most of the studies have used a vignette-based questionnaire to evaluate the ability to label psychiatric symptoms.[14] The study too adapted a similar method. The participants were designated a depression case vignette and were asked to give the impression of what the person in the vignette is suffering from. In the study, only 58 (11.0%) participants had responded that the person in the vignette was suffering from depression, and 108 (20.5%) participants gave other miscellaneous impressions regarding the case in the vignette. A previous study by Loureiro et al. depicted similar results stating that in response to an open-ended question, around a quarter of the participants failed to recognize depression in the vignette.[15] The probable explanation for the lack of correct labeling of psychiatric symptoms as a clinical entity could be that most participants endorsed psychological and social factors as the cause of mental illness.

In the present study, sedatives were considered as a harmful treatment option for the person described in the vignette. The lifestyle modifications and other recreational activities were considered “helpful” by most of the study participants. These findings were concurrent with the study done by Jorm et al., who reported that respondents who had depression in the past endorsed recreational measures as helpful, while the helpfulness of antidepressants/sedatives was less endorsed.[10]

The study reveals that perception regarding the basis of mental illness plays an important role in the recognition of symptoms. Our study confirmed that students from nursing college had a higher chance of labeling psychiatric symptoms correctly, which could be attributed to the fact that the nursing students are often encouraged to attend clinical postings and classes in the psychiatry department which was in harmony with the inference drawn from a study by Dahlberg et al., stating that participants who were able to recognize the symptoms of mental illness were mostly students from professional courses, thus further substantiating the fact that recognition of symptoms and the curriculum had an influence on other aspects of mental health literacy.[16]

In the study, participants showed a tendency toward “weak but not sick” and unpredictable but not dangerous concepts when evaluated for their personal beliefs and attitude toward the person described in the vignette.[17] This was consistent with the study done by Yap et al. in which the respondents were showing a similar tendency of “weak but not sick” and “unpredictable” concepts toward the depression case vignette.[18] The study stated that when a similar set of statements were presented to estimate the community's beliefs and attitudes, a striking difference in responses was noted. This was less evident for depression but more evident for schizophrenia vignette.[19] Studies had also correlated that such tendencies led to higher social distancing and negative stigmatizing attitudes toward people suffering from mental illness.[19],[20] However, such a correlation was beyond the scope of the present study.

The strength of this study lies in the fact that not only was a vignette-based questionnaire that allows respondents to articulate their thoughts was used but also two other tools that is “Scale measuring the level of contact” and “Participant's opinion regarding the cause of mental illness using a module of 10 statements” were used to assess mental health literacy in Indian population. Inclusion of four different colleges so that comparison between these students, with different academic exposure and curriculum, could be gauged further adds novelty to the study.

Mental illness has been considered a stigma since ages, especially in a developing country like India. This study enhances the sensitization of the students on the importance of mental health literacy, thus paving way toward augmentation of mental health awareness.

If mental disorders are to be recognized early in the community and appropriate intervention sought, the level of mental health literacy needs to be raised. Poor literacy is associated with lower rates of help-seeking and service use, as well as societal stigma and discriminatory behavior. Thus, mental health literacy, especially for the general population, is still a pertinent issue.[10],[21]

Individual and group educational programs such as Headstrong are effective in improving mental health literacy. This effect is moderate to large immediately postintervention, but weakens over time, suggesting supplementary teaching is required throughout the year.[21]

Obviously, interventions targeting mental health literacy augmentation such as the Headstrong program, General awareness talk, movies portraying mental illness in correct manner, information in social media platform, including mental health and mental well-being in school curriculum will definitely contribute to improving help-seeking attitudes, reducing stigma, and increasing confidence or willingness in helping someone with mental health problems. The decimalization of suicide, the presence of General Hospital Psychiatry Unit, discussions and debates in media, news, and other platforms have already brought changes in the general perception and attitude towards mental illness.[22],[23]

Studies show that recognition and discrimination about mental illness improved with MHL. Regarding the help-seeking behavior, there is no significant improvement among participants of the Headstrong program.[22],[23],[24]

However, few potential limitations of our study were that it was done in a subset of the population comprising more of engineering students. The scale used to evaluate the opinion of the reasons of mental illness did not have options about family discord and other related problems. The study depicted more of a cross-sectional assessment. Therefore, to overcome these downsides, further research could be done using standardized scales with a different vignette-based questionnaire that could estimate mental health awareness in a larger general population. Furthermore, a study to evaluate mental health literacy after mental health educational intervention can be attempted in future.


Mental health literacy is integral in the early diagnosis of symptoms and timely interventions toward treating these disorders. Moreover, mental health literacy is the first step toward curbing the age-old stigma attached to mental disorders. However, more extensive multi-centric research is needed to generalize the study findings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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