Série IV - n.° 4 - jan./fev./mar. 2015

pp.79-88Revista de Enfermagem Referência

Abstract

Resumo Resumen

R E S E A R C H P A P E R

Questionnaire for Assessment of Mental Health Literacy – QuALiSMental: study of psychometric propertiesQuestionário de Avaliação da Literacia em Saúde Mental – QuALiSMental: estudo das propriedades psicométricas Cuestionario de Evaluación de la Alfabetización en la Salud Mental – QuALiSMental: estudio de las propiedades psicométricas

Luís Manuel de Jesus Loureiro*

Theoretical framework: The assessment of mental health literacy is a key aspect in the design and implementation of mental health education and awareness programmes, specifically in school settings, given the high prevalence of mental disorders in adolescents and young people and the need for interventions adjusted to specific settings and target groups.Objectives: To describe the assessment of the psychometric properties of the Questionnaire for Assessment of Mental Health Literacy (QuALiSMental).Methodology: Administration of the questionnaire to a random and representative sample of 4.938 Portuguese adolescents and young people attending schools in the area of coverage of the Regional Directorate of Education - Centre.Results: The QuALiSMental has acceptable levels of reliability and a factor structure which is consistent with the theoretical components of mental health literacy.Conclusion: The questionnaire may be applied both as a screening measure of literacy and as a measure for assessing the impact of interventions on the promotion of mental health among adolescents and young people.

Keywords: mental health; questionnaires; mental health literacy; adolescent.

*Ph.D., Adjunct Professor, Nursing School of Coimbra, 3046-851, Coimbra, Portugal [luis.loureiro@esenfc.pt]. Address for correspondence: Urbanização Vale do Rosal, Lote 17, 2º Dtº., 3040-339 Coimbra, Portugal.

Received for publication: 20.03.14Accepted for publication: 09.09.14

Marco contextual: La evaluación de la alfabetización en la salud mental es un aspecto fundamental para el diseño y la implementación de programas de educación y sensibilización para la salud mental, especialmente en el contexto escolar, dada la alta prevalencia de trastornos mentales en los adolescentes y jóvenes y la necesidad de intervenciones ajustadas a los contextos y al público objetivo.Objetivos: Presentar la evaluación de las propiedades psicométricas del Cuestionario de Evaluación de la Alfabetización en Salud Mental (QuaLiSMental).Metodología: Estudio realizado con la aplicación del cuestionario a una muestra aleatoria y representativa de 4.938 adolescentes y jóvenes portugueses que asisten a escuelas en el ámbito de la Dirección Regional de Educación del Centro.Resultados: El QuaLiSMental tiene niveles de fiabilidad aceptables y una estructura factorial que es consistente con los componentes teóricos de la alfabetización en la salud mental.Conclusión: El cuestionario se puede aplicar tanto como medida de detección de la alfabetización como medida para evaluar el impacto de las intervenciones en la promoción de la salud mental de los adolescentes y jóvenes.

Palabras clave: salud mental; cuestionarios; alfabetización en salud mental; adolescente.

Enquadramento: A avaliação da literacia em saúde mental é um aspeto fundamental para a concepção e implementação de programas de educação e sensibilização para a saúde mental, especificamente no contexto escolar, dado a elevada prevalência de perturbações mentais em adolescentes e jovens e a necessidade de intervenções ajustadas aos contextos e públicos-alvo. Objectivos: Apresentar a avaliação das propriedades psicométricas do Questionário de Avaliação da Literacia em Saúde Mental (QuALiSMental). Metodologia: Estudo realizado com a aplicação do questionário a uma amostra aleatória e representativa de 4.938 adolescentes e jovens portugueses, que frequentam as escolas da região de Abrangência da Direcção Regional de Educação do Centro. Resultados: O QuaLiSMental apresenta índices de fiabilidade aceitáveis e uma estrutura fatorial que é consistente com as componentes teóricas da literacia em saúde mental. Conclusão: O questionário poderá ser aplicado, quer como medida de rastreio da literacia, quer ainda como medida de avaliação do impacto das intervenções no domínio da promoção da saúde mental de adolescentes e jovens.

Palavras-chave: saúde mental; questionários; literacia em saúde mental; adolescente.

ISSNe: 2182.2883 | ISSNp: 0874.0283Disponível em: http://dx.doi.org/10.12707/RIV14031

Revista de Enfermagem Referência - IV - n.° 4 - 2015 Questionnaire for Assessment of Mental Health Literacy – QuALiSMental: study of psychometric properties

80

Introduction

Mental health literacy may be defined as the knowledge and beliefs about mental problems and disorders which allow for their recognition, management (in the sense of self-care) and prevention ( Jorm, 2012; Loureiro & Abrantes, 2014; Jorm, 2014). This is a core concept that has been occupying a leading position in the most diverse areas of knowledge and professional intervention, such as Nursing (Loureiro, Mendes et al., 2012).Since 1997, when both the concept and the results of the first study conducted in Australia were presented ( Jorm, Korten, Rodgers et al., 1997), many studies have been developed in several countries and continents, in different situational, economic, social and cultural contexts ( Jorm, 2012; Jorm, 2014). With regard to data collection instruments and as proposed by Jorm, Korten, Jacomb et al. (1997), almost all published studies assessing mental health literacy use the Survey of Mental Health Literacy in Young People - Interview Version ( Jorm, Korten, Rodgers et al., 1997). This instrument allows assessing the components of mental health literacy in relation to different disorders. It has different versions, which maintain the key structure and, therefore, allow studying, with the necessary adaptations, samples of adolescents, young people and adults ( Jorm, Korten, Rodgers et al., 1997; Jorm et al., 2000; Jorm, Mackinnon, Christensen, & Griffiths, 2005).In Portugal, there is only one instrument to assess mental health literacy – the Questionário de Avali-ação da Literacia em Saúde Mental (QuALiSMental) (Questionnaire for Assessment of Mental Health Literacy) (Loureiro, Pedreiro, & Correia, 2012). This questionnaire is an adapted version of the Survey of Mental Health Literacy in Young People - Interview Version for both adolescents and young people. The QuALiSMental has been recurrently used to assess mental health literacy in portuguese adolescents and young people (Loureiro, Jorm et al., 2013; Loureiro, Barroso et al., 2013; Loureiro, Jorm et al., 2014).The aim of this paper is to describe the assessment of the psychometric properties of the version for adolescents and young people of the QuALiSMental regarding their level of depression. It also aims to assess the predictive ability of the questionnaire concerning mental health help-seeking intentions.

Background

The concept of mental health literacy, as defined in the introduction, involves a set of components, such as: (a) the recognition of mental disorders in order to promote and facilitate help-seeking; (b) knowledge about the professionals and treatments available; (c) knowledge of the effectiveness of self-help strategies; (d) knowledge and skills to provide support and first aid to others; (e) knowledge of how to prevent mental disorders ( Jorm, 2012; 2014).Although there are instruments in the literature to assess, even if indirectly, some components of mental health literacy, only the Survey of Mental Health Literacy in Young People - Interview Version was designed to simultaneously assess all components of mental health literacy for different types of disorders.The generalised use of this instrument has several positive aspects, namely the fact that it allows comparing mental health literacy in different cultural, social and economic contexts, which translates into an added value in terms of the intervention needs and challenges in this field ( Jorm, 2014).As for the study and assessment of the psychometric qualities of the original instrument, the published studies relate only to some components ( Jorm, Korten, Rodgers et al., 1997; Jorm et al., 2000; Jorm et al., 2005). For example, there are no validation studies of the recognition of disorders component, although dozens of studies assess this specific component of literacy.In 1997, the authors published an analysis concerning the items of the knowledge about the professionals and treatments available component ( Jorm, Korten, Rodgers et al., 1997), using a sample of 2031 Australians aged between 18 and 74 years. The factor analysis showed a 3-factor structure, which the authors designated as Medical (including items related to prescribed medication), Psychological (items related to professional help and therapies) and Lifestyle (items related to non-professional help, e.g. teas, vitamins, close friends, family members or physical activity). Later on, the results of another analysis on the same items were also published, though applying a Confirmatory Factor Analysis ( Jorm et al., 2000). The sample was composed of 3.109 australian adults ( Jorm et al., 2000). Results were similar to those obtained in the previous study, and the designations

Revista de Enfermagem Referência - IV - n.° 4 - 2015LUÍS MANUEL DE JESUS LOUREIRO

81

sections relating to each component of mental health literacy. A vignette reporting a case of depression is previously presented according to the DSM-IV-TR diagnostic criteria for alcohol abuse (Associação Americana de Psiquiatria, 2006).The recognition of disorders component is composed of several expressions that individuals can choose from using a multiple choice format. In addition to the expressions (e.g.: depression, burnout), it also includes response options: there is nothing wrong with him/her, I don’t know, he/she has a problem and other, in which the problem should be specified.The knowledge about the professionals and treatments available component consists of 16 items in total and has the following response format: helpful, harmful and neither. Both components - knowledge of the effectiveness of self-help strategies and knowledge and skills needed to provide support and first aid to others - are composed of 12 and 10 items, respectively, with the following response format: useful, harmful and neither. The last component of mental health literacy in the QuALiSMental (the knowledge of how to prevent mental disorders) is composed of 8 items, with the following response format: yes, no and I don’t know.The content of the items of all dimensions are shown in the tables of results.

Methodological procedures Data were collected between November 2011 and May 2012, using a cluster sampling approach. The questionnaire was administered in classroom settings, in collective sessions, under the supervision of a member of the research team and a teacher of the class. The time of response was between 40 and 50 minutes.

Ethical-legal considerationsThe QuALiSMental was submitted to the Directorate-General for Innovation and Curriculum Development of the Ministry of Education of the Portuguese Government (process no. 0252500001) and the Ethics Committee of the Health Sciences Research Unit - Nursing (UICISA: E) of the Nursing School of Coimbra (No.: P58-12/ 2011). Both entities approved the use of the questionnaire and allowed for its application. Given the characteristics of the sample (mostly composed of underage students), an informed

of the factors remained the same in comparison to the former study. In 2005, the same authors published another study (sample of 3.998 Australian adults), except that now they added the items of the effectiveness of self-help strategies component to the knowledge about the professionals and treatments available component ( Jorm et al., 2005). Items were subjected to exploratory factor analyses and a 4-factor structure was obtained: lifestyle, psychological, medical and information seeking actions. The last factor included items relating to the search for mental health information, such as looking up a website giving information about the problem and reading a self-help book.

Methodology

Type of studyThis is a quantitative methodological study, which mainly fits into the type and assumptions of the work carried out. SampleData were collected in the central region of mainland Portugal, using a representative sample of adolescents and young people aged between 14 and 24 years. Participants attended the 3rd cycle of basic and secondary education in 50 schools belonging to the area of coverage of the Regional Directorate of Education - Centre (DREC).Both schools and classes were selected through a multistage cluster sampling using the Random Sequence Generator. The sample consisted of 4.938 portuguese adolescents and young people: 43.3% were males and 56.7% were females, with a mean age of 16.75 years and a standard deviation of 1.62 years.

Data collection instrumentThe data collection instrument (QuALiSMental) consists of a set of items aimed at assessing the five components of mental health literacy, using different response formats, as detailed in the description of the instrument in the presentation results.The 1st part of the questionnaire includes instructions for completion and questions on socio-demographic characteristics (gender, age, place of residence, district and parents’ academic qualifications). The 2nd part is composed of different

Revista de Enfermagem Referência - IV - n.° 4 - 2015 Questionnaire for Assessment of Mental Health Literacy – QuALiSMental: study of psychometric properties

82

consent form was added to the instrument to be signed by parents/tutors or, in case young people were aged ≥ 18 years, a specific consent form was added to be signed by participants .Data were inserted and analysed using the IBM-SPSS software, 22.0 version. The appropriate summary statistics and both the absolute and percentage frequencies were calculated whenever necessary. The construct validity study was performed for the items of all components using Exploratory Factor Analyses based on the matrix of Spearman’s correlations, phi coefficient (j) and Cramer’s V , given the items’ response format, with factor extraction using the principal components analysis (PCA) followed by orthogonal Varimax rotation (Maroco, 2011).The decision on the number of factors to be retained in the analysis was based on the eigenvalue-greater-than-one rule, supported by the scree test and the percentage of variance explained by factor. Prior to the EFA, the KMO measure was obtained and the Bartlett’s test of sphericity was performed. The reliability analysis was performed using the Cronbach’s alpha coefficients for each factor that emerged from the analysis.Subsequently, the scores of the factors that emerged from the analysis of all components were subjected to a (binary) Logistic Regression Analysis.

Results

As regards the recognition of disorders component, the matrix of phi coefficients (j) was calculated and an EFA was performed based on the matrix with extraction of the factors using the PCA method followed by Varimax rotation. The KMO measure was 0.65 (a low value for recommendation of FA). Still, the test of sphericity showed statistical significance (p<.001), thus we continued with the analysis. As can be seen (Table 1), the solution found points to five factors with eigenvalues greater than 1.00, which explained 46.84% of the variance. The 1st factor includes the following labels with loadings >.40: Depression, Stress, Nervous break-down and Psychological/emotional/mental problems, and explained 9.72% of the variance. The 2nd factor includes the items Alcoholism and Substance abuse, and explained a total of 9.69% of the variance. The 3rd factor includes the items Schizophrenia, Psychosis, Mental illness and Cancer, and explained 9.36% of the variance. The 4th factor corresponds to the labels Bulimia and Anorexia and explained 9.27% of the variance. The last factor (5th) includes the items He/she has a problem, Age crisis and Stress, and explained 8.79% of the variance.

Table 1Factor loadings of each item (expression) in the five retained factors, including eigenvalues and % of explained variance, after the EFA with factor extraction using the Principal Components Analysis followed by Varimax rotation

1 2 3 4 5Depression .65Schizophrenia .68Psychosis .55Mental illness .57Bulimia .79Stress .48 .45Nervous breakdown .71Substance abuse .76Age crisis .66Psychological/mental/emotional problems .43Anorexia .80Has a problem .69Alcoholism .79Cancer .36Eigenvalues% of Explained variance Kuder-Richardon (K-20)

1.369.72.50

1.369.69.45

1.319.36.40

1.309.27.49

1.238.79.36

KMO Measure =.65; Bartlett’s Test of Sphericity: c(2)(91)= 2504.73; p<.001

Revista de Enfermagem Referência - IV - n.° 4 - 2015LUÍS MANUEL DE JESUS LOUREIRO

83

Table 2 Factor loadings of each item in the five retained factors, including eigenvalues and % of explained variance, after the EFA with factor extraction using the Principal Components Analysis followed by Varimax rotation

1 2 3 4 5Family doctor .45Teacher .31Psychologist .45Nurse .51Social Worker .47Psychiatrist .59Telephonic Helpline .40Close Family Member .38Close Friend .37Solving problems on his/her own .59Vitamins .23Teas (e.g. Camomile or hypericum) .49Tranquilizers/Sedatives .71Antidepressants .77Antipsychotics .74Sleeping pills .68Becoming more physically active .48Getting relaxation training .63Practicing meditation .63Getting acupuncture .47Getting up early each morning and getting out in the sunlight .41

The items related to the knowledge about the professionals and treatments available and knowledge of self-help strategies components were analysed according to the original validity studies ( Jorm, Korten, Rodgers et al., 1997; Jorm et al., 2000; Jorm et al., 2005). Thus, the items were subjected to an EFA based on the matrix of Spearman’s correlations, given the response format, with factor extraction using the PCA followed by Varimax rotation.The KMO value was acceptable (0.77) and the Bartlett’s test was statistically significant (p<.001). As can be seen (Table 2), the 5-factor solution explained approximately 40.00% of the variance.The 1st factor - professionals and professional help - explained 8.83% of the variance. It includes the items Family physician, Psychologist, Nurse, Social worker and Psychiatrist, as well as the items Joining a support group of people with similar problems and Going to a specialised mental health service.The 2nd factor - harmful strategies - explained 8.07% of the variance. It includes the following items: Solving problems on his/her own, Using alcohol to relax and Smoking cigarettes to relax.

The 3rd factor – medication – explained 8.06% of the variance. It includes the items relating to prescribed medication, such as Tranquilisers/Sedatives, Anti-depressants, Antipsychotics and Sleeping pills.The 4th factor – self-help strategies - explained 7.85% of the variance. It includes the items relating to non-medical products, that is, over-the-counter drugs such as Vitamins and Teas, and items relating to self-help strategies such as Becoming more physically active, Getting relaxation training, Practicing meditation, Getting acupuncture and Getting up early and getting out in the sunlight.The last factor (5) - informal help - explained 6.32% of the variance. It includes two items relating to informal help, namely talking to a Close family member and Close friend, and the items relating to seeking information and support (Telephonic helpline, Looking up a website giving information about the problem or Reading a self-help book on the problem). Despite being low in some factors, the values obtained in the reliability analysis were acceptable.

Revista de Enfermagem Referência - IV - n.° 4 - 2015 Questionnaire for Assessment of Mental Health Literacy – QuALiSMental: study of psychometric properties

84

Receiving therapy with a specialised professional .55Looking up a website giving information about the problem .73Reading a self-help book on the problem .72Joining a support group .43Going to a specialised mental health service .59Using alcohol to relax .80Smoking cigarettes to relax .79Eigenvalues% of Explained varianceInternal Consistency (Cronbach’s alpha)

2.478.830.68

2.268.070.72

2.268.060.72

2.207.850.55

1.776.320.52

KMO Measure =.77; Bartlett’s Test of Sphericity: c(2)(378)= 22620.65

As regards the items of the knowledge and skills needed to provide first aid component, the KMO value obtained was low. However, the result of the Bartlett’s test of sphericity proved to be statistically significant (p<.05).As may be seen in the Table 3, the 3-factor solution explained a total of 47.24% of the variance. Thus, the 1st factor explained 16.99% of the variance. It includes the items perceived by the participants as negative strategies, namely Ask her/him whether he/she is feeling suicidal, Suggest him/her to have a few drinks to forget his/her troubles and Not acknowledging his/her problem, ignoring him/her until he/she gets over it. The item Listening to his/her problems in an understanding way lacks transformation of identity.

The 2nd factor – non-professional self-help strategies - explained 15.35% of the variance. It includes the items Talk to him/her firmly about getting his/her act together, Rally friends to cheer him/her up, Keep him/her busy to keep his/her mind off problems and Encourage him/her to become more physically active.The 3rd factor – suggestion of professional help - explained 14.96% of the variance. It included the items Suggest him/her to seek professional help and Make an appointment for him/her to see a GP with his/her knowledge.As can be seen in the Table 4, the Cronbach’s alpha values used to assess the items’ were very low.

Table 3 Factor loadings of each item in the three retained factors, including eigenvalues and % of explained variance, after the EFA with factor extraction using the Principal Components Analysis followed by Varimax rotation

Items: knowledge to provide first aid 1 2 3Listen to his/her problems in an understanding way* -.52Talk to him/her firmly about getting his/her act together .50Suggest him/her to seek professional help .80Make an appointment with the family doctor .81Ask whether he/she is feeling suicidal .48Suggest him/her to have a few drinks to forget his/her troubles .77Rally friends to cheer him/her up .61Not acknowledging his/her problem, ignoring it until he/she gets over it .74Keep him/her busy to keep his/her mind off problems .70Encourage him/her to become more physically active .57Eigenvalues% of Explained varianceInternal Consistency (Cronbach’s alpha)

1.7016.99.45

1.5315.35.44

1.5014.95.59

KMO Measure=.63; Bartlett’s Test of Sphericity: c(2)(45)= 3856.69; p<.001; *Transformation of identity

In relation to the last component of mental health literacy – knowledge of how to prevent mental disorders –, the results obtained by the EFA (performed based on the Cramer’s V matrix)

pointed to a 2-factor solution that explained 55.63% of the variance. The KMO value was acceptable; however, the Bartlett’s test of sphericity was statistically significant (p<.05).

Revista de Enfermagem Referência - IV - n.° 4 - 2015LUÍS MANUEL DE JESUS LOUREIRO

85

The 1st factor explained 30.76% of the variance. It is composed of three items that are associated with Positive strategies focused on social support networks, Relaxation and Exercise. The 2nd factor

Table 4 Factor loadings of each item in the two retained factors, including eigenvalues and % of explained variance, after the EFA with factor extraction using the Principal Components Analysis followed by Varimax rotation

Items of knowledge about prevention 1 2Keeping physically active .38Avoiding situations that might be stressful .47Keeping regular contact with friends .88Keeping regular contact with family .86Not using drugs .89Never drinking alcohol .91Making regular time for relaxing activities .45Eigenvalues% of Explained varianceInternal Consistency (Cronbach’s alpha)

2.1530.76.60

1.7424.88.82

explained 24.88% of the variance. It encompasses all strategies perceived as negative, such as alcohol and drug use. The reliability values obtained were acceptable.

In order to identify the factors that emerged from the various factor analyses performed to mental health literacy components (measured using the QuALiSMental) which are predictors of mental health help-seeking intentions, a Binary Logistic Regression was conducted based on the answers to the question If you were in a similar situation as Joana, would you seek help? Two response options were possible: yes (value 1) and no (value 0).As shown in Table 5, the statistical significant factors in the recognition of disorders component were factor 4 (B=.15; OR=1.16), composed of the expressions Anorexia and Bulimia, and factor 5 (B=-.12; OR=.88), composed of the expressions Stress, Age crisis and He/she has a problem. As regards the knowledge about the professionals and treatments available and knowledge of self-help

strategies components, the factors Professionals and professional help (B=.08; OR=1.08) and harmful strategies (B=-.13; OR=.88) are included in the model. Two factors are retained by the model: the factor referral for professional help (B=.38; OR=1.46, p <.001) of the knowledge and skills to provide support component and the factor negative strategies (B=.07; OR=1.08; p<.01) of the knowledge on how to prevent mental disorders component. The model had moderate Cox & Snell (R2=.85) and Nagelkerke (R2=.12) values. The interpretation of Odds Ratios allows concluding that the model adjusted with these predictors is appropriate at the criterion variable level, as the intention to seek help is associated with more appropriate levels of mental health literacy.

Revista de Enfermagem Referência - IV - n.° 4 - 2015 Questionnaire for Assessment of Mental Health Literacy – QuALiSMental: study of psychometric properties

86

Discussion

As can be seen, some conclusions may be drawn from the results obtained in these analyses.The first conclusion relates to the purpose of the factor analysis performed on the various expressions of the recognition of mental disorders component. In fact, if the aim is to assess the effective knowledge of both adolescents and young people, that is, their ability to properly recognise a mental disorder by reading the expressions presented, then the factor analysis may not be appropriate, since it provides no information on such aspect. Therefore, it is more appropriate to analyse the individual answers on the items (expressions) marked and, eventually, the combinations that allow concluding that the individual is able to properly recognise the problem/disorder (Loureiro, Jorm et al., 2013). In most cases, the design of programmes should begin with the analysis of the deficits in this area, thus the creation of scores based on the loadings of each factor item may not be appropriate; there is even the potential to miss relevant information. This problem may be

Table 5 Logit coefficients of the logistic regression model of the help-seeking intention variable based on the factors that emerged from the EFA (N=4938)

B S,E, Wald OR (95% CI)Component 1Factor 1Factor 2Factor 3Factor 4Factor 5

Components 2 and 3Professionals and professional helpHarmful strategiesMedicationSelf-help strategiesInformal help

Component 4Negative strategiesNon-professional help strategiesReferral to professional help

Component 5Positive strategiesNegative strategiesConstant

.03-.11.15.15-.12

.08-.13.03.00.00

-.01-.02.38

.01

.07-.75

.03

.14

.11

.06

.04

.01

.03

.01

.02

.02

.03

.02

.03

.02

.03

.11

.73

.561.905.44*

8.70***

31.54***

17.57***

3.26.05.01

.111.25

119.83***

.207.13**

46.19***

1.03 (.97-1.09).90 (.68-1.42)1.16 (.94-.132)1.16 (1.02-1.32)

.88 (.81-.96)

1.08 (1.05-1.11).88 (.82-.93)

1.03 (1.00-1.06)1.00 (.97-1.04)1.00 (.96-1.04)

.99 (.94-1.05)

.98 (.94-1.02)1.46 (1.37-.157)

1.01 (.97-1.05)1.08 (1.02-1.13)

.47Cox & Snell R2=.85; Nagelkerke R2=,12; Hosmer-Lemeshow Test c2

(8)=5.04;p=.754

*p<0,05; **p<0,01; ***p<0,001

true with all components, thus the analysis of the QuALiSMental should focus on the objectives of the study and, at the end, present the results.However, the use of the Factor Analysis on this component and the respective creation of scores aimed at breaking down the items into smaller sets of factors that allow us to observe how adolescents and young people perceive depression based on the expressions presented. Thus, we concluded that there is a different prespective on the problem raised by the vignette of depression.The factor analysis revealed for the items of the knowledge about the professionals and treatments available and knowledge of self-help strategies components was also satisfactory, even if it slightly differed from the results presented in other studies ( Jorm et al., 2005). The knowledge and skills to provide support and first aid to others component was the one to show the most unsatisfactory results, in terms of both the complexity of the factor structure and the value of the factor reliability, even if less items are included in each factor. Still, as mentioned at the beginning of the

Revista de Enfermagem Referência - IV - n.° 4 - 2015LUÍS MANUEL DE JESUS LOUREIRO

87

discussion, the use of scores calculated on the basis of the EFA results should be cautiously considered. If it is regarded as a key component, for example, to assess the impact of training sessions on mental health first aid for adolescents and young people (Loureiro, Sousa, & Gomes, 2014), then it is certainly preferable to use the individual analysis of the items. Finally, the knowledge of how to prevent mental disorders component ( Jorm, 2012; 2014) showed that adolescents and young people anticipate prevention by both maintaining and promoting social support networks and adopting healthy behaviours, such as avoiding the use of alcohol and other drugs.The results of the (binary) Logistic Regression Analysis suggest that the higher levels of literacy in its components tend to be associated with mental health help-seeking intentions, which supports the questionnaire findings.

Conclusion

In view of the foregoing, it is concluded that the QuALiSMental is a valid (with construct validity) and reliable (with satisfactory reliability values) instru-ment, and may be used to assess mental health literacy. The results found adjust to the theoretical rationale underlying the questionnaire and the results obtained by factor analysis.Thus, its use in the research field and also in nursing practice is justified, given the broad field of activity of the professionals involved, namely in the field of health education and promotion, for example, in school settings or self-care management. It may, therefore, be used as a measure of mental health literacy and be adapted to different disorders. Given its nature and length, it may easily and quickly be applied.Future studies should include other measures associated with mental health literacy, both related to psychological assessment and other dimensions, such as (personal and perceived) stigma and familiarity with the disorders.

ReferencesAssociação Americana de Psiquiatria. (2006). DSM-IV-TR: Manual

de diagnóstico e estatística das perturbações mentais. Lisboa, Portugal: Artmed.

Jorm, A. F. (2014). Mental health literacy: Promoting public action to reduce mental health problems. In Literacia em saúde mental: Capacitar as pessoas e as comunidades para agir ( Vol. 8, pp. 27-39). Coimbra, Portugal: Unidade de Investigação em Ciências da Saúde: Enfermagem.

Jorm, A. F., Christensen, H., Medway, J., Korten, A. E., Jacomb, P. A., & Rodgers, B. (2000). Public belief systems about the helpfulness of interventions for depression: Associations with history of depression and professional help-seeking. Social Psychiatry and Psychiatric Epidemiology, 35(5), 211-219. doi: 10.1007/s001270050230

Jorm, A. F., Korten, A. E., Jacomb, P. A., Christensen, H., Rodgers, B., & Pollitt, P. (1997). “Mental health literacy”: A survey of the public’s ability to recognize mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166(4), 182-186.

Jorm, A. F., Korten, A. E., Rodgers, B., Pollitt, P., Jacomb, P. A., Christensen, H., & Jiao, Z. (1997). Beliefs systems of the general public concerning the appropriate treatmens for mental disorders. Social Psychiatry and Psychiatric Epidemiology, 32(8), 468-473.

Jorm, A. F., Mackinnon, A., Christensen, H., & Griffiths, K. M. (2005). “Structure of beliefs about nthe helpfulness of interventions for depression and schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 40(11), 877-883. doi: 10.1007/s00127-005-0991-x

Jorm, A. F. (2012). Mental health literacy: Empowering the community to take action for better mental health. American Psychologist, 67(3), 231-243. doi: 10.1037/a0025957

Loureiro, L., Mendes, A., Barroso, T., Santos, J. C., Oliveira, R., & Ferreira, R. (2012). Literacia em saúde mental de adolescentes e jovens: Conceitos e desafios. Revista de Enfermagem Referência, 3(6), 157–166. doi: 10.12707/RIII11112

Loureiro, L. (2013a). Barreiras e determinantes da intenção de procura de ajuda informal na depressão. International Journal of Developmental and Educational Psychology, 1(1), 733-746.

Loureiro, L. M., & Abrantes, A. R. (2014). Estigma e procura de ajuda em saúde mental. In Literacia em saúde mental: Capacitar as pessoas e as comunidades para agir ( Vol. 8, pp. 41-61). Coimbra, Portugal: Unidade de Investigação em Ciências da Saúde: Enfermagem.

Loureiro, L. M., Sousa, C. S., & Gomes, S. P. (2014). Primeira ajuda em saúde mental: Pressupostos e linhas orientadoras de acção. In Literacia em saúde mental: Capacitar as pessoas e as comunidades para agir ( Vol. 8, pp. 63-77). Coimbra, Portugal: Unidade de Investigação em Ciências da Saúde: Enfermagem.

Loureiro, L., Barroso, T., Mendes, A., Rodrigues, M., Oliveira, R., & Oliveira, N. (2013). Literacia em saúde mental dos adolescentes e jovens portugueses sobre abuso de álcool. Escola Anna Nery Revista de Enfermagem, 17(3), 474-481. doi: 10.1590/S1414-81452013000300010

Revista de Enfermagem Referência - IV - n.° 4 - 2015 Questionnaire for Assessment of Mental Health Literacy – QuALiSMental: study of psychometric properties

88

Loureiro, L., Jorm, A. F., Oliveira, R., Mendes, A., Santos, J. C., Rodrigues, M., & Sousa, C. S. (2014). Mental health Literacy about schizophrenia: A survey of portuguese youth. Early Intervention in Psychiatry. Publicação electrónica antecipada. doi:10.1111/eip.12123

Loureiro, L., Pedreiro, A., & Correia, S. (2012). Tradução, adaptação e validação de um Questionário de Avaliação da Literacia em Saúde Mental (QuALiSMental) para adolescentes e jovens portugueses a partir de um focus group. Revista de Investigação em Enfermagem, 25, 42-48.

Loureiro, L. M., Jorm, A. F., Mendes, A. C., Santos, J. C., Ferreira, R. O., & Pedreiro, A. T. (2013). Mental health literacy about depression: A survey of portuguese youth. BMC Psychiatry, 13(129), 1-8. doi:10.1186/1471-244X-13-129

Marôco, J. (2011). Análise estatística com o SPSS statistics (5th ed.). Pero Pinheiro, Portugal: ReportNumber.