|ORIGINAL RESEARCH REPORT
|Year : 2021 | Volume
| Issue : 3 | Page : 148-154
Knowledge and Attitude toward Depression among Adolescents Attending Secondary Schools in an Urban Local Government Area of Lagos State, Nigeria: A cross sectional survey
Awujoola F Lesi1, Mobolanle R Balogun2, Temitope W Ladi-Akinyemi1, Ugonnaya U Igwilo3
1 Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
2 Department of Community Health and Primary Care, College of Medicine of the University of Lagos; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Submission||30-Sep-2020|
|Date of Acceptance||01-Apr-2021|
|Date of Web Publication||23-Aug-2021|
Dr. Awujoola F Lesi
Faculty of Clinical Sciences, College of Medicine of the University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Background: Globally, depression is the fourth leading cause of mental illness and disability among adolescents (15–19 years). This study aimed to assess knowledge and attitude toward depression among adolescents attending secondary schools. Methods: This was a descriptive cross-sectional study among 257 adolescents attending secondary schools in an urban area of Lagos State. Multistage sampling technique was used to identify appropriate schools, and a semi-structured self-administered questionnaire that contained a vignette depicting depression was used to collect data. Data were analyzed using SPSS version 20. Results: Overall, 257 students participated in the study. The mean age was 15.8 ± 1.3 years. Majority (91.5%) had prior knowledge about depression. The most common sources of information were from school (38.9%), family and friends (23.3%), and social media (20.6%). Majority (87.9%) correctly recognized depression in the vignette. Attempted suicide and social withdrawal from friends (71% and 67.3%, respectively) were less recognized as symptoms of depression. Similarly, only 36.2% recognized depression as a real medical condition. Students in science (76.9%) had better knowledge about depression than students in arts (43.5%) and commerce (43.8%) (P = 0.006). The teacher was considered as the primary access to care compared to the need for specialized care. Majority of the respondents had positive attitudes toward depression and 75.4% believed that people with depression should not be stigmatized. Conclusion: This study showed important gaps in knowledge of causes, symptoms, and the need for professional or psychiatric care of depression. It highlights the need to promote mental health literacy in schools.
Keywords: Adolescents, attitudes, depression, knowledge, Lagos
|How to cite this article:|
Lesi AF, Balogun MR, Ladi-Akinyemi TW, Igwilo UU. Knowledge and Attitude toward Depression among Adolescents Attending Secondary Schools in an Urban Local Government Area of Lagos State, Nigeria: A cross sectional survey. J Clin Sci 2021;18:148-54
|How to cite this URL:|
Lesi AF, Balogun MR, Ladi-Akinyemi TW, Igwilo UU. Knowledge and Attitude toward Depression among Adolescents Attending Secondary Schools in an Urban Local Government Area of Lagos State, Nigeria: A cross sectional survey. J Clin Sci [serial online] 2021 [cited 2023 Jun 9];18:148-54. Available from: https://www.jcsjournal.org/text.asp?2021/18/3/148/324406
| Introduction|| |
Globally, mental disorders make up about one-third of the burden of illness in adolescence and young adulthood, and depression is said to be the fourth leading cause of illness and disability among adolescents, with suicide being the third leading cause of death in older adolescents (15–19 years).,
In 2016, an estimated 3.1 million adolescents (12.8%) aged 12–17 years in the United States had at least one major depressive episode. The prevalence of major depressive episode was higher among adolescent females (19.4%) compared to males (6.4%), and it has been shown that in primary care settings in the US, the rates of depression are as high as 28% for adolescents.,
In Nigeria, there are about 41 million adolescents aged between 10 and 19 years, which is about 22.3% of the total population. In a 2015 study, the prevalence of moderate depression was lowest (2.3%) at the age of 10 and highest (6.2%) at the age of 13 while the prevalence of severe depression was lowest (1.9%) at the age of 11 and highest (7.4%) at the age of 12.
Studies have shown that approximately 70%–75% of adult mental health problems and mental disorders start manifesting during adolescence or early adulthood (from ages 12 to 25). In the long run, a significant proportion of depressed adolescents continue to have mental health problems in adult life.,, The negative impact of depression on their social life and their behavior toward others often leads to poor academic performance and substantially increased risk of suicide.,, Therefore, mental health literacy among adolescents is essential for the maintenance of good health as they are at a developmental age where they have less contact with the health-care system and may seek information from their peers., Mental health literacy among adolescents is, therefore, a crucial research area to identify and bridge gaps in mental health literacy.
The few studies done on the knowledge of depression among adolescents in Nigeria found inadequate knowledge.,, A study conducted among secondary school students in South-East Nigeria showed that only 4.8% of the participants could correctly identify depression in the vignette presented. Regarding attitudes to depression, a study among secondary students in Bayelsa State, Nigeria, revealed that 55% of the participants had positive attitudes toward mental disorders (depression), with majority (79%) believing that most people with a serious mental illness can, with treatment, get well and return to productive lives. About 61% of the respondents agreed that people with mental illness are, by far, more dangerous than the general population and 68% agreed that mental health facilities should be kept out of residential areas.
Mental health literacy among adolescents is an under-researched area in Nigeria. In this age of easy access to information, we sought to determine if that translated to better knowledge and attitudes toward depression. The current study was also an opportunity to add to the existing body of literature among adolescents, and it aimed to determine the level of knowledge and attitudes toward depression among adolescent secondary school students in Lagos, Nigeria.
| Methods|| |
The study was a descriptive cross-sectional survey conducted among senior secondary school students in Lagos, Nigeria.
The inclusion criteria for this study included male and female adolescents between the ages of 10 and 19 years in senior secondary classes.
Sample size determination
The minimum sample size needed for this study was 225 as determined by the Cochran's formula. It was increased to 300 to allow for contingencies.
A multistage random sampling technique was used, and the participants were adolescent students recruited from three (of 74) secondary schools in Surulere Local Government Area of Lagos, Nigeria. The schools were chosen by balloting method. Three arms (science, commercial, and art) of each class of the selected schools were chosen. In each of the selected classes, about 10 students from each arm (science, commercial, and arts) of each class (SS1, SS2, and SS3) were chosen. At each stage of the sampling, participants were randomly selected by balloting method. A total of 300 students from three arms/classes each from grades 10–12 in each of the three participating schools took part in this study. The study was conducted from October 2018 to January 2019.
Data collection tool
The data collection tool (questionnaire) was adapted from the National Survey of Mental Health Literacy and Stigma Youth Boost survey V5 that also included case-based vignettes that described depression. The vignette portrayed a character who was showing signs of a depressive episode as described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition and the International Classification of Diseases, tenth edition., The vignette was followed by a series of closed-ended questions which was meant to elicit the participants recognition of depression and this vignette style of questioning has been used by earlier researchers in Nigeria. The self-administered questionnaire was pretested in secondary schools in a different local government area.
The study outcome was the correct identification and knowledge of depression and assessment of attitudes to depression.
The data were collated and analyzed using the IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. The scoring and grading of the knowledge and attitudes of the respondents were done using Microsoft Excel 2016 while the quantitative data generated from the study were analyzed as descriptive frequencies, percentages, and cross tabulations and presented in form of tables and charts.
Administrative approval was obtained from the schools. Informed consent was obtained from the parents and caregivers of the students while assent was obtained from the students. Ethical approval was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital.
| Results|| |
A total of 300 questionnaires were administered and 277 (92.3%) were adequately completed. Among the respondents, 257 (92.8%) had prior knowledge of depression while 20 (7.2%) had no knowledge and were excluded from further analysis.
About half (52.9%, n = 135) of the respondents were male and 120 (47.1%) were female. The students were aged between 12 and 19 years with a mean age of 15.8 ± 1.3 years. About one-third (34.9%) were in science class, 31.7% were in commercial class, and 33.1% were in arts class. Majority (91.5%) of the respondents had prior knowledge about depression, and the major sources of information were from school (38.9%), family and friends (23.3%), and social media (20.6%). Less common sources of information were from television (7.0%), newspaper/magazine (5.8%), and radio (1.9%). In the vignette given, which portrayed a character who was experiencing symptoms of depression, majority of the respondents (89.9%) recognized that depression was the possible cause of the character's symptoms.
Parental separation (90.7%), maltreatment at home (91.8%), and stressful life event (84.8%) were the most common causes of depression identified by the respondents. Medical disease such as chemical imbalance or brain diseases or hereditary causes of depression were much less identified as causes of depression [Table 1]. Poor performance in school (91.8%) was identified as the most common symptom of depression. However, weight loss, alcohol and substance abuse, attempted suicide, and social withdrawal from friends (76%, 72%, 71%, and 67.3%, respectively) were less commonly recognized as key symptoms of depression [Table 1].
Of all the sources of potential support and care [Table 2], the teacher (83.3%) was identified as most helpful. Only 28.8% of the respondents considered specialist psychiatric care as helpful. Religious prayers (91.8%), reading a self-help book (80.2%), and exercise (76.3%) were the most endorsed intervention identified by the students [Table 2]. Students identified that they had an important role to support their friends who may have depression. Such support includes [Table 2] listening empathically to problems in an understanding way (93.4%) and encouraging more physical activity (86.8%). Fewer students recognized the need for professional care (74.7%). Not acknowledging the problem, ignoring her till she gets over it was identified as harmful (86.0%). Keeping physically active (86.8%) and making time for relaxing activities (82.5%) were considered as important prevention activities [Table 2].
|Table 2: Respondents' knowledge on appropriate interventions for depression|
Click here to view
Regarding the respondents' attitudes toward depression [Table 3], majority (75.9%) of the respondents disagreed with the idea that depression is a spiritual problem, 75.9% disagreed with the concept of avoiding people with depression, so they do not become depressed themselves, and 72.8% disagreed with the notion of not telling anyone if they were depressed. It is notable that only 36.2% recognized that depression is a real medical condition.
| Discussion|| |
This study assessed the knowledge and attitudes toward depression among a sample of secondary school students in Lagos, Nigeria. Majority of the respondents in this study (91.5%) had prior knowledge about depression. The most common sources of information about mental health were from school/teacher (38.9%), family/friends (23.3%), and social media (20.6%). The least common source of information was radio and newspaper. These findings corroborate a study done in Bayelsa State, Nigeria, that showed that the majority of the respondents derived information about mental health disorders from their teachers. This emphasizes that teachers and schools are a useful resource that can be utilized in expanding awareness on mental health disorders and improving mental health literacy among school-going adolescents. Students with enlightened mothers were significantly more likely to have some knowledge of depression, and this highlights the role of parents as important source of information. The higher literacy of students in science class compared to students in arts or commerce may reflect the influence of knowledge of biological science in disease causation. The identification of social media as an important source of adolescent information is reflective of widespread use of social media among these students and should be considered when disseminating mental health information and correcting misinformation that can arise from unrestricted social media. Newspaper and radio were less effective in reaching this population.
A vignette regarding a 16-year-old girl, unusually sad for several weeks with poor concentration in school associated with worsening school grades, was used to highlight adolescent depression. Various options were proposed to explain her conditions, and these ranged from eating disorder to depression and cancer. Possible causes and solutions were identified from a variety of proposed options in the vignette. Most (89.9%) of the respondents correctly recognized depression as the possible cause of the symptoms in the vignette. This high rate of identification of depression corroborates a similar study done in India. In contrast, in South-East Nigeria, only 4.4% of 285 adolescents had any knowledge about depression. In a similar study, only 10.4% of 302 adolescents in Lagos had ever heard about depression., The differences in these studies may be attributed to the study methodology. These studies used open-ended questions which require significant thought and depth of understanding of depression. Our study, however, used a vignette with closed-ended questions and statements with multiple options and thus may not fully reflect respondents' understanding of the subject. Although vignettes stimulate the elements of research in varying grades, they are unable to fully capture the elements of reality or explore the depth of knowledge. The strength of vignettes, however, lies in the fact that it could be used effectively to highlight sensitive issues and can be used as an efficient tool for theoretical sampling as in this study.
Poor performance in school (91.8%) and social withdrawal and not wanting to hang out with friends (67.3%) were recognized by the respondents as symptoms of depression. However, others such as running away from home (63.4%), substance abuse (72.0%), and attempted suicide (71.2%) were less recognized as a symptom of severe depression. This is similar to the findings in an adolescent population in India and may be related to the poor understanding of depression as a mental health disease.
The most common causes of depression identified in this study were parental separation (90.7%), maltreatment at home (91.8%), and stressful life event (84.8%). Some of the least identified causes of depression were chemical imbalance in the brain (57.2%) or hereditary-inherited from parents (30.0%). These findings have also been documented in other studies in adolescents and highlight a gap in in-depth knowledge or pathophysiology of depression.
The most common sources of psychosocial support for depression that were found most helpful in this African population were the teacher (83.3%), family doctor (80.9%), and religious person (e.g., pastor or imam) (76.7%). The psychiatrist was found as the least helpful (28.8%) professional. In contrast, in a similar study conducted in Portugal, the psychiatrist was found to provide significantly more support compared to the teacher. The reasons for these differences are unclear but may be due to social backgrounds and limited access to specialist care in Nigeria.
In this current study, the teacher was recognized as the most helpful caregiver for the person with depression. This is not surprising as the schoolteacher is often the main provider of education and information. The low awareness of the role of psychiatrists in this study is probably because depression is not perceived by the adolescents to be a medical or psychiatric disorder. This emphasizes the importance of improving mental literacy among adolescents, including the effects of severe depression and the role of mental health professionals such as psychiatrists and psychologists in the care of depression in adolescents.
The most common interventions for depression identified by the respondents in this study included prayers (91.8%), reading a self-help book (80.2%), and exercise (76.3%). Less commonly endorsed was going to see a health worker (65.8%). These findings are similar to the findings from a study done in Portugal, in which the main interventions were getting relaxation training (82.9%), receiving therapy with a specialized professional (74.8%), and becoming more physically active (66.2%). In this study, more of the respondents chose reading a self-help book and exercise over seeing a health worker, while in the study done in Portugal, getting relaxation training was chosen more than receiving therapy with a specialist, which may mean that the adolescents do not fully understand the relevance of medical care in treating depression.
In response to the vignette, most respondents in this study identified the important role of social interactions and friendship in providing support and guidance. Ignoring friends with depression or failing to acknowledge the problem was correctly identified as harmful. There is evidence that when people experience a mental health problem like depression, they are more likely to seek help when it is suggested by someone close to them, whether it is a friend or a family member.,,, Improving mental health literacy in schools can encourage friends, students, and peers to provide nonjudgmental support groups in the identification, management, and recovery from depression.
Alcohol and substance abuse are being increasingly documented in adolescents. In the current study, drinking alcohol to prevent depression was seen as most harmful by 91.8% of the participants. From this study, it can be deduced that adolescents believe that is possible to prevent depression, specifically by avoiding situations that might be stressful, regular contact with friends and family, and not using drugs.,,
The attitudes of the respondents toward depression from this study suggest that majority of them have positive attitudes toward depression as 75% and would not avoid people showing symptoms of depression. Many, however, incorrectly thought that depression was a sign of personal weakness (73.2%), people with depression can easily snap out of if they want to (72.4%), and that depression is not a real medical condition (54.9%). This showed that there are still a lot of misconceptions about depression among adolescents as indicated by some of their responses, and therefore points to the need for strengthened mental health education in the school health program. These findings are similar to a study done in India, where only 30% of the respondents believed that depression is a real illness and <10% believed that people with depression should be avoided.
Providing correct information about mental health disorders can help reduce the fears, myths, and negative beliefs that some people have about such disorders. Research done at the Canadian Centre for Addiction and Mental Health has confirmed that programs aimed at increasing young people's knowledge of mental health through education have shown positive results in reducing negative attitudes and stigma toward people with these disorders. There is definitely a need to promote mental health literacy in schools to improve awareness and identification of depression, reducing negative attitudes and facilitating access to effective care. Such early identification and care can prevent disease progression that leads to suicidal thoughts and attempted suicide in adolescents.
Although this study effectively highlighted the knowledge and attitude gaps, and the need for strengthening mental health literacy in adolescents, there were important limitations. The use of vignettes and closed-ended questions may overestimate the knowledge of the respondents. There is a need to conduct further research in adolescents to support the decision-making in developing appropriate adolescent-friendly mental health education and services in Nigeria.
| Conclusion|| |
Although this study found a high rate of depression recognition and literacy using a case-based vignette, the failure of recognition of depression as a significant mental health disease and the lack of knowledge about the role of specialized care from a psychiatrist was a significant gap in the knowledge of this group of adolescents. There is a need for targeted interventions with the aim of further addressing myths and misconceptions about depression thereby increasing the knowledge of depression among adolescents. The targeted interventions can also help in training parents, teachers, and school workers on how to recognize the symptoms of depression and give the required support to the adolescents.
We would like to thank the principals of all the secondary schools that were used for this study for giving us access to their students. We appreciate Prof. F. E. A Lesi for reviewing this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wei Y, McGrath PJ, Hayden J, Kutcher S. Mental health literacy measures evaluating knowledge, attitudes and help-seeking: A scoping review. BMC Psychiatry 2015;15:291.
Chinawa JM, Manyike PC, Obu HA, Aronu AE, Odutola O, Chinawa AT. Depression among adolescents attending secondary schools in South East Nigeria. Ann Afr Med 2015;14:46-51.
] [Full text]
McLaughlin KA. The public health impact of major depression: A call for interdisciplinary prevention efforts. Prev Sci 2011;12:361-71.
Rice F, Rawal A. Can basic risk research help in the prevention of childhood and adolescent depression? Examining a cognitive and emotional regulation approach. Depress Res Treat. 2011;2011:871245. doi:10.1155/2011/871245.
Kutcher S, Wei Y, Coniglio C. Mental health literacy: Past, present, and future. Can J Psychiatry 2016;61:154-8.
Aluh DO, Anyachebelu OC, Anosike C, Anizoba EL. Mental health literacy: What do Nigerian adolescents know about depression? Int J Ment Health Syst 2018;12:8.
Adeosun I. Adolescent students' knowledge of depression and appropriate help-seeking in Nigeria. Int Neuropsy Dis J 2016;6:1-6.
Attygalle UR, Perera H, Jayamanne BDW. Mental health literacy in adolescents: Ability to recognise problems, helpful interventions and outcomes. Child Adolesc Psychiatry Ment Health 2017;11:38.
Ogorchukwu JM, Sekaran VC, Nair S, Ashok L. Mental health literacy among late adolescents in South India: What they know and what attitudes drive them. Indian J Psychol Med 2016;38:234-41.
] [Full text]
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders-DSM-IV. 5th
ed. Arlington V A: American Psychiatric Publishing; 2013.
International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. A conceptual framework for the revision of the ICD-10 classification of mental and behavioural disorders. World Psychiatry 2011;10:86-92.
Sharma M, Banerjee B, Garg S. Assessment of mental health literacy in school-going adolescents. Child Adolescent Mental Health 2017;13:263-83.
Erfanian F, Latifnejad Roudsari R, Heydari A, Noghani Dokht Bahmani MA. Narrative on using vignettes: Its advantages and drawbacks. J Midwife Reprod Health 2020;8:2134-45.
Nigam T, Pole R, Vankar GK. Depression literacy among high school adolescents. Arch Indian Psychiatry 2013;15:37-41.
Loureiro LM, Jorm AF, Mendes AC, Santos JC, Ferreira RO, Pedreiro AT. Mental health literacy about depression: A survey of Portuguese youth. BMC Psychiatry 2013;13:129.
Watson AC, Otey E, Westbrook AL, Gardner AL, Lamb TA, Corrigan PW, et al
. Changing middle schoolers' attitudes about mental illness through education. Schizophr Bull 2004;30:563-72.
Centre for Addiction and Mental Health, Canadian Mental Health Association. Talking about Mental Illness: A Guide for Developing an Awareness Program for Youth. Teacher' s Resource. Toronto: Centre for Addiction and Mental Health; 2001.
[Table 1], [Table 2], [Table 3]