Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Stigma and Attitude Toward Service Use Among Korean American Parents of Adolescent Children: Does Depression Literacy Act as a Mediator and/or Moderator?

Yoo Mi Jeong, PhD, PMHNP, RN; Young-Me Lee, PhD, RN; Kunsook Bernstein, PhD, RN, PMHNP-BC, FAAN; Chang Park, PhD

Abstract

The current study used secondary data analysis to examine mediating and moderating effects of depression literacy on the relationship between depression stigma and attitude toward use of mental health care services in Korean American parents. Of 141 survey respondents, 36 (25.2%) were fathers and 105 (74.8%) were mothers. In mediation analysis, the indirect effects of personal stigma (B = −0.14, p < 0.05) and total stigma (B = −0.09, p < 0.05) were statistically significant. The moderating eff ect of depression literacy on the relationship between personal stigma and attitudes was also significant (B = −0.06, p < 0.05). The current study found that only the relationship between personal stigma and attitude toward mental health care service use was mediated by depression literacy. [Journal of Psychosocial Nursing and Mental Health Services, 56(11), 46–55.]

Abstract

The current study used secondary data analysis to examine mediating and moderating effects of depression literacy on the relationship between depression stigma and attitude toward use of mental health care services in Korean American parents. Of 141 survey respondents, 36 (25.2%) were fathers and 105 (74.8%) were mothers. In mediation analysis, the indirect effects of personal stigma (B = −0.14, p < 0.05) and total stigma (B = −0.09, p < 0.05) were statistically significant. The moderating eff ect of depression literacy on the relationship between personal stigma and attitudes was also significant (B = −0.06, p < 0.05). The current study found that only the relationship between personal stigma and attitude toward mental health care service use was mediated by depression literacy. [Journal of Psychosocial Nursing and Mental Health Services, 56(11), 46–55.]

Depression is one of the most common and serious diseases affecting individuals across the lifespan in the United States. Approximately 2.6 million adolescents ages 12 to 17 had depression in 2013 (National Institute of Mental Health, 2016). Moreover, racial/ethnic disparities exist in the rates of depression diagnosis and mental health care service use. Compared with White youth, minority youth were less likely to be diagnosed with depression; odds ratios (ORs) for diagnosis varied among individuals who were Hispanic (OR = 0.51), Black (OR = 0.31), and Asian/Pacific Islander (OR = 0.16) (Richardson, DiGiuseppe, Garrison, & Christakis, 2003). With respect to disparities in depression treatment, compared with non-Hispanic White individuals, Asian American individuals are 50% less likely to receive any mental health treatment (Alegría et al., 2008). Using 5 years of data collected by the National Survey on Drug Use and Health, Cummings and Druss (2011) found racial/ethnic differences in treatment of adolescent depression in particular. Among the subsample of adolescents who experienced a major depressive episode in the past 1 year, Asian American adolescents reported the lowest rate of treatment (19%) compared with White (40%) and African American (32%) adolescents. These findings reflect a substantial unmet need for mental health treatment among all adolescents, but particularly among Asian American adolescents.

According to the mental health literacy model (Jorm, 2000), high depression literacy has been shown to have a positive association with positive attitudes toward mental health care services (Christensen, Leach, Barney, Mackinnon, & Griffiths, 2006; Jorm, 2000) and a negative relationship with depression stigma (Jang, Gum, & Chiriboga, 2011). Depression literacy is defined as the ability to recognize depression and make decisions about its treatment (Rickwood, Deane, Wilson, & Ciarrochi, 2005). A growing body of literature has consistently reported that depression literacy is significantly associated with depression and poor health outcomes (Swami, 2012).

Parental depression literacy may be a key moderating factor between depression and adolescent use of mental health care services (Rickwood et al., 2005). Family interest in and communication about health issues could increase the rate of using health care services (Marcell, Ford, Pleck, & Sonenstein, 2007). Therefore, in the context of adolescent depression, it is important for parents to recognize adolescents' depressive symptoms as early as possible. In addition to parental depression literacy, barriers such as stigma, knowledge deficits of individuals with depression and their families, and lack of mental health resources should be addressed to improve access to mental health care. In the mental health literacy model proposed by Jorm (2000), recognition of depression is the starting point of disease management; therefore, recognition of depression by the affected individual, family members, significant others, and primary care providers is essential. Recognition can be enhanced by increasing depression literacy. However, Jorm's (2000) model includes only perceived public stigma, whereas both perceived public and personal stigma have led to feelings of vulnerability in individuals with depression, as well as low use of mental health care services. Therefore, personal as well as perceived public stigma should be considered in examination of the relationship between stigma and help-seeking behaviors.

According to youth self-report data for 138 Korean American adolescents, approximately 18% experienced clinically significant mental health problems. Anxiety and depression were the primary mental health problems observed; approximately 40% of those exhibiting problems were in the borderline range for clinically diagnosed depression (Kim, Chen, Kools, & Weiss, 2016). Although depression has been acknowledged as a clinical condition, Korean American individuals with depression, as well as the public as a whole, often perceive the condition as being shameful, unproductive, and socially undesirable (Wolpert, 2011). Public stigma is defined as the degree to which negative and discriminatory views are held by the public against certain groups of people; personal stigma, on the other hand, can be defined as negative self-views (Corrigan, 2004; Kanter, Rusch, & Brondino, 2008). These negative perceptions of self may cause individuals to feel devalued; thus, public and personal stigma are attributes of depression. These attributes are significant barriers to using mental health care services in many ethnic minority groups, such as Hispanic, African American, and Asian/Pacific Islander groups (Golberstein, Eisenberg, & Gollust, 2008; Juon, Kim, Shankar, & Han, 2004; Kanter et al., 2008). With regard to depression, personal stigma influences individuals' attitudes toward their own depression, and perceived public stigma reflects individuals' beliefs about the attitudes of others toward their depression (Golberstein et al., 2008; Griffiths, Crisp, Jorm, & Christensen, 2011). Both types of stigma are related to inadequate use of mental health care services (Griffiths, Christensen, Jorm, Evans, & Groves, 2004). With respect to adolescents with depressive symptoms, such stigma is influenced not only by public perceptions of depression, but also by cultural views of their parents (Kramer, Kwong, Lee, & Chung, 2002). For instance, excessive traditionalism (i.e., adherence to a particular native culture) in parents was associated with lower use of mental health care services to address their adolescents' psychiatric symptoms (Kramer et al., 2002).

Although previous studies reported the important role of personal and public stigma in depression literacy, few studies have examined the relationship between depression literacy, stigma toward individuals with depression, and help-seeking behavior in parents of Korean American adolescents. Several studies have indicated that education focused on enhancing depression literacy was limited in improving service use (Jang et al., 2011; Sin, Jordan, & Park, 2011). It is also unclear whether depression literacy acts as a mediator or moderator in the relationship between stigma and help-seeking behavior. Yet, understanding these parental factors is crucial to develop educational programs that effectively promote adolescent use of health care services for depression. The aim of the current study was to examine the mediating and/or moderating effect of depression literacy on the relationship between three subtypes of depression stigma (i.e., personal, public, total) and attitudes toward mental health care service use in parents of Korean American adolescents. The purposes of the current study were to (a) examine the relationship between demographic variables, parental depression literacy, and parental help-seeking behavior, measured as the attitude toward mental health care service use; and (b) test the mediation and moderation effects of parental depression literacy on the three subtypes of depression stigma and attitudes toward mental health care service use as a help-seeking behavior in parents of Korean American adolescents.

Method

Design

The current study involved secondary analysis of existing data to further examine the relationship between subtypes of depression stigma and attitudes toward mental health care service use in parents of Korean American adolescents. Data collection was completed between April 2015 and September 2015 using a self-administered survey.

Sample and Settings

Study participants were recruited from Korean community centers, churches, hair salons, and commercial business markets in the Chicago area using snowball sampling via telephone or e-mail contact. Sample inclusion criteria were: (a) Korean American, (b) parents living with adolescent children ages 12 to 19, and (c) able to read and write Korean fluently. One hundred forty-three Korean American parents participated in the study.

Data Collection

Korean Version of the Parental Depression Literacy Scale. The 18-item Korean version of the Parental Depression Literacy (D-Lit) scale was used to examine depression literacy (Jeong et al., 2016). Scores (0 or 1) for the dichotomous items were summed, and total sum scores were used, with higher total sum scores indicating higher depression literacy. The instrument exhibited acceptable construct and concurrent validity and reliability (Jeong et al., 2016). Construct validity was shown by a root mean square error of approximation of 0.056 with the three-factor model (Kline, 2011; MacCallum, Browne, & Sugawara, 1996), and concurrent validity was indicated by the correlation with attitudes toward mental health-care service use (r = 0.34, p < 0.001) and stigma (r = −0.29, p < 0.001) (Jeong et al., 2016). Reliability was shown with the Kuder– Richardson Formula 20 (KR-20) value of 0.71 (Jeong et al., 2016). Examples of items are “people with depression may feel guilty when they are not at fault” and “major depression is one of the leading causes of disability and loss of quality of life in the world” (Jeong et al., 2016, p. 716).

Vignette for Recognizing Depression. Ability to recognize depression was assessed using a vignette created by Link, Phelan, Bresnahan, Stueve, and Pescosolido (1999). Greater ability to recognize depression has been identified as one component of depression literacy and is associated with positive attitudes toward mental health care services (Jorm, 2000). The current researchers used a Korean-translated version of the vignette. Reliability in the study by Link et al. (1999) was 0.8.

Attitudes Toward Seeking Psychological Help Scale. Attitudes toward seeking professional help for depression were measured using the 10-question Attitudes Toward Seeking Psychological Help (ASPH) Scale with 5-point Likert-type response scales (Whittlesey, 2000). Higher total scores indicated more positive attitudes toward seeking professional help. Items 2, 4, 8, 9, and 10 were reverse-scored because they indicated a negative attitude toward mental health care service use; for example, Question 10 was “Personal and emotional troubles, like many things, tend to work out by themselves” (Whittlesey, 2000, p. 370). Scores of the 10 items were then summed (Whittlesey, 2000). Cronbach's alpha for the ASPH was 0.76 (Whittlesey, 2000).

Depression Stigma Scale. The 15-item adapted Depression Stigma Scale from the original 18-item Depression Stigma Scale developed by Griffiths, Christensen, and Jorm (2008) was used to measure personal (six items) and public (nine items) stigma associated with depression (Jeong et al., 2016). Personal depression stigma items were: (a) individuals with depression could snap out of it if they wanted, (b) depression is a sign of personal weakness, and (c) depression is not a real medical illness. Public depression stigma items were: (a) most individuals would not tell anyone if they had depression, (b) most individuals would not employ someone they knew had been depressed, and (c) most individuals would not vote for a politician they knew had been depressed. Each item was measured from 0 to 4, with a total score ranging from 0 to 60; higher scores indicated greater stigma. Cronbach's alpha for the adapted scale reported in Jeong et al. (2016) for Korean American parents was 0.82.

The Short Version of Suinn-Lew Asian Self-Identity Acculturation Scale. Acculturation was measured using the 12-item Suinn-Lew Asian Self-Identity Acculturation (SL-ASIA) scale that includes five factors underlying acculturation scores: reading/writing/cultural preferences, ethnic interaction, friendship choice, food preferences, and music preferences (Hofstetter et al., 2004; Suinn, Khoo, & Ahuna, 1995). The summary score for the revised SL-ASIA scale is the average of total scores of the 12 items and ranges from 1 (low acculturation) to 5 (high acculturation), with 3 as the acculturation midpoint (Hofstetter et al., 2004; Suinn et al., 1995). This version of the SL-ASIA scale was tested among Korean American individuals in California and was found to have internal consistency equivalent to that of the original scale (Cronbach's alpha = 0.88 to 0.90) (Hofstetter et al., 2004). In the current study, Cronbach's alpha for the 12-item SL-ASIA scale was 0.81.

Sample Size Determination and Data Analysis

Power analysis was performed with the product of two effects (i.e., the indirect effect); medium effect size was used (small effect size = 0.1, medium effect size = 0.3, and large effect size = 0.5) (Kenny, 2016). The sample size for a medium effect size, power = 0.8 and alpha = 0.05, was 109; thus, the current sample of 141 individuals was sufficient to detect statistical significance for mediation analysis (Kenny, 2016).

As the first step, correlational analysis was performed to examine relationships among parental depression literacy, depression stigma, and attitude toward use of mental health care services. Multivariate linear regression was then used to identify significant covariates to be included in mediation analyses, as well as to examine associations between depression literacy and stigma subtypes while controlling for covariates. In the multiple regression analysis, both subtypes of depression stigma were related to depression literacy. For the third step, using attitude toward mental health care service use as the outcome in the multiple regression models, both subtypes of depression stigma and depression literacy were included as predictors. In the fourth and final step, to establish that depression literacy completely mediated the relationship between depression stigma and attitude toward service use, the effect of stigma on attitude toward service use was evaluated while controlling for depression literacy, and the effect was 0. In addition, a mediation analysis was performed to determine the indirect effect of depression literacy on the relationship between stigma subtypes and attitude toward service use while controlling covariates, including age, gender, and education level (Kenny, 2016). To test indirect effects, a bootstrapping method was used (Kenny, 2016).

Moderation analysis was performed to examine the moderating effect of depression literacy on the relationship between stigma subtypes and attitude toward service use while controlling for covariates (i.e., age, gender, education level). Moderation analysis was also performed by gender to determine whether results were applicable to both genders.

Protection of Human Subjects

Before recruitment began, the study was approved by the Institutional Review Board of the University of Illinois at Chicago.

Results

Sample Characteristics

A total of 141 participants completed the survey. Sample characteristics are presented in Table 1. Participants included 36 (25.5%) fathers and 105 (74.5%) mothers. Participants' overall mean age was 46.7 years (SD = 5 years); fathers' mean age was 47.8 years (SD = 4.1 years), and mothers' mean age was 46.4 years (SD = 5.3 years). Overall mean duration of living in the United States was 18.8 years (SD = 8.6 years); fathers had lived in the United States longer than mothers. Fathers also had more years of education in the United States (mean = 3.5 years, SD = 3.7 years) than mothers (mean = 2.4 years, SD = 3.6 years). Participants were generally highly educated, with more than 87% having a bachelor's degree or above.

Sample Characteristics (N = 141)

Table 1:

Sample Characteristics (N = 141)

Descriptions of Main Variables

The mean depression literacy score for survey participants was 14.1 (SD = 2.8, range = 1 to 18). The mean score for attitudes toward use of mental health care services was 25.1 (SD = 5.4, range = 10 to 39), and the mean total score for depression stigma was 21.7 (SD = 6.2, range = 0 to 37).

Relationship Between Demographics and Depression Literacy

Differences in depression literacy among individuals of different ages, genders, education levels, and acculturation levels were examined (Table 2). In the current study, a significant difference in depression literacy was found among the three participant age groups at the p < 0.05 level (F [2, 138] = 7.07, p = 0.012). Participants 45 and younger were found to have higher depression literacy (mean score = 9.2, SD = 2.5) than participants ages 46 to 55 (mean score = 8.9, SD = 2.6) and 56 and older (mean score = 6.6, SD = 3.6).

Depression Literacy and Attitude Toward Mental Health Care Service Use Results Using the 18-Item Parental Depression Literacy Scale

Table 2:

Depression Literacy and Attitude Toward Mental Health Care Service Use Results Using the 18-Item Parental Depression Literacy Scale

Fathers (mean score = 8.4, SD = 3.0) were found to have lower depression literacy than mothers (mean score = 0.1, SD = 2.5), but the difference was negligible (t[139] = 1.27, p > 0.05).The relationship between depression literacy and education levels was statistically significant (F [2, 138] = 7.07, p = 0.012). Participants with a bachelor's degree had higher depression literacy (mean score = 10.1, SD = 2.4) than those with a master's degree (mean score= 8.8, SD = 2.4) or high school diploma (mean score = 7.2, SD = 3.2). With regard to acculturation, measured as years of education in the United States and language skill, no significant differences in depression literacy scores were found.

Differences in Attitudes Toward Mental Health Service Use Among Demographics

Participants ages 46 to 55 demonstrated the most positive attitude toward mental health care service use among the three age groups (mean score = 24.9, SD = 5.4; F [2, 138] = 1.93, p = 0.004). Moreover, for attitude toward mental health care service use, women had a slightly higher score than men. Among men and women, the higher the education level, the more positive the attitude toward mental health care service use (Table 2).

Relationship Among Stigma, Attitude, and Depression Literacy

Total stigma was negatively correlated with depression literacy (r = −0.30, p < 0.001) and attitude toward mental health care service use (r = −0.24, p < 0.01). In addition, personal stigma was negatively correlated with depression literacy (r = −0.30, p < 0.001) and attitude toward mental health care service use (r = −0.32, p < 0.001) (Table 3). Personal stigma was a statistically significant predictor of attitude toward service use (B = −0.67, SE = 0.27, p < 0.05) (Table 4).

Correlations Among Attitude Toward Mental Health Care Service Use, Depression Literacy, and Stigma Subtypes

Table 3:

Correlations Among Attitude Toward Mental Health Care Service Use, Depression Literacy, and Stigma Subtypes

Multiple Regression for Attitude Toward Mental Health Care Service Use by Stigma Subtype

Table 4:

Multiple Regression for Attitude Toward Mental Health Care Service Use by Stigma Subtype

In the simple mediation analysis for depression literacy by stigma subtype, partial mediation of personal and total stigma was significant. The indirect effects of personal stigma (B = −0.14, p < 0.05) and total stigma (B = −0.09, p < 0.05) were statistically significant. The total effects of personal stigma (B = −0.56, p < 0.001) and total stigma (B = −0.24, p < 0.05) were also statistically significant. The proportions of the total effect of depression literacy on personal and total stigma that were mediated were approximately 25% and 38%, respectively. The mediation effect on public stigma was not statistically significant. In the mediation analysis for depression literacy, the indirect and total effects of stigma subtypes were not significant (Figure 1 and Figure 2).

Mediation analysis of depression literacy on the relationship between personal stigma and attitude toward mental health care service use.**p < 0.01; ***p < 0.001.

Figure 1.

Mediation analysis of depression literacy on the relationship between personal stigma and attitude toward mental health care service use.

**p < 0.01; ***p < 0.001.

Mediation analysis of depression literacy on the relationship between total stigma and attitude toward mental health care service use.*p < 0.05; **p < 0.01; ***p < 0.001.

Figure 2.

Mediation analysis of depression literacy on the relationship between total stigma and attitude toward mental health care service use.

*p < 0.05; **p < 0.01; ***p < 0.001.

To determine whether mediation analysis results were applicable to both genders, mediation analysis was also performed by gender. In the simple mediation analysis by stigma subtypes, among fathers (n = 36) there was no statistically significant mediation effect of depression literacy on the relationships between stigma subtypes and attitudes toward service use. Conversely, among mothers (n = 105) the indirect effects of personal stigma (B = −0.17, p < 0.05) and total stigma (B = −0.10, p < 0.05) on attitudes were statistically significant. The total effects of personal stigma (B = −0.55, p < 0.05) and total stigma (B = −0.21, p < 0.05) were also statistically significant. The proportions of mediated effect from the total effect of depression literacy on personal and total stigma that were mediated were approximately 31% and 48%, respectively. The mediation effect of depression literacy on the relationship between public stigma and attitudes was not statistically significant.

Moderation analyses were performed in two steps using Elite Research, LLC 2013. First, in a regression model predicting attitude toward mental health care service use based on depression stigma and depression literacy, both effects and the model (r2) were significant. Essentially, the moderation effect of depression literacy on the relationship between stigma subtypes and attitude toward mental health care service use was significant (B = −0.06, p < 0.05) (Table 5 and Figure 3). Second, in adding the interaction effect to the regression model, a significant r2 change and an effect by the new interaction term were observed. For participants with stigma scores of 0, higher depression literacy improved attitude toward mental health care service use more than for individuals with personal stigma scores of 18. However, there were no statistically significant differences in the moderation effect of depression literacy on the relationship between total and public stigma and attitude toward mental health care service use. In regression analysis with moderation effect by depression literacy on the relationship between stigma subtype and attitudes, among fathers (n = 36), there was no statistically significant moderation effect, but among mothers (n = 105), there was a statistically significant moderation effect of depression literacy on the relationship between personal stigma and attitudes (B = −0.11, p < 0.05).

Moderation Effect of Depression Literacy on the Relationship Between Personal Stigma and Attitude Toward Mental Health Care Service Use

Table 5:

Moderation Effect of Depression Literacy on the Relationship Between Personal Stigma and Attitude Toward Mental Health Care Service Use

Moderation analysis of depression literacy on the relationship between attitude toward mental health care service use and total stigma.

Figure 3.

Moderation analysis of depression literacy on the relationship between attitude toward mental health care service use and total stigma.

Discussion

The purpose of the current study was to examine the mediating and/or moderating effect of depression literacy on the relationship between three sub-types of depression stigma (personal, public, and total) and attitudes toward mental health care service use in parents of Korean American adolescents. Korean American parents participating in the current study who reported lower depression literacy had higher depression stigma and more negative attitudes toward mental health care service use. These findings confirm that different levels of depression literacy influence the relationship between stigma levels and attitudes toward service use (Griffiths et al., 2004; Griffiths et al., 2008; Holman, 2015; Kelly, Jorm, & Wright, 2007; Wu, Lee, Fang, & Liu, 2016). Specifically, parents with better abilities to recognize and understand depression tended to have more positive attitudes toward mental health care services. In addition, young adults with higher levels of education could better recognize depression and demonstrated less treatment stigma than those with lower levels of education, a finding that is consistent with Holman (2015). These findings can be used to expand existing educational services for depression, as well as to develop programs that are more effective at improving mental health care service use for racially and ethnically diverse populations.

According to the current study findings, the relationship between personal stigma and attitude toward mental health care service use was mediated by depression literacy, and the relationship between total stigma and service use was moderated by depression literacy. These findings reveal that educational programs designed to increase depression literacy may be effective in decreasing existing personal stigma. In studies by Latalova, Kamaradova, and Prasko (2014) and Eisenberg, Downs, Golberstein, and Zivin (2009), Asian individuals were shown to have higher personal stigma of depression than any other racial/ethnic groups. To reduce existing personal stigma of depression and its treatment, cultural context should be understood to support mental health care service use and influence the outcomes of depression in culturally relevant contexts (Pescosolido, 2006; Pescosolido, Olafsdottir, Martin, & Long, 2008). In traditional Korean culture, individuals' relationships with their family and neighborhood affect their sense of well-being (Hahn, 2006). Likewise, collectivistic attitudes value group harmony more than individual concerns; thus, valuation of self and family is likely to be affected by social comparisons (Shavitt, Lalwani, Zhang, & Torelli, 2006). Consequently, it is important that nurses plan interventions aimed at improving recognition and treatment of depression and that those interventions address individual and group norms and beliefs. For example, educational programs that increase community awareness of depression and incorporate case studies of its successful treatment may be an effective strategy in increasing social acceptance of depression and its treatment. In addition, treatment of depression among Korean American adolescents should consider family and community contexts. For example, nurses should keep in mind traditional Korean values and social stigma toward depression, and their strong influence on recognition of and seeking help for depression.

Interestingly, the current study found gender differences in the mediation effect of depression literacy on the relationships between stigma subtypes and attitudes toward mental health care service use. For mothers in the study, personal stigma and total stigma were mediated by depression literacy; however, for fathers, the mediation effects of depression literacy on stigma subtypes were not statistically significant. These results differed from those of Latalova et al. (2014), which showed a significant relationship between depression literacy and personal stigma. The current study's small sample size of men (n = 36) may have limited the ability to capture gender differences in the relationship among depression literacy, depression stigma, and attitude toward service use. These results indicate that a similar study needs to be conducted according to gender to avoid overgeneralizing the results of depression literacy and help-seeking behaviors.

In addition, findings suggest that educational interventions focusing on depression literacy may be more effective for decreasing stigma in mothers than fathers. In regression analysis, no stigma subtypes were found to be significant predictors of fathers' attitudes toward use of mental health care services. This finding implies that variables other than stigma subtypes should be examined in fathers to identify facilitators of and barriers to use of mental health care services. In addition, interventions other than educational programs should be considered to promote fathers' help-seeking behaviors for their children's depression.

Regarding the moderation effects of depression literacy on the relationship between stigma subtypes and attitudes toward mental health care services, depression literacy was shown to have a significant effect on the relationship between personal stigma and attitudes. In general, it appears that the less personal stigma Korean American parents have, the more their depression literacy has a moderating effect on the relationship between stigma and attitudes. Depression literacy has been shown to have a moderating effect on the relationship between stigma and attitudes, even for individuals with a high total stigma. This moderating effect implies that although it may be hard to change attitudes toward mental health care service use for those with existing stigma, educational programs should still be conducted to enhance knowledge and positive attitudes toward mental health care service use.

Limitations

The current study had several limitations. First, the study used convenience sampling, and participants were predominantly female and all were volunteers, indicating that the sample is not representative of all Korean American parents—even within the Chicago metropolitan area. A relatively small number of Korean American fathers participated in the study, which may have limited the ability to capture gender differences in depression literacy, stigma, and attitudes toward mental health care services. Individuals not engaged in Korean churches and community centers may be underrep-resented, further limiting generaliz-ability. Second, the study design was cross-sectional, precluding explanation of causal relationships among variables.

Conclusion

Among Korean American parents, the current study found that only the relationship between personal stigma and attitude toward mental health care service use was mediated by depression literacy. These findings suggest that educational programs addressing recognition and importance of adequate treatment for depression may be effective in decreasing existing personal stigma and thus promoting use of mental health care services for adolescent depression in this population. Additional research on the Parental D-Lit scale should use larger samples, more Korean American fathers, and Korean American individuals in various regions of the United States.

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Sample Characteristics (N = 141)

VariableMean (SD) (Range)
Age (years)46.7 (5.0) (33 to 61)
Years living in country
  United States18.8 (8.6) (1 to 43)
  Korea27.6 (8.1) (9 to 54)
Years of education in the United States2.7 (3.7) (0 to 20)
Depression literacy8.9 (2.7) (0 to 13)
Attitude toward service use25.3 (6.2) (10 to 60)
Stigma
  Total21.7 (6.2) (0 to 30)
  Public20.0 (6.5)
  Personal9.8 (3.6)
n (%)
Gender
  Female105 (74.5)
  Male36 (25.5)
Education
  Less than high school18 (12.8)
  Bachelor's degree93 (66.0)
  Master's degree or higher30 (21.3)
Recognition of depressiona
  Yes79 (56.0)
  No62 (44.0)

Depression Literacy and Attitude Toward Mental Health Care Service Use Results Using the 18-Item Parental Depression Literacy Scale

VariableDepression LiteracyaAttitude Toward Service Useb
Participants (n)Total Score (Mean [SD])Participants (n)Total Score (Mean [SD])
Age* (years)
  36 to 45689.2 (2.5)6826.2 (7.0)
  46 to 55648.9 (2.6)6424.9 (5.4)
  ≥5696.6 (3.6)922.3 (2.6)
Gender*
  Female1059.1 (2.5)10526.2 (6.1)
  Male368.4 (3.0)3622.9 (5.8)
Education**
  High school or less187.2 (3.2)1823.2 (3.9)
  Bachelor's degree938.8 (2.4)9325.9 (6.2)
  Master's degree or higher3010.1 (2.4)3024.8 (7.0)
SL-ASIA scale score (%)
  0 to 252513.1 (2.7)
  26 to 505813.1 (3.3)
  51 to 752814.3 (2.2)
  76 to 1003012 (2.7)
Years of education
  In the United States772.7 (0.3)7725.3 (6.2)
  In South Korea6414.6 (0.3)6425.3 (6.2)
Preferred language
  English or Korean169.5 (1.7)1627.3 (6.5)
  English28 (5.7)224.5 (2.1)
  Korean1238.9 (2.7)12325.1 (6.2)

Correlations Among Attitude Toward Mental Health Care Service Use, Depression Literacy, and Stigma Subtypes

Total ScoreAttitude Toward Service UseDepression LiteracyPersonal StigmaPublic StigmaTotal Stigma
Attitude toward service use1
Depression literacy0.34***1
Personal stigma−0.32***−0.30***1
Public stigma−0.09−0.110.28***1
Total stigma−0.24**−0.30***0.78***0.67***1

Multiple Regression for Attitude Toward Mental Health Care Service Use by Stigma Subtype

VariableBSEp Value
Stigma subtype
  Total0.090.200.667
  Personal−0.670.270 .014*
  Public−0.050.120.669
Gender
  Male−2.361.190.050
Age−0.250.110.029*
Years living in United States0.020.080.770
Education
  Bachelor's degree1
  High school or less−1.751.340.193
  Master's degree or higher−1.371.690.420
Acculturation−0.121.590.941

Moderation Effect of Depression Literacy on the Relationship Between Personal Stigma and Attitude Toward Mental Health Care Service Use

Attitude Toward Mental Health Care Service UseB
Depression literacy1.73**
Personal stigma0.66
Depression literacy × personal stigma−0.11*
Authors

Dr. Jeong is Assistant Professor, College of Nursing, Konyang University, Daejun-si, South Korea; Dr. Lee is Associate Professor, School of Nursing, DePaul University, and Dr. Park is Assistant Professor, College of Nursing, University of Illinois at Chicago, Chicago, Illinois; and Dr. Bernstein is Professor, Hunter-Bellevue School of Nursing, City University of New York, New York, New York.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was reviewed and approved by the appropriate ethics committee for the protection of human subjects at the University of Illinois at Chicago (UIC). UIC holds a Federal Wide Assurance (FWA) #00000083 from the Office for Human Research Protections (OHRP) in the Department of Health and Human Services (DHHS). This FWA is an agreement between DHHS and UIC to review and approve research involving human subjects in accordance with the ethical principles outlined in the Belmont Report and the DHHS regulations 45 CFR Part 46.

Address correspondence to Yoo Mi Jeong, PhD, PMHNP, RN, Assistant Professor, College of Nursing, 209, Konyang University, 35365 Gwanjeodonglo 158, Seo-gu, Daejun-si, Chungnam-do, South Korea; e-mail: yjeong20@konyang.ac.kr.

Received: November 28, 2017
Accepted: March 16, 2018
Posted Online: August 22, 2018

10.3928/02793695-20180815-01

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