Tablet-based education to reduce depression-related stigma

568434HEJ0010.1177/0017896914568434Health Education JournalLu et al. research-article2015 Original Article Tablet-based education to reduce depression-related stigma Health Education Journal 2016, Vol. 75(1) 84 93 The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalspermissions.nav DOI: 10.1177/0017896914568434 hej.sagepub.com Catherine Lu a, Megan Winkelman a and Shane Shucheng Wong a,b a Stanford University, Stanford, CA, USA b Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Abstract Objectives: This study investigated the efficacy of a tablet-based multimedia education application, the Project Not Alone Depression Module, in improving depression literacy and reducing depression stigma among a community-based mental health clinic population. Methods: A total of 93 participants completed either a tablet-based multimedia education or a print education module containing the same content on depression. Primary outcomes were changes in depression literacy as measured by a knowledge quiz and stigma as measured by the Depression Stigma Scale administered before and after the education intervention. Secondary outcomes included participant preference, ease of use, and likeliness to discuss topic with a physician. Results: In comparison to print education, tablet-based multimedia education significantly increased depression-related knowledge and reduced depression stigma (p <.05). Among all participants, a reduction in the personal stigma was correlated with an increase in knowledge (p <.05). Participants preferred the tablet-based module to a human health educator (p <.05). Conclusion: With advantages of scalability, user preference, and efficacy in improving depression literacy and stigma, tablet-based multimedia education has the potential to improve the health outcomes of mental health clinic populations. Although the study findings are limited by small sample size and lack of randomisation, the results are encouraging for future research and development in tablet-based multimedia patient education. Keywords Depression literacy, multimedia application, psychoeducation, stigma Corresponding author: Shane Shucheng Wong, Department of Psychiatry, Massachusetts General Hospital, 55 Parkman Street, WACC 812, Boston, MA 02114, USA. Email: swong20@partners.org

Lu et al. 85 Introduction Depression is a leading cause of global disease burden (Ferrari et al., 2013). Depression symptom severity, treatment adherence and related psychosocial variables including self-esteem have a robust relationship with internalised stigma, which relates to the shame, hopelessness, guilt and fear of discrimination felt by an individual towards their illness (Brohan et al., 2010; Livingston and Boyd, 2010). One primary approach to targeting stigma is through psychoeducation, which addresses stigmatising beliefs, which has particular benefit to patients most in need or uncertain about mental health treatment (Lewis, 1999; Mittal et al., 2012). However, both the high prevalence of stigma and a lack of patient education remain major barriers to the prevention and treatment of mental illness, indicating an urgent need for such public health interventions (O Connell et al., 2009). Unfortunately, traditional health education interventions comprising printed material are written for reading levels at or above the 10th grade, making such materials inaccessible to millions of US Americans without adequate literacy (Parker, 2000). Interactive technologies with audio and video capabilities offer a potentially more accessible method of health education. Studies of such technologies in community clinics have demonstrated high user enjoyability, trust of information and learning retention (Leeman-Castillo et al., 2007; Lewis, 1999). Mental health multimedia content targeting patients at high risk of suicide and survivors of traumatic injury has also shown promise in accessibility of education and improving illness awareness (Alvidrez et al., 2009; Mokkenstorm et al., 2012). Thus, multimedia applications may be a promising platform for delivery of mental health education. The Project Not Alone Depression Module was developed as a tablet-based multimedia application addressing the topic depression. It was built through an iterative collaboration between a community-based mental health clinic staff and patients, and researchers. The goals driving the design and content of the application were to improve depression literacy with a focus on the symptoms, aetiologies and treatments, and to reduce the stigma of depression. The module counters beliefs regarding depression that underlie its stigma, including a fear of discrimination linked to the belief that depression is rare, hopelessness related to the belief that depression cannot be successfully treated and shame associated with the belief that those experiencing depression are weak in character. Despite research demonstrating that stigma associated with depression is an important barrier to health-promoting behaviour and outcomes, there remains a lack of evidence-based educational interventions designed to improve depression literacy and reduce depression stigma. The purpose of this study is to investigate the efficacy of a tablet-based multimedia application, the Project Not Alone Depression Module, in comparison to a traditional printed brochure, in addressing depression literacy and stigma. Methods Participants Participants were 93 adult patients visiting a community mental health clinic. The clinics were non-profit community-based clinics located in Northern California, USA, serving mostly patients in receipt of Medi-Cal or Medicare which are state and national social insurance programmes serving populations that include the elderly, disabled and low-income populations. For patients with insurance, the clinic offers sliding scale fees. The mean participant age was 45.4 years (standard deviation [SD] = 11.0 years), with a range of 20 70 years old. Of the participants, 65% were female. All participants were patients actively seeing a doctor for a mental health illness, and most had previously been diagnosed with depression (Table 1).

86 Health Education Journal 75(1) Table 1. Sociodemographics of sample size. Print module Multimedia module Sample size n = 70 n = 23 Gender (%) Female 63.8 65.2 Male 36.2 34.8 Age (years) 45.4 45.1 Education (%) Less than high school 20.0 17.4 High school 52.9 52.2 Greater than high school 27.1 30.4 Race (%) African American 37.7 34.8 Asian 7.2 0 Mexican/Hispanic 15.9 13.0 Native American 2.9 0 White 27.5 34.8 Multiracial 8.7 17.4 Depression (%) Previously or currently diagnosed with depression 85.1 90.6 Education modules A multimedia education module was developed for use as a tablet-based application for community clinics. An initial print prototype describing the symptoms, diagnosis, risk factors and treatments for depression, and a corresponding knowledge test, was administered to 20 patients with a range of mental health concerns. Based on their qualitative feedback, the prototype was modified to produce two education modules based on the same informational content: a print brochure and a multimedia application designed for Android tablets. The same information was shared using two different methods of delivery. 1 The multimedia application uses multiple animated videos with subtitles accompanying the audio and requires users to tap a button to advance videos. Between videos are short quizzes that users are prompted to complete. Procedure The protocol was approved by the Stanford Institutional Review Board. The participants were recruited by a researcher in the waiting area of the community clinic. They were asked whether they would be willing to participate in a research study on learning about mental illness. An initial questionnaire was administered to assess sociodemographics, baseline depression knowledge and baseline depression stigma. The participants were then asked to complete the education module (i.e. print brochure or the tablet-based application). Upon completion of the module, a final questionnaire assessed post-intervention depression knowledge and stigma. A research assistant was available throughout the process to help answer questions. Participants asked to complete the brochure had the option for the brochure to be read out loud as they were going through it, to diminish the barrier of literacy. Of the participants, 55.2% assigned to the print module asked for at least parts of the brochure to be read to them by a research assistant. Participants assigned to the tablet application listened to the audio with subtitles shown on the video, so they were not offered help reading out loud. One patient was excluded from the brochure trial due to an inability to comprehend the brochure content and respond to the questions.

Lu et al. 87 In the first trial, 70 participants were assigned the print education module. In the second trial, 23 patients were assigned to the multimedia education module. Sequential assignment of the participants to the trials precluded randomisation. The multimedia education module had fewer participants because the efficacy of the application was demonstrated in the analysis. This prompted final design revisions to the application, followed by permanent installation of the tablet application in the clinic to provide greater access to the module, and release of the module for the public in the Google Play Store. Measurement A sociodemographics questionnaire assessed participant gender, age, education attainment, race and previous depression diagnoses. An initial questionnaire assessed both baseline depression literacy and depression stigma. The former was d using a 20-item quiz on symptoms, diagnosis, risk factors and treatments for depression, and the latter was based on the Depression Stigma Scale (Griffiths et al., 2008). A final questionnaire assessed post-intervention depression literacy and stigma, using the same 20-item knowledge quiz and Depression Stigma Scale. The quiz s depression knowledge was totalled out of 20 points, with 1 point gained for each correct response to a multiple-choice question. The Depression Stigma Scale, which measures the cognitive components of depression stigma, was validated in a previous study (Griffiths et al., 2004). An 18-item test assesses beliefs that depression is an illness, the extent to which it may be under personal fault, its dangerousness, unpredictability, shame and an individual s avoidant attitudes towards the illness. Nine items measure the personal stigma scale, which reflects personal stigmatising attitudes towards depression. The remaining 9 items comprise the perceived stigma scale which reflects a participant s perceptions towards other people s beliefs regarding depression. For each of the 18 statements, participants were asked how much they agreed with the statement, circling a from 1 to 5, 1 being strongly disagree and 5 being strongly agree. A lower indicates that participants did not agree with stigmatising statements. In our analysis, we calculated a personal stigma scale and a perceived stigma scale, which summated to the total stigma. Cronbach s alpha values for the total, personal and perceived depression stigma scales were.78,.76 and.82, respectively, and the test retest reliability of the personal and perceived stigma scales were.71 and.67, respectively. Given the nature of the procedure, with recruitment and assessment carried out in the same session, complete data were collected for every participant. Statistical analysis SPSS version 21.0 was used for statistical analysis. Independent samples t-tests were used to detect significant differences in sociodemographics, depression diagnoses, depression knowledge s and depression stigma s between educational intervention module groups. Correlational analyses were used to investigate the association between depression knowledge s and depression stigma s. Results There were no significant differences in sociodemographics: gender, age, education attainment and depression diagnoses were similar between the print and multimedia module groups (see Table 1).

88 Health Education Journal 75(1) Table 2. Comparison of baseline and change in mental health knowledge and stigma s by type of education module groups. Print module Multimedia module Difference between modules Mean (SD) Mean (SD) Mean (SE) Baseline knowledge 11.8 (3.2) 12.0 (2.2) 0.17 (0.72) Change in knowledge 1.5 (2.9)** 3.0 (3.1)** 1.4 (0.72)* Baseline stigma Total 30.0 (10.7) 28.6 (11.8) 1.36 (2.6) Personal stigma 12.2 (6.5) 11.1 (7.2) 1.1 (1.6) Perceived stigma 17.7 (7.0) 17.5 (6.9) 0.22 (1.7) Change in stigma Total 1.7 (7.1)* 6.6 (10.7)** 4.9 (2.0)* Personal stigma 1.2 (4.2)* 6.4 (7.1)** 5.3 (1.2)** Perceived stigma 0.48 (5.3) 0.10 (6.1) 0.36 (1.3) SD: standard deviation; SE: standard error. Change s were calculated as post-education minus baseline s. Differences between module s were calculated as print module minus multimedia module s. *p <.05; **p <.001. The print module group had a significantly greater number of patients self-reporting Asian ethnicity compared to the multimedia module group (7.4% vs 0%; p <.05), but no other statistically significant sociodemographic differences were found between the two groups. Effects for knowledge s There were no differences in the baseline knowledge s between the two groups (see Table 2). The print module group had an average increase of 1.5 on the knowledge after the education module (p <.001). The multimedia group had an increase of 3.0 in the knowledge (p <.001), which was significantly greater than the increase in the print module group (p <.05). Effects for stigma s There were no differences in the baseline stigma s between the groups. The print module had a significant average decrease of 1.7 in their total stigma after completing the education module (p <.05). In individual scales, the print group showed a significant decrease of 1.2 on the personal stigma scale (p <.05), but not on the perceived stigma scale. The multimedia module group had an average decrease of 6.6 in the total stigma (p <.001), with individual scales showing a decrease of 6.4 on the personal stigma scale (p <.001), but a non-significant decrease on the perceived stigma sale. Comparing the two module types, the multimedia module group had a significantly greater decrease in total stigma compared to the print group (p <.05), as well as a significantly greater decrease in personal stigma ( 6.4 vs 1.25; p <.001). No significant differences were found in the change in perceived stigma between the groups.

Lu et al. 89 Table 3. Correlation between knowledge s and stigma s. Baseline knowledge Post-module knowledge Change in knowledge Baseline stigma Post-module stigma Change in stigma Total.24* Personal stigma.40** Perceived stigma.01 Total.27* Personal stigma.31** Perceived stigma.12 Total.20 Personal stigma.21* Perceived stigma.095 *p <.05; **p <.001. Association between knowledge and stigma s Among all participants at baseline, higher knowledge s were associated with lower stigma (r =.24; p <.05) on the personal stigma scale (r =.40; p <.001), but not on the perceived stigma scale (Table 3). After intervention with the education modules, the correlations between knowledge s and both the total and personal stigma s remained significant (r =.27 and.31; p <.05). The increase in knowledge was associated with a reduction in the personal stigma (r =.21; p <.05), but not the total stigma. There were no significant correlations between the perceived stigma scale and knowledge s among any groups. Mediation analysis of knowledge s predicting stigma reduction Table 4 summarises the results of the mediation analysis for education type predicting stigma change, with knowledge change as the mediator. The standardised regression coefficients and significance for the pathways among variables for the model are presented. When personal stigma change was regressed on education type, education type was significantly associated with personal stigma change, accounting for 16% of variance (β =.42, p <.001). When knowledge change was regressed on education type in the second regression equation, education type was significantly associated with knowledge change, accounting for 3.2% of variance (β =.21, p <.05). When both education type and knowledge change were entered into the equation predicting personal stigma change in the fourth equation, knowledge change was not significantly related to personal stigma change (β =.13, p >.05), although the regression β for education type decreased from β =.42 (p <.001) in the first equation to β =.39 (p <.001) when knowledge change was entered as the mediating variable in the fourth equation. Educational module feedback Between the two groups, there were no significant differences between perceived length of the educational material, the amount of information in the material, the ease of use, or the likelihood of speaking to a doctor about depression (Table 5). Both groups reported favourable responses to

90 Health Education Journal 75(1) Table 4. Mediation analysis of education type predicting personal stigma change with knowledge change as the mediator. Model predicting stigma change Variance (adjusted R 2 ) Dependent variable Independent variable 1 β Significance Independent variable 2 A: Education Stigma.16 Personal stigma change Education type.42 p <.001 B: Education Knowledge.032 Knowledge change Education type.21 p <.05 C: Knowledge Stigma.035 Personal stigma Knowledge change.21 p <.05 change D: Education + Knowledge Stigma.17 Personal stigma change Education type.39 p <.001 Knowledge change β Significance.13 p >.05

Lu et al. 91 Table 5. Education module feedback from participants. Print Multimedia Group difference Fields Mean (SD) Mean (SD) Mean (SE) Text helpfulness 4.2 (0.89) 4.4 (0.73) 0.25 (0.21) 5 very helpful, 1 not helpful at all Visual helpfulness 3.9 (1.0) 4.4 (0.66) 0.53 (0.23)* 5 very helpful, 1 not helpful at all Length 3.1 (0.83) 3.3 (0.56) 0.17 (0.19) 5 way too long, 3 just right, 1 way too short Amount of information 3.0 (0.60) 2.9 (0.67) 0.10 (0.15) 5 way too much, 3 just right, 1 way too little Ease of use 4.0 (0.85) 4.4 (0.50) 0.32 (0.19) 5 very easy, 1 very hard Preference to human 2.7 (1.5) 3.6 (1.4) 0.95 (0.35)** 5 definitely prefer module/ brochure, 1 definitely prefer health educator Want to go through more 3.9 (1.1) 4.3 (1.1) 0.36 (0.27) 5 definitely go through them, 1 definitely not go through them Likeliness to speak to doctor 3.9 (0.98) 4.1 (1.1) 0.26 (0.24) 5 much more likely to talk to the doctor, 1 much less likely to talk to the doctor SD: standard deviation; SE: standard error. Change s were calculated as post-education minus baseline s. *p <.05; **p <.001. the education modules. For example, 87% of participants reported the educational module as easy or very easy to use, and 69% of patients reported being more likely to speak to a doctor after some form of the educational module. Participants exposed to the multimedia module reported that the visuals were more helpful than did participants exposed to the print module (p <.05). Furthermore, the multimedia group was more likely to prefer their education module compared to a human health educator, in comparison to the print group (p <.01). Discussion This controlled trial demonstrates that relative to a print brochure, a tablet-based multimedia education programme led to a significant improvement in depression literacy and a reduction in personal stigma among patients diagnosed or at high risk of depression. Although the print education module also improved knowledge and reduces stigma, the effect size of the multimedia module was significantly greater. Overall, a reduction in the personal stigma was significantly correlated with an increase in knowledge (r =.21; p <.05), though mediation analysis suggests that this reduction in personal stigma was not mediated by an increase in depression knowledge. There may be several reasons for the greater efficacy of the tablet-based multimedia programme in reducing self-stigma. A previous study on changing food safety beliefs has shown that an interactive technology-based experience may provide more enjoyment and thus greater patient engagement, as well as a greater trust in the information presented (Trepka et al., 2006). Although we found that stigma reduction was associated with knowledge change, mediation analysis showed that the reduction in personal depression stigma was largely independent of improvements in depression-related knowledge. This replicates results from a similar study of

92 Health Education Journal 75(1) stigma reduction, which utilised Internet-based informational content as the educational intervention (Griffiths et al., 2004). Furthermore, our results replicated the differential effects of educational intervention on self-stigma, but not perceived stigma, in a study of an audiovisual computer education module on infection treatment (Leeman-Castillo et al., 2007). Qualitative feedback showed that patient ratings regarding visual effectiveness in the multimedia module were significantly higher, suggesting that virtual contact with an animated narrative figure may be underlying the greater changes in depression literacy and stigma. In a study of different stigma reduction strategies, a contact strategy, defined as facilitating interactions with persons with the illness, produced reductions in depression stigma exceeding a knowledgebased educational strategy (Corrigan and Watson, 2002). However, other studies have shown that increased contact with an individual with mental illness may be associated with greater psychiatric stigma (Griffiths et al., 2008). Huxley (1993) identified that direct contact with people who have had beneficial treatment for mental illness is a key factor in stigma reduction. Thus, a video of animated persons reporting treatment benefits may be sufficient to facilitate the effects of contact strategies in reducing stigma. The majority of patients exposed to both the print and multimedia education interventions report greater likelihood to speak to physicians about depression after the module. The higher use preference and visual ratings of the tablet-based multimedia suggest an intervention that is both practical and feasible. Moreover, a high percentage (55.2%) of participants asked for help with the print brochure, suggesting that traditional brochures are not optimised for patients in community clinics where literacy may be more limited. Such literacy barriers are naturally minimised in an audiovisual media that combines narrating voice and written subtitles. Moreover, printed pamphlets and brochures are often outdated and disregarded by the community clinic population. Limitations of the study include a lack of randomisation, due to the developmental timeline for the multimedia prototype that prevented simultaneous implementation of both modules. Our mediation analysis must also be considered exploratory, given a lack of power to detect significances in our sample size given a modest effect size (Luxton et al., 2011). Thus, we cannot conclude with certainty that stigma reduction is not mediated by knowledge improvement. Finally, the knowledge quiz was created by researchers based on the module s educational content and has not been externally validated. Future research should investigate whether the immediate improvements in depression literacy and stigma persist over time. Follow-up studies should also study the relationship between education modules and their impact on health behaviours, such as communication with health-care professionals and treatment adherence, and most importantly, illness and rehabilitation outcomes. Given the barriers of stigma in seeking care and its relation to poor illness outcomes, it is essential to address stigma among populations diagnosed and at risk of depression. Populations with depressive symptoms are nearly three times more likely to have poor health (Gazmarrarian et al., 2000). Low-cost, sustainable and preventative health education programmes are particularly useful for non-profit clinics that face time, budget and human resource constraints. Further studies are needed to replicate our findings of a tablet-based education module towards improving depression literacy and reducing stigma and to extend the investigation towards health-seeking behaviours and illness outcomes. Although limited by small sample size and the absence of randomisation, this pilot study suggests that such applications may play an important role in improving outcomes for community-based populations at risk of mental illness. Funding This research received funding support from the Dalai Llama Fellows Program.

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