Introduction

Research has reported immigrants to have lower depression literacy (depression knowledge) and different conceptualisations of what constitutes depressive symptoms and appropriate treatment compared to their Australian counterparts [1–3], signifying that national depression promotion campaigns in Australia such as Beyondblue may not have effectively reached immigrant populations.

It has been suggested that one of the detrimental effects of lower depression literacy has been the associated stigma of depression. Both self stigma (personal attitudes towards depression) and perceived stigma (attitude of others) relating to depression have been found to be mediated by one’s cultural background [1, 2, 4]. Immigrants are often used to dealing with severe psychosocial stressors and experiences and therefore depressive symptoms may be interpreted as being part of everyday life experiences and not an indicator of mental health problems. Seeking help for depressive symptoms may be viewed as a sign of personal weakness rather than an appropriate course of action of a medical condition [1, 5]. Several researchers have suggested that such conceptualisations are the result of not viewing the disorder as being caused by biological factors but as being in the individual’s control or governed by supernatural forces [6]. Furthermore, given that dignity, respect and intergroup acceptance and status are highly valued in many collectivistic groups, depression and mental health disclosure are not in line with these values and are perceived as being highly detrimental to the individual [7, 8].

Immigrants from former Yugoslavia (FY), including regions of Bosnia and Herzegovina, Croatia and Serbia, have been neglected from the majority of mental health research in the Australian context. No study to our knowledge has assessed mental health knowledge and attitudes in this immigrant group. This is of a great concern as immigrants from FY make up a substantial proportion of the Australian population (92,000) [9]. Moreover, given their turbulent migration history, marked by wars and tensions, this immigrant population is placed at a higher risk of developing mental health problems [10–12]. Studies of other immigrant groups in Australia have found that mid to older aged immigrants are more susceptible to depression and least likely to seek appropriate help [7]. Furthermore, the majority of first generation immigrants from the FY living in Victoria are over the age of 45. Hence, the current project aims to examine level of depression literacy and depression related stigma in adult immigrants from the FY and compare these with their Anglo-Australian counterparts.

Method

Participants

The community sample comprised of 54 immigrants born in the FY and 54 AA born participants living in Melbourne, Victoria. For the FY immigrant sample, 19 were male and 35 were female with a mean age of 57.61 years (SD = 8.90). For the AA sample, 14 were male and 40 were female with a mean age of 60.41 years (SD = 8.90). There was no difference in age between the two groups, t (106) = −1.60, P < .11. The average length of stay in Australia for immigrants from FY was 18.98 years (SD = 12.09). The participants from FY were recruited through various ethno specific social clubs in Melbourne. Similarly, the AA sample was recruited through various social clubs. Eligibility criteria for the immigrants from FY included being 45 years of age and over and being born in one of the three former-Yugoslavian countries which included Croatia, Serbia and Bosnia and Herzegovina. For the AA sample, eligibility criteria included being born in Australia and being of an Anglo-Celtic background.

Measures

For the immigrants from the FY, all surveys were translated from English to Serbian/Croatian by an accredited translator using the back translation method. All item translations were then reviewed by the first author who is bilingual and a bilingual psychologist to ensure accuracy of the translations.

Socio-Demographic Variables

Demographic variables collected included measures of age, gender, country of birth, marital status, education level and current occupation. For the immigrant group year of arrival to Australia, reason for migration and English language proficiency were also collected.

Depression Literacy

Depression Literacy was assessed using the D-Lit scale [13] which is a 21-item questionnaire of depression knowledge using a true/false response scale. The scale assessed general information regarding depression including common symptoms and evidence-based questions relating to medical, psychological and alternative lifestyle treatments for depression. Higher scores indicated greater depression literacy. The internal reliability for the former Yugoslavian sample in the current study indicated an α coefficient of .60 and .61 for the Anglo-Australian sample.

Depression Stigma

Stigmatising attitudes toward depression was measured using the 18-item Depression Stigma Scale (DSS) [14]. The current study employed the vignette version of the scale. Participants were presented with a vignette describing a 30 year old person (Mary) with depressive symptoms satisfying the DSM IV criteria for depression at a minimal or moderate level of severity in order to assess attitudes toward early stages of the disorder. The first 9 items on the scale assessed the respondent’s personal attitudes towards Mary (Personal stigma), and the remaining 9 items on the scale assessed other people’s attitude towards Mary (Perceived stigma).

Overall Cronbach’s alpha values for the total, personal and perceived depression stigma scales were .78, .76 and .82 respectively and the correlation between the personal and perceived scale was .10 [13]. For the former Yugoslavian immigrant sample, Cronbach’s α values for the Total, Personal and Perceived stigma were .80, .75 and .71 respectively. For the Anglo Australian sample, Cronbach’s α values for the Total, Personal and Perceived stigma scales were .81, .91 and .72.

Level of Acculturation

Level of acculturation for the immigrant group was assessed using the 25-item Language, Identity and Behaviour (LIB) Acculturation scale for both the Australian and Slavic culture [15]. The LIB scale consisted of a 9-item Language subscale, 9-item Behaviour subscale and a 7-item Identity subscale assessing both the Australian and Slavic cultures. Each item on the 25-item LIB measure was assessed on a 4-point Likert scale (ranging from 1 = not at all to 4 = very much), with higher scores indicating greater acculturation to the particular culture. The total sum of the three subscale scores produced the Total Score of Acculturation for the two cultures ranging from 25 to 100.

The internal reliability for the former Yugoslavian sample in the current study indicated an α coefficient of .98 for the English Language subscale of the LIB, an α coefficient of .96 for the Australian Identity subscale of the LIB, an α coefficient of .86 for Australian Behaviour subscale on the LIB. The α coefficient for the Yugoslavian Identity subscale of the LIB was .96 and an α coefficient of .79 for Australian Behaviour subscale on the LIB.

Data Collection

The Monash University Committee on Ethics in Research Involving Humans granted approval for the study. The researcher explained the purpose of the study during a presentation at various social clubs and at the conclusion of the presentation the audience members were invited to participate.

A written explanatory statement was provided to the participants and written informed consent was obtained before proceeding with the interview. The questionnaires were administered to the participants in a face to face format. All participants chose to have the survey administered in the Slavic language. Testing was conducted in a quiet and convenient location and was conducted by the first author who is fluent in both English and the Slavic languages.

Results

Differences between the two groups on a variety of demographic characteristics are summarised in Table 1.

Table 1 Demographic characteristic of respondents
Full size table

Overall there were no differences between the two groups for marital status and gender. Differences were observed in level of education.

Comparison of Depression Literacy, and Self and Perceived Stigma Between the Two Groups

One-way analyses of variance were conducted to compare the scores on the Depression Literacy, Personal Stigma and Perceived Stigma between the two groups. Table 2 reports the means, standard deviations and F values for comparison of dependent measures between the two cultural groups.

Table 2 Means, standard deviations and F values for depression literacy, personal stigma and perceived stigma between the two birth groups
Full size table

As shown in Table 2, immigrants from FY scored significantly higher on personal and perceived stigma, and lower on depression literacy score in comparison to the AA sample.

Recognition of Depression Symptoms Between the Groups

Explanations of the symptoms presented in the vignette are presented in Table 3.

Table 3 Causes of symptoms depicted in the depression vignette as perceived by respondents
Full size table

As can be seen in Table 3 majority of immigrants from former Yugoslavia stated that the symptoms depicted in the vignette were caused by stress. This was in contrast to the Anglo-Australian sample, the majority whom correctly reported that the symptoms presented were caused by depression.

Adjusted Comparisons Between the Groups

Controlling for education level, the AA group still scored significantly higher on depression literacy than the group from FY, F (1, 103) = 41.87, P < .001, partial η 2 = .29. Personal stigma scores amongst immigrants from FY were significantly higher, F (1, 103) = 37.50, P < .001, partial η 2 = .27, as well as perceived stigma scores, F (1, 103) = 5.56, P < .05, partial η 2 = .05, compared to the AA group.

Relationship Between Level of Acculturation and Depression Literacy and Personal and Perceived Stigma

A Spearman rank order correlation was employed to assess the relationship between levels of acculturation and various dependent measures including depression literacy and personal and perceived stigma. Table 4 reports the correlations between acculturation measures (Language, Identity and Behaviour and Total Acculturation), Depression Literacy, Personal Stigma and Perceived Stigma.

Table 4 Summary of intercorrelations between acculturation scores, depression literacy and personal stigma and perceived stigma
Full size table

Cultural affiliation was significantly correlated with the dependent measures. As seen in Table 4, there was a positive correlation between depression literacy and total Australian acculturation and both the Australian language and identity subscales of the Acculturation measure. Self stigma was positively correlated with the Total Yugoslavian Acculturation Score as well as the Yugoslavian Identity and Behaviour subscales of the Acculturation measure.

Discussion

The lower depression literacy in immigrants from FY is consistent with previous research which has found similar results in other immigrant groups living in Australia [7] and also suggests that health promotion campaigns targeting depression such as Beyondblue may not have reached immigrant communities in Australia. The inability of immigrants from FY to recognise depressive symptoms depicted in the vignette, in comparison to their AA counterparts, could partly explain why these immigrants may present at a much later stage of their disorder when symptoms become more severe and treatment becomes more difficult [16]. These immigrants also displayed limited English proficiency (and low literacy levels in their first language) which may also make it more difficult for them to access and understand the available depression information.

The finding that level of self stigma was significantly higher in the participants from FY compared to AA participants is consistent with previous research which has found higher stigmatising attitudes amongst people from culturally diverse backgrounds [17]. Relatedly there was a negative association between depression literacy and self stigma which suggests that inaccurate beliefs about depression are related to higher self stigma in participants from FY [6]. Furthermore, the positive association between self stigma and Yugoslavian Identity, Behaviour and Total Acculturation scores also provide support for the influence of cultural values and beliefs on levels of self stigma.

Similarly, higher perceived stigma levels were found in participants from the FY compared to the AA group which is consistent with previous research [17, 18]. The positive association between perceived stigma and the Yugoslavian Identification subscale score on the Acculturation measure also provides support for the role of cultural influences upon perceived stigma levels in the participants from FY. Given the known importance of group identification in collectivist groups such as those from FY [8], mental illness disclosure could be perceived to be more threatening in these groups due to the importance of maintaining friendships and networks with one’s own community for cultural maintenance and financial and social support [7]. Hence, perceived stigma may be more prevalent in those from FY due to the increased likelihood of in group transmission of having a mental illness.

Limitations

Several limitations could impact on generalisation of the research findings including the small sample sizes, overrepresentation of female participants, and that the selection of participants in contact with social clubs and community centres may not be representative of those from the FY living in Australia. This gives rise to the possibility that the current study may have underestimated the true levels of depression literacy and stigma in the cohort from FY as those who attend these clubs were more willing to undertake an interview relating to their knowledge and attitudes about depression. The current study also used translated versions of questionnaires which were originally designed and implemented in English. Therefore, the constructs being measured might not have been “equivalent” between the two groups. Also, face- to-face interviews may have increased the desire for participants to present a more favourable attitude regarding sensitive issues such as depression stigma and depression literacy.

Future Research

Future studies need to verify the current results in other immigrant communities and in those immigrants who have depression. In addition research also needs to examine the mediating role of personal contact on individual’s level of depression literacy and depression related stigma.

New Contribution to the Literature

The current study found lower depression literacy and higher perceived and personal stigma levels in immigrants from the FY compared to AAs. The current results suggest that culture strongly influences attitudes and awareness of depression.