By Richard Trembath
‘What sort of people live about here?’
‘In that direction’, the Cat said, waving its right paw round, ‘lives a Hatter: and in that direction’, waving the other paw, ‘lives a March Hare. Visit either you like: they’re both mad.’
‘But I don’t want to go among mad people’, Alice remarked.
‘Oh, you can’t help that’, said the Cat: ‘we’re all mad here. I’m mad. You’re mad.’[i]
In my previous essay for Australian Policy and History I argued that there was plenty of it about. Mental illness, that is. I examined both the increased provision of psychological services, broadly interpreted, in Australia over recent decades, and the increased recourse to such services. And, of course, there was also the apparent rise in demand for mental health treatment spurred by the COVID pandemic.[ii]
Here, I shall discuss the concept of mental health literacy, which has attracted considerable attention in the past twenty-five years amongst those concerned with reducing the burden of health disability in Australia. Outside that circle it is less well known if the results of a recent survey I conducted can be trusted. Admittedly, the group I surveyed consisted of a few of my friends and family – tertiary educated for the most part – but, overall, their ignorance of what mental health literacy might be was profound. This article will, I hope, establish the significance, or potential significance of enhanced mental health literacy in preventing the occurrence of full-blown psychological disorders with their attendant social and economic consequences.
By way of preface, I would say that ‘literacy’ has become the go-to word if you are looking to give a new concept some heft and credibility. There is the parent – literacy literacy – the one to do with reading and writing skills. There is health literacy which one could argue is the set containing the subset dealing with mental health. There is science literacy as illustrated recently by National Science Week being conducted in Australia. The ubiquitous Karl Kruzselnicki argued then that science literacy was vital as ‘science is a way to not get fooled, so [people] don’t get tricked into lies about Covid vaccines, or flat Earth, or climate change’.[iii] And, I recently discovered, there is death literacy. It was held that ‘being able to talk about death, dying and loss is an important aspect of what psychologists and palliative care specialists refer to as “death literacy” ’, as is the ability to ‘make informed choices about end-of-life and death care options.’[iv] As an aside, I think that ‘literacy’ is semantically an inappropriate term in all these contexts, but for the time being we are stuck with it and it gives off a sort of buzz, I suppose.[v]
Let us have some Australian definitions of ‘health literacy’. The first comes from a Federal government agency in 2014.
Individual health literacy is the skills, knowledge, motivation and capacity of a person to gain access to, understand, appraise and apply information to make effective decisions about health and health care, and take appropriate action
Health literacy environment is the infrastructure, policies, processes, materials, people and relationships that make up the healthcare system and affect the way that people gain access to, understand, appraise and apply health-related information and services.[vi]
I may be carping again, but this, and similar government and academic pronouncements on the subject, smack of the focus group and corporate lingo with unnecessary wording prevalent. A more specific, and better written, statement comes from the Australian Medical Association:
Health literacy is a concept that covers a number of knowledge areas. In part, health literacy refers to how well people understand and enact healthy behaviours – for example, healthy foods and appropriate nutrition; exercise; the effects of substances like alcohol, tobacco, and illicit drugs; sun safety, personal hygiene; and sexual behaviours. It may also refer to how much individuals know about health conditions – whether they can understand and identify symptoms of common illness, manage ongoing health conditions like diabetes or asthma, or recognise and appreciate differences in mental ill-health.[vii]
And, of course, to be able to make their way successfully through that parallel universe, the Australian health system.
Early reports of the extent of the health literacy gap in Australia were alarming. Prior to 2018 measurement of health literacy in Australia was largely based on the 2006 Adult Literacy and Health and Life Skills Survey. This stated, ‘that only 40 % of adults can understand and follow health messages in the way in which they are usually represented’.[viii] And, therefore, it was argued, those who have insufficient health literacy tend to have poorer health outcomes. If ‘health illiteracy’ were a permissible term, and not seen as pejorative, then this would have meant that 60% of Australians were health illiterate.[ix] This seems counter-intuitive. What could produce such a result? A complete failure of this country’s educational systems, dodgy statistics and improper modelling, setting the bar for health literacy too high? When questionnaires are THE research instrument there are often major difficulties in reaching statistical conclusions with substantive merit. Inherent problems with survey design and self-reporting include choice of factors to investigate, wording of questions, options in answering – the list is extensive. Different surveys will use different determinants, making comparisons problematic, at times impossible. This is definitely true of health literacy research. As the Australian Institute of Health and Welfare stated in July this year:
[The] ability to measure health literacy is hampered by the broad range of definitions, a lack of consensus on what to measure, and the multiple approaches to measuring it. This makes it difficult to provide comparable reporting on health literacy over time.[x]
The 2018 Health Literacy Questionnaire [HLQ], conducted by the Australian Bureau of Statistics, as part of the National Health Survey, was more nuanced.[xi] The HLQ took ‘a more wholistic approach’, that is, its survey covered a wider range of topics. 91 % of respondents agreed or strongly agreed that ‘they could actively manage their health’. But only 26% of respondents reported that ‘they always found it easy to navigate the healthcare system, with younger people more likely to find it difficult than older people.’ One advantage, one of the few, in getting older. If you didn’t know you were in your sixties, then the myriad of health practitioners you are consulting then could inform you.[xii]
Now I finally get around to mental health literacy. In this section of the article, I shall refer to the work of Professor Tony Jorm, not only because he is an Australian expert in this field, but also because he introduced me to this subject – an honour he almost certainly does not remember.[xiii] Jorm and others argue that, while provision of mental health services has increased in Australia, there has been little reduction in the incidence of such illnesses. This, of course, entails a high level of suffering and poor life outcomes for those affected, while families, friends and the wider community are subject to adverse circumstances. Further, the social consequences of mental health problems include significant economic costs for Australia as a whole. It is proposed then that more attention be given to warding off these disorders by early intervention in several forms, these programs forming a mental health National Prevention Strategy. This could focus on the following areas:
- prevention in families
- prevention in schools
- prevention in workplaces
- prevention in whole of population.[xiv]
The techniques used to implement these objectives vary from information sharing, awareness programs, educational activities and cognitive based therapy where appropriate. In aiming to strike early in order to prevent the rise of full-blown illness, the prevention strategies partly resemble the much publicised, and sometimes controversial, initiatives of Patrick McGorry in early intervention in cases of psychosis where the latter may also involve the prescription of anti-psychotic drugs to teenagers. The mental health strategies I have summarised in the above bullet points are more educational, than psychiatric.
Are there actual or potential problems with the proposed preventative measures suggested by Jorm and others? I am not competent to assess that question except to comment on the school side of things and a couple of other points. There is an issue with jamming more into an already overcrowded school curriculum. I call this the Maddie O’Callaghan syndrome as a small tribute to the Australian swimming champion. In an interview after her 100 metre freestyle triumph at Birmingham, ‘she spent a minute trying to cram an assortment of trinkets into a tiny bag in a moment of impromptu physical comedy, each new addition prompting another to tumble back onto the floor’.[xv] There were would be very few school teachers in Australia, primary or secondary, private or public system, who would not wince at the thought of yet another non-curriculum program being inserted into a day, a week, or term – none of which can be extended. COVID gave teachers rare accolades. Instead of being blamed for perceived deficiencies in educating children, they were lauded – briefly- for their hard work in maintaining some semblance of teaching during lockdown, isolation and remote learning. Now that many people pretend that COVID has vanished like the morning dew, the media, especially its right-wing component, is returning to its critique of schools, notably in the government sector, blaming them for weaknesses in STEM subjects, especially mathematics, failure to teach English adequately, and, of course, bias in teaching history. Incorporation of health literacy programs of any sort may be beneficial, but something would have to yield its place. Sport perhaps? Then schools could be blamed for unfit or obese children.
I tentatively raise another concern. In my previous article I briefly referred to Gail Bell’s striking Quarterly Essay, ‘The Worried Well’. I have some reservations with this work. But we must consider her argument that the notion of depression has since the 1970s expanded greatly in Western societies to include not only melancholia with no apparent cause, but also ‘[s]adness or “normal” depression’ which was once seen as ‘a universal human response. A response to grief, to mourning, to loss, to relationship disaster. These were not considered ‘psychopathologic, unless they persisted beyond accepted time limits.’ Only then were you clinically depressed. If, and I am so cautious here, we familiarise the young with the application of medical labels for their states of mind, are we running the risk of categorising them too quickly as depressed, ADHD, or ‘on the spectrum?’[xvi] Or am I falling into the same trap as those doughty conservatives who consider that running sex education programs in schools entails promiscuity, sexual license, the end of civilisation?
A final comment is that provision of mental health services may well have increased in say the last twenty years in Australia. Yet, and I risk repeating myself here, there are still major holes in this welfare blanket. Outside the major cities which dominate this country, distance and lack of providers make access difficult in regions and remote areas of the continent. The poor miss out, Indigenous Australians miss out, those without higher education miss out, and the mentally ill miss out. This is due to class divisions as much as mental health literacy. More so. But the dreaded C word, is like COVID these days, better not spoken about in polite company.[xvii]
‘I am no Doctor’, I replied. ‘Do I look so like one? Or what makes you think it?’
She pointed to the book I had been reading, which was so lying that its title, Diseases of the Heart, was plainly visible.
‘One needn’t be a Doctor’, I said, ‘to take an interest in medical books. There’s another class of readers, who are yet more deeply interested’
‘You mean the Patients”, she interrupted . . . [xviii]
I left the prefatory quote from Lewis Carroll unexplained. It is almost mandatory to mention the Cheshire’s cat conversation with Alice when discussing mental health. The extract from Carroll’s much less familiar Sylvie and Bruno needs some comment though. I chose it because, yes, it is important that those outside the medical profession know what terms mean, what treatments involve, how the multiple layers of our unnecessarily complicated health system work. Health literacy is vital; specific mental health literacy programs are significant. Has mental health literacy improved in Australia over say the last twenty-five years? It is hard to tell. School programs are now in progress aimed at raising awareness of mental health issues and reducing stigma.[xix] It may be too early to assess their effectiveness. Support organisations such as Beyond Blue and SANE Australia are active and at times attract wide public attention. Yet my provisional opinion is that it is still early days for assessment of progress and that progress might be small at this stage. Perhaps, what is more important, or at least as important, is reducing social disadvantage and eliminating the divide between a starved government education system and a cossetted private one. Once people are equally literate then they might be equally mentally health literate.
[i] Lewis Carroll, Alice’s Adventures in Wonderland (1865).
[ii] Richard Trembath, ‘Stricken Deer: Psychology and Counselling in Contemporary Australia’, Australian Policy and History, 12 April, 2022.
[iii] Natasha May, ‘ “Not some weird elitist class”: the scientists bringing an urgent message to the streets of Hobart’, Guardian Australia, 20 August 2022, https://www.theguardian.com/science/2022/aug20/not-some-weird-elitist-class-the-scientits-bringing-an-urgent-message-to-the-streets-of-hobart, accessed 24 August 2022.
[iv] Lisa Graham-Wisener, ‘Death Literacy: why it’s important to talk about dying’, The Conversation, 29 June 2022, https://theconversation.com/death-literacy-why-its-important-to-talk-about-dying-184087, accessed 14 August 2022.
[v] An emphasis on advancing science numeracy, or just numeracy per se, is, in my opinion, crucial people to greater understanding of mathematical concepts such as probability, assessment of evidence etc. But I digress.
[vi] Australian Commission on Safety and Quality in Health Care, ‘Health Literacy’, https://www.safetyandquality.gov.au/standards/nsqs-standards/partnering-consumers-standard/health-literacy, accessed 6 July 2022. See also ‘What is health literacy’, at https:www.ncbi.alm.nih.gov and ‘A systematic review and integration of definitions and models’ at https:bcmipublichealth.biomedcentral.com
[vii] Australian Medical Association, ‘AMA Position Statement – Health Literacy -2021’, https://www.ama.com.au/articles/health-literacy-2021
[viii] Australian Commission on Safety and Quality in Health Care, ‘Health Literacy’.
[ix] I am assuming ‘health illiteracy’ is regarded as pejorative. I have not actually seen such a statement in the literature though I may have missed something.
[x] Australian Institute of Health and Welfare, ‘Health Literacy’, https://www.aihw.gov.au/reports/australias-health/health-literacy, accessed 14 July 2022
[xi] Australian Bureau of Statistics, ‘National Health Survey: Health Literacy’, 2018, https:////www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-health-literacy/latest-release, accessed 14 July 2022.
[xii] Australian Medical Association, ‘AMA Position Statement – Health Literacy- 2021’.
[xiii] If readers of APH wish to consult relevant literature on mental health literacy they can contact me via the editors and I can provide ample references.
[xiv] This paragraph is based in part on lectures given by Tony Jorm to students of Living Longer, a course I co-ordinated at the University of Melbourne. The lecture title in 2016 was ‘Why Hasn’t the Mental Health of Australians Improved? The Need for a National Prevention Strategy.’
[xv] Sydney Morning Herald, 3 August 2022.
[xvi] Gail Bell, ‘The Worried Well: The Depression Epidemic and the Medicalisation of our Sorrows’, Quarterly Essay 18 (2005), Schwartz Publishing, Melbourne. I have not provided page numbers in this endnote due to the significant difference in the pagination between the printed version and my pdf.
[xvii]Here, I would refer readers of APH to Sarah Krasnostein,’ Not Waving, Drowning: Mental Illness and Vulnerability in Australia’, Quarterly Essay 85, March 2022, Schwartz Publishing, Melbourne. A marvellous piece of work.
[xviii] Lewis Carroll, Sylvie and Bruno (1889).
[xix] And reduction of stigma about mental illness is related to the preventative aspect of literacy programs but is not the same thing.