An exploration of perspective of knowledge, attitude and help seeking behaviour in pregnant women and their families towards psychiatric ailments in a primary health care setting in South India – A cross sectional study

Abstract

Background:

Mental illness, often linked to ignorance and superstitions, significantly impacts women’s mental health, particularly during pregnancy—marked by significant physical, emotional, and psychological changes. Prenatal mental health screening face challenges like stigma and lack of standardized protocols, while family support is essential reducing stress and enhancing well-being.

Aim:

To assess knowledge, attitude and help seeking behaviors towards mental ailments among pregnant women and their families visiting primary health centers (PHCs).

Methods:

A cross-sectional study conducted at a PHC during antenatal checkup days over 1 month recruiting pregnant women and their family members aged ≥18 years. A total of 230 participants were recruited. Data were collected using a semi-structured questionnaire and validated scales: Mental Health Knowledge Schedule (MAKS), Community Attitudes towards Mental Illness (CAMI-12 item) and Mental Help Seeking Attitudes Scale (MHSAS). Descriptive statistics, Chi-square test, Student’s t-test, one-way ANOVA, Pearson correlation, and linear regression were used. A P value < 0.05 was considered statistically significant.

Results:

Most participants lacked awareness of mental illness during pregnancy and childbirth. Higher education levels among participants correlated with better mental health knowledge. Participants with greater knowledge and positive attitudes demonstrated increased help-seeking behaviors. Positive correlations were observed between mental health knowledge, favorable attitudes, and help-seeking behaviors.

Conclusion:

Poor knowledge and unfavorable attitude toward mental illness impact help seeking behaviour, among pregnant women and their families, compromising maternal and child health. Intervention to enhance knowledge, and promoting perinatal mental health services are essential to address these gaps.

INTRODUCTION

The World Health Organization estimates that mental illness affects 25% of the global population,[1,2] with India having the prevalence rate of 10.6%.[3] This substantial burden is worsened by pervasive stigma, causing significant distress and impairments in daily functioning.[4] Negative attitude toward psychiatric illness is often due to the inaccurate information, limited contact with those with mental illness, and low awareness, particularly in developing countries like India.[5] Stigma hinders individuals from seeking essential mental health care and acknowledging issues, often perceived as signs of weakness or failure. Consequently, affected individuals encounter barriers to prevention, treatment, and rehabilitation services, reducing their overall quality of life.[6]

Among women of reproductive age, the physiological and emotional transitions during pregnancy may act as contributing factors to mental health vulnerability.[7] The World Health Organization states that 10%–16% of pregnant women and 13%–20% of postpartum women experience mental disorders.[8] Psychological disturbances during pregnancy are linked to inadequate antenatal care and the lack of routine mental health screenings, leading to adverse outcomes like low birth weight and preterm delivery. In the postpartum period, these issues can lead to emotional detachment, neglect, and hostility toward the newborn.[7]

Despite the need, routine prenatal mental health screening is limited due to barriers such as the lack of standardized protocols, stigma, and difficulty distinguishing normal emotional changes from concerning symptoms. Informed family members can provide crucial support, creating an environment where the expectant mother feels safe to express her struggles and seek help.[9] When family members understand the signs, symptoms, and impacts of mental health issues, they can offer effective support and intervention. Positive and empathetic attitudes towards mental health foster a safe space for expectant mothers to seek help, while negative attitudes can lead to stigma, isolation, and reluctance to seek care, exacerbating mental health challenges.

Supportive family dynamics, grounded in knowledge and compassion, can significantly alleviate stress and anxiety, promote adherence to medical advice, and enhance overall emotional well-being during pregnancy. This supportive environment is crucial for the mother’s mental health, leading to healthier pregnancy outcomes and better well-being for both mother and child.

Hence, this study aims to ascertain knowledge gap, attitudes towards mental illness, as well as mental help-seeking behaviors in pregnant women and their families. Addressing these challenges will enable healthcare providers to better support maternal mental health and improve outcomes for both mothers and their children.

METHODOLOGY

The present study is cross-sectional in nature. It was conducted at a primary health center (PHC) at a frequency of once a week during antenatal checkup days for 1 month (May 2024). Consecutive pregnant women and their family members visiting the PHC for antenatal checkups were recruited for the study. Participants eligible for inclusion were individuals aged over 18 who were visiting the PHC for antenatal checkups. Participants with intellectual disability were excluded from the study. Written informed consent was obtained from participants. A structured questionnaire was used to collect demographic details. Validated scales were used to collect information on knowledge, community attitude and mental help seeking attitude toward mental disorders. The Institutional ethics committee has approved the study.

Measurements

Mental Health Knowledge Schedule (MAKS): This 12-item scale assesses knowledge related to stigma towards mental illness, with each item rated on a 1–5 scale. Higher total scores indicate greater knowledge. Respondents were categorized as having good or poor knowledge based on the mean score (good knowledge defined as scores above the mean score).[10]

Community Attitude Towards Mental Illness (CAMI-12): This scale measures public stigma attitudes with 12 items on a five-point Likert scale. Negative statements were reverse scored, with higher scores indicating more stigmatizing attitudes. It includes four subscales: authoritarianism, benevolence, social restrictiveness, and community mental health ideology. Respondents were categorized as having favorable or unfavorable attitudes based on the mean score (unfavorable attitude defined as scores above the mean score).[11]

Mental Help Seeking Attitudes Scale (MHSAS): This nine-item scale measures attitudes towards seeking help from a mental health professional, with scores ranging from 9 to 63. Higher scores indicate a more positive help seeking behaviour. Respondents were categorized as having favorable or unfavorable behaviour based on the mean score (favorable behaviour defined as scores above the mean score).[12]

Statistical analysis

The data was analyzed using SPSS for Windows version 16.0 software (SPSS.INC Chicago, Il, USA). Results obtained were analyzed using mean, standard deviation, frequency, and percentage. Categorical variables were compared using the Chi-square test, while continuous data were analyzed using Student’s t-test and one-way ANOVA. Pearson correlation and linear regression were used to examine the association between knowledge, attitude and help seeking behaviors. A P value of < 0.05 was considered statistically significant.

RESULT

Of the 230 total participants in the study, 100 were pregnant women and 130 were family members. The mean age of the pregnant women was 26.16 ± 3.75 years, while that of the family members was 40.63 ± 11.11 years. Approximately 66% of pregnant women and 61% of family members had an educational level ranging from primary to higher secondary school (1^st to 12^th standard). Most participants (85%) identified as Hindu, followed by 8 to 10% identifying as Muslim with the remaining participants from other religion.

About 82% of pregnant women were homemakers by their occupation, with 8% engaged in unskilled work such as daily wage labors and the remaining 10% in semi-skilled or skilled jobs. Similarly, among the family members, 44% were homemakers, 21% held semi-skilled job and the rest were engaged in unskilled or skilled occupations. According to socio-economic status, 36% of pregnant women were from the lower class, 24% from the upper lower class and 22% from the lower middle class. Similarly, among the family members, 32% belonged to the lower class, 29% to the lower middle class, 18% to the upper lower socioeconomic status. Among the pregnant women, 38% were gravida 1, another 38% were gravida 2, 14% were gravida 3, and 10% were gravida 4 [Table 1].

Table 1.

Socio-demographic details of pregnant women and their family members

Variables	Pregnant women (n=100)	Family members (n=130)	Statistical analysis
Age (mean years)	26.16±3.75	40.63±11.11	t=8.823, P<0.001*
Education   Illiterate   Schooling (1st to 12th std)   Degree	14 (14%) 66 (66%) 20 (20%)	30 (23.07%) 80 (61.53%) 20 (15.38%)	χ2=1.65 P=0.437
Religion   Hindu   Muslim   Christian	84 (84%) 10 (10%) 6 (6%)	112 (86%) 10 (8%) 8 (6%)	χ2=0.189 P=0.909
Occupation   Housewife   Unskilled labor   Semi-skilled labor   Skilled labor	82 (82%) 8 (8%) 6 (6%) 4 (4%)	58 (44.62%) 18 (13.85%) 28 (21.53%) 26 (20%)	χ2=17.505 P=0.0005*
Socio-economic status   Upper class   Upper middle class   Lower middle class   Upper lower class   Lower class	2 (2%) 16 (16%) 22 (22%) 24 (24%) 36 (36%)	4 (3.07%) 22 (16.9%) 38 (29.23%) 24 (18.46%) 42 (32.30%)	χ2=4.83 P=0.304
Gravida   1   2   3   4	38 (38%) 38 (38%) 14 (14%) 10 (10%)

The study revealed significant differences in mean age and occupation between pregnant women and family members, with a higher proportion of pregnant women being housewives [Table 1].

An assessment of awareness regarding mental health issues among pregnant women and their family members revealed that approximately 93% of participants lacked awareness about mental health concerns related to pregnancy, childbirth, and the menstrual cycle. Furthermore, a substantial majority between 85%–90% reported that symptoms such as excessive irritability, mood swings, crying spells and bloating are common during or before menstrual cycle. Nearly 78% of pregnant women and 61% of their family members regarded feeling of sadness, anxiety, difficulties in taking care of baby and poor sleep at night lasting for more than 2 weeks after child birth as normal. However, 80% of respondents believed that experiences such as speaking irrelevantly, excessive fear, paranoia about being harmed, auditory hallucinations and neglecting infant care following child birth are not normal [Table 2].

Table 2.

Semi-structured questionnaire to assess awareness among pregnant women and their family members

Questions	Pregnant women (n=100)	Family members (n=130)	Statistical analysis
Awareness about any mental illness related to pregnancy, childbirth, menstrual cycle.   Yes   No	6 (6%) 94 (94%)	10 (7.69%) 120 (92.31%)	χ2=0.125 P=0.723
Having excessive irritability, mood swings, crying spells, bloating is common during or before menstrual cycle?   Yes   No	90 (90%) 10 (10%)	112 (86.1%) 18 (13.9%)	χ2=0.391 P=0.531
Women feeling very sad, anxious, is unable to take care of baby and has poor sleep at night lasting for more than 2 weeks immediately after child birth, do you think it is normal?   Yes   No	78 (78%) 22 (22%)	80 (61.5%) 50 (38.5%)	χ2=3.56 P=0.591
After child birth, mother is speaking irrelevantly, fearful, believes that people may harm her, hearing voices and does not take care of the baby, do you think it is normal?   Yes   No	24 (24%) 76 (76%)	22 (16.9%) 108 (83.1%)	χ2=0.88 P=0.346
Having hot flushes, feeling anxious, irritable, loss of sleep, fatigue after women stops menstruating is normal?   Yes   No	94 (94%) 6 (6%)	120 (92.3%) 10 (7.7%)	χ2=0.125 P=0.723

No significant differences were observed in mental health knowledge, community attitudes toward mental illness, or help-seeking behaviors across different age groups and socio-economic statuses, among pregnant women and their family members. However, participants with higher education levels had higher scores in mental health knowledge and help-seeking behaviors, and lower scores in community attitudes, indicating better mental health awareness and more positive attitudes toward mental illness and help-seeking [Tables 3 and 4].

Table 3.

Distribution of MAKS, CAMI-12, and MHSAS scores among pregnant women across socio-demographic variables

Variables	MAKS score	Statistical analysis	CAMI scale	Statistical analysis	MHSAS	Statistical analysis
Age (in years)   20–25   26–30   31–35	22±3.68 21.94±3.7 23.28±3.35	F=0.388 P=0.618	35.44±6.57 34.36±7.77 31.66±4.63	F=0.744 P=0.481	37.25±9.7 36.73±8.2 36.28±9.6	F=0.037 P=0.964
Education   Illiterate   Schooling   (1st to 12th Std.)   Degree	19.42±1.71 22.6±3.40 22.6±2.14	F=3.337 P=0.044*	39.57±6.17 34.18±6.44 31.6±6.55	F=3.232 P=0.048*	32.1±5.70 36.33±8.23 41.85±7.67	F=3.27 P=0.046*
Socio-economic status   Upper class   Upper middle class   Lower middle class   Upper lower class   Lower class	25±1.41 22.75±4.94 22.81±3.89 21.18±3.54 21.77±2.96	F=0.693 P=0.601	30.5±13.43 34±6.54 32.18±7.18 35.27±7.17 36.44±5.95	F=0.889 P=0.478	47±1 37.62±5.15 35.36±9.73 41.6±8.7 34.38±8.7	F=2.404 P=0.064

Table 4.

Distribution of MAKS, CAMI-12 and MHSAS scores among family members based on socio-demographic variables

Variables	MAKS score	Statistical analysis	CAMI scale	Statistical analysis	MHSAS	Statistical analysis
Age (in years)   21–35   35–50   51–65	21.67±3.7 22.8±8 20.88±2.26	F=0.646 P=0.528	33.48±6.45 35.5±6.08 34.68±7.19	F=0.594 P=0.555	42.66±11.83 38.31±13.67 40.5±12.75	F=0.71 P=0.494
Education   Illiterate   Schooling (1st to 12th std)   Degree	17.75±2.87 20.8±2.82 21.8±2.43	F=3.546 P=0.035*	41.2±5.71 34.43±5.8 32.25±5.9	F=4.38 P=0.0165*	32.87±6.23 34.43±5.89 41.2±5.71	F=3.744 P=0.029*
Socio-economic status   Upper class   Upper middle class   Lower middle class   Upper lower class   Lower class	19.5±0.7 21.27±2.79 21.14±3.11 20.15±2.73 20.5±2.93	F=0.502 P=0.734	29.5±10.6 35.27±5.84 32.95±6.52 36.25±5.86 34±6.22	F=1.080 P=0.374	52.4±11.05 37.5±9.57 36.23±12.78 44.42±11.33 39.66±13.70	F=2.495 P=0.052

In our study, Pearson correlation analyses revealed a weak positive correlation between mental health knowledge and attitudes towards mental health among pregnant women that is statistically significant (r = 0.313, P = 0.027). In contrast, family members demonstrated a weak positive correlation between these variables (r = 0.166, P = 0.185), which was not statistically significant.

Similarly, weak positive correlation was identified between attitudes towards mental health and help-seeking behaviors among pregnant women (r = 0.230, P = 0.108) and their family members (r = 0.017, P = 0.83). However, the high P value (P > 0.05) indicates that these correlations are not statistically significant.

Moreover, when examining the relationship between family members and the pregnant women, positive correlation in mental health knowledge was observed (r = 0.13, P = 0.35). Nevertheless, the high P value indicates that this relationship is not statistically significant. There was also a very weak positive correlation were also observed between their attitudes towards mental health (r = 0.096, P = 0.504) and help seeking behaviors (r = 0.16, P = 0.267), yet neither of these correlations were statistically significant.

DISCUSSION

Pregnancy is one of the happy phases for most women yet it can be a stressful life event. Pregnancy is associated with various psychological, social, emotional, and physical changes. Of late, there has been increase in reporting of mental health problems from both developing and underdeveloped countries.[13] There have been studies which have shown that mental health problems in pregnancy are associated with various complications such as preterm, low birth weight babies, increased risk of developing postpartum depression, poor mother–child bonding, and overall poor maternal outcome leading to increased maternal morbidity.[14,15] Studies on antenatal psychological well-being are on a rise in recent years.[16] It has been observed that prevalence of psychological problems in pregnancy are occurring more commonly in developing countries than developed countries.[17] This could be because of the lack of awareness about mental health problems in pregnancy, lack of mental health services, and various beliefs and cultural practices in that area.[7]

A study conducted in rural southern India revealed that 85% of mothers were unaware of mental illness, and in 97.3% of cases, treating physicians did not inquire about mental health symptoms, findings that is like our study where majority of participants are unaware of mental illness during childbirth, pregnancy, and menstrual cycle.[7]

Educational status, socioeconomic status, and access to information significantly influence knowledge and attitudes towards mental health. Higher educational attainment and socioeconomic status are associated with better mental health knowledge and more favorable attitudes. Despite these advantages, disparities persist, emphasizing the need for targeted education and awareness campaigns.[18] In our study, participants with higher level of educational status had higher scores in respective scales, indicating the importance of education and awareness in mental health outcomes. Furthermore, our data reveals similar finding among family members too where, it was found that education levels significantly impact family member’s score in the respective scales.

In Ethiopia, a study highlighted that better mental health literacy, measured by the MAKS, is linked to more supportive attitudes towards mental health care and reduced stigma.[18] Similarly in our study also, increased knowledge about mental health is associated with positive attitude towards mental health and eventually having positive help seeking behaviors.

Research consistently shows that family members, who understand mental health are less likely to stigmatize affected individuals and more supportive of seeking help. Addressing stigma is critical as it can deter individuals from seeking necessary mental health care. Study by Alsabi et al. higlights how higher mental health knowledge among family members reduces stigma and promotes professional help-seeking.[19] Moreover, strong support networks led by informed family members provide vital emotional and practical support, enhancing treatment adherence and recovery.[18] Our study showed that there is a positive correlation relationship between mental health knowledge and attitudes among the pregnant women and their family members. Improving mental health literacy among family members is associated with more positive attitudes, improved help seeking behaviors and better mental health outcomes for pregnant women.

In summary, our findings emphasize that enhancing mental health literacy can lead to more positive attitudes, among pregnant women and their families. Both the knowledge and attitudes of pregnant women and their families significantly influence their readiness to seek mental health support. Strengthening mental health literacy and improving positive attitudes are essential steps in effectively managing mental health conditions during pregnancy and beyond, despite the weak correlations observed in our study between various aspects of mental health knowledge and attitudes among pregnant women and their family members.

Limitations of our study include a small sample size and recruitment from a single PHC center, which limits the generalizability of our findings to the broader community or tertiary care settings.

CONCLUSION

There is poor awareness of mental health problems among pregnant women and their family members. The reasons for the same are lack of awareness, low levels of education, lower socioeconomic status, cultural beliefs and practices, lack of mental health services, and stigma associated with mental illness.

People with higher level of education have better mental health knowledge and awareness about mental health problems resulting in higher positive attitude and help-seeking behaviour toward mental illness as compared to those with a lower level of education. Current study emphasizes the importance of improving mental health literacy and encouraging positive attitudes, among the family members that has positive influence on pregnant women’s knowledge and attitude.

Enhancement of mental health literacy during pregnancy or postpartum can be achieved by increasing the education through adult learning methods such as awareness videos, flip chart images, brochures, and so on. This may aid the frontline health professionals in routine screening during perinatal period.

The future research focusing on larger, more diverse samples representing various socioeconomic groups, rural, urban, and tribal populations to enhance generalizability. Comparative research between nuclear and joint families, as well as rural versus urban settings, can offer insights into context-specific factors influencing mental health. Longitudinal studies can assess the sustained impact of awareness interventions over time. Additionally, evaluating the effectiveness of adult learning methods—such as group sessions, visual aids, and community engagement—in improving mental health knowledge and attitudes is recommended. Exploring digital tools and involving male family members may further strengthen future intervention strategies.

Declaration

The author(s) attest that there was no use of generative artificial intelligence (AI) technology in the generation of text, figures, or other informational content of this manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.