Comparing the Impact on Latinos of a Depression Brochure and an Entertainment-Education Depression Fotonovela

Abstract

Objective

The purpose was to evaluate the impact of a depression fotonovela in increasing knowledge of depression symptoms and treatments and reducing stigma among Latinos.

Methods

Data were from a randomized controlled trial in which Latinos from adult schools (N=132) were assigned to receive the fotonovela or a depression brochure and were assessed on knowledge and stigma measures before and after reading the material and one month later. Random-effects linear and logistic regression models assessed changes within and between groups.

Results

No significant differences were found between groups in symptom knowledge, social distance, and perceptions of dangerousness. Gains in depression treatment knowledge were significantly greater for the fotonovela than for the depression brochure group.

Conclusions

Findings suggest that a depression fotonovela informed by an entertainment-education approach is a useful tool for improving depression treatment knowledge among Latinos but is limited in improving symptom knowledge and reducing stigma related to social distance and perceptions of dangerousness.

Mental health stigma among Latinos is fueled by fears, cultural norms that view mental illness as a sign of weakness, low health literacy, and lack of knowledge about mental illness and treatments (1). Improving knowledge and reducing stigma in the Latino community are important goals as these are persistent barriers that prevent many Latinos from seeking, using, and engaging in mental health care (1–3). Few studies have compared the effectiveness of different health communication approaches for improving mental health knowledge and reducing stigma in the Latino community. In this study, we used data from an existing randomized controlled trial (4) to compare the effectiveness between an entertainment-education depression fotonovela and a standard depression brochure in increasing knowledge of depression symptoms and treatments and reducing stigma among Latino adults.

Fotonovelas are popular health education tools that use posed photographs, captions, and soap opera narratives to engage audiences and raise awareness about health or social issues (5). We have developed a depression fotonovela written in English and Spanish entitled “Secret Feelings” that counteracts common misconceptions and stigmatizing attitudes about depression and its treatments common in Latinos (6). “Secret Feelings” achieves cultural relevance through the use of characters, language, and common expressions familiar to Latinos and by placing the plot of the soap opera within a family context (6). This fotonovela uses an entertainment-education framework that incorporates educational messages into popular entertainment media to increase knowledge, create favorable attitudes, and motivate behavioral change (7). Raising awareness and increasing knowledge are important first steps toward information-seeking and attitudes change which ultimately influences behavior. Integrating entertainment-education into health communication tools can also be an effective anti-stigma strategy as it facilitates the processing of new information and reduces counter-arguing by allowing the audience to be emotionally and cognitively involved with the new information while simultaneously challenging maladaptive social norms and attitudes (8). “Secret Feelings” uses education and vicarious contact with characters coping with mental illness, two strategies known to reduce stigma (9).

“Secret Feelings” has been shown to improve overall depression knowledge and decreases some indicators of stigma (e.g., mental health care stigma, antidepressant stigma) (4, 10). In the present study, we extend this work by examining the impact of “Secret Feelings” on different dimensions of depression knowledge and two common public stigma indicators (i.e., social distance and perceptions of dangerousness) that have not been evaluated in previous studies. Since “Secret Feelings” was designed to increase both knowledge of depression symptoms and depression treatments and reduce stigma, we hypothesize that this fotonovela will be more effective than a depression brochure in increasing both of these knowledge outcomes and in reducing the desire for social distance and perceptions that people with depression are dangerous.

Methods

The data for this study were drawn from an RCT comparing the effectiveness of “Secret Feelings” and the NIMH Depression brochure (4). Institutional review boards approved all study procedures. Study methods have been described elsewhere (4) and are briefly summarized here. The study was conducted between January and April 2011 with a convenience sample of students at three adult night schools in Los Angeles, California that offer a variety of classes to a predominantly Latino population. All students at the schools were invited to participate except those in medical education classes (e.g., medical assistants). A total of 222 students were eligible and present on the data collection day at the three schools. A 185 agreed (83%) to participate and completed pre- and post-tests. Of those, 157 (85%) completed the 1-month follow-up, but 25 were excluded (7 did not self-identify as Hispanic, 18 did not answer the ethnicity question). The analytical sample consisted of 132 participants.

Bilingual data collectors visited each class, explained the study, answered students’ questions, and obtained informed consent. Participants received a sealed envelope containing a pre-test survey, a randomly inserted depression fotonovela or brochure, and a post-test survey. Participants were directed to open their envelopes and fill out the pre-test survey without looking at the other materials. After approximately 25 minutes, the pre-test surveys were collected and participants were then given 30 minutes to read the brochure or fotonovela. After 30 minutes, participants were instructed to put the reading materials aside and were given 20 minutes to complete the post-test survey. Post-test surveys were collected, and participants were able to keep their reading materials. A month later, data collectors returned to the schools and distributed follow-up surveys in the students’ classrooms. Students who were absent at that time had an opportunity to complete the follow-up surveys during the next week’s class.

The development of the depression fotonovela is described in detail elsewhere (6). “Secret Feelings” is written at a 4^th grade reading level in English and Spanish and uses posed photographs of Latino/a actors and text bubbles to depict a soap opera story of a Latina wife and mother experiencing depression and her pathway to seeking care. The NIMH “Depression” brochure (NIH publication 08 3561) is publicly available in English and Spanish and provides basic information about depression symptoms and treatments. The brochure was chosen as the comparison condition since it is widely used, designed for low-literacy audiences, and is approximately the same length as the fotonovela (26 vs. 30 pages, respectively). Participants received the English and Spanish versions of their respective reading materials and were instructed to read the materials in their preferred language.

Surveys were available in English and Spanish. Participants’ demographics were collected at the pre-test. Knowledge, attitudinal and behavioral intention measures were assessed at all time points. For this paper, we focus on two depression knowledge measures and two common public stigma indicators. Participants were presented a list of 10 symptoms, including 5 DSM-IV symptoms of depression and 5 non-depressive symptoms, and asked to correctly identify depressive symptoms. Participants received one point for each symptom that was correctly identified. The items were summed and scores ranged from 0 to 10 with higher scores indicating higher knowledge. Depression treatment knowledge was assessed with 7 knowledge items (e.g., “antidepressants are addictive”) derived from the D-Lit Measure (11). Each item was scored as true, false or don’t know. Participants received one point for each correct answer and 0 for incorrect answers. Answers were summed and scores ranged from 0 to 7 with higher scores representing higher treatment knowledge (Cronbach’s alpha at pre = 0.50, post = 0.67, and 1 month follow-up = 0.65).

Two public stigma measures were used. Desire for social distance was assessed with three true-false items derived from previous stigma studies (12, 13) that asked participants whether they would: be friends, work closely, and marry a person who is or has been in treatment for depression. Responses to these items were reverse scored and summed so that higher scores represented more desire for social distance. Scores ranged from 0 to 3 (Cronbach’s alpha at pre = 0.58, post = 0.52, and 1 month follow-up = 0.55). The perception that people with depression are dangerous was assessed with a true-false question. Iterations of this item have been used in previous stigma studies (12, 13).

We examined whether knowledge and stigma outcomes differed between the fotonovela and brochure groups over time (pre to post to 1 month follow-up) using random-effects linear and logistic regression models. Random effects were included for person and school because participants had an observation at each of the three time points and were nested within schools. For statistically significant findings between the brochure and fotonovela groups, we calculated effect sizes using Cohen’s d. All analyses were conducted in Stata 12.0

Results

Sample characteristics are presented in Appendix 1 (see online supplemental material). There were no significant differences in demographics characteristics between the depression brochure and fotonovela groups. The average scores for the depression knowledge and stigma outcome measures are presented in Appendix 2 (see online supplemental material) stratified by groups and time periods. At baseline, there were no significant differences between the brochure and fotonovela groups on the outcome measures. Scores on the depression symptom knowledge and social distance measures were fairly consistent across the 3 time periods and between groups resulting in no significant findings. The fotonovela reduced perceptions of dangerousness (from 35% at pre to 24% at post to 28% at one month follow-up) but these reductions were not statistically significant when compared to the depression brochure.

We found significant differences across time and between groups for depression treatment knowledge (Table 1). At posttest, participants in the fotonovela group had significantly higher depression treatment knowledge scores than participants in the brochure group (B=1.22, p<.001); the scores were slightly lower but the difference remained significant at the one-month follow-up (B=.81, p<.01). Cohen’s d for these two differences were .91 at posttest and .53 at one month follow-up, suggesting large and medium effect sizes, respectively.

Table 1.

Effects of the depression fotonovela on depression knowledge and stigma outcomes

	Depression Knowledge Outcomes				Stigma Outcomes
	Depression symptomsa		Depression treatmentsb		Social Distanceb		Perceptions of Dangerousnessc
	B	SE	B	SE	B	SE	OR	95% CI
Group
Brochure	Ref		Ref		Ref		Ref
Fotonovela	0.02	0.25	0.13	0.27	−0.03	0.14	0.67	0.17–2.65
Time
Pre	Ref		Ref		Ref		Ref
Post	−0.11	0.21	1.14***	0.23	−0.6	0.09	0.89	0.33–2.43
1 month follow-up	0.02	0.21	0.92***	0.22	−0.17	0.09	1.27	0.48–3.40
Group × Time
Fotonovela × Post	0.53	0.30	1.22***	0.32	−0.08	0.13	0.37	0.08–1.59
Fotonovela × 1 month follow-up	0.02	0.30	0.81**	0.32	0.003	0.13	0.37	0.08–1.32

Notes:

^aRandom-effects linear regression model, n = 132;

^bRandom-effects linear regression model, n= 122,

^cRandom-effect logistic regression model, n = 124.

SE = standard error. All models included random effects for person and schools.

^*p < 0.05,

^**p ≤ 0.01,

^***p ≤ 0.001.

Discussion

We found partial support for our hypothesis. Although no statistically significant differences were observed between the depression brochure and fotonovela on depression symptom knowledge, social distance, and perceptions of dangerousness measures, the fotonovela produced significantly greater gains than the depression brochure in depression treatment knowledge at post and one month follow-up. Previous studies have found that “Secret Feelings” produced significant improvements in depression knowledge using a measure that combined symptom and treatment knowledge into one score (4, 10). This approach confounded two knowledge indicators that are independently linked to help-seeking behaviors and targeted by our fotonovela. Our study extends previous work and indicates that the gain in knowledge produced by our fotonovela was driven by improvements in depression treatment knowledge rather than symptom knowledge. A ceiling effect may explain why we found no significant changes in depression symptom knowledge since participants in both groups reported, on average, high levels of symptom knowledge from baseline to the 1 month follow-up period. The treatment knowledge finding is relevant for improving psychoeducation efforts in the Latino community as it suggests that communicating treatment information in this community benefits from tools that use entertainment-education approaches rather than textual approaches commonly used in health brochures. This finding is consistent with studies documenting the effectiveness of culturally-based narrative approaches in communicating health information to underserved communities (14).

We found no significant differences between the two groups on our stigma outcomes. The null finding for social distance can be partially explained by a floor effect in which both groups reported, on average, low scores in the social distance scale and sustained these scores at the post and follow-up periods. A recent meta-analysis of anti-stigma studies indicates that contact approaches, particularly direct contact versus vicarious contact (e.g., video), were more effective than educational approaches in reducing public stigma among adults (8). More intensive anti-stigma approaches that combine “Secret Feelings” with direct contact with a person recovering from a mental disorder (e.g., peer specialist) may be needed to reduce public stigma indicators in the Latino community.

Study findings should be interpreted in light of several limitations. This study used a small convenience sample, thus findings cannot be generalized to other Latino groups. Study measures focused on knowledge and attitudes, some had low Cronbach’s alphas, and included a short follow-up period. Future studies should include more reliable measures, behavioral outcomes, and a longer follow-up period. We could not rule out the possibility of contamination between groups at the one month follow-up since participants may have discussed the information they learned with each other. In fact, the fotonovela was more likely to be shared and discussed with others than the brochure (4), thus possibly reducing differences in outcomes between the two groups. Despite this potential contamination issue, we found significant gains in depression treatment knowledge suggesting that these fotonovela effects were robust.

Conclusions

The failure of health information to reach Latinos in a manner that is relevant, engaging, and appealing contributes to health and mental health disparities in this growing population (15). The use of “Secret Feelings” can help reduce this communication gap because it has a narrative-based format that is contextualized to the realities, preferences, and cultural norms of Latino audiences. The findings suggest that a depression fotonovela informed by an entertainment-education approach is a useful tool for improving depression treatment knowledge in the Latino community but is limited in improving depression symptom knowledge and reducing stigma indicators related to social distance and perceptions of dangerousness.