Original Article

Enabling mothers through improving mental health literacy and parenting skills

Introduction

The preservation of mental well-being and the prevention of mental disorders stand as primary objectives in public health,¹ particularly at the community level. Mental health literacy (MHL) assumes a pivotal role in advancing individuals’ mental health status.^2,3 Substantial evidence supports the notion that augmenting MHL serves as an effective strategy for mental health improvement and prevention.⁴ Conversely, studies highlight that a deficiency in MHL correlates with mental disorders and delays in seeking psychological assistance.^5,6

MHL encompasses individuals’ knowledge regarding specific mental disorders, contributing to prevention or management of such conditions.⁷ Parents play a crucial role in recognizing their children’s problems and promoting help-seeking behaviors.⁸ To effectively assist children with mental health problems, parents must possess adequate MHL.⁷ Several studies reveal that parental MHL tends to be generally lower.⁹ Insufficient knowledge about the causes, symptoms,^10,11 and treatments¹² of mental health problems poses challenges in recognizing such issues in their children.^13,14 A systematic review suggests that despite parents’ potential to identify their children’s mental health problems, the lack of parental MHL could be a target for future research and interventions.¹⁵ Additionally, studies support the idea that mothers play a more significant role in children’s mental health.^16,17 Mothers, especially in younger adolescents’ development, wield considerable influence, particularly among daughters.¹⁸ Consequently, maternal health literacy empowers women to address factors affecting outcomes for both mothers and children.^19,20

Moreover, parents, as integral components of the home environment, exert direct and indirect influence on their children’s outcomes through their parenting styles.²¹ Parenting styles are critical social and environmental factors shaping children and adolescents’ development.¹² These styles are pivotal and modifiable factors contributing to adolescent mental health.^22,23 Authoritatively raised children tend to exhibit independence, self-confidence, and emotional stability more frequently.^24,25 They also demonstrate enhanced performance, superior social skills, and more effective coping strategies in school compared to children raised with other parenting styles.^26,27 Reports suggest that mothers have a more substantial impact on their children’s mental well-being than fathers,²⁸ spending more than twice as much time with their children.²⁹

Consequently, health institutions^4,30 advocate for comprehensive, integrated, and evidence-based programs to detect and enhance the mental health of young people, particularly in settings such as schools.³¹ They acknowledge educational centers as ideal environments for promoting health and emotional well-being.^31,32 To the best of our knowledge, this study represents the first attempt to evaluate the effectiveness of a Mental Health Literacy & Parenting Styles program in Iran. Furthermore, we assessed MHL programs of varying durations, with the primary aim of determining whether the intervention has a short-term (post-intervention) and long-term (8-week follow-up) impact on increasing MHL and parenting skills among mothers.

Materials and Methods

Study design and participants

This quasi-experimental study with a control group was conducted among mothers of female high school students in grades eight and nine in Tabriz, Iran, spanning from September to December 2020. Within the five educational districts of Tabriz, one district with five sub-districts was randomly chosen. Subsequently, two high schools with similar educational and environmental characteristics were randomly selected within the chosen sub-district, designating them as the intervention and control groups. Upon coordination with the Education organization, mothers of all 8th and 9th graders (n = 130) were invited to participate, with 126 meeting the inclusion criteria (126 in the intervention and 126 in the control groups). The inclusion criteria comprised mothers with daughters in eighth and ninth grades, along with their consent to participate. Exclusion criteria included having a university education in psychology, medicine, or nursing, severe psychological disorders under psychiatric treatment (such as schizophrenia, delusional disorders, depression, and bipolar disorders), illiteracy, and the unwillingness of mothers to continue cooperation.

The study unfolded in two stages. In the initial stage, all mothers in both the intervention and control groups were evaluated for the study’s main variables. The second stage, guided by the pretest data analysis, employed CDC guidelines for improving health literacy³³ and implemented the Parent Information Network (PIN) strategy. The program spanned three months, and assessments were conducted at three points in time (pre-intervention, one-week post-intervention, and eight weeks’ post-intervention). Participants who did not consistently attend at least 80% of the sessions were excluded from the post-test data collection and follow-up. The intervention program was explained to all participants, emphasizing the study’s purpose and ensuring the confidentiality of their information. The control group did not receive any educational intervention.

Intervention

The intervention comprised a comprehensive training program delivered over seven two-hour sessions, held twice per week. Educational materials were tailored based on information gathered during the pre-test stage, focusing on children’s mental health problems, parental dissatisfaction, and communication issues within families. The intervention program encompassed active mother participation, the establishment and enhancement of communication networks, provision of informational resources to empower mothers in promoting their children’s mental health, development of effective parenting skills, and enhancement of maternal MHL. Sessions were conducted collaboratively by one of the researchers and a psychologist. Table 1 outlines the key topics covered in each session. Educational methods included lectures, question-and-answer sessions, and PowerPoint presentations aligned with each session’s content.

Instruments

Demographics

Demographic data encompassed details such as the mother’s occupation, literacy level, number of family members, and a record of visits to a psychiatrist.

Mental health literacy

To assess the MHL of participants, the Persian version of the Mental Health Literacy Scale (P-MHLS) was employed. The P-MHLS is a self-reported tool, featuring 30 items rated on a 4-point (1–4) or a 5-point (1–5) Likert-type scale. The total score’s theoretical range is 30 to 137, with higher scores indicative of elevated levels of MHL.³⁴

Parenting Style-Four Factor Questionnaire

The Parenting Style-Four Factor Questionnaire (PS-FFQ)³⁵ is a self-reported tool comprising 32 items rated on a 5-point Likert scale ranging from 1 to 5. The theoretical range for the total score is 32 to 160, with higher scores indicating elevated levels of each parenting style.³⁶

Statistical Methods

Prespecified statistical analyses were conducted using IBM SPSS Statistics, version 27.0.³⁷ Analytical techniques included the chi-square test of independence, independent samples t-test, analysis of covariance (ANCOVA), one-way analysis of variance (ANOVA), and repeated measure ANOVA. The level of significance was predetermined at 0.05.

Results

Initially, there was no statistically significant difference between the intervention and control groups concerning demographic and MHL score variables, except for job status. In all pretest group differences analyses, none were statistically significant, as anticipated due to the random assignment of participants, confirming pre-experimental equivalence. Results are summarized in Table 2.

Group differences based on total MHL, the domains of MHL, and parenting style (authoritative, authoritarian, permissive, and uninvolved) are outlined in Table 3.

As depicted in Table 3, the MHL intervention program significantly enhanced the total mean MHL score and its relevant domains, including the ability to recognize mental disorders, confidentiality of mental health practitioners, skills in seeking mental health information, beliefs about mental illnesses, and attitudes toward patients with mental illness after one week (P < 0.001). These improvements were sustained after eight weeks (P < 0.001) in the intervention group. All group differences were statistically significant, favoring the intervention group.

Furthermore, our results in Table 4 reveal that the parenting skills development program, in conjunction with the MHL improvement initiative, contributed to enhanced parenting skills favoring the authoritative parenting style within the intervention group. Consequently, the scores for authoritarian, permissive, and uninvolved parenting styles shifted towards the authoritative parenting style, and all group differences were statistically significant (P < 0.001).

Moreover, repeated measures ANOVA demonstrated statistically significant intra-group differences within the intervention group, indicating a notable time effect (P < 0.05). Specifically, the findings showed significant improvements that were sustained after one week and eight weeks, as compared to the pre-intervention phase.

Discussion

The primary achievement of this study lies in the significant improvement observed in the MHL of mothers, acknowledging their crucial role in the well-being of their children, as reported by Simkiss et al³⁸ Recognizing the strengths and weaknesses of parents’ MHL and its impact on their children’s mental health status provides valuable insights for mental health professionals aiming to design community-level interventions.³⁹ Limited studies have assessed the effects of MHL programs on parents’ skills concerning mental health issues.⁴⁰ The existing research suggests that parental MHL is generally lacking and requires enhancement.⁹ Parents often lack sufficient knowledge about the causes and symptoms of mental disorders in children.⁴¹ Moreover, investigations into MHL in low and middle-income countries indicate that MHL improvement programs and mental health promotion for children and youth are not prioritized in many health systems.⁴² However, evidence suggests that increasing MHL serves as an effective tool for mental health improvement and prevention.⁴ Children and young people consistently express a desire for more information and support regarding mental health.⁴³ Systematic reviews emphasize the crucial role of parental support in acquiring MHL.⁴⁴ Thus, the implementation of MHL promotion programs among mothers becomes imperative.

Our findings also reveal an improvement in parenting style, specifically towards the authoritative parenting style, aligning with previous studies.⁴⁵ Prior research indicates that parenting styles are linked to adolescents’ prosocial behavior ⁴⁶ and play a crucial role in children’s socialization and the mother–child relationship,⁴⁷ parenting programs promoting parental competency in healthy lifestyles have shown promising results for enhancing parenting styles.⁴⁸ While parenting is ideally a shared responsibility between both parents, not all fathers may have sufficient time to contribute to childcare, leaving much of the responsibility on mothers. Young mothers, particularly those with low education levels, may face challenges in providing adequate support for their children’s growth and development.^49,50 The low education level of mothers is often associated with a lower socioeconomic status.⁵¹ Addressing these challenges requires special attention and support in the form of affordable and easily accessible care services. Consequently, planners and policymakers should consider designing and implementing programs to promote MHL and parenting skills among mothers.

Strengths and limitations

This study boasts several strengths, including the evaluation of results over two different periods (one week and 8 weeks after the intervention) and the use of comprehensive statistical tests to assess changes. However, limitations include the study’s setting in a large city, potentially limiting generalizability. Additionally, the sampling method focused solely on mothers, suggesting the need for future studies encompassing both parents.

Conclusion

The findings of this study underscore the impact of MHL and parenting styles programs on children’s mental health, emphasizing the pivotal role of mothers in their daughters’ health status. Implementing such programs among mothers is deemed essential for enhancing MHL and contributing to the stability of school-age children’s mental well-being. Policymakers and healthcare providers should prioritize and implement these programs for parents within the school setting to foster a supportive environment for children’s mental health.

Competing Interests

Hamid Alahverdipour and Mohammad Asgharijafarabadi are the advisory boards of the Biosocial Health Journal. Other authors declare that they have no competing interests.

Ethical Approval

The study adhered to ethical standards outlined in the 1964 Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from all participants, and permission to conduct the study was granted by the Ethical Research Committee of Tabriz University of Medical Sciences (#IR.TBZMED.REC.1397.527).

Funding

Tabriz University of Medical Sciences funded this study (IR.TBZMED.REC.1397.527).

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