International Psychogeriatrics (2017), 29:2, 269–279 © International Psychogeriatric Association 2016

doi:10.1017/S1041610216001721

Mental health literacy as a mediator in use of mental health

services among older korean adults
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Young Sun Kim,1 T. Greg Rhee,2 Hee Yun Lee,3 Byung Hyun Park4
and Monica L. Sharratt3
1
Graduate School of East-West Medical Science, Kyung Hee University, Gyeonggi-Do, South Korea
2
Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Twin Cities, MN, USA
3
School of Social Work, College of Education and Human Development, University of Minnesota, Twin Cities, MN, USA
4
Department of Social Welfare, Pusan National University, Busan, South Korea

ABSTRACT

Background: Existing literature suggests that mental health literacy is positively associated with mental health
services utilization. Despite an aging population that faces significant mental health concerns in Korea, the
role of mental health literacy on mental health services utilization is not known among older adults in Korea.
This study aimed to (1) identify whether mental health literacy mediates the association between population
characteristics and mental health services utilization and (2) identify an optimal path model for mental health
services utilization among Korean older adults.
Methods: Using a cross-sectional survey with a quota sampling strategy, we collected and analyzed responses
from 596 community-dwelling individuals ages 65 years and older. We used structural equation modeling
(SEM) to estimate the effect of mental health literacy as a mediator.
Results: When controlling for other relevant covariates in the optimal path model, mental health literacy
mediated the relationships between three socio-demographic factors (education, general literacy, and health
status) and mental health services utilization. The model fit index shows that the SEM fits very well (CFI =
0.92, NFI = 0.90, RMSEA = 0.07).
Conclusions: Efforts to improve mental health literacy through community-based education programs may
need to particularly target Korean older adults with the relevant socio-demographic characteristics to enhance
their utilization of appropriate mental health services.

Key words: mental health literacy, mental health, service utilization, Korean, older adults, health literacy

Introduction issues (Lee and Moon, 2011; Lee and Chang,

2012). For example, while suicide is ranked the
With extended life expectancies and the retirement fourth leading cause of death in South Korea overall
of baby boomers, South Korea is facing rapid (Ahn, 2012; Jeon, 2012), the suicide rate among
growth in its older population. In 2000, adults ages older adults is seven times higher than that of
65 years or older accounted for at least 7.0% of younger adults in their 20s (National Statistical
the population in Korea, and that proportion is Office of Korea, 2009). Several reasons for mental
expected to increase to 14.3% by 2018 and 20.8% health problems among the Korean elderly have
by 2026 (Korea Institute for Health and Social been identified, such as loneliness and isolation,
Affairs, 2007). Korean older adults are considered health problems, financial difficulties, loss of social
vulnerable, as they face significant mental health status and social support, and fear of dying (Lee
and Moon, 2011; Ko et al., 2012).
Correspondence should be address to: Young Sun Kim, PhD, Assistant Professor,
To our knowledge, the level of mental health
Graduate School of East-West Medical Science, Kyung Hee University, 1732 services utilization among older adults in South
Deogyeong-Daero, Giheung-Gu, Yongin-Si, Gyeonggi-Do, 446-701, South Korea is not known. In the USA, studies have
Korea. Phone: 82-31-201-3719. Email: ysunkim@khu.ac.kr. Received 14 May
2016; revision requested 26 Jun 2016; revised version received 21 Aug 2016;
reported that Korean Americans under-utilize
accepted 16 Sep 2016. First published online 20 October 2016. community-based mental health services (Jang
270 Y. S. Kim et al.
et al., 2007; Jang et al., 2009). In their study,
Jang et al. (2007, 2009) found that culture-
embedded beliefs, such as misconceptions and
social stigma, played substantial, negative roles
in Korean Americans’ attitudes toward mental
health services utilization. To comprehensively
assess factors associated with the level of mental
health services utilization, understanding the role of
mental health literacy is critical. However, relatively
little is known about the potential role of mental
health literacy on mental health services utilization
among Korean and Korean American older
adults.
Mental health literacy consists of “(i) the ability
to recognize specific disorders or different types of
psychological distress; (ii) knowledge and beliefs
about risk factors and causes; (iii) knowledge
and beliefs about self-help interventions; (iv)
knowledge and beliefs about professional help
available; (v) attitudes which facilitate recognition
and appropriate help-seeking; and (vi) knowledge
of how to seek mental health information” (Jorm,
2000, p. 396). While there is no evidence about
how mental health literacy is related to mental
health outcomes and service utilization, there are
some studies that report a significant positive
relationship between health literacy, which is
defined as degree to which individuals have the
capacity to obtain, process, and understand basic
health information and services needed to make
appropriate health decisions (Ratzan and Parker,
2000, p. vi), and the two outcome variables. Adults
with low health literacy are more likely to report
symptoms of depression (Coffman and Norton,
2010; Lee et al., 2015; Rhee et al., 2016). In Rhee
and colleagues’ (2016) study, Korean older adults,
who had a lower level of health literacy, were more
likely to have depressive symptoms. Korean older
adults who showed lower health literacy were also
less likely to use healthcare services (Kripalani et al.,
2006; Kim et al., 2016).
Interventions specifically targeting mental health
literacy have been found to benefit participants in
multiple ways. For example, Kelly and colleagues
(2007) systematically reviewed 12 different mental
health literacy interventions and found that
individuals could better identify depression and
improve help-seeking behaviors for depression
after attending community-based mental health
awareness programs; individuals also showed a
significant reduction in stigmatizing attitudes.
These studies, however, focused only on how
mental health literacy influences mental health
outcomes, not investigating its relationship with
mental health services utilization. Furthermore,
these studies only focused on young adults ages
18 to 25 years outside of Asia. No study has yet
identified the role of mental health literacy in older
adults in South Korea.
Guided by Andersen’s health behavioral model
(Andersen, 1995), we used mediation and path
analysis to identify the role of mental health literacy
in the relationship between population charac-
teristics and mental health services utilization.
Andersen (1995) outlined (1) predisposing factors
as exogenous influences on health service use,
such as demographic characteristics, (2) enabling
factors as resource-related determinants that either
encourage or impede healthcare services utilization,
and (3) need factors as perceived needs for the
use of healthcare services. When all three types of
factors are in place, the model posits that successful
health service utilization will occur. While a study
conducted by Lindamer and colleagues (2012)
suggests that enabling and need factors have
the strongest associations with high utilization of
acute mental health services, a recent systematic
review on Andersen’s health behavioral model
(Babitsch et al., 2012) concludes that different
operationalizations of the model may lead to a
small common set of variables (e.g. age and
gender) to predict and/or understand health care
utilization. Relying on Andersen’s health behavioral
model as a theoretical guide, we developed our
own framework with the population characteristics
classified as predisposing, enabling, or need factors
(see Figure 1).
Although mental health literacy is considered
a critical factor in determining mental health
disparities, there is limited research on this
topic in South Korea, particularly among older
adults. To our knowledge, this is the first study
investigating a relationship between mental health
literacy and mental health services utilization in
this vulnerable group. Given that Korean older
adults reported the highest suicide rates across
age groups, and limited evidence related to their
mental health literacy currently exists, a deeper
understanding of the population’s mental health
literacy and its impact on service utilization is
necessary and timely. Therefore, our objectives
were to identify: (1) whether mental health literacy
mediates the association between population char-
acteristics and mental health services utilization,
and (2) an optimal path model for mental health
services utilization among Korean older adults.
Understanding descriptive patterns of the role of
mental health literacy in mental health services
utilization will allow healthcare professionals
and policy-makers to develop community-based
mental health programs and policies focused
on improving mental health literacy and mental
health services utilization among Korean older
adults.

Independent Variables – Population Characteristics
Predisposing Factors Enabling Factors
- Age - Educational attainment
- Gender - Income
- Marital status - Employment status
- Geographic location - General literacy level
- Status of assigned
hospital
- Social support
- Social network
Figure 1. Conceptual model of the study.
Methods
Research design and data source
We used a cross-sectional survey research design
to investigate the proposed study aims. Using a
quota sampling strategy, we recruited a sample
of 640 community-dwelling Korean adults ages
65 years or older living in six metropolitan,
four suburban, and four rural areas in South
Korea from September to December 2009. The
sampling method was appropriate to ensure
proportional numbers of participants in different
geographic areas (Neuman, 1994). We recruited
study participants from local social services centers
across the country. Before conducting a full survey,
we also had a preliminary pilot study with ten
Korean older adults to assess the accessibility
(e.g. readability), cultural sensitivity, and ability
to complete the survey form. We provided a
self-administered questionnaire to five randomly
selected older adults, and completed face-to-face
interviews with the other five older adults. We
conducted a statistical test of the equality of
alpha reliability (Feldt, 1969), which showed no
significant difference in reliability between these
two different groups. After completing the pilot
study, a self-administered questionnaire was given
to the study sample. Prior to data collection,
we explained the purpose of the study, eligibility
criteria, confidentiality, and the voluntary nature of
participation to every participant in both oral and
written formats. The response rate for the survey
was 90.6%. Upon examining all participants’
responses (e.g. missing data), we only included 596
responses in the final study. The research procedure
for this study was approved by the University of
Minnesota Institutional Review Board.
Instruments
D e pe n d e n t va r i a b l e
The utilization of mental health services was the
primary outcome of interest in our study. Each
Mental health literacy and services utilization 271
Dependent Variables
Need Factors Mental health
- Self-rated health status literacy
- Number of chronic (Mediator)
diseases
- Depressive symptoms
Health Behavior
Mental health services
utilization
participant was asked whether or not he or she had
used mental health services (0 = No, 1 = Yes).
I n d e pe n d e n t ( m e d i at i n g ) va r i a b l e
Mental health literacy was the mediating variable.
We used a ten-item scale adapted from Epps et al.
(2007) and Davis et al. (2008). The reliability
measure using Cronbach’s α was 0.93 and the
factor analysis suggested that the constructed
mediating variable was appropriate. We used a
5-point Likert scale for each item from “not at
all” (1) to “always” (5). The summated score
ranged from 10 to 50, where a higher score
indicates a higher level of mental health literacy.
The detailed description of the constructed mental
health literacy variable was reported elsewhere
(Kim et al., under review).
C o n t ro l l i n g va r i a b l e s
Based on existing literature and our conceptual
framework, for predisposing factors, we included age,
gender, marital status, and geographic location.
For enabling factors, we included educational
attainment, income, employment status, general
literacy level, having a primary hospital, social
support, and social network. Since South Korea
has a national health insurance policy, we did not
include a health insurance variable as an enabling
factor. For need factors, self-rated health status,
number of chronic conditions, and depressive
symptoms were used. Self-rated health status was
measured using a 5-point Likert-type rating scale
ranging from “very poor” (1) to “very good” (5).
We computed the number of chronic conditions by
summing each participant’s indication of whether
or not they experienced each of the seven most
common chronic conditions, such as arthritis
and diabetes. Finally, depressive symptoms were
assessed using a short form of the Center for
Epidemiologic Studies Depression Scale (CES-D)
(Andersen et al., 1994; Radloff, 1997). The ten
items were rated based on four response categories
272 Y. S. Kim et al.
from “very rarely” (0) to “always” (3); the sum
score ranged from 0 to 30 accordingly, where higher
scores indicate more severe depressive symptoms.
Data analysis
First, we presented descriptive statistics of the
socio-demographic characteristics of our sample
by the levels of mental health literacy and mental
health service utilization. We used structural
equation modeling (SEM) to estimate the medi-
ating role of mental health literacy between the
socio-demographic characteristics and the outcome
of interest, mental health services utilization.
We observed and tested multiple patterns, and
identified the optimal pathway to mental health
services utilization. To perform these analyses, we
used the maximum likelihood method with AMOS
21.0.0 statistical software (Arbuckle, 2012). We
further used Normed fit index (NFI) (Bentler
and Bonett, 1980), comparative fit index (CFI)
(Bentler, 1990), and root mean square error of
approximation (RMSEA) (Steiger and Lind, 1980)
to estimate the best model fit in our SEM.
Results
Socio-demographic characteristics of the
study sample
Table 1 summarizes study participants’ socio-
demographic characteristics. Among 596 parti-
cipants, 59.5% were female and 60.3% were in
their 70s. Only 14.2% of the study sample had
some college education or higher and 75.2% had an
income of less than $2,000 a month. The majority
(88.0%) showed adequate literacy in both reading
and writing. Slightly over a quarter (26.5%) of
the sample responded that their health status was
“good” or “very good,” while roughly the same
proportion (26.7%) had two or more chronic
conditions. With regard to mental health literacy,
those who were married, were college graduates,
had higher income, a higher general literacy level,
a higher self-rated health status, and a lower level
of depression were more likely to have higher
mental health literacy, respectively (p < 0.05).
With regard to mental health services utilization,
the distributions of gender, location, income,
employment status, general literacy, and depressive
symptoms significantly differed by the status of
mental health services utilization (p < 0.05).
Mediation effect of mental health literacy
Table 2 describes estimates of path analysis for
each independent variable on the mediating and
outcome variables. Mental health literacy played a
significant mediating role for education, income,
and general literacy level in enabling factors (p <
0.01 and p < 0.05 for income) and health status
and depressive symptoms in need factors (p < 0.01).
Optimal path model
We drew the final path model for mediation analysis
based on the conceptual framework to explain
the mediating role of mental health literacy on
mental health services utilization when controlling
for other pertinent socio-demographic factors.
Figure 2 shows the optimal path model, suggesting
that mental health literacy was a mediator between
education, general literacy level, and health status
and the outcome variable of interest, mental
health services utilization, holding other variables
constant.
Table 3 summarizes the decomposition of direct
and indirect effects, when adjusted for other
covariates. Most enabling factors, such as education,
social support, social network, and general literacy
level, and one need factor, health status, had direct
effects on mental health literacy. For mental health
services utilization, income, employment status,
and mental health literacy had significant direct
effects. While income was negatively associated
with mental health services utilization (p < 0.01),
employment status, and mental health literacy were
positively associated with mental health services
utilization (p < 0.01). Mental health literacy played
a significant mediating role for the effects of
education, general literacy level, and health status
on mental health services utilization. The model fit
index shows that this model fits very well (CFI =
0.92, NFI = 0.90, RMSEA = 0.07).
Discussion
This is the first study to investigate the role of
mental health literacy on mental health services
utilization among older adults in South Korea.
In particular, the current study extends the
existing literature on mental health literacy by
investigating its potential role as a mediator
between population characteristics and mental
health services utilization. As shown in the final
optimal path model, mental health literacy had a
significant mediating role between three factors –
education, general literacy, and health status – and
mental health services utilization, all in positive
directions.
First of all, education had a direct positive
association with mental health literacy. Other
researchers have similarly found that higher
education predicted successful recognition of
depression (Dahlberg et al., 2008) and greater
 Mental health literacy and services utilization 273

Table 1. Socio-demographic characteristics of the study sample (n = 596)

MHL (1 to 5) MHSU (y e s / n o )

fa c t o r va r i a b l e r e s po n s e co u n t (%) m e a n (SD) F m e a n (SD) χ2

............................................................................................................................................................................................................................................................................................................................

Predisposing Gender Female 353 (59.5) 2.70 (0.96) 0.026 0.12 (0.33) 7.120∗∗
Male 240 (40.5) 2.72 (1.00) 0.06 (0.23)
Age 65 to 69 120 (20.5) 2.77 (0.91) 1.893 0.08 (0.28) 0.299
70’s 353 (60.3) 2.73 (0.99) 0.10 (0.30)
80 or older 112 (19.1) 2.55 (0.98) 0.09 (0.29)
Marital status Not married 363 (61.0) 2.78 (1.01) 5.504∗ 0.09 (0.28) 1.262
Married 232 (39.0) 2.59 (0.91) 0.12 (0.32)
Location Urban 207 (34.7) 2.73 (0.96) 3.471∗ 0.07 (0.25) 6.911∗
Suburban 194 (32.6) 2.82 (1.04) 0.09 (0.28)
Rural 195 (32.7) 2.56 (0.90) 0.14 (0.35)
Enabling Education Less than high 298 (50.5) 2.48 (0.92) 8.991∗∗ 0.13 (0.34) 8.180
school
High school 208 (35.3) 2.89 (0.97) 0.07 (0.25)
Some college 15 (2.5) 2.84 (1.10) 0.07 (0.26)
University 62 (10.5) 3.09 (0.93) 0.06 (0.25)
Graduate school 7 (1.2) 2.86 (1.16) 0.00 (0.00)
Monthly Less than $1,000 231 (38.8) 2.56 (0.95) 3.443∗ 0.15 (0.36) 14.518∗∗
income $1,000–1,999 217 (36.4) 2.74 (0.98) 0.09 (0.28)
$2,000–2,999 89 (14.9) 2.84 (0.99) 0.03 (0.18)
More than $3,000 59 (9.9) 2.94 (0.97) 0.03 (0.18)
Employment Unemployed 401 (67.3) 2.68 (1.00) 0.497 0.07 (0.26) 9.777∗∗
status Employed 195 (32.7) 2.74 (0.91) 0.15 (0.36)
Primary No 397 (67.2) 2.71 (1.01) 0.004 0.11 (0.31) 0.478
hospital Yes 194 (32.8) 2.70 (0.90) 0.09 (0.28)
General Unable to read 29 (4.9) 2.29 (0.92) 14.049∗∗ 0.24 (0.44) 11.773∗∗
literacy level and write
Reads only 43 (7.2) 2.65 (1.15) 0.16 (0.37)
Able to read and 352 (59.1) 2.56 (0.89) 0.10 (0.30)
write
Reads and writes 172 (28.9) 3.08 (0.99) 0.06 (0.23)
fluently

Mean (SD) Correlation with Correlation with

MHL MHSU
Social support 3.42 (0.9) 0.302∗∗ 0.027
∗∗
Social network 2.63(1.1) 0.296 0.026

Count (%) Mean (SD) F Mean (SD) F

∗∗
Need Self-rated Very poor 19 (3.2) 2.48 (1.06) 10.188 0.47 (0.51) 36.482
health status Poor 90 (15.2) 2.48 (0.89) 0.11 (0.32)
Neutral 327 (55.1) 2.59 (0.90) 0.10 (0.31)
Good 131 (22.1) 3.07 (1.04) 0.04 (0.19)
Very Good 26 (4.4) 3.29 (1.04) 0.04 (0.20)
Number of None 178 (29.9) 2.86 (0.99) 3.395∗ 0.04 (0.19) 17.820
chronic 1 259 (43.5) 2.67 (0.96) 0.09 (0.29)
conditions ≥2 159 (26.7) 2.60 (0.97) 0.18 (0.38)

Mean (SD) Correlation with Correlation with

MHL MHSU

Depressive symptoms 2.25 (0.5) −0.178∗∗ 0.105∗

Note: ∗ p < 0.05, ∗∗ p < 0.01.

274 Y. S. Kim et al.

Table 2. Standardized regression coefficients of path analysis

pat h
co e f f i c i e n t
α (t ota l β (i n d i r e c t γ (i n d i r e c t δ (d i r e c t e f f e c t
p r e d i c t o r va r i a b l e effect) e f f e c t o n MHL) e f f e c t o n MHSU) o n MHSU)
............................................................................................................................................................................................................................................................................................................................

Predisposing Age 0.009

Factors Gender − 0.110∗∗ 0.007 0.073 − 0.111
Marital status 0.046
Location 0.104∗ − 0.071 0.080∗ 0.110∗∗
Enabling Education − 0.122∗∗ 0.259∗∗ 0.112∗∗ − 0.152∗∗
Factors Income − 0.165∗∗ 0.089∗ − 0.174∗∗ 0.088
Employment status 0.128∗∗ 0.029 0.126∗∗ 0.069
Primary hospital − 0.028
Social support 0.027
Social network 0.026
General literacy − 0.138∗∗ 0.215∗∗ − 0.161∗∗ 0.107∗
level
Need Health status − 0.182∗∗ 0.227∗∗ − 0.209∗∗ 0.120∗∗
Factors depressive 0.105∗∗ − 0.178∗∗ 0.122∗∗ 0.094∗
symptoms
Number of chronic 0.174∗∗ − 0.067 0.179∗∗ 0.084∗
conditions

Note: ∗ p < 0.05; ∗∗ p < 0.01.

Social
support
.57 .17**
-.08
Social
.13** e1
-.11 network
.11 -.10 Mental
-.06 -.02 health
.14
.15
15
Age
literacy
.19 -.04
.17
.11 -.18 Location
.15**
.23 .16**
-.16 -.02
.09* **
Education .11 e2
-.02
.10
.47 -.06
.01
General literacy -.09
.21
21 .24
Mental health
-.19*
Health status services utilization

-.13** .15**

Income Employment status

CFI=.918 NFI=.899, RMSEA=0.071 -.08

Figure 2. Final path model for mediating effect of mental health literacy on mental health services utilization.

insight and awareness about mood disorders in research has shown that higher education predicts a
individuals with depression (Yen et al., 2005). On greater likelihood of visiting health professionals for
the other hand, this study found no significant mental health reasons (Alegria et al., 2000; Parslow
direct association between education and mental and Jorm, 2000; Steele et al., 2007; Amone-
health services utilization. While this finding is P’Olak et al., 2010). This effect may partially be
in line with a study that demonstrated no effect explained by the tendency for individuals with
of education on help-seeking for psychological higher education to have more positive attitudes
problems (Judd et al., 2006), most of the existing toward mental health services, an association found
 Mental health literacy and services utilization 275

Table 3. Decomposition of direct and indirect effects

d e pe n d e n t i n d e pe n d e n t direct indirect t ota l
............................................................................................................................................................................................................................................................................................................................

Mental health literacy Age − 0.021 – − 0.021

Location − 0.037 – − 0.037
Education 0.151∗∗ – 0.151∗∗
Social support 0.171∗∗ – 0.171∗∗
Social network 0.135∗∗ – 0.135∗∗
General literacy level 0.089∗ – 0.089∗
Health status 0.112∗∗ – 0.112∗∗
Mental health services utilization Education − 0.064 0.024 − 0.040
General literacy level − 0.093 0.014 − 0.078
Health status − 0.189 0.018 − 0.171∗
Income − 0.126∗∗ – − 0.126∗∗
Employment status 0.145∗∗ – 0.145∗∗
Mental health literacy 0.160∗∗ – 0.160∗∗

Note: ∗ p < 0.05; ∗∗ p < 0.01.

among Korean American participants (Jang et al., of literacy – competence in reading and writing,
2009). However, current findings imply that mental as opposed to general years of education – the
health literacy plays a significant mediating role relationships among literacy, mental health, and
between education and the use of mental health service utilization merit further focused attention.
services among Korean older adults. In addition, The final factor for which mental health
previous studies have found that education has an literacy played a mediating role in its relationship
inverse association with the likelihood of mental with mental health services utilization was health
health problems and diagnoses (Araya et al., 2003; status, which also had a direct positive association
Hoeymans et al., 2004; Howard et al., 2006). with mental health literacy. While the connection
Together, these trends suggest that individuals with between health literacy and health outcome
lower education, who may be most in need of measures has already been established for older
mental health services, tend to be less likely to adults (Wolf et al., 2005; Sudore et al., 2006),
access such services, due in part to inadequate the relationship between health status and mental
mental health literacy. health literacy specifically has not been thoroughly
As with education, general literacy level had studied in any ethnic population group. However,
a direct positive association with mental health a randomized controlled trial of an intervention
literacy, though no direct association with mental designed to increase mental health literacy ef-
health services utilization. While the positive fectively improved the mental health status of
association between health and education has been participants (Kitchener and Jorm, 2004), signifying
thoroughly recognized (Ross and Wu, 1995; Lleras- a connection between mental health literacy and
Muney, 2005; Silles, 2009), the paths by which the psychological aspects of health. In addition, the
education exerts its impact are less established. bidirectional interaction between physical health
Literacy has emerged as one such path, as it status and mental health is well-known (Chapman
has been previously identified as a mediator of et al., 2005; Al-Nsour et al., 2013). Overall, health
the relationship between education and various also appears to impact mental health services
health outcome variables, such as glycemic control utilization, as an adverse physical health event
(Schillinger et al., 2006), blood pressure control significantly increased the likelihood of accessing
(Pandit et al., 2009), and even cardiovascular treatment for mental health problems (Yoon and
mortality (Baker et al., 2007). The current study Bernell, 2013). Conversely, the current study found
expands the body of knowledge into the realm of a positive indirect association between physical
mental health by highlighting the role of mental health and mental health services utilizations,
health literacy as a mediator between general mediated by mental health literacy, indicating the
literacy and mental health services utilization. need for future research to clarify the nature of
Although educational attainment and literacy are these relationships.
strongly linked, with higher educational attainment
predicting greater literacy skills (Park and Kyei,
2011; Cohen et al., 2012), literacy is only one of Implications and future directions
many possible outcomes of education. Because of Due to its direct positive effects on mental health
the more specific skills connoted by the definition services utilization, mental health literacy warrants
276 Y. S. Kim et al.
greater public health attention. Knowledge of the
appropriate steps for the recognition, prevention,
and treatment of mental distress and/or disorders
would serve not only to bolster the use of mental
health services, but also foster improved overall
community mental health. Evidence has shown
that interventions including Mental Health First Aid
training, community campaigns, and informational
websites can successfully increase mental health
literacy (Jorm, 2012). As older adults tend to score
lower on health literacy measures in general (Baker
et al., 2000; Morrow et al., 2006) and mental health
literacy measures specifically (Fisher and Goldney,
2003; Farrer et al., 2008), these interventions
should tailor unique aspects of their approach
to specifically target this age group. For optimal
engagement in interventions, all aspects should be
culturally tailored to the population of interest,
in this case, Korean older adults. Because mental
illness carries a strong stigma in South Korea
and other Asian countries (Seo and Kim, 2005;
Lauber and Rossler, 2007), framing mental health
campaigns in terms of “wellness enhancement”
or “happy living” programs may increase their
acceptance and satisfaction in the community.
While we discovered that mental health literacy
mediates the relationships of education, general
literacy, and health status with mental health
services utilization, the mediating role of mental
health literacy may be found with additional
population characteristics not included in this
study. Investigation into this topic among culturally
diverse populations of older adults and various age
groups constitute important next steps. Previous
findings demonstrating cultural influences on
attitudes toward mental health (e.g. Yoo et al.,
2005; Hovey et al., 2006; Jang et al., 2007) imply a
need for further research into beliefs about mental
health among Korean older adults and how they
influence both mental health literacy and mental
health services utilization. In addition, as our study
only examined whether or not individuals had ever
used any mental health service, greater under-
standing of the patterns of mental health service
utilization among Korean older adults, including
the types of services used by individuals with
varying demographic characteristics and for which
perceived mental health issues, would be beneficial,
particularly examining for which types of services
mental health literacy plays a mediating role.
Limitations
This study has several limitations. First, as a
cross-sectional survey design that used convenience
sampling, the study findings may not be generalized
to other populations and assumptions cannot be
made regarding causality. Second, the mental
health literacy measure has not been utilized
and tested in this population previously. Further,
the measure was originally developed for family
caregivers taking care of mentally ill family
members (Epps et al., 2007). Thus, developing a
culturally competent scale to accurately measure
the population’s level of mental health literacy is
urgently needed, given its importance in increasing
mental health service utilization. Third, the mental
health literacy measure was based entirely on
self-report, the validity of which depends on
participants’ levels of insight into their own
knowledge and skills. Comparing responses on
the self-report measure to a more objective test
of mental health literacy (e.g. knowledge of
psychiatric symptoms) would clarify the accuracy
of the measure we used. Fourth, the study had
an exclusively quantitative approach and, therefore,
did not explore the ascribed meaning behind
participants’ responses, including their perspectives
on and experiences with mental health literacy and
mental health services utilization. A mixed method
research approach would produce rich data that
uncover the deeper meaning behind participants’
responses.
Conclusion
This marks the first study to report on the
important role of mental health literacy as a
mediator between population characteristics and
the utilization of mental health services and to
devise an optimal path model to explain such
relationships. Based on initial evidence from the
current findings, interventions promoting mental
health literacy among Korean older adults should
pay particular attention to individuals with lower
education, general literacy and/or health status. By
improving mental health literacy, the appropriate
utilization of mental health services is expected to
improve accordingly, potentially leading to better
mental health outcomes. With the Korean older
adult population expanding at a rapid rate and
having a markedly high rate of suicide, the need
to promote mental health through targeted mental
health literacy interventions and effective service
delivery will only become more salient.
Conflict of interest
None.
Description of authors’ roles
Dr Kim conceived the study, developed the survey,
collected the data, supervised data analysis and

interpretation, led the writing of the paper, and
oversaw all aspects of the study. Dr Rhee analyzed
and interpreted the data and led the writing of the
paper. Dr Lee designed the study and developed
the survey, supervised data collection and analysis,
and reviewed and approved the final version of the
paper. Dr Park developed the survey, supervised
the data collection, and provided critical review
of the paper. Ms Sharratt assisted with review
of literature, citation management, and critically
revising the paper.
Acknowledgments
This research was supported by the fund from the
Ministry of Health and Welfare in Korea.
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