Volume 74, No.2: 2022 Siriraj Medical Journal
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Gobhathai Sittironnarit, M.D., Rungsipohn Sripen, M.Sc., Sucheera Phattharayuttawat, Ph.D.
Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Psychometric Properties of the Thai Mental Health
Literacy Scale in Sixth-Year Medical Students
ABSTRACT
Objective: To assess the psychometric properties of the ai Mental Health Literacy Scale (TMHLS) in sixth-year
medical students.
Materials and Methods: By using the purposive sampling method, we enrolled 202 participants in this study.
Descriptive statistics were used to analyze demographic data. e index of item-objective congruence (IOC) was
used to verify content validity. Exploratory factor analysis (EFA) was performed to establish the construct validity
of the TMHLS. e internal consistency was estimated by computing Cronbach’s coecient alpha.
Results: e TMHLS had good content validity (IOC=.85) and construct validity. e EFA resulted in ve factors,
which included 32 of the 35 items and accounted for 46.86% of the variance. e factors were the ability to recognize
mental disorders; condentiality of mental health practitioners; skills of mental health information seeking; beliefs
about mental illnesses; and attitudes toward patients with mental illness. e reliability coecient of the TMHLS
total test was .851, and reliability coecient in subdomains were range from .197 to .872. Individuals who had a
mental health professional as an intimate contact and individuals who had a history of seeking help from mental
health professional(s) in person showed signicantly higher mental health literacy than those who did not.
Conclusions: e TMHLS has good psychometric properties. Dynamic knowledge transfer and exchange with a
close mental health professional should be applied to promote mental health literacy in medical students.
Keywords: assessment; experience; help-seeking; medical externs; professional; reliability; validity (Siriraj Med J
2022; 74: 100-107)
Corresponding author: Gobhathai Sittironnarit
E-mail: gobhathai.kua@mahidol.edu
Received 1 October 2021 Revised 26 October 2021 Accepted 16 November 2021
ORCID ID: https://orcid.org/0000-0001-8902-4903
http://dx.doi.org/10.33192/Smj.2022.13
INTRODUCTION
Mental health problems have been increasing
throughout the world
1
, with young adults being the
most aected group. irty percent of them have mental
disorders while the remaining are also at risk.
2
Because of
poor mental health literacy, high mental health problems
and low engagement in help-seeking behaviors were
reported in these individuals.
3-7
Mental health literacy reduces the risk of developing
mental disorders along with increasing help-seeking
behaviors.
8
People with high mental health literacy will
be able to recognize, manage, and prevent mental health
problems. Oppositely, people with low mental health
literacy may not be able to appropriately manage and oen
end up with more serious complications.
9
Unfortunately,
there is no assessment tool for mental health literacy in
ai at the time.
Sixth-year medical students were targeted in this
study because they were young adults at risk of mental
disorders
2,10-11
who already gained mental experiences
that may aect their mental health literacy.
12-13
Due to the lack of an instrument to measure mental
health literacy among ai people, this study aimed to
assess the psychometric properties of the ai mental
Sittironnarit et al.
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Original Article
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health literacy scale (TMHLS) in sixth-year medical
students who may exemplify the young adults at risk
of mental disorder.
MATERIALS AND METHODS
Participants
e number of participants in this study was determined
by the Cochran formula.
14
We enrolled 250 sixth-year
medical students from the Faculty of Medicine Siriraj
Hospital in Bangkok who had registered for the rst
semester in academic year 2017 and voluntarily answered
the questionnaires using purposive sampling method.
Tools
A demographic questionnaire was used to collect
data from participants including gender, age, sources
of mental health experiences, and their mental illness
if applicable.
e translation of mental health literacy scale (MHLS)
The MHLS was translated to Thai under the
supervision of a language expert. e index of item-
objective congruence (IOC) was used to verify content
validity by three mental health experts: one psychiatrist
and one licensed clinical psychologist from the Department
of Psychiatry, Faculty of Medicine Siriraj Hospital; and
one licensed clinical psychologist from the Faculty of
Psychology, Chulalongkorn University. All mental health
experts discussed the translated version until reaching a
consensus. e ai mental health literacy scale (TMHLS)
was nally completed following expert opinion.
e TMHLS is a self-reporting questionnaire with
35 items covering six attributes of mental health literacy:
the ability to recognize a disorder; knowledge of where to
seek information; knowledge of risk factors and causes;
knowledge of self-treatment; knowledge of professional
help available and attitudes that promote recognition or
appropriate help-seeking behavior. e total score is the
summation of all items. erefore, the maximum score
is 160 whereas the minimum score is 35. A higher score
means greater mental health literacy.
Statistical analyses
All statistical analyses were performed by PASW 18.0.
16
Descriptive statistics were used to analyze demographic
data. e IOC was used to verify content validity. e
factor solution was determined based on the number
of eigenvalues greater than one.
17
We conducted the
exploratory factor analysis (EFA) using .30 as a factor
loading criterion
18
, ve to ten participants per item
19
, and
a minimum sample size of 200.
20-21
e EFA began with
an initial analysis run to obtain eigenvalues for each factor
in the data. e Kaiser-Meyer-Olkin (KMO) Measure of
Sampling Adequacy test and Bartlett’s Test of Sphericity
were executed to determine construct validity and to
conrm those data were appropriate. e KMO test was
used to verify the sampling adequacy for the analysis,
and Bartlett’s Test of Sphericity was used to determine
if correlations between items were suciently large for
EFA. Bartlett’s Test of Sphericity should reach a statistical
signicance of less than .05 in order to conduct an EFA.
e reliability of an instrument is concerned with the
consistency, stability, and dependability of the scores.
22
For this reason, the internal consistency was tested using
Cronbach’s alpha for each competency.
RESULTS
e sixth-year medical students
Two-hundred and two of the 250 participants (80.8%)
answered the questionnaires. e majority of respondents
were female (n=133; 65.8%) aged between 22-24 years
(M = 23, SD = 0.46). Psychiatric rotation was the most
popular source of their mental health experience (n=190;
94.1%). irteen out of 202 medical students had major
depressive disorder (6.4%), the most common diagnoses
among the samples (Table 1).
e psychometric properties of the ai mental health
literacy scale (TMHLS)
Content validity
e rst-round IOC of the TMHLS was .67 with 9
of 35 items (items number 2, 3, 5, 6, 7, 8, 15, 20 and 24)
dened as required revision (IOC > .05). Aer revision
of those 9 items, content validity in the second round
increased to .85. However, 4 of 9 items (items number
3, 5, 15 and 20) were still dened as required revision
(IOC > .05).
Construct Validity
e EFA revealed ve meaningful constructs emerged,
namely, ability to recognize mental disorders (item
1, 2, 3, 4, 5, 6, 7, 8); condentiality of mental health
practitioners (item 22, 23, 25, 26, 27, 28); skills of mental
health information seeking (item 16, 17, 18, 19); beliefs
about mental illnesses (item 9, 11, 12, 13, 20, 21, 24);
and attitudes toward patient with mental illness (item
29, 30, 31, 32, 33, 34, 35), which accounted for 46.86%
of the cumulative variance. ree items (item 10, 14 and
15) did not load on any of the factors (Table 2).
Reliability
Total Cronbach’s alpha coecient of the TMHLS
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Attributes Frequency Percent
(n) (%)
Responserates 202 80.8
Sex Female 133 65.8
Male 69 34.2
Age(years) 22 22 10.9
23 158 78.2
24 22 10.9
(M=23,SD=0.46,Range22-24years)
Sources of mental health experiences
(Mutual items and answers reasonable)
• Fifth-year rotation (psychiatry) 190 94.1
• Media (internet/ newspaper/ television) 139 68.8
• Having family members or friends with mental disorder(s) 110 54.5
• Self-experience of mental disorder(s) 31 15.3
• Havingamentalhealthprofessionalasanintimatecontact 29 14.4
• History of seeking help from mental health professional(s) in person 19 9.4
• History of seeking help from mental health professional(s) 16 7.9
for family members or friends
Types of mental illness
• Major depressive disorder (MDD) 13 6.4
• Panic disorder 3 1.5
• Adjustmentdisorder 2 1
• Attentiondecithyperactivitydisorder(ADHD) 2 1
• Bipolar disorder 1 0.5
• Premenstrual dysphoric disorder (PMDD) 1 0.5
• Relationship problems 1 0.5
• Unspecied 8 4
TABLE 1. Demographic data of the sixth-year medical students (n=202).
was .851. Still, there were 6 items (items 9, 10, 11, 12,
15 and 20) in the reliability coecients of all items that
do not meet the criterion (CITC < .20). e Cronbach’s
alpha if item deleted was .872 which was in the same
interval before withdrawing the 6 items. e Cronbach’s
alpha if item deleted for each item was slightly dierent
from the Cronbach’s alpha of all items. Therefore,
all items that do not meet the criterion still remain
(Table 3). e reliability coecient in subdomains of
TMHLS were range from .197 to .872 (Table 4).
e mental health literacy in sixth-year medical students
e medical students’ mean score of mental health
literacy was 123.09 (S.D. ± 11.55, 95% CI = 121.49–124.69).
Multiple comparisons of our participants’ mental health
experiences showed having intimate contact with a mental
Sittironnarit et al.
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TABLE 2. Factor structure of the ai Mental Health Literacy Scale (TMHLS).
Item F1 F2 F3 F4 F5
Q8 .866
Q5 .831
Q7 .752
Q3 .714
Q6 .696
Q4 .662
Q1 .648
Q2 .540
Q28 .697
Q27 .683
Q26 .612
Q22 .529
Q25 .524
Q23 .397
Q19 .799
Q17 .791
Q16 .753
Q18 .634
Q11 .558
Q20 -.502
Q21 -.461
Q24 -.442
Q13 .422
Q12 -.351
Q9 .337
Q33 .781
Q32 .775
Q30 .758
Q31 .747
Q34 .725
Q35 .725
Q29 .724
Note: F1 =ability to recognize mental disorders, F2 = condentiality of mental health practitioners, F3 = skills of mental health information
seeking, F4 = beliefs about mental illnesses, F5 = attitudes toward patient with mental illness
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TABLE 3. Reliability coecients of all 35 Items from the ai Mental Health Literacy Scale (TMHLS).
Items ScaleMeanScaleVarianceCorrectedItem- Cronbach'sAlpha
ifItemDeletedifItemDeletedTotalCorrelation ifItemDeleted
1 120.0050 127.146 .388 .847
2 120.1608 126.206 .440 .845
3 119.7186 127.203 .444 .846
4 120.0101 125.677 .442 .845
5 119.6734 125.160 .509 .844
6 120.0151 127.096 .339 .848
7 119.8442 126.263 .402 .846
8 119.6482 124.320 .544 .843
9 120.1709 132.405 .124** .853
10 120.4121136.213-.122** .857
11 119.9447 133.113 .089** .853
12 120.6783 133.586 .028** .856
13 119.9146 130.887 .223 .850
14 119.6131 128.370 .394 .847
15 120.3568 131.443 .140** .853
16 119.1005 129.444 .318 .848
17 119.1256 129.878 .295 .849
18 118.9447 129.578 .292 .849
19 118.8543 129.085 .399 .847
20 120.4472 131.945 .077** .857
21 119.2563 125.616 .367 .847
22 118.9095 126.770 .384 .847
23 119.1859 126.657 .413 .846
24 118.9548 124.649 .492 .844
25 119.3920 129.179 .254 .850
26 118.7286 126.936 .420 .846
27 118.7337 127.762 .414 .846
28 118.6734 128.504 .374 .847
29 120.4573 125.886 .411 .846
30 119.7688 125.360 .461 .845
31 119.3618 123.444 .572 .842
32 119.5879 124.233 .494 .844
33 120.4874 124.776 .414 .846
34 120.0050 124.601 .401 .846
35 119.6784 124.957 .454 .845
**Items that have corrected item-total correlation less than 2 are not pass the criterion.
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TABLE 4. Reliability coecients in subdomain and total of the ai Mental Health Literacy Scale (TMHLS).
Factors Number Cronbach'sAlpha
(subdomain) ofItems coefcient
F1 8 .867
F2 6 .683
F3 4 .782
F4 7 .197
F5 7 .873
Note: F1 =ability to recognize mental disorders, F2 = condentiality of mental health practitioners, F3 = skills of mental health information
seeking, F4 = beliefs about mental illnesses, F5 = attitudes toward patient with mental illness; Total Cronbach's alpha coecient =.851
health professional and a history of seeking help from
a mental health professional(s) in person signicantly
correlated with the participants’ mental health literacy
score. e mental health literacy of individuals who had
intimate contact with a mental health professional was
signicantly higher than those who did not (mean±SD
was 127.41±13.96 and 122.37±10.99, respectively; t (200)
= 2.196, p < .05). Likewise, mental health literacy of
individuals who had a history of seeking help from
mental health professional(s) in person was higher than
those who did not (mean±SD was 128.84±10.25 and
122.50±11.55, respectively; t (200) = 2.302, p < .05.)
(Table 5).
TABLE 5. e comparison of mental health literacy by mental health experiences.
Mental health experiences n x S.D. t p
Media (internet/ newspaper/ television)
have 139 123.98 11.94 1.622 .106
nothave 63 121.14 10.49
Having family members or friends with a mental illness
have 110 123.83 11.78 .986 .325
nothave 92 122.22 11.28
Self-experienceofmentaldisorder(s)
have 31 126.16 10.13 1.612 .108
nothave 171 122.54 11.74
Having a mental health professional as an intimate contact
have 29 127.41 13.96 2.196* .029
nothave 173 122.37 10.99
History of seeking help from mental health professional(s)
in person
have 19 128.84 10.25 2.302* .022
nothave 183 122.50 11.55
History of seeking help from mental health professional(s)
for family members or friends
have 16 124.94 10.85 .664 .507
nothave 186 122.94 11.63
* p < .05
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DISCUSSION
e sixth-year medical students
Major depressive disorder was the most common
diagnosis in this study which was in accordance with
previous ai, Malaysian and Chinese Studies.
23-25
e Psychometric properties of the ai mental health
literacy scale (TMHLS)
e TMHLS has good validity. e content validity
by the IOC in the second-round was .85, and only 4
out of 9 items needed to be revised. According to the
original study
15
that stated measurement cannot assess
all attributes of mental health literacy when some of
the items needed to be removed, all items were used in
the scale altogether. Consistent with a previous Persian
study
26
, the EFA of data resulted in ve meaningful factors
that were similar to the original ones
15
, and accounted
for 46.86% of the variance. e trivial dierences could
have been due to cultural diversities of the participants.
Socioeconomic status, cultural and language variances
interact with health literacy.
27
Total Cronbach’s alpha coecient of the TMHLS
was .851 which was considered in a good criterion. e
reliability coecient in subdomains were range from
.197 to .872. Still, there were 6 items that did not meet
the criterion. e Cronbach’s alpha if item deleted for
each item was slightly dierent from the Cronbach’s
alpha of all items. According to the original study
15
that
stated the measurement cannot assess all attributes of
mental health literacy when some of the items needed to
be removed. erefore, those 6 items that do not meet
the criterion were persevered.
e mental health literacy in sixth-year medical students
e mental health literacy of our medical students
was aligned but slightly lower than a prior British study.
13
Our score was marginally inferior than an Australian
study exploring university students.
15
is may uncover
dierences in mental health literacy between developing
and developed countries. e necessity of mental health
literacy acknowledgement in village health workers was
mentioned in a previous ai study.
28
A South African
study urged for mental health education in healthcare
professionals.
29
Language deviance and questionnaire
format may also be responsible for the dierent results.
Our participants had already gained mental health
experiences that may aect their mental health literacy.
Previous works also showed higher mental health literacy
in individuals who encountered mental health problems
than the individuals who did not.
12,30
e more exposure
someone has, the more mentally health literate they are.
12
Consistent with the original study
15
, the mental health
literacy of individuals who had a history of seeking help
from mental health professional(s) in person was higher
than those who did not. Dynamic knowledge transfer
and exchange with a close mental health professional,
like in family businesses
31
, could be a reason for higher
mental health literacy of individuals who had a mental
health professional as an intimate partner than those
who did not.
e questionnaire comments
The main concern about the TMHLS was the
complexity and clarity of the questions. However, the
items that should be allocated were not mentioned. A
separate version of TMHLS between medical students
and general population was advised. Although some
participants described the questionnaire as easy and
clear to answer, an equal number expressed the overly
theoretical concerns. Some of them requested more
attitude questions.
Limitations
Information and recall bias may have been presented
in this observational descriptive cross-sectional study.
Based on purposive sampling method, the results cannot
legitimize any generalizations. We did not perform
back-translation process; hence the quality assurance of
the TMHLS should be concerned. As the EFA is not a
sucient tool to test the theoretical foundations of the
instrument, a conrmatory factor analysis (CFA) should
be conducted to further the knowledge in this area. Since
we used Cronbach’s alpha for reliability testing, the
interitem covariance and the measurement assumptions
error could be considered as the alpha value cannot be
equivalent with the reliability of the test score. Additional
studies in other population are recommended to validate
this instrument to widen its application.
CONCLUSION
e TMHLS has good validity and reliability. Dynamic
knowledge transfer and exchange with a close mental
health professional should be applied to promote mental
health literacy in medical students.
ACKNOWLEDGEMENT
We gratefully acknowledge Matt O’Connor, Ph.D.
for his kind permission to allow us to use MHLS in
this work; the Postgraduate Education Division and
Deputy Dean of Undergraduate Education of Faculty
of Medicine Siriraj Hospital for the scholarship and
permission to collect data, correspondingly. We also
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thank all expert validators, Boonjira ungsuk, M.A.
(English); Tikumporn Hosiri, MD; Panida Yomaboot,
Ph.D. and Kullaya Pisitsungkagarn, Ph.D. for their
superb suggestions about the TMHLS. And last but
not least, we thank all the participants in this study for
their contribution.
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