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10.1136/bmjopen-2023-083374
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Original Research
Public Health
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Knowledge of and attitude towards depression among urban and rural residents in Beijing: a cross-sectional study
http://orcid.org/0000-0001-8884-2808
Cong Anan 12018946215543@163.com

Shang Lili 20shangllpku@163.com

Yan Fang 20yanfang2019@ccmu.edu.cn

Zhao Yanjie 2yzhao118@126.com

Qi Han 34qihan23@126.com

Huang Qingzhi 2cyfox1977@126.com

Li Jingyuan 513911154181@139.com

Sun Hui 62240713426@qq.com

Han Lili 71098964997@qq.com

Zhang Feifei 8chinese_love@126.com

Li Shuxuan 8susanliwisdom@126.com

Ma Laifu 9life163@163.com

Tian Qinghua 10103317808@qq.com

Zhou Qi 111142073825@qq.com

Zhang Ling 212*zlanding@163.com

Wang Gang 113gangwangdoc@ccmu.edu.cn

1 Capital Medical University, Beijing, China
2 Beijing An Ding Hospital, Beijing, Beijing, China
3 Epidemiology and Health Statistics, Capital Medical University School of Public Health, Beijing, Beijing, China
4 Beijing Key Laboratory of Clinical Epidemiology, Capital Medical University School of Public Health, Beijing, Beijing, China
5 Medical Department, The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
6 Haidian District Mental Rehabilitation Hospital, Beijing, China
7 Dongcheng Mental Health Hospital, Beijing, China
8 The Third Hospital of Beijing Chaoyang District, Beijing, China
9 Anjia Hospital, Beijing, China
10 Shunan Hospital, Beijing, China
11 Tongzhou Psychiatric Hospital, Beijing, China
12 Laboratory for Clinical Medicine, Capital Medical University, Beijing, China
13 Department of Psychiatry, Center of Depression, Beijing, China
Professor; gangwangdoc@ccmu.edu.cn
ProfessorLingZhang; zlanding@163.com
None declared.

AC, LS and FY contributed equally.

2024
13 9 2024
14 9 e08337418 12 2023
28 8 2024
Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
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Abstract

Objectives

To compare the level of knowledge of depression, recognition ability and attitudes towards depression among urban and rural residents in Beijing.

Design

A cross-sectional study.

Setting

Six districts in Beijing, China, 2021.

Participants

A total of 6463 participants aged 18 years and above who had lived for more than 6 months over the last year in Beijing were selected in this study.

Outcome

The awareness and recognition of depression and the views of residents towards people with depression.

Results

A total of 2554 urban and 2043 rural residents completed the survey. Urban residents of Beijing exhibited a higher average total score on the Depression Knowledge Questionnaire [(20.4±3.3) vs (18.7±3.5), p<0.001] and a higher rate of correctly identifying individuals with depression (47.9% vs 36.6%, p<0.001) than their counterparts in rural areas. Residents who correctly identified people with depression had higher scores on the Depression Knowledge Questionnaire. Depression knowledge varied significantly among urban and rural residents. The multivariate linear regression analysis revealed that rural residents scored significantly lower on measures of depression knowledge compared with urban residents (B=−0.83, 95%CI=−1.03 to −0.63, p<0.001). Older individuals (aged 50+) showed lower understanding compared with the 18–49 age group, with significant negative regression coefficients (Urban: B=−1.06, Rural: B=−1.35, both p<0.001). Higher educational levels were positively associated with greater depression knowledge (Urban: B=1.40, Rural: B=1.21, both p<0.001). Employment was linked to higher knowledge levels than unemployment (Urban: B=−0.60, Rural: B=−0.58, both p=0.00). A monthly income of 8000 yuan or more correlated with better depression understanding than lower incomes (Urban: B=0.81, Rural: B=1.04, both p<0.001). Additionally, in urban areas, unmarried residents scored higher in depression knowledge than those divorced (B=−0.55, p=0.04). Residents in urban areas had relatively positive attitudes towards individuals with depression.

Conclusions

Rural residents of Beijing had lower levels of knowledge and recognition of depression and more negative attitudes towards individuals with depression than those from urban areas. The health authority needs to focus on the poor level of knowledge and increase mental health resources in rural areas as a priority site for future psychological popularisation efforts.

Depression & mood disorders
Knowledge
Attitude
Health Surveys
Prevention and Control of Major Infectious Diseases grant XM202111 Beijing Key Diseases Flow Control and Prevention grant ZX035 Sci-Tech Innovation 2030- Major Project of Brain Science and Brain-inspired Intelligence Technology project 2021ZD0200600
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pmcSTRENGTHS AND LIMITATIONS OF THIS STUDY

Interviews were conducted with 2554 urban and 2043 rural residents to compare the level of knowledge of depression, recognition ability and attitudes towards depression.

This study added clinical manifestations and treatment items based on the original questionnaire to obtain a more comprehensive grasp of the residents’ knowledge of depression.

However, it should be noted that the conclusion should be cautiously extrapolated to the entire population of Beijing.

This study lacks a survey on the acceptance of health education by Beijing residents. It also does not include the analysis of residents whose residence are different from their working location.

Introduction

Depression is the most common mental disorder and a leading cause of disability worldwide.1 In China, awareness of depression remains inadequate, the rates of recognition and treatment of depression are low, as well as persistent prejudice and discrimination against those with the condition 2. Insufficient knowledge about depression significantly hampers individuals' understanding of the disorder, thereby delaying help-seeking behaviours and adherence to prescribed treatments, ultimately affecting the prognosis for effective management.3 Social stigmatisation and prejudicial attitudes towards individuals with mental health conditions can internalise adverse self-views among patients, exacerbating the severity of their depressive symptoms and reducing their self-esteem.4 These factors collectively deteriorate the quality of life, delay the initiation of therapeutic interventions, hinder rehabilitation and increase the overall burden of the disorder.57

The ‘Healthy China 2030’ initiative underscores the imperative of enhancing mental health by amplifying public awareness campaigns and information dissemination endeavours to enhance mental health literacy and promote the mental health of the population.8

Previous relevant studies in China predominantly focused on assessing the prevalence of knowledge about depression 911. However, due to variations in economic, social and cultural levels across provinces and cities, coupled with rapid societal developments and educational advancements, the representativeness of earlier data has become limited. Meanwhile, there was a notable absence of research examining the capacity for depression recognition and a paucity of comparative investigations discerning disparities between urban and rural residents. As part of a large-scale epidemiological study of the Beijing Mental Health Survey (BMHS), using the Mental Health Indicators Survey Questionnaire as a foundation, which was developed by the Ministry of Health in 2010 to assess the implementation of mental health work scientifically and included a questionnaire on knowledge of mental health and mental healthcare and a case quiz,12 the questionnaire made revisions tailored to the survey objectives of this study, in addition to the general knowledge, aetiological and prognosis of depression, items about clinical manifestations and treatment modalities related to depression were supplemented according to the purpose of the study to understand the residents' knowledge related to depression more accurately. This study explored depression-related knowledge, recognition rates and attitudes towards individuals experiencing depression in the urban and rural areas of Beijing. Targeted knowledge dissemination and educational campaigns aimed at enhancing mental health literacy serve the dual purpose of furnishing empirical data and establishing a scientific foundation for developing mental health-related policies and interventions.

Methods

Participants and sampling

The administrative composition of Beijing comprises 6 urban areas and 10 rural areas as reported by the National Bureau of Statistics.13 This study was a part of BMHS conducted from October to December 2021. Employing a classic four-stage non-proportional stratified sampling method,14 three districts from both the urban (Haidian, Dongcheng and Chaoyang) and rural (Huairou, Shunyi and Tongzhou) areas were selected as survey sites and used to select residents aged 18 years and above who had lived in Beijing for more than 6 months in the previous year and exclude residents who were blind, pregnant women and persons living in closed communities within Beijing (eg, enterprises, institutions, construction zones, military establishments, schools, hospitals, nursing homes, etc.). Out of 6463 initial samples across these districts, 4597 completed the survey after accounting for non-responses and refusals, resulting in a response rate of 71.13%.

Research tool

Demographics

The socio-demographic attributes of the respondents were assessed regarding gender, age, nationality, duration of education, employment status, monthly income, marital status and religious affiliation.

Depression knowledge questionnaire

According to the Knowledge of Mental Health and Mental Disease Prevention in the General Population in the Mental Health Indicators Survey Questionnaire,12 the self-made questionnaire consisted of 26 items. Items 1, 2 and 3 assessed general knowledge about depression. Knowledge of the causes of depression was evaluated using items 4, 5, 7, 8 and 13. Depressive symptoms and treatment knowledge were measured with items 9, 10, 11, 12, 14 and 26, and items 6, 16, 18, 19, 20, 21, 22 and 23, respectively. Items 15, 17, 24 and 25 were used to assess prognostic understanding of depression. Participants were instructed to provide binary responses by selecting ‘Yes’ or ‘No’.

Case quiz questionnaire

The case quiz questionnaire is a short medical record and eight-item scale that describes the symptoms of a case suffering from depression first and then captures respondents’ understanding and attitude towards depression by asking them their insights and views about the case.12

Case: Mr. Wang, 30 years old, has been feeling very sad and gloomy in recent weeks. He always feels tired and has difficulty falling asleep almost every night. He has no appetite and has lost weight. Concentrating on work, making decisions or even coping with daily tasks are difficult, which caught the attention of his boss, who was worried about his inefficiency.

Item 1 was designed to identify whether the residents can recognise depression. Item 2 aimed to investigate the residents‘ understanding of the aetiology of depression. Item 3 sought to assess the residents‘ knowledge on how to provide support for individuals with depression. Item 4 focused on exploring the perceptions of the residents towards individuals with depression. Item 5 was about figuring out whether the residents believe they would get depression in the future. The residents were asked in items 6, 7 and 8 whether they believed individuals with depression possessed the cognitive capacity to differentiate between right and wrong, the ability to engage in work activities and the potential for causing harm.

Procedure

The study was approved by the Ethics Committee of Beijing Anding Hospital affiliated with Capital Medical University. All respondents provided written informed consent.

This study used a face-to-face interview mode, each item was read aloud to respondents without any explanation by a highly trained interviewer who had passed a consistency test, and the respondents' answers were recorded using a software application on the tablet devices carried by the investigators. This bespoke software, developed by professional engineers specifically for this survey, encompasses modules such as raw data entry, data result export at each sampling point and quality control.

Statistical analyses

Descriptive statistics, including means, SDs, frequencies and percentages, were used to characterise the socio-demographic attributes and questionnaire item scores. X2 tests and t-tests assessed differences in demographic characteristics between urban and rural groups. The depression knowledge total scores were examined across various socio-demographic characteristics using t-tests and analysis of variance. Multiple linear regression analysis was used to explore the correlation between depression recognition and depression knowledge questionnaire scores and the associated factors of depression knowledge total score among residents in Beijing. The statistical significance level was assigned at p<0.05 (two-tailed). All statistical analyses were conducted using the Statistical Package for the Social Sciences version 28 (IBM Inc., Armonk, New York, USA).

Patient and public involvement

No patients were involved in this study.

Results

Sociodemographic characteristics

This survey included 4597 respondents, of which 2554 were from urban areas of Beijing and 2043 from rural areas.

There were no significant differences in gender, nationality and employment status across urban and rural residents in Beijing (p>0.05). However, urban residents had higher education levels and monthly incomes than rural residents. Rural areas exhibited a higher religious adherence prevalence than their urban area counterparts. In addition, significant disparities among respondents were observed concerning age and marital status when comparing urban and rural areas (P＜0.001). The detailed socio-demographic characteristics of the respondents in this study are shown in table 1.

Table 1 Socio-demographic characteristic

Features	Urban (n=2554)	Rural (n=2043)	Univariable analysis	
N (%)	N (%)	χ2	P	
Gender			0.08	0.78	
 Female	1497 (58.6)	1206 (59.0)	
 Male	1057 (41.4)	837 (41.0)	
Nationality			0.13	0.71	
 Ethnic Han	2437 (95.4)	1954 (95.6)	
 Minority	117 (4.6)	89 (4.4)	
Employment status					
 Employed	1210 (47.4)	957 (46.8)	0.13	0.72	
 Unemployed	1344 (52.6)	1086 (53.2)			
Monthly income (yuan)					
 0–2999	328 (12.9)	1087 (53.2)	906.14	<0.001	
 3000–7999	1544 (60.6)	776 (38.0)			
 ≥8000	677 (26.6)	179 (8.8)			
Marital status					
 Unmarried	201 (7.9)	93 (4.6)	48.80	<0.001	
 Married	1957 (76.6)	1732 (84.8)			
 Divorced/other	396 (15.5)	218 (10.7)			
Religious affiliation			28.88	<0.001	
 No religion	2395 (93.8)	1986 (97.2)	
 Religion	157 (6.2)	57 (2.8)	
	Mean (SD)	Mean (SD)	t	P	
 Age (years)	53.9 (15.6)	53.6 (13.7)	0.6	0.28	
 Duration of education (years)	12.8 (3.8)	10.2 (3.5)	23.6	<0.001	

Knowledge of depression

The average score [(20.4±3.3) vs (18.7±3.5), t=17.3, p<0.001] of the knowledge questionnaire of the samples from urban areas was higher than those of the samples from rural areas. The scores of five items in the Depression Knowledge Questionnaire (items 7, 9, 12, 21 and 26) were not significantly different among different regions. Except for item 6, the scores of other items in urban samples were higher than those in rural samples. Among the 26 items, item 24, ‘Optimistic and cheerful attitude towards life, good interpersonal relationships, and healthy living habits help us to maintain mental health’ had the highest correct rate (99.6% and 98.6% in urban and rural areas, respectively). Item 5’‘Depression is due to introversion, too sensitive ’, item 8 ‘If you're open-minded, you won't be depressed’, and item 21 ‘long-term use of antidepressants will cause dependence’ had relatively lower correct rates (47.9%, 41.7%, 32% and 25.8%, 21.3% and 32.5% in urban and rural areas, respectively). Table 2 details the accuracy rate of each item of the Depression Knowledge Questionnaire.

Table 2 Comparison of the accuracy rate of each item of the questionnaire / N (%)

Item	Urban (n=2554)	Rural (n=2043)	χ2	P	
Depression is not a mental illness.	1896 (74.3)	1296 (63.4)	63.08	<0.001	
Depression is a common disease.	1810 (70.9)	1393 (68.2)	4.04	0.05	
Depressive symptoms can occur at almost any age.	2305 (90.3)	1736 (85.0)	30.61	<0.001	
Depression is caused by stimulation.	1413 (55.4)	693 (33.9)	210.24	<0.001	
Depression is due to introversion, too sensitive.	1223 (47.9)	528 (25.8)	234.85	<0.001	
If you suspect a psychological problem or depression, go to visit a psychologist or psychiatrist.	2283 (89.5)	1877 (91.9)	7.72	0.01	
People with a family history of depression are more likely to develop depression than the general population.	2016 (79.0)	1588 (77.7)	1.13	0.29	
If you're open-minded, you won't be depressed.	1063 (41.7)	435 (21.3)	214.09	<0.001	
The common manifestations of depression are low mood, loss of interest and low efficiency.	2365 (92.7)	1899 (93.0)	0.10	0.75	
Not happy is depression.	2041 (80.0)	1216 (59.5)	230.78	<0.001	
Sleep problems are one of the common symptoms of depression patients.	2133 (83.6)	1642 (80.4)	8.14	0.00	
Feeling uncomfortable or aching everywhere can be a sign of depression.	1206 (47.3)	974 (47.7)	0.07	0.79	
Some women experience symptoms of depression after childbirth.	2264 (88.7)	1710 (83.8)	24.02	<0.001	
If you don't think about suicide, it’s not depression.	2243 (87.9)	1528 (74.8)	132.41	<0.001	
Depression does not affect learning efficiency or ability to work.	2287 (89.7)	1675 (82.0)	56.19	<0.001	
Depression can go away without treatment.	2116 (82.9)	1626 (79.6)	8.28	0.00	
The vast majority of depression is incurable.	2120 (83.1)	1585 (77.6)	21.88	<0.001	
Diagnosed with depression, take medicine for a period of time, and you can stop taking medicine when your condition gets better.	1909 (74.9)	1277 (62.5)	81.10	<0.001	
You don't have to treat depression if it’s not suicidal.	2389 (93.6)	1728 (84.6)	99.48	<0.001	
Antidepressants are harmful to the body and should be avoided as much as possible.	1703 (66.8)	1160 (56.8)	47.83	<0.001	
Long-term use of antidepressants can lead to dependence.	816 (32.0)	664 (32.5)	0.15	0.70	
The duration of medication for depression should be determined according to each person’s attack cycle, and the doctor’s specific advice should be listened to.	2526 (99.0)	1985 (97.2)	21.22	<0.001	
Recurrent episodes of depression require long-term treatment.	2474 (97.0)	1915 (93.8)	27.38	<0.001	
An optimistic and cheerful attitude towards life, good interpersonal relationships and healthy living habits help us to maintain mental health.	2541 (99.6)	2013 (98.6)	15.74	<0.001	
Moderate exercise benefits emotional health and can prevent and relieve anxiety and depression.	2535 (99.4)	2005 (98.2)	13.96	<0.001	
In the process of taking antidepressants, if there is more than the average level of happiness, talk more, the brain turns faster than usual, energy, sleep less and not sleepy, the plan is more than usual, to be vigilant about the possibility of phase change, to go to the doctor in time to reflect their condition changes.	2431 (95.3)	1966 (96.3)	2.49	0.12	

Multivariate analysis of depression knowledge

The aggregate depression knowledge scores based on different socio-demographic features are shown in table 3. Urban residents’ depression knowledge scores exhibit significant differences across various factors such as age, duration of education, employment status, monthly income and marital status. Similarly, rural residents’ depression knowledge scores also demonstrate notable disparities with respect to age, nationality, duration of education, employment status, monthly income and marital status.

Table 3 Differences in depression knowledge total scores by socio-demographic characteristics

Group	Urban (n=2554)	Rural (n=2043)	
N	Depression knowledge total score (Mean±SD)	T	P	N	Depression knowledge total score (Mean±SD)	T	P	
Gender	 	 	 	 	 	 	 	 	
 Female	1497	20.51±3.39	3.42	0.06	1206	18.76±3.48	0.62	0.11	
 Male	1057	20.25±3.23	 	 	837	18.51±3.44	 	 	
Age (years)	 	 	 	 	 	 	 	 	
 18–49	1032	21.96±2.86	15.75	<0.001	718	20.69±3.12	2.55	<0.001	
 ≥50	1522	19.35±3.21	 	 	1325	17.55±3.13	 	 	
Nationality	 	 	 	 	 	 	 	 	
 Ethnic Han	2437	20.40±3.33	1.11	0.82	1954	18.61±3.47	2.76	0.00	
 Minority	117	20.47±3.18	 	 	89	19.75±3.29	 	 	
Duration of education (years)	 	 	 	 	 	 	 	 	
 0–8	230	17.78±3.13	266.03	<0.001	540	16.76±3.17	273.83	<0.001	
 9–12	1084	19.42±3.02	 	 	1085	18.53±3.07	 	 	
 ≥13	1240	21.75±3.02	 	 	418	21.44±2.98	 	 	
Employment status	 	 	 	 	 	 	 	 	
 Employed	1210	21.68±2.99	3.24	<0.001	957	19.92±3.35	0.77	<0.001	
 Unemployed	1344	19.25±3.19	 	 	1086	17.55±3.18	 	 	
Monthly income (yuan)	 	 	 	 	 	 	 	 	
 0–2999	328	19.42±3.39	135.28	<0.001	1087	17.74±3.37	126.62	<0.001	
 3000–7999	1544	19.88±3.24	 	 	776	19.28±3.20	 	 	
 ≥8000	677	22.09±2.77	 	 	179	21.55±2.97	 	 	
Marital status	 	 	 	 	 	 	 	 	
 Unmarried	328	21.96±2.99	43.99	<0.001	93	21.25±3.49	40.72	<0.001	
 Married	1544	20.46±3.24	 	 	1732	18.67±3.43	 	 	
 Divorced/other	677	19.34±3.57	 	 	218	17.45±3.13	 	 	
Religious affiliation	 	 	 	 	 	 	 	 	
 No religion	2395	20.42±3.30	1.11	0.27	1986	18.67±3.47	0.22	0.31	
 Religion	157	20.11±3.69	 	 	57	18.19±3.46	 	 	

After adjusting for covariates including gender, age, nationality, duration of education, employment status, monthly income, marital status, and religious affiliation, the multivariate linear regression analysis revealed that rural residents scored significantly lower on measures of depression knowledge compared with urban residents (B=−0.83, 95%CI=−1.03~−0.63, p<0.001). The independent associated factors of depression knowledge total score of urban residents and rural residents are shown in table 4. We found that both urban and rural residents, aged 50 and above residents had a lower overall understanding of depression knowledge than those in the 18–49 age group (B=−1.06, 95%CI=−1.40~−0.71, p<0.001; B=−1.35, 95%CI=−1.73~−0.97, p<0.001). Education level was also found to be a significant factor, as individuals with higher levels of education scored higher on depression knowledge (B=1.40, 95%CI=0.98~1.82, p<0.001; B=1.21, 95%CI=0.89~1.54, p<0.001). Employed individuals also demonstrated a higher level of understanding than the unemployed (B=−0.60, 95%CI=−0.94~−0.26, p=0.00; B=−0.58, 95%CI=−0.91~−0.25, p=0.00). Residents with a monthly income of 8000 yuan or above had a better understanding of depression than those with the monthly income of 2999 yuan (B=0.81, 95%CI=0.37~1.25, p<0.001; B=1.04, 95%CI=0.49~1.59, p<0.001). Furthermore, for urban residents, unmarried residents had a higher total score of depression knowledge compared with divorced status residents (B=−0.55, 95%CI=−1.08~−0.03, p=0.04).

Table 4 The multiple linear regression analysis of the depression knowledge total scores

Constant	Urban (n=2554)	Rural (n=2043)	
Unstandardized coefficients	Standardised coefficients	T	P	Unstandardized coefficients	Standardised coefficients	T	P	
B	Std. error	β	B	Std. error	β	
Age (years)	 	 	 	 	 	 	 	 	 	 	
 18–49*	0	 	 	 	 	0	 	 	 	 	
 ≥50	−1.06	0.18	−0.16	−5.98	<0.001	−1.35	0.19	−0.19	−7.01	<0.001	
Nationality	 	 	 	 	 	 	 	 	 	 	
 Ethnic Han*	–	0	 	 	 	 	
 Minority	0.38	0.32	0.02	1.19	0.24	
Duration of education (years)	 	 	 	 	 	 	 	 	 	 	
 0–8*	0	 	 	 	 	0	 	 	 	 	
 9–12	1.40	0.21	0.21	6.56	<0.001	1.21	0.16	0.17	7.36	<0.001	
 ≥13	2.61	0.23	0.40	11.19	<0.001	2.74	0.25	0.32	10.76	<0.001	
Employment status	 	 	 	 	 	 	 	 	 	 	
 Employed*	0	 	 	 	 	0	 	 	 	 	
 Unemployed	−0.60	0.17	−0.09	−3.46	0.00	−0.58	0.17	−0.08	−3.46	0.00	
 Monthly income (yuan)	 	 	 	 	 	 	 	 	 	 	
 0–2999*	0	 	 	 	 	0	 	 	 	 	
 3000–7999	0.11	0.18	0.02	0.58	0.56	0.31	0.15	0.04	2.04	0.04	
 ≥8000	0.81	0.22	0.11	3.62	<0.001	1.04	0.28	0.08	3.72	<0.001	
Marital status	 	 	 	 	 	 	 	 	 	 	
 Unmarried*	0	 	 	 	 	0	 	 	 	 	
 Married	−0.19	0.22	−0.03	−0.86	0.39	−0.34	0.33	−0.03	−1.02	0.31	
 Divorced/Other	−0.55	0.27	−0.06	−2.06	0.04	−0.70	0.39	−0.06	−1.78	0.08	
* : Control Group.

Recognition of depression

The views and attitudes towards people with depression in urban and rural residents are summarised in table 5. The overall recognition rate of depression, denoting the proportion of participants who answered ‘depression’ in the first question of the Case Quiz Questionnaire, stood at 42.9%. Within urban areas of Beijing, 47.9% of the participants could recognise depression, surpassing the recognition rate of 36.6% observed in rural areas (X2=92.7, p<0.001).

Table 5 Comparison of urban area and rural area residents' recognition of depression and views and attitudes towards depression (N, %)

Item	Urban	Rural	χ2	P	
1. His problem is most likely to be:			92.71	<0.001	
 Excessive fatigue	602 (23.6)	597 (29.2)	
 Poor physical health	82 (3.2)	97 (4.7)	
 Neurasthenia	488 (19.1)	474 (23.2)	
 Depression	1223 (47.9)	747 (36.6)	
 Be bewitched	12 (0.5)	18 (0.9)	
 Others	24 (0.0)	4 (0.0)	
 Unknown	119 (4.7)	105 (5.1)	
2. The main reason you think the case became what he is now is:			23.93	0.00	
 Suffering from negative life events	166 (6.5)	134 (6.6)	
 Excessive work pressure	1720 (67.3)	1425 (69.8)	
 Hereditary disease	66 (2.6)	48 (2.3)	
 Inappropriate thoughts	382 (15.0)	313 (15.3)	
 Be possessed	7 (0.3)	14 (0.7)	
 Others	29 (1.1)	7 (0.3)	
 Unknown	178 (7.0)	100 (4.9)	
3. If you want to help him, you will advise him to:			50.32	<0.001	
 Talk to a trusted friend or family member and talk about your pain	536 (21.0)	423 (20.7)	
 Take plenty of rest, no special measures are required	288 (11.3)	334 (16.3)	
 See a doctor of internal medicine	68 (2.7)	47 (2.3)	
 See a doctor of traditional Chinese medicine	93 (3.6)	106 (5.2)	
 See a psychiatrist	633 (24.8)	435 (21.3)	
 Get psychological counselling	855 (33.5)	609 (29.8)	
 Others	24 (0.9)	15 (0.7)	
 Unknown	53 (2.1)	73 (3.6)	
4. In your opinion, what will the people around the case think of him:			49.35	<0.001	
 People around him might think he is strange	238 (9.3)	159 (7.8)	
 People around him might worry about what bad things he will do	680 (26.6)	552 (27.0)	
 People around him might think he is pitiful	296 (11.6)	229 (11.2)	
 No opinion	1246 (48.8)	1088 (53.3)	
 Others	89 (3.5)	14 (0.7)	
5. Do you think you may be in the same situation as the case in the future:			11.54	0.01	
 Yes	365 (14.3)	234 (11.5)	
 No	1951 (76.4)	1631 (79.8)	
 Unknown	232 (9.1)	177 (8.7)	
6. Do you think the case still has the ability to judge right from wrong in this situation:			25.93	<0.001	
 Yes	1855 (72.6)	1389 (68.0)	
 No	314 (12.3)	356 (17.4)	
 Hard to say	380 (14.9)	297 (14.5)	
7. Do you think the case still has the ability to work in this situation:			91.53	<0.001	
 Yes	342 (13.4)	339 (16.6)	
 Yes after rest	790 (30.9)	599 (29.3)	
 Yes after treatment	1329 (52.0)	910 (44.5)	
 No	88 (3.4)	194 (9.5)	
8. Do you think the case is more harmful than the ordinary people:			37.26	<0.001	
 Yes	560 (21.9)	478 (23.4)	
 No	1386 (54.3)	1133 (55.5)	
 Unknown	595 (23.3)	387 (18.9)	

Views and attitudes of depression

Most of the urban and rural residents (67.3% and 69.8% respectively) think that too much working pressure is the main cause of depression. Counselling was the preference of 33.5% and 29.8% of residents in urban and rural areas, whereas 24.8% and 21.3% of residents opted to see a psychiatrist, respectively. Significant differences were found between attitudes from people living in urban and rural areas towards individuals with depression, judgments about their ability to discriminate between right and wrong, harmfulness and the ability to work (all p<0.05). After adjusting the demographic factors, residents who could correctly identify patients with depression had higher scores on the Depression Knowledge Questionnaire.

Discussion

A previous study has revealed that individuals residing in urban regions exhibit a higher prevalence of depression when contrasted with those in rural regions.15 Despite this, urban populations benefit from a richer array of healthcare resources.16 Building on this foundation, our investigation delves deeper into the disparities in depression-related knowledge between urban and rural communities. This study found that compared with rural residents of Beijing, urban residents had better knowledge and a higher recognition rate of depression. Males and residents with older ages, lower education years, unemployed, lower monthly income and married and divorced tended to have poor knowledge about depression in Beijing, which was consistent with previous reports.91720

Differential analysis of depression knowledge between urban and rural areas

Studies from developing countries, based on uncorrected comparisons, often report significant disparities in health literacy levels between rural and urban populations, partly due to poverty and rapid urbanisation,21 22 and these differences are exacerbated by uneven resource distribution, lower availability of healthcare resources and differing socioeconomic statuses, leading to variations in health knowledge awareness between urban and rural residents.16 Second, geographic isolation and lack of local health responses can affect rural residents' acquiring, processing and understanding of relevant knowledge.22 Third, urban areas typically experience higher working and social stress, increasing residents' susceptibility to stress-related mental problems,23 prompting a proactive pursuit of relevant knowledge. In addition, rural residents may have their own distinctive cultures of beliefs and practices and hold traditional beliefs about the causes of disorder that differ from mainstream biomedical explanations, which can lead to poorer health outcomes.22 Concurrently, the stronger stigma associated with mental illness in rural areas leads to secrecy and subjective misperceptions about depression, impeding objective and scientific understanding.24

Factors influencing depression knowledge were also associated with age, duration of education, employment status, income and marital status. Older residents have lower levels of knowledge, which may be related to their education, social networks, social support and health status.25 Therefore, it is recommended to intensify the dissemination of depression-related information among the elderly population, especially those in rural areas, leveraging multiple communication channels such as television, public service advertisements and health lectures, and the adoption of an easy-to-understand approach can be effective in improving the attention and comprehension of depression among older adults.26 27 Furthermore, unmarried urban residents typically demonstrate higher depression knowledge literacy compared with those who are divorced. This may be related to the fact that married residents depend on their spouses, which may reduce the opportunity to learn about the healthcare system or health information.28 At the same time, unmarried status is also affected by age, which affects knowledge level to a certain extent. Future health promotion priorities should also include divorced residents.

Previous studies have shown that educational level was found to affect the level of health literacy and make a significant contribution to it.29 The present study’s findings illustrate that individuals with greater educational attainment exhibit a more advanced level of knowledge regarding depression. This could potentially be attributed to an amplification in their access to information, as well as their experiential background. Conversely, limited access to culturally appropriate healthcare services can pose significant challenges for low-income residents. Urban residents, who typically have higher levels of education and income, demonstrated a superior understanding of depression compared with their rural counterparts, aligning with earlier findings.9 22 30 Additionally, employed individuals exhibit better health literacy than the unemployed, a factor attributable to greater information exposure and a broader knowledge base within their work environments.31 This correlation is also supported by the necessity for higher education in obtaining employment, which subsequently increases the economic income and access to healthcare resources, thus enhancing health literacy.32 Furthermore, Halverson et al found that differences in health literacy between rural and urban groups were primarily mediated by educational and income disparities, rather than rural or urban settings per se.33

Knowledge of the aetiology and symptoms of depression

The Depression Knowledge Questionnaire revealed notably low correct rates on items related to the aetiology of depression. A predominant belief among most participants was that depression stemmed from introverted personality traits and heightened sensitivity, with the conviction that adopting a more open mindset could serve as a preventive measure. Furthermore, some participants attributed depression to external factors, such as workplace stressors. Concerning the symptomatic manifestation of depression, it was noted that over half of the respondents were unaware that somatic discomfort could also indicate depression. This misunderstanding may delay the initiation of treatment, particularly among rural residents.

A majority of the interpretations regarding depression, as articulated by participants residing in both urban and rural areas, predominantly focused on elevated work pressure. This phenomenon might indicate cultural influences, whereby individuals often attribute the condition to circumstances deemed more socially acceptable by the general population, such as excessive stress, heightened anxiety or unsatisfactory professional performance.34 35 Currently, the aetiology of depression remains unclear, with the prevailing understanding suggesting a complex interplay of multifarious factors, encompassing both internal and external elements.36 Nevertheless, only a small proportion of residents believe that the main reason of depression is hereditary attributes, thus indicating a pressing requirement for heightened dissemination of information concerning the aetiology of depression.

Knowledge of treatment of depression

Regarding the treatment of depression, only 24.8% and 21.3% of urban and rural residents chose to see a psychiatrist, while a larger number preferred psychological counselling, aligning with findings from previous studies.37 These observations suggest that the residents exhibit a limited understanding of depression and display a relatively low inclination towards psychiatric medical interventions. Such reluctance might reflect a prevalent bias against pharmaceutical treatments for depression, favouring counselling approaches instead. Consequently, enhancing awareness and education about psychiatric medications should be a primary focus of mental health initiatives. Additionally, an overwhelming proportion, exceeding two-thirds of the residents, held the belief that prolonged usage of antidepressants could engender dependency and one-third of them perceived that medication could be discontinued once their condition ameliorated. This lack of medication adherence is particularly pronounced in rural areas. Therefore, improving mental health knowledge is crucial to boosting medication compliance, enhancing patient conditions and quality of life and increasing patient satisfaction rates.38 39

Recognition of depression

Urban residents demonstrated a notably higher ability to accurately identify individuals afflicted with depression, a proficiency that correlated with their broader knowledge of the condition. It is not difficult to explain that a higher reserve of depression knowledge equips individuals to understand better and identify patients with depression. This study recorded an overall depression recognition rate of 42.9% among residents, which surpasses the rates observed in previous studies conducted in other parts of the country.2 40 41 However, it is notable that the overall recognition rate remains relatively modest. Hence, continued efforts are needed to promote depression recognition and within rural areas specifically, potentially incentivising them to seek professional assistance when required.42 43

Attitude towards people with depression

Most residents do not have a particular view of people with depression. It is noteworthy that a greater proportion of urban residents, compared with rural residents’ counterparts, have concerns about their susceptibility to future experiences of depression. This observed discrepancy is potentially associated with the heightened work demands, accelerated pace of life and elevated stress levels of urban areas, underscoring the necessity for early intervention targeting this subpopulation. In addition, more urban residents believe that people with depression have the ability to recognise right from wrong and can continue to work after treatment or rest, suggesting that urban residents have a more positive attitude towards people with depression, which is also consistent with previous research findings.44 Conversely, findings from an earlier study indicated that urban residents of Beijing have a higher negative attitude towards individuals with mental disorders than those in rural areas of Beijing.45 Considerable emphasis has traditionally been directed towards the bias within residents' understanding of preventive treatment for depression, with comparatively limited attention afforded to aspects related to the prognosis of individuals with depression and the constructive facets of their societal functional capabilities. Notably, certain media tend to accentuate scant facets of depression that attract public attention, thereby inadvertently reinforcing a negative attitude towards depression in the general population. It is suggested that we should not only improve the awareness rate of depression knowledge among the residents but also give people a correct understanding of the patients with depression through effective propaganda strategies. Additionally, it is prudent to adequately reinforce the positive portrayal of the social functional capacities of individuals living with depression, consequently mitigating discrimination towards those with depression.

Conclusion

While disparities exist regarding the questionnaires employed compared with other studies, this study refrains from a direct quantitative comparison of the results. Nevertheless, the overarching assessment reveals a general inadequacy in the residents' comprehension of depression, notably characterised by the lower levels of depression-related knowledge and recognition rates among rural residents, as well as a relatively more negative attitude towards individuals with depression. The health authority needs to focus on the weak level of knowledge and increase mental health resources in rural areas as a priority site for future psychological popularisation efforts. However, evidence suggests that rural areas alone do not fully explain these differences, including factors such as age, education and economic income often responsible for urban–rural differences. Therefore, it is significant to carry out relevant knowledge education for specific subgroups and publicity for the weak part of depression knowledge to reduce the urban–rural health gap.

Acknowledgements

We are grateful to all respondents and respondents' families from six districts of Beijing. The authors would also like to thank the full support of the Beijing Municipal Health Commission, the Beijing Mental Health Care Institute and the Mental Health Prevention and Control Centers of all six Beijing districts.

Data availability statement

Data are available upon reasonable request.

Review Process File
13 09 2024

Funding: This survey was supported by the Sci-Tech Innovation 2030- Major Project of Brain Science and Brain-inspired Intelligence Technology project (2021ZD0200600). Financial support was also provided by a Beijing Key Diseases Flow Control and Prevention grant (ZX035) and a Prevention and Control of Major Infectious Diseases grant (XM202111).

Prepublication history for this paper is available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2023-083374).

Patient consent for publication: Not applicable.

Ethics approval: This study involves human participants and was approved by Ethics Committee of Beijing Anding Hospital (MR-11-23-010737) Participants gave informed consent to participate in the study before taking part.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Data availability free text: Data are available on reasonable request. The data are not publicly available due to privacy or ethical restrictions.
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