The research findings revealed that the Brazilian Portuguese version of the MHLS exhibited a four-factor structure, in a shorter version, containing 18 items with adequate factor loadings and high reliability indices. These aspects indicate that the instrument is internally consistent and reliable, and is effective in measuring mental health literacy.
In agreement with what was found in other attempts to validate the MHLS, the confirmatory factor analysis indicated that the model with a single-factor structure does not present a good fit. In fact, the four-factor structure, which was found to be the most appropriate for the MHLS, is consistent with the findings of other studies [17, 22, 23]. The validation of the instrument for Portugal [16] revealed a set of items similar to that found in this study but with a different structure. The European Portuguese version has three factors.
Although the structure is similar, the present version is shorter than the Slovenian, Saudi Arabian, and Vietnamese versions, considering that the factor loadings of some items were lower. This is probably because the sample in this research is more heterogeneous than the others. This can be seen by the greater flattening of the distribution of MHLS values in the sample of the present study (Kurtosis: 0.684) in relation to the others O’Connor and Casey (2015) = −0.231; Krohne et al. (2022) = 0.41; BinDhim et al. (2023) = −0.05, suggesting that there is more variation in the scores, with a greater number of individuals with very high or very low results than in the other versions of the MHLS.
The differences in scales validated for different contexts can be attributed to variations in population characteristics and sampling methods. This study utilized a representative sample from the Federal District in Brazil, a region distinguished by its diverse and mixed population due to historical migration from various parts of Brazil. Consequently, this area displays greater diversity and socioeconomic disparity compared to countries like Saudi Arabia [17] and Slovenia [23], featuring significant ethnic, social, economic, and cultural distinctions. In contrast, other studies, such as the one by O’Connor and Casey (2015), used sampling methods like the snowball technique, which tends to produce more homogeneous samples by involving participants who are interconnected.
Additionally, the construct of mental health literacy may evolve over time, suggesting that future studies could explore the development of new scales to better capture this dynamism. Nevertheless, our research provides critical insights into the validity of the MHLS within a heterogeneous and culturally diverse setting in the global south. It lays a solid foundation for subsequent studies aimed at evaluating the construct’s validity across various Brazilian demographics, extending work previously initiated in Buta et al. [24].
However, regarding the distribution of scores, the scores in the present study were more similar to those found by the Slovenian and Saudi Arabic versions [17, 23] than to those of the original Scale [11], which is quite asymmetric. The asymmetry to the left suggests that more people tend to have higher mental health literacy scores, with fewer individuals presenting very low scores.
Categories adopted for the factors were similar to those adopted in the Slovenian and Saudi Arabic versions[17, 23], covering: attitudes towards people with mental disorders, which refers to aspects related to social stigma behavior; general attitudes toward mental health, related to the behavior of denying the disorder; mental health recognition, referring to the skills to recognize disorder and seek treatment; and information seeking, related to the knowledge about where to look for information.
The results demonstrated a strong positive correlation between the total scores from both scales, indicating that the reduction in the number of items did not affect the construct. Additionally, the theoretical aspect was considered, revealing substantial similarities with the literature, as previously noted. It is important to mention that the remaining items encompass the attributes stated in the original scale, except for those that include specific aspects of Australian culture (e.g., ‘Knowledge of risk factors and causes’) or those requiring very specific or in-depth technical knowledge (e.g., ‘To what extent do you think it is likely that Cognitive Behavior Therapy (CBT) is a therapy based on challenging negative thoughts and increasing helpful behaviors’, or ‘To what extent do you think it is likely that Dysthymia is a disorder’). In short, adapting the MHLS to Portuguese offers a more parsimonious scale, facilitating its application with potential research subjects.
The average score of the present sample is 123.01, which is lower than that found by O’Connor and Casey (2015), 127.38 for Australian adults; Brooker and Tocque (2023), 128 for probation staff in European countries; and Dias et al. (2021), 129.1 for Portuguese adults. However, several studies reported lower overall MHLS scores; for example, Dang et al.(2018) reported a score of 106.15 for Vietnamese teachers; Dessauvagie et al. (2022) reported a score of 108.13 for Vietnamese and Cambodian university students; Krohne et al. (2022) reported a score of 114.09 for the Slovenian general population; BinDhim et al. (2023) reported a score of 115.5 for Arabic-speaking Saudi adults; and Snow et al. (2023) reported a score of 121 for Polynesian adults residing in the USA.
We observed a difference in mental health literacy according to gender, with women having higher MHL than men. This finding is in line with most of the literature [14,15,16,17,18,19,20]. These findings may reflect strong cultural characteristics. Men tend to perceive the recognition of mental disorders, the expression of emotional challenges, and the seeking of external help as signs of personal weakness and typically feminine behaviors [15, 33].
Age also proved to be a relevant factor for the MHLS score. We observe higher levels of literacy among young adults (18–30 years old) and people over 50 years old. A greater prevalence of mental health literacy was observed in individuals aged 30 to 40 years in some studies thatincluded general samples of the community [15, 16, 19]. Others observe higher levels of mental health literacy among younger groups (18-22) [14, 20] These studies, however, focus on university students. There are still those who do not observe significant differences in the level of MHLS between different age groups[18]. However, it has been observed in the literature that people over fifty years of age have lower levels of health literacy [15, 18], which could be related to a negative attitude toward mental health, given the loss of vocational activity related to retirement [15], or even intergenerational cultural differences.
We also observed higher MHL scores in people with higher educational levels. This finding is in line with the literature [13, 14, 16,17,18,19,20]. However, it is interesting to note that groups with ongoing undergraduate courses had higher MHL scores than groups of people who had completed higher education.
The type of health service used by the respondents was another factor related to the level of MHL. Those who use private services have greater literacy than those who use public services. Although no significant differences were observed depending on income, this result may be related to income, since people who exclusively use private health services tend to have higher income levels than those who use public services. In fact, not having observed significant differences in MHS depending on income may be a bias related to this sample, since this is a factor described in the literature as capable of influencing MHL [19, 20].
Furthermore, there is evidence of significant differences in MHL between groups of people with certain health conditions. People who suffer from common mental health disorders, such as depression and anxiety, tend to have higher MHLS scores. This finding is consistent with other studies reporting higher levels of literacy in people previously diagnosed with mental disorders [11, 14, 17, 18, 20]. It is possible that people who have been diagnosed and accepted such a diagnosis are more likely to seek help. In fact, people who are aware of mental health issues tend to be more inclined to seek professional help [20]. In addition, prior contact with mental health professionals tends to increase knowledge about personal treatments.
Finally, no significant differences in MHL were observed depending on race, labor situation, housing condition, or use of medication. There are indications in the literature about the relationships between MHL and labor situation and housing conditions, which contradicts these findings. People who lose their vocational activity tend to have negative mental health outcomes. In addition, married people who have greater family support tend to experience positive attitudes toward mental health [15].
This study has some limitations. First, it is important to state that the sample was not obtained randomly, so the results cannot be extrapolated to the population. Also, the study is based on a translation of the MHLS previously made by other researchers, so the authors had no control over this process. Moreover, other factors not assessed here may be related to mental health literacy, such as profession, history of mental disorders in family members, educational level of the respondents’ parents, etc. This should be observed in future studies. In addition, the differences found in the MHL across various sociodemographic characteristics and health conditions are based on direct peer comparisons within these specific groups. To ensure that these differences are not affected by other variables, other analyses are needed.
Despite these limitations, it should be highlighted that no previous MHLS evaluations carried out with Brazilians were found. Therefore, to the best of our knowledge, this is the first study that measures the MHLS in a sample of Brazilians. In addition, a shorter version of the MHLS adheres to the principle of parsimony, allowing a few items to measure the same construct effectively. This simplification enhances the instrument’s applicability and the efficiency of the data collection process. Furthermore, the four-dimensional structure provides significant informational gains by enabling the distinction of various aspects that constitute the MHL construct, which a one-dimensional structure cannot achieve. This distinction allows to identify which aspects of literacy individuals need greater support in.