Beliefs of Australian health professionals about the helpfulness of interventions for mental disorders: differences between professions and change over time

The ethical imperative of trauma-sensitive care for electroconvulsive therapy (ECT)

BACKGROUND

The empirical literature on the lived experience of electroconvulsive therapy (ECT) is limited, divergent, and largely focused on the experiences of procedures, (adverse) effects, information provision, or decision-making.

AIMS

This study aimed to investigate aspects related to the lived experience and meaning-making of people who have had ECT.

METHOD

In-depth interviews with 21 women (21-65 years old) were analyzed using interpretative phenomenological analysis (IPA).

FINDINGS

A subgroup of nine participants described more negative experiences with ECT. A common factor for these participants was the experience of trauma that remained under-treated. The superordinate themes identified were a lack of trauma-based and recovery-oriented treatment. The rest of the sample (12) expressed more positive experiences with ECT.

CONCLUSIONS

This study suggests that exploring more broadly the impacts of ECT at the long term offers insights that can help design more person-centered services aligned to the needs of the treatment recipients. Educational modules for mental health care staff should include, besides knowledge on the methods' effectiveness, additional evidence about treatment recipients' subjective concerns and the relevance of trauma and recovery-oriented care models.

Physicians' and medical students' beliefs and attitudes toward psychotic disorders: A systematic review

OBJECTIVE

The aim of this study was to analyze physicians' and medical students' (MS) beliefs and attitudes toward people with psychotic disorders.

METHODS

This systematic review follows the PRISMA guidelines. It was conducted on 5 databases (Pubmed, PsycINFO, Pascal & Francis, Scopus and EMBASE) with a keyword string combining words for physicians' and students' professional status, attitudes toward people, and psychotic disorders. No limitations on publication dates were imposed.

RESULTS

This review includes 39 articles, among which quantitative studies are in the majority, and general practioners are mainly represented. Schizophrenia is the main condition used to illustrate psychotic disorders and measure stigmatizing attitudes. Physicians' and MS' beliefs toward people with psychotic disorders are mainly represented by dangerousness and unpredictability. They can be reinforced with socio-demographic criteria (age and female gender) or physicians' beliefs about the disease's etiology. The desire for social distance is higher toward patients with schizophrenia compared to other psychiatric disorders, and medical care could be impacted with a tendency to refer them at psychiatric specific care or to anticipate their difficulties and to modify their treatment plan. Stigma scores remain globally high during medical training. Even if specific anti-stigma trainings have a positive impact on beliefs and attitudes, these effects do not last in time.

CONCLUSION

This review highlights the importance to explore physicians' and medical students' representations about patient with psychosis to understand better their difficulties in the management of these patients.

Development of the Mental Health Support Scale: A New Measure of Mental Health First Aid Behaviors

Mental health first aid (MHFA) courses teach community members the knowledge and skills needed to recognize and respond to mental health problems until professional help is received or the crisis resolves. This study aimed to develop a reliable and valid measure of MHFA behaviors. A pool of actions that were recommended and not recommended were selected from MHFA guidelines and developed into two scales measuring either intended or provided support. Items were tested with a sample of 697 adults. Item response theory guided the selection of final items. The Mental Health Support Scale (MHSS) Intended version has 23 items across two subscales and the MHSS-Provided has 12 items across two subscales. These scales demonstrated convergent validity, discrimination between respondents with and without MHFA expertise, and acceptable measurement precision across a range of skill levels. Overall, findings suggest that the MHSS is a valid and useful measure of MHFA behaviors.

A national study of the mental health literacy of community pharmacists

BACKGROUND

Community pharmacists are in a prime position to communicate with and assist those with mental health needs. However, mental health literacy, which includes beliefs and knowledge of mental health conditions, can impact the provision of pharmacy services. The mental health literacy of community pharmacists in New Zealand is currently unknown.

OBJECTIVES

To assess the mental health literacy of community pharmacists in New Zealand.

METHODS

We employed a national cross-sectional online survey, evaluating attitudes towards mental illness, ability to recognise depression using a vignette and followed by questions related to the helpfulness of various interventions, and willingness to provide pharmacy services for people with mental illness in comparison to cardiovascular diseases. Additionally, opportunities for mental health training were explored. Participants were community pharmacists working in New Zealand contacted via mailing lists of professional bodies.

RESULTS

We received responses from 346 participants. The majority of participants showed positive attitudes towards mental illness and correctly identified depression in the vignette (87%). Participants rated counsellors (84%) and physical activity (92%) as the most helpful professionals and intervention respectively while only 43% considered antidepressants as helpful for depression. When compared to other people in the community, long-term functioning of the individual described in the vignette was rated poorly, especially in terms of increased likelihood to attempt suicide (85%) and reduced likelihood to be a productive worker (64%). Approximately 30% of participants reported reduced confidence/comfort while approximately half of participants reported greater interest in providing mental health-related care compared to cardiovascular disease. The participants also highlighted several areas for future mental health training they wished to undertake.

CONCLUSIONS

We have identified positive attitudes towards mental illness in our study. Participants correctly identified and supported evidence-based interventions for mild to moderate depression. However, we highlighted the need for ongoing mental health training to address knowledge gaps and enhance the confidence in providing mental health-related care.

Longer-term effectiveness of eLearning and blended delivery of Mental Health First Aid training in the workplace: 2-Year follow-up of a randomised controlled trial

INTRODUCTION

Evidence relating to long-term outcomes of online education programs is largely lacking and head-to-head comparisons of different delivery formats are very rare. The aims of the study were to test whether eLearning Mental Health First Aid (MHFA) or blended training (eLearning plus face-to-face course delivery), implemented in an Australian public sector workplace, were more effective than a control intervention at 1-year and 2-year follow-up, and whether blended MHFA training was more effective than eLearning alone.

MATERIAL AND METHODS

Australian public servants (n = 608 at baseline) were randomly assigned to complete an eLearning MHFA course, a blended MHFA course or Red Cross eLearning Provide First Aid (PFA) (the control) and completed online questionnaires pre- and post-training and one and two years later (n = 289, n = 272, n = 243 at post, 1- and 2-year follow-up respectively). The questionnaires were based on vignettes describing a person with depression or post-traumatic stress disorder (PTSD). Primary outcomes were mental health first aid knowledge, desire for social distance and quality of support provided to a person in the workplace. Secondary outcomes were recognition of mental health problems, beliefs about treatment, helping intentions and confidence, personal stigma, quality of support provided to a person outside the workplace, self-reported professional help seeking and psychological distress.

RESULTS

At 1-year follow-up, both eLearning and blended courses produced greater improvements than PFA training in knowledge, confidence and intentions to help a person with depression or PTSD, beliefs about dangerousness and desire for social distance. At 2-year follow-up, some of these improvements were maintained, particularly those relating to knowledge and intentions to help someone with PTSD. When eLearning and blended courses were compared at 1-year follow-up, the blended course led to greater improvements in knowledge and in confidence and intentions to help a person with depression. At 2-year follow-up, improvements in the quality of help provided to a person with a mental health problem outside the workplace were greater in participants in the blended course.

CONCLUSIONS

Both blended and eLearning MHFA courses led to significant longer-term improvements in knowledge, attitudes and intentions to help a person with a mental health problem. Blended MHFA training led to an improvement in the quality of helping behaviours and appears to be more effective than online training alone.Trial registrationACTRN12614000623695 registered on 13/06/2014 (prospectively registered).Trial registry record url: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366410&isReview=true.

The Effects of Virtual Simulation on Undergraduate Nursing Students' Mental Health Literacy: A Prospective Cohort Study

This prospective cohort study aimed to evaluate the long-term effects of virtual simulation on nursing education by measuring undergraduate nursing students' mental health literacy. Students' beliefs about the helpfulness of specific interventions for managing depression and schizophrenia were compared between the simulation cohort (n = 149) and the non-simulation cohort (n = 150) from a school of nursing in the U.S. Students in the simulation cohort showed significant increase in knowledge and acceptance of available treatment options for managing depression and schizophrenia over a one-year period. The finding supports the use of virtual simulation in undergraduate mental health nursing education with active faculty engagement.

How the Australian public came to think more like psychiatrists

Over the past 25 years, a remarkable change has occurred in Australia, whereby the public have become much more like psychiatrists in their thinking. This is seen both in the everyday use of psychiatric concepts and in beliefs about appropriate treatment. This article examines evidence for this change, discusses what might have produced it, asks whether it has benefited the mental health of Australians and considers what further changes in thinking might be needed.

Patterns of Integrative Korean Medicine Practice for Anxiety Disorders: A Survey among Korean Medicine Doctors (KMDs) in Korea

Anxiety disorder is known as the most common disease among psychiatric disorders. However, many studies have not been conducted in the Korean medicine area. This study explores the current state of anxiety disorder treatments of Korean medicine through a survey research. The survey for Korean medicine doctors (KMDs) on Korean medicine (KM) diagnosis and treatments for anxiety disorder was conducted online from December 21, 2016, to December 29, 2016. The results were divided into two groups, KMDs and Korean medicine neuropsychiatric specialists (KMNPS), and comparatively analyzed. Self-evaluation and counseling were the most common in both diagnostic methods and evaluation of treatment effects, and KMNPS tended to make extensive use of objective indicators. There was no difference in the rate of psychiatric medication use among the patients between KMD and KMNPS. The main reason for patients wanting KM treatment was the tapering cessation of psychiatric medications. The most common treatments were acupuncture, herbal medicine, and moxibustion, in addition to dry cupping in KMD and psychotherapy in KMNPS. The most important factor for treatment was herbal medicine treatment, followed by rapport formation in KMD and patient's temperament in KMNPS. Opinions on various items were presented as treatment barriers, and KMNPS tended to think more importantly about the patient's family problems. For the items to be additionally trained in the future, KMD chose the diagnostic tools and KMNPS chose psychotherapies. This study is the first study to analyze the clinical patterns for anxiety disorder in KMDs. KMD and KMNPS showed similar patterns in the perception, diagnosis, and treatment of anxiety disorders, but KMNPS tended to use objective indicators and psychotherapy more actively. Further clinical studies for the development of clinical guidelines should be additionally required.

Exercise and mental health literacy in an Australian adult population

BACKGROUND

Exercise is a well-established treatment for depression, and its use in clinical care is supported by consumers and clinicians. However, whether public health messages regarding the benefits of exercise for depression have translated to public knowledge remains unknown. This study aims to examine the community's mental health literacy, and views regarding exercise delivery for people with depression.

METHODS

A vignette was presented as part of the telephone-based 2017 National Social Survey (n = 1,265). Interviewees identified what (if anything) was wrong with the person described, who they should seek help from, whether exercise might be beneficial, and how exercise should be delivered for the person described in the vignette. Results are reported using descriptive statistics.

RESULTS

From 1,265 respondents (response rate = 24%, n = 598 males, mean age 54.7 years [range 18-101]), almost two-thirds correctly identified the condition described in the vignette as depression. There was widespread support for seeking help from a general practitioner. Exercise was well supported in the treatment of the person described in the vignette, with general practitioners and accredited exercise physiologists highlighted as persons to consult regarding exercise. Views regarding the type of program were consistent with current best practice recommendations.

CONCLUSIONS

Australian adults demonstrate a high level of exercise and mental health literacy. The high level of support for accredited exercise physiologists is evidence of the effectiveness of health promotion campaigns from peak exercise professional agencies.

Associations between ability to recognise a mental health disorder and lived experience of mental illness in an Australian sample

Community awareness of mental illness is crucial for helping people access mental health support. The association between ability to recognise mental health disorders and lived experience is not well examined in Australian populations. Australian adults (n = 1265) provided responses to a vignette depicting a person with depression and self-reported a previous diagnosis of depression and/or anxiety. People who had lived experience with depression and/or anxiety had significantly higher levels of this aspect of mental health literacy than people without lived experience. Public mental health literacy promotion efforts should consider incorporating insights from people with lived experience of mental illness.

Effectiveness of eLearning and blended modes of delivery of Mental Health First Aid training in the workplace: randomised controlled trial

BACKGROUND

The aim of the WorkplaceAid study was to compare the effects of eLearning or blended (eLearning plus face-to-face course delivery) Mental Health First Aid (MHFA) courses on public servants' knowledge, stigmatising attitudes, confidence in providing support and intentions to provide support to a person with depression or post-traumatic stress disorder (PTSD).

METHODS

A randomized controlled trial was carried out with 608 Australian public servants. Participants were randomly assigned to complete an eLearning MHFA course, a blended MHFA course or Red Cross eLearning Provide First Aid (PFA) (the control). The effects of the interventions were evaluated using online questionnaires pre- and post-training. The questionnaires centred around vignettes describing a person meeting the criteria for depression or PTSD. Primary outcomes were mental health first aid knowledge and desire for social distance. Secondary outcomes were recognition of mental health problems, beliefs about treatment, helping intentions and confidence and personal stigma. Feedback on the usefulness of the courses was also collected.

RESULTS

Both the eLearning MHFA and blended MHFA courses had positive effects compared to PFA eLearning on mental health first aid knowledge, desire for social distance, beliefs about professional treatments, intentions and confidence in helping a person and personal stigma towards a person with depression or PTSD. There were very small non-significant differences between the eLearning MHFA and blended MHFA courses on these outcome measures. However, users were more likely to highly rate the blended MHFA course in terms of usefulness, amount learned and intentions to recommend the course to others.

CONCLUSIONS

The blended MHFA course was only minimally more effective than eLearning MHFA in improving knowledge and attitudes. However, course satisfaction ratings were higher from participants in the blended MHFA course, potentially leading to greater benefits in the future. Longer-term follow-up is needed to explore this.

TRIAL REGISTRATION

ACTRN12614000623695 registered on 13/06/2015 (prospectively registered).

Systematic review and meta-analysis of Mental Health First Aid training: Effects on knowledge, stigma, and helping behaviour

OBJECTIVE

To provide an up-to-date assessment of the effectiveness of the Mental Health First Aid (MHFA) training program on improving mental health knowledge, stigma and helping behaviour.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search of electronic databases was conducted in October 2017 to identify randomised controlled trials or controlled trials of the MHFA program. Eligible trials were in adults, used any comparison condition, and assessed one or more of the following outcomes: mental health first aid knowledge; recognition of mental disorders; treatment knowledge; stigma and social distance; confidence in or intentions to provide mental health first aid; provision of mental health first aid; mental health of trainees or recipients of mental health first aid. Risk of bias was assessed and effect sizes (Cohen's d) were pooled using a random effects model. Separate meta-analyses examined effects at post-training, up to 6 months post-training, and greater than 6 months post-training.

RESULTS

A total of 18 trials (5936 participants) were included. Overall, effects were generally small-to-moderate post-training and up to 6 months later, with effects up to 12-months later unclear. MHFA training led to improved mental health first aid knowledge (ds 0.31-0.72), recognition of mental disorders (ds 0.22-0.52) and beliefs about effective treatments (ds 0.19-0.45). There were also small reductions in stigma (ds 0.08-0.14). Improvements were also observed in confidence in helping a person with a mental health problem (ds 0.21-0.58) and intentions to provide first aid (ds 0.26-0.75). There were small improvements in the amount of help provided to a person with a mental health problem at follow-up (d = 0.23) but changes in the quality of behaviours offered were unclear.

CONCLUSION

This review supports the effectiveness of MHFA training in improving mental health literacy and appropriate support for those with mental health problems up to 6 months after training.

TRIAL REGISTRATION

PROSPERO (CRD42017060596).

Implementation in action: how Australian Exercise Physiologists approach exercise prescription for people with mental illness

BACKGROUND

Accredited Exercise Physiologists (AEPs) are trained to deliver exercise and physical activity interventions for people with chronic and complex health conditions including those with mental illness. However, their views on exercise for mental illness, their exercise prescription practices, and need for further training are unknown.

AIMS

To examine the way in which Australian AEPs prescribe exercise for people with mental illness.

METHODS

Eighty-one AEPs (33.3 ± 10.4 years) completed an online version of the Exercise in Mental Illness Questionnaire. Findings are reported using descriptive statistics.

RESULTS

AEPs report a high level of knowledge and confidence in prescribing exercise for people with mental illness. AEPs rate exercise to be at least of equal value to many established treatments for mental illness, and frequently prescribe exercise based on current best-practice principles. A need for additional training was identified. The response rate was low (2.4%) making generalisations from the findings difficult.

CONCLUSIONS

Exercise prescription practices utilised by AEPs are consistent with current best-practice guidelines and there is frequent consultation with consumers to individualise exercise based on their preferences and available resources. Further training is deemed important.

Barriers to exercise prescription and participation in people with mental illness: the perspectives of nurses working in mental health

ACCESSIBLE SUMMARY

Exercise is valuable in the treatment of mental illness, yet personal and organizational barriers limit widespread implementation by nurses in mental health settings. Using a self-report questionnaire, we sought to identify how often nurses prescribe exercise and their level of agreement with previously identified barriers to exercise prescription and participation for mental health consumers. Nurses disagree that many of the previously identified barriers should impede exercise prescription for people with mental illness. Nurses agree that many of the barriers expressed by mental health consumers might prevent exercise participation. Our study provides valuable new insight into the role of nurses in the provision of exercise for people with mental illness; however, it is limited to a small sample. Confirmation of these findings in larger, geographically and professionally diverse groups is needed.

ABSTRACT

Evidence is mounting for the efficacy of exercise in the treatment of people with mental illness. Nurses working in mental health settings are well placed to provide exercise advice for people with mental illness. However, quantitative examinations of the barriers to exercise prescription experienced by nurses, or their views regarding the barriers to exercise participation experienced by people with mental illness, are lacking. In this study, 34 nurses completed the Exercise in Mental Illness Questionnaire-Health Professionals Version (EMIQ-HP). This survey examined the frequency of exercise prescription and the level of agreement with statements regarding barriers to exercise prescription for, and exercise participation by, people with mental illness. The level of agreement scores for statements for each section was summed, with a higher score indicating a higher level of agreement. Nurses disagree with many of the barriers to exercise prescription presented in the literature. The level of agreement scores did not differ between nurses who prescribe exercise 'Always', 'Most of the time', 'Occasionally' or 'Never'. We found a non-significant negative relationship between frequency of exercise prescription and summed level of agreement scores for barriers to exercise prescription. Consensus regarding barriers to exercise participation by mental health consumers is less clear. This study provides valuable new insight into the role of nurses in the provision of exercise for people with mental illness. Confirmation in larger samples is needed before translation of research to practice.

Investigating the exercise-prescription practices of nurses working in inpatient mental health settings

Nurses working in mental health are well positioned to prescribe exercise to people with mental illness. However, little is known regarding their exercise-prescription practices. We examined the self-reported physical activity and exercise-prescription practices of nurses working in inpatient mental health facilities. Thirty-four nurses completed the Exercise in Mental Illness Questionnaire - Health Practitioner Version. Non-parametric bivariate statistics revealed no relationship between nurses' self-reported physical activity participation and the frequency of exercise prescription for people with mental illness. Exercise-prescription parameters used by nurses are consistent with those recommended for both the general population and for people with mental illness. A substantial number of barriers to effective exercise prescription, including lack of training, systemic issues (such as prioritization and lack of time), and lack of consumer motivation, impact on the prescription of exercise for people with mental illness. Addressing the barriers to exercise prescription could improve the proportion of nurses who routinely prescribe exercise. Collaboration with exercise professionals, such as accredited exercise physiologists or physiotherapists, might improve knowledge of evidence-based exercise-prescription practices for people with mental illness, thereby improving both physical and mental health outcomes for this vulnerable population.

A call to action: exercise as treatment for patients with mental illness

Mental illness affects the lives of a significant number of Australians. In addition to pharmacological and psychological interventions, exercise has demonstrated benefits for people with mental illness including symptom reduction, improved cardiovascular risk profile and improved physical capacity. Unfortunately, evidence shows that clinician-delivered exercise advice is not routinely offered. This is despite patient acceptability for exercise. This article summarises the recent evidence supporting the prescription of exercise for people with mental illness and offers a model incorporating basic exercise prescription, and referral pathways for specialised advice. Current exercise prescription patterns for people with mental illness may not meet patient expectations; therefore, clinicians should consider exercise referral schemes to increase the accessibility of interventions for people with a mental illness.

Beliefs about mental disorder treatment and prognosis: comparison of health professionals with the Australian public

OBJECTIVE

In the 1990s, large differences in beliefs about the helpfulness of treatments for mental disorders were observed between the Australian public and health professionals. This study evaluates whether gaps in public and professional beliefs remain by comparing beliefs of the public and health professionals on the helpfulness of interventions and likely prognosis for six mental health problems: depression, depression with suicidal thoughts, early schizophrenia, chronic schizophrenia, social phobia, and post-traumatic stress disorder.

METHODS

Mental health literacy surveys based around a vignette of a person with a mental disorder were carried out in a nationally representative sample of the Australian public (n=6019) in 2011 and samples of Australian general practitioners, psychiatrists, and psychologists (n=1536) in 2012. Respondents were asked to rate the helpfulness of a range of interventions and the likely outcome with or without appropriate professional treatment. Differences between groups were examined with chi-square tests.

RESULTS

There were many significant differences in treatment beliefs, but most of these were small in size. Medium-sized differences tended to be consistent across vignettes and relate to the greater belief by the public in the helpfulness of close family or friends, a counsellor, vitamins and minerals, a special diet or avoiding certain foods, and having an occasional alcohol drink to relax. In contrast, professionals showed a greater belief in psychotherapy and cognitive behaviour therapy for depression and anxiety, and antipsychotics for schizophrenia. Findings on prognosis showed mostly small differences in beliefs.

CONCLUSIONS

Overall, the results indicate that the views of the public and professionals are more aligned than in the 1990s. There are now few large gaps in treatment beliefs, but there remain some areas that could be improved.

Stigmatising attitudes towards people with mental disorders: a comparison of Australian health professionals with the general community

OBJECTIVE

The aim of this paper was to explore attitudes towards people with mental disorders among Australian health professionals (psychiatrists, psychologists and general practitioners (GPs)) and to compare their attitudes with members of the general community.

METHODS

The study involved a postal survey of 518 GPs, 506 psychiatrists and 498 clinical psychologists and a telephone survey of 6019 members of the general community. Participants were given a case vignette describing a person with either depression, depression with suicidal thoughts, early schizophrenia, chronic schizophrenia, post-traumatic stress disorder (PTSD) or social phobia and two questionnaires to assess stigmatising attitudes (the Depression Stigma Scale and the Social Distance Scale). Exploratory structural equation modelling was used to elucidate the structure of stigma as measured by the two scales, to establish dimensions of stigma and to compare patterns of association according to gender, age, vignette and professional grouping.

RESULTS

The measurement characteristics of stigmatising attitudes in health professionals were found to be comparable to those in members of the general community in social distance and also in personal and perceived attitude stigma, with each forming distinct dimensions and each comprising 'Weak-not-sick' and 'Dangerous/unpredictable' components. Among health professionals, female gender, age and being a GP were associated with higher scores on the personal stigma scales. Mental health professionals had lower scores on the personal 'Weak-not-sick' and 'Dangerous/unpredictable' scales than members of the general community, while there were no significant differences in the desire for social distance between health professionals and the general community.

CONCLUSIONS

While mental health professionals have less stigmatising attitudes than the general public, the greater beliefs in dangerousness and personal weakness by GPs should be addressed.

Development of scales to assess mental health literacy relating to recognition of and interventions for depression, anxiety disorders and schizophrenia/psychosis

OBJECTIVE

The aim of this study was to develop scales to assess mental health literacy relating to affective disorders, anxiety disorders and schizophrenia/psychosis.

METHOD

Scales were created to assess mental health literacy in relation to depression, depression with suicidal thoughts, early schizophrenia, chronic schizophrenia, social phobia and post-traumatic stress disorder using data from a survey of 1536 health professionals (general practitioners, clinical psychologists and psychiatrists), assessing recognition of these disorders and beliefs about the helpfulness of interventions. This was done by using the consensus of experts about the helpfulness and harmfulness of treatments for each disorder as a criterion. Data from a general population survey of 6019 Australians aged ≥ 15 was used to examine associations between scale scores, exposure to mental disorders and sociodemographic variables, to assess scale validity.

RESULTS

Those with a close friend or family member with a mental disorder had significantly higher mean scores on all mental health literacy scales, providing support for scale validity. Personal experience of the problem and working with people with a similar problem was linked to higher scores on some scales. Male sex, a lower level of education and age > 60 were linked to lower levels of mental health literacy. Higher scores were also linked to a greater belief that people with mental disorders are sick rather than weak.

CONCLUSIONS

The scales developed in this study allow for the assessment of mental health literacy in relation to depression, depression with suicidal thoughts, early schizophrenia, chronic schizophrenia, social phobia and PTSD. Those with exposure to mental disorders had higher scores on the scales, and analyses of the links between scale scores and sociodemographic variables of age, gender and level of education were in line with those seen in other studies, providing support for scale validity.