|Year : 2015 | Volume
| Issue : 1 | Page : 70-75
Perceived stigma among attendees of psychiatric and nonpsychiatric outpatients department in an industrial township: A comparative study
Abhishek Mahajan, Amitav Banerjee
Department of Community Medicine, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Web Publication||16-Jul-2015|
Department of Community Medicine, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune - 411 018,
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction and Context: Stigma associated with psychiatric disorders and few somatic disorders such as sexually transmitted diseases (STDs), tuberculosis and leprosy, adversely effects treatment seeking behavior, leads to concealment, and poor compliance with treatment. In busy outpatient departments (OPDs), the issue of stigma is likely to be overlooked. Materials and Methods: We carried out a cross-sectional study collecting data on an 8-item stigma scale from patients attending psychiatry and other OPDs of a Tertiary Care Teaching Hospital in an industrial township. Information was collected by face to face interview from 400 patients attending psychiatry OPD and 401 patients attending other OPDs. Validations of the scale were done by face, content, and construct validity. Reliability was appraised by Cronbach's alpha and Guttmann split-half coefficients. Significant differences in answers to the 8-item questionnaire were explored by Chi-square test for individual responses and Kruskal-Wallis test for difference in total stigma score. Results: Patients attending psychiatry OPD consistently gave responses indicating a greater degree of perceived stigma than those attending OPD for somatic disorders. This difference was almost 3-4 times more on most of the items (P < 0.001). Among somatic disorders, stigma was highest (even higher than psychiatric disorders) among STDs, tuberculosis and leprosy patients among these and psychiatric disorders the score was almost 3 times more compared to other somatic disorders (P < 0.001). The scale demonstrated good face, content, and construct validity. Reliability was also very high with Cronbach's alpha coefficient and Guttmann split-half reliability coefficient 0.932 and 0.901 indicating very good internal consistency of the 8-item scale. Conclusion: Stigma was higher among STD patients, tuberculosis, leprosy, and psychiatry patients as compared to patients suffering from somatic disorders. Assessment of stigma among these groups of patients can help in planning management and intervention to deal with stigma. This in turn can improve patient compliance.
Keywords: Leprosy, psychiatry patients, sexually transmitted diseases, stigma, tuberculosis
|How to cite this article:|
Mahajan A, Banerjee A. Perceived stigma among attendees of psychiatric and nonpsychiatric outpatients department in an industrial township: A comparative study. Ind Psychiatry J 2015;24:70-5
|How to cite this URL:|
Mahajan A, Banerjee A. Perceived stigma among attendees of psychiatric and nonpsychiatric outpatients department in an industrial township: A comparative study. Ind Psychiatry J [serial online] 2015 [cited 2020 Sep 29];24:70-5. Available from: http://www.industrialpsychiatry.org/text.asp?2015/24/1/70/160938
Psychosocial consequences as a result of stigma lead to intense suffering, particularly among those suffering from mental illness and their families. Stigma can be a barrier to recovery from mental illness as it can lead to delays in treatment seeking and interferes with compliance.  Even after recovery, stigma can affect the quality of social relations of the patient. Research and strategies to reduce stigma among people suffering from mental illness have been recommended.  Besides, mental illnesses, certain other conditions such as HIV/AIDS, leprosy, tuberculosis, epilepsy, etc., are associated with stigma which aggravates the misery of the affected patients. ,,,,,
In spite of different cultural settings, the areas of life affected by stigma are similar.  They include marriage, interpersonal relationships, employment, education, mobility, leisure activities, and discrimination at social functions. Though stigma, particularly among psychiatric patients is prevalent and well-known in our country, not much research on stigma has been carried out in non-Western societies on psychiatric stigma. 
The idea of measuring stigma quantitatively has been in vogue for quite sometime. However, most attempts were directed to measure attitudes among the community rather than the patients themselves.  There is also evidence to suggest that stigma is a clinical condition which needs an intervention.  To plan intervention strategies for stigma in clinical practice, one has to tailor the anti-stigma therapy at the individual level.
A gap in stigma research has been that stigma has been studied in isolation for different disease conditions such as mental illness, HIV/AIDS, leprosy, tuberculosis, etc. There is not much literature comparing stigma across different diseases.
The present study was undertaken against the above background, to compare the perceived stigma faced by outpatient psychiatric patients with those attending nonpsychiatric outpatient department (OPD) in a Tertiary Care Teaching Hospital situated in an industrial belt. Since industrialization has been associated with rapid social and economic changes which have been reported to have an impact on incidence of mental illness,  a condition often associated with stigma, the study, carried out in an industrial township, provided an ideal background for the objectives of the study.
| Materials and methods|| |
Type of study
A hospital OPD based cross-sectional analytic study.
OPDs of a Tertiary Care Teaching Hospital in the twin industrial township of Pimpri-Chinchwad in Pune District in the Indian state of Maharashtra. It is located in the North-West of Pune. According to the 2011 census, Pimpri-Chinchwad has a population of over 17.28 lakhs. The male population is 9.45 lakhs and the female population is 7.83 lakhs. Pimpri-Chinchwad is a major industrial hub and hosts one of the biggest industrial zones in Asia.
All patients of both genders above 18 years of age attending various OPDs in the Medical College Hospital, who gave consent. In cases of patients attending psychiatric OPD, consent of next of kin was also obtained.
Patients below 18 years of age, and those patients who refused consent. Patients with severe psychotic conditions who were difficult to interview were also excluded. Patients with acute conditions were also excluded on the premise that chronicity is a factor for stigma. Similarly, patients with severe disease and fatal conditions were also excluded.
Sample size calculation
The sample calculation was done in the following manner:
The following inputs were taken for calculating sample size:
The above inputs were taken to calculate sample size with the help of WHO/CDC statistical software EPI Info. The sample size generated using these inputs was 307 psychiatric patients and 307 patients with somatic disorders.
- Prevalence of stigma in patients with somatic disorders = 10%
- The strength of association of mental disorders with stigma in terms of odds ratio = 2
- Power of the study = 80%
- Confidence interval = 95%.
Since most of the inputs were guesstimates, we included a larger sample size than calculated by administering the questionnaire to 400 psychiatric OPD patients and 401 nonpsychiatric OPD patients (total = 801).
Selection of sample
Consecutive OPD patients who were ambulant and met the eligibility criteria were approached for data collection on OPD days, till the required sample size was met.
Data were collected by face to face interview after pretesting and validating the questionnaire. The questionnaire was administered to the respondents by one of the authors (AM).
Instrument (questionnaire) used in the study and stigma scoring system
One of the scales which have been developed to measure stigma and used in different settings is the explanatory model interview catalog.  In this instrument, responses are recorded in an ordinal scale ranging from 0 to 3. In this scale, 0 - means no perceived stigma; 1 - means uncertain; 2 - is possibly; and 3- denotes yes. The scale used in this study was adapted from this model. We recorded these responses over the following eight-dimensions (items): Concealment; avoidance of social contacts; self-pity; ridicule (people making fun); respect by people; impact on marriage or prospects for those unmarried; job discrimination; and job prospects. Stigma scores were calculated for each participant by adding up the scores on each of the 8-items, giving a maximum possible score of 24.
Besides, we also collected information on general demographic and socioeconomic variables such as gender; age; number of years of schooling; religion; type of family; per capita income; occupation; and marital status. The questionnaire used in the study is given at the end of the paper as "Appendix 1"
Validity and reliability of the study instrument
Validation of the instrument was appraised in the following manner:  (a) Face and content validity: Since the 8-items in the instrument covered all the aspects the social environment (which provides the context for stigma) we concluded that the questionnaire had adequate face and content validity. (b) Construct validity: We appraised the construct validity of the instrument by comparing the stigma scores among psychiatric patients with patients of tuberculosis, leprosy, and sexually transmitted diseases (STDs) which are also associated with stigma. We appraised the reliability of the instrument using the measures of internal consistency, that is, Cronbach's alpha coefficient and Guttmann split-half coefficient using SPSS version 20 software manufactured by IBM Corp Armonk New York, USA.
For comparing responses to individual items on the stigma interview scale, the responses were summarized in percentages and Chi-square test was used to see for any significant differences in the response to these items among psychiatric and nonpsychiatric patients. Kruskal-Wallis test was used to see whether any significant difference was present in the stigma score among patients attending different OPDs. Statistical software, Epi Info Version 7 developed by Centers for Disease Control and Prevention (CDC) Atlanta, Georgia, USA was used for Chi-square and Kruskal-Wallis tests.
The clearance from the Institutional Ethical Committee was obtained. Besides, informed consent was taken from each study subject and the next of kin in case of psychiatric patients.
| Results|| |
Age, gender, marital status, family type, religion, education, occupation, and income of the study population. This is shown in [Table 1]. By and large the patients attending psychiatric and nonpsychiatric OPD were well-matched in demographic and socioeconomic profile, except for the age profile (psychiatric patients were on the average about 6 years younger), income (which was little more in the psychiatric patients), religion (the "others" category was more among psychiatric patients), and occupation (professionals were more among the psychiatric patients).
|Table 1: Age, gender, marital status, family type, religion, education, occupation, and income |
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Perceived stigma among the psychiatric and nonpsychiatric patients
The responses to each of the 8-item stigma questionnaire are shown in [Table 2]. Patients attending psychiatric OPDs consistently gave responses in all the 8-item which indicated that they had a greater degree of perceived stigma than nonpsychiatric patients. This greater degree of felt stigma among psychiatric patients compared to nonpsychiatric patients were highly significant in all the 8-item of the questionnaire.
|Table 2: Response on 8-point questionnaire to elicit perceived stigma among the study subjects |
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Mean stigma score among the study participants
This is shown in [Table 3]. While psychiatric patients had the mean stigma score on the higher side (10.57), not surprisingly patients with STDs, tuberculosis, and leprosy also scored high. In fact, stigma score of STD patients was highest at 15.75. Stigma scores among patients with other somatic disorders were much lower, almost 1/3 rd of the scores on the higher end comprising psychiatric disorders, STD, TB, and leprosy.
Validation of the scale
(a) Face validity: Since the 8-item in the instrument covered all the aspects the social environment (which provides the context for stigma), we concluded that the questionnaire had adequate face and content validity. (b) Construct validity: [Table 3] shows patient suffering from diseases such as STD, tuberculosis, leprosy, also had high stigma scores, sometimes even higher than those with psychiatric illnesses. Since it is well-know that these groups of diseases are associated with stigma we can reasonably conclude that the scale had good construct validity. (c) Reliability: Cronbach's alpha coefficient and Guttman split-half coefficient were 0.932 and 0.901 respectively, indicating very good internal consistency of the 8-item scale.
| Discussion|| |
Our study found that except for patients attending certain OPDs such as STD, tuberculosis, and leprosy, those attending OPD for somatic disorders had much lower stigma scores compared to those attending psychiatric OPD. Similarly, based on the responses to the 8-item instrument, perceived stigma among psychiatric patients were 3 to 4 times more compared to patients with somatic disorders.
The scale used by us also had a good face, content and construct validity. Besides, it demonstrated very high reliability. An advantage of this instrument is that it is simple, short and easy to administer. It was adapted and made shorter from the commonly used scale recommended by King et al.  In view of these advantages, we recommend that the questionnaire be included for measuring stigma among patients of psychiatric disorders and also among those with STD, tuberculosis, and leprosy both in the clinical setting and for research purposes. For research purposes when data need to be collected from a very large number of subjects, with aid of many interviewers, a scale with very high reliability such as the one we used in this study would be ideal. Moreover, a short scale is easy to translate and back-translate in different languages which would be of relevance in our country with many linguistic groups.
Psychiatric patients experience stigma is well-established. Lai et al.,  elicited views of patients attending psychiatric OPD, mental health care workers, and cardiac OPD patients regarding stigma. They found that a significant percentage of patients with severe mental disorders perceived that stigma had a negative effect on their self-esteem, relationships, and job opportunities in comparison with cardiac patients among whom feeling of stigma was much less. Dickerson et al.,  assessed outpatients with schizophrenia receiving community care using a questionnaire and found that all but one responses indicated having at least one stigma experience. The most common worries were those related with social isolation and their attempts to conceal their illness.
Stigma associated with certain diseases besides mental disorders such as STD leads to discrimination. This has been cited as one of the reasons for lack of STD data in India.  Historically in the 19 th century, not much was known about the etiology and cure of tuberculosis. This ignorance led to fear and stigmatization. Though tuberculosis is much better understood today fear and stigma associated with tuberculosis persists and interfere with effective management. 
Similarly, stigma due to leprosy has deep historical roots.  Alienation and discrimination toward patients suffering from leprosy still persists. As recent as the 20 th century, stigmatizing attitudes were incorporated in the legal system. In India, the Motor Vehicles Act of 1939 forbade the grant of driving license to leprosy sufferers and till recently, Indian Christian, Hindu, and Muslim Marriage Acts accepted leprosy (and also mental illness) as grounds for divorce. 
The issue of stigma faced by patients suffering from psychiatric disorders attending hospital OPD has also been addressed by Kumari et al.  In their study, they compared stigma and self-esteem among patients attending OPD in the hospital with those who were served by a community outreach program. They found lower stigma scores among patients attending community outreach program. Based on their findings, they recommend further studies and if their findings are replicated a policy decision can be taken to start more community outreach activities by hospitals. Besides reducing stigma, an added advantage would be that services will be available nearer the patients' homes.
The present study had a number of limitations. The 8-item scale though easy to administer may not cover all the cultural and ethnic nuances of stigma. For exploring these, in-depth qualitative studies are indicated which should be able to complement the quantitative findings elicited by the quantitative instrument and also suggest additions and refinements of the scale in the cultural context. The sample in the present study comprised patients attending the OPD. This may not exactly represent the general population. However, the direction of bias introduced due to this self-selected sample of OPD patients would be toward underestimation of stigma which is known to prevent health seeking behavior. , In view of this, the actual stigma among patients with psychiatric disorders, STD, leprosy, and tuberculosis is likely to be more than estimated in the present study. We also did not differentiate between different psychiatric conditions which may be associated with varying degrees of stigma. We have only assessed the stigma associated with psychiatric consultation excluding psychosis which is likely to be associated with greater stigma compared to less severe mental illnesses. Furthermore, we excluded acute medical, surgical, and with life threatening patients. Besides the logistic problems, this was based on the premise that stigma is more likely to be associated with chronic conditions. We also concede that the number or STD and TB patients were very limited in our sample.
| Conclusion|| |
The 8-item stigma scale to measure stigma among OPD patients can be used to quantify stigma. This scale had good face, content and construct validity and very high reliability. These features would be ideal for research purposes also when information need to be collected from large number of participants involving many field workers. We recommend further rapid surveys using this scale under different settings to establish the validity of the scale.
Financial support and sponsorship
Conflict of interest
There are no conflict of interest.
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[Table 1], [Table 2], [Table 3]