|Year : 2017 | Volume
| Issue : 2 | Page : 223-227
Indian nursing students' attitudes toward mental illness and persons with mental illness
Vanteemar S Sreeraj1, Seema Parija2, NA Uvais3, Sandhyarani Mohanty4, Sudhir Kumar4
1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Psychiatry, Iqra Hospital, Calicut, Kerala, India
4 Department of Psychiatry, Institute of Mental Health And Hospital, Agra, Uttar Pradesh, India
|Date of Web Publication||10-Jul-2018|
Dr. Seema Parija
Department of Psychiatry, Kalinga Institute of Medical Sciences, Bhubaneswar - 751 024, Odisha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Nursing fraternity play a pivotal role in psychiatric services. Negative attitudes toward mental illness have been consistently reported in nursing students. Psychiatric conditions and persons suffering from them may elicit different kinds of attitudinal responses. Objective: The current study aimed at assessing the attitude toward mental illness and also at comparative evaluation of the attitude toward persons with different psychiatric, physical, and social conditions. Materials and Methods: The present study was carried out among conveniently selected nursing students (n = 100) using Attitude Scale for Mental Illness (ASMI) and Attitude to Mental Illness Questionnaire (AMIQ) on their 1st day of psychiatric posting. Results: Higher stereotype (3.1 ± 0.8), benevolence (3.7 ± 0.6), and pessimistic prediction (3.4 ± 0.9) were reported toward mental illness. Negative attitude was noted toward persons with criminal background (4.8 ± 3.7), heroin abuse (3.2 ± 3.6), suicidal depression (1.36 ± 3.6), alcohol use (0.59 ± 4.38), and schizophrenia (0.03 ± 3.2) in the same order, with positive attitude toward diabetic (−4.4 ± 3.9) and religious persons (−5.13 ± 3.6). Significant correlation of ASMI scores was noted mainly with schizophrenia of AMIQ but not with other psychiatric conditions. Conclusion: High negative attitudes in nursing students underline the need for stronger antistigma measures. Differences in attitude toward mental illness in general and specific psychiatric conditions need further systematic evaluation.
Keywords: Attitude toward medical conditions, attitude toward mental illness, attitude toward social conditions, nursing students
|How to cite this article:|
Sreeraj VS, Parija S, Uvais N A, Mohanty S, Kumar S. Indian nursing students' attitudes toward mental illness and persons with mental illness. Ind Psychiatry J 2017;26:223-7
Mental health though being a major component of general health is often neglected in comparison to the physical health. Stigma and discrimination are the major factors impeding on the resource allotment and utilization of psychiatric services. Nursing staff play a major role in health services. Their involvement is more critical in developing countries with lower patient–doctor's ratio. With a higher contact time, the role of nurses in educating and influencing the attitude of general population as well as mental health consumers is significantly higher.
Medical and paramedical students represent the prospect of the health care of a society. Studies over different time frames and across continents have shown nursing students and staff harboring a high level of negative attitudes toward mental illness., Attitudes toward psychiatry, psychiatric disorders, and persons suffering from psychiatric conditions could be different. Few studies have attempted in differentiating the attitude toward mental illness and psychiatry ,, while studying students being trained for health profession. The attitude expressed might vary when a person is described with a generic term of mental illness and when described with their behavioral problems with person in the center of the theme.
We aimed at assessing attitudes of nursing students toward mental illness. We also aimed at evaluating and comparing their attitude toward persons with different mental, physical, and social conditions, when person rather than the illness is the center of the issue and the association of the two measures. In addition, we explored the relation of different factors implicating on these attitudes.
| Materials and Methods|| |
The study was conducted at a tertiary care psychiatric institute which is also a training center for various medical and paramedical professionals on mental health. Students from different nursing colleges of north Indian states Punjab, Haryana, Uttarakhand, and Uttar Pradesh gets trained in mental health care at the institute through short postings.
The attitudes of the nursing students attending this clinical posting were surveyed in the present study on their 1st day of the visit with their consent after explaining the condition of confidentiality and anonymity. Informed consent was obtained from all the participants and their supervisors. Approval from the institutional committee was obtained for conducting the study. All the 100 students who were under training during the time of this study were assessed using self-rated questionnaires. All of them were registered for general nursing and midwifery courses under different universities of North India.
Sociodemographic data were collected using a semi-structured pro forma designed for the study. Sociodemographic data evaluated age, sex, education, domicile, and state of residence. Years of experience in general health and mental health and presence of mental illness and substance abuse in family members and relatives or close friends were also assessed. Attitude toward mental illness was assessed using Attitude Scale for Mental Illness (ASMI). For evaluating attitude toward persons with mental illness, modified Attitudes to Mental Illness Questionnaire (AMIQ) was used.
ASMI is a modified version of Opinion Towards Mental Illness in Chinese Community, which has 34 items responded on a 5-point Likert scale ranging from “totally disagree” to “totally agree.” Eight of these 34 items were reverse scored. The scale has been used in different surveys and studies in different countries including Indian communities. The ASMI scale had yielded a Cronbach's α of 0.87. This scale on factor analysis had yielded six factors. The six subscales were as follows:
- Separatism: Identifies the emphasis on uniqueness and keeping a distance from people with mental illness
- Stereotyping: Defining people with mental illness on a set pattern of behavior and abilities
- Restrictiveness: Holding an uncertain view about rights of people with mental illness
- Benevolence: Showing kindness toward people with mental illness
- Pessimistic prediction: View that improvement in people with mental illness is unlikely and pessimistic about the way society treats them
- Stigmatization: Explaining mental illness is shameful and needs to be hidden.
The AMIQ  is a short instrument used to assess stigmatized attitudes toward patients with mental illness. The original scale has been validated and found to have good construct validity, content validity, and reliability. It has also been used in an Indian study. The questionnaire consists of seven different short case vignettes, describing person with heroin abuse, depression with suicidal attempt, alcohol dependence, convicted criminal, diabetes mellitus, and schizophrenia. The seventh person is a religious and spiritual person. The questions were modified to Indian names and culture (e.g., the vignette: “Steve is a practicing Christian. He attends church every Sunday and attempts to lead a Christian life” was modified to “Shankar is a religious person. He visits “satsang” every week and attempts to lead a spiritual life”). Five questions were asked regarding all the persons to be answered on a 5-point Likert scale (very likely to neutral to very unlikely). The five items represented occupational ability, co-worker preference, inviting to social gathering, ability to maintain personal relationships, and risks of legal problems. Two items (co-worker preference and socialization) in each were reversed scored. Hence, the higher the mean score, the more the negative attitude. It provides imaginary persons with different conditions rather than just the illness and thus would better assess the attitude. The items most likely assess attitudes toward people with mental illness rather than mental illness per se.
A pro forma containing the questionnaire was provided for each participant to fill, discouraging them to discuss among themselves until the completion. They were asked to clear any doubts regarding the questionnaire anytime during the session and were guided with appropriate translations by the investigators if so ever needed.
Data were assessed using SPSS 16 (SPSS Inc, SPSS for Windows, Version 16.0. Chicago, SPSS Inc.) using descriptive statistics for sociodemographic variables. Levene's test was used for testing the homogeneity of variance of the continuous variables and Freidman's test was applied to compare the stigma across the subscales of the AMIQ. Spearman's correlation was used to find the association between the two scales measuring the attitudes toward mental illness and the sociodemographic factors.
| Results|| |
The sample consisted of 100 students predominated by females (90) and age ranging between 19 and 29 years, with a mean age of 21.65 years (standard deviation (SD) - 2.6). The sample consisted of students from three different states of Punjab (23%), Uttar Pradesh (32%), and Haryana (45%), and most of them hailed from an urban background (66%). Among the 100 students, 60 were in the 2nd year of training, 36 in the 3rd year, and 4 in the final year of training. None of them had any professional experience in mental health care and none reported of having any family member or friends known to be suffering from mental illness. Four of them acknowledged of having known a family member having problematic substance use and six reported of knowing a close friend with any substance abuse.
On ASMI, mean scores of stereotype (3.1 ± 0.8), benevolence (3.7 ± 0.6), and pessimistic prediction (3.4 ± 0.9) were noted to be higher. Separatism (2.6 ± 0.5), restrictiveness (2.4 ± 1.0), and stigmatization (2.1 ± 0.7) were at a lower level. Participants had more stereotypic and pessimistic prediction on mental illness but were nonstigmatizing, kind, and open for social involvement.
In nonparametric Freidman's test, a statistical difference (P < 0.01) was noted among the mean ranks of the attitude scores for different conditions in AMIQ, with Chi-square value of 279.35. Negative attitude was noted more in criminals (mean ± SD = 4.8 ± 3.7) and those using heroin (3.2 ± 3.6) [Table 1]. Attitude towards persons with depression/suicidal thoughts (1.36 ± 3.6), problematic alcohol user (0.59 ± 4.38), and schizophrenia (0.03 ± 3.2) were found to have spread across both positive and negative scores with mean towards neutral attitude. Positive attitude was reported in persons with diabetes (−4.4 ± 3.9) and high religiosity (−5.13 ± 3.6). The Freidman's test was significant across different items of AMIQ and almost similar to those as the total [Table 2]. Overall, participants were skeptical of the ability to maintain interpersonal relationship with all the seven cases, comparatively persons with depression were seen as better able to maintain a relationship. Persons with schizophrenia were not preferred as co-workers viewing them as having major occupational difficulty. But they were also not preferred to be in the social gatherings though were seen as persons who have an ability to maintain personal relationship.
|Table 1: Descriptive statistics of scores in scales measuring attitude toward mental illness|
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|Table 2: Comparison of mean ranks of different condition in Attitude to Mental Illness Questionnaire|
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On Spearman's correlation, male students had significantly more stereotypic views on mental illness (r = 0.209, P < 0.05). The number of years spent in nursing field as a student was significantly associated with lesser benevolence (r = 0.227, P < 0.05). None of the other sociodemographic parameters correlated with any of the attitude measures.
Negative attitudes toward persons with alcohol use (r = 0.22, P < 0.05), diabetes (r = 0.25, P < 0.05), and religiosity (r = 0.32, P < 0.05) but positive attitude toward criminals (r = 34, P < 0.01) were associated with lesser benevolence toward mental illness. Negative attitudes toward patients with schizophrenia correlated with more pessimistic prediction (r = 0.24, P < 0.05), separatism (r = 0.22, P < 0.05), and more stigma (r = 0.21, P < 0.05) on mental illness. More negative attitude toward religious person also correlated well with stigma (r = 0.34, P < 0.05) and separatism (r = 0.3, <0.01) opinion on mental illness.
| Discussion|| |
This study showed the presence of negative attitude toward mental illness and people suffering from it. When attitude was assessed using the generic term of “mental illness,” nursing students had a stereotypic view by thinking them as easily distinguishable person with strange behavior and low intellectual abilities. This was associated with a prejudice of predicting a poorer outcome in them. Similarly, high negative attitudes were noted in Indian nursing students in some of the previous studies as well., In contrast to other studies which showed higher reporting on stereotype, separatism and pessimistic prediction, nursing students in our sample distinctively rated only stereotype and pessimistic prediction as very high. However, they were more kind and benevolent with less negative stigmatizing attitudes such as need of shame, anger, or secretiveness. Nursing students did not expect the need for separation and restriction on activities as found in the nursing students from South India.
When vignettes were given of different persons, negative attitude toward person with mental illness persisted. However, the overall attitude was worse for those with criminal background and heroin use. Heroin being an illicit drug, negative attitude was high for domains with higher rank for legal encounters. Negative attitude was noted for alcohol dependence as well. Indian studies have evaluated at the attitudes of students toward addiction and had similar findings., Students though think that they have adequate knowledge about substance abuse and their consequences, they are actually not properly aware of illness model and the available medical treatment facilities. This leads to higher stigma and lower help-seeking behavior.
Attitude toward a person with depression having had a suicidal attempt was more than that toward person with alcohol problem and schizophrenia. Students had a positive attitude toward person with physical illness (diabetes) and religious person as expected. A qualitative study in India had also shown negative attitude towards suicide in Indian nurses. Another study conducted on eastern Indian health providers showed a majority believing that depression and suicide are a sign of weakness, and though circumstances play a major role in these conditions, it is the person who needs to be blamed for these conditions showing ignorance toward any such clinical diagnosis. Higher legal liability with suicidal depression could be influenced by the law of the land considering suicide as an offence, even though decriminalization under the premise of mental illness is under process.
Only attitude toward person with schizophrenia but not with other psychiatric conditions (viz., depression and substance-related disorders) correlated with the attitude toward mental illness. This would reflect the general knowledge of considering schizophrenia as a mental illness. The lack of coherence in the attitude toward other psychiatric disorders supports the findings of lack of awareness regarding substance dependence and the health-care facilities available for getting abstinent. A stereotypic view would be precipitated and encouraged when the term “person with mental illness” is used in the questionnaires, though this would be beneficial in evaluating the impact on psychiatric service utilization and attempting choice of psychiatry as a career. However, when a person is kept as a center of focus in evaluation, it would tap the true attitude that would be portrayed in real life which would impact the people at the perceiving end of stigma. This will be helpful in the differential evaluation of the disorders under consideration as psychiatric ailments.
Although a high negative attitude was noted, the students were assessed before their beginning of psychiatric postings. This needs to be considered before generalizing our findings to nursing students. The difference in attitude toward “mental illness” and person with specific “psychiatric problems” needs further systematic evaluation. The tools used here tapped into overlapping but differing domains of the attitudes. Identifying the tools which caters to the similar categories/subscales would have yielded a better understanding. The hypothesis of possibility of differential evaluation needs to be proven in a larger sample and various types of population.
| Conclusion|| |
Negative attitudes toward mental illness are noted in nursing students. Questionnaires assessing the opinions toward mental illness may not be the same as those assessing attitudes toward person with specific mental disorders. Understanding the differences and assessing both the aspects would pave new paths in dealing with the stigma and its consequences in psychiatry.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]