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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 40-47

Knowledge and attitudes toward schizophrenia among high school adolescents


1 Department of Psychiatry, Index Medical College, Indore, India
2 Department of Psychiatry, People's College of Medical Sciences and Research Center, Bhopal, Madhya Pradesh, India
3 Department of Psychiatry, B.J. Medical College, Ahmedabad, Gujarat, India

Date of Submission03-Aug-2019
Date of Decision26-Sep-2019
Date of Acceptance01-Oct-2019
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Ganpat K Vankar
Department of Psychiatry, People's College of Medical Sciences and Research Center, Bhanpur, Bhopal - 462 037, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_50_19

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  Abstract 


Context: Poor awareness about schizophrenia and stigma toward people with schizophrenia is an important factor impacting early detection, support, and treatment. Aims: This study aims to assess the knowledge and attitude of adolescents in 9th to 12th classes in high schools toward people with schizophrenia. Settings and Design: The descriptive, cross-sectional study was conducted in 4 schools as part of a schizophrenia awareness program. Subjects and Methods: This was a descriptive, cross-sectional study to assess the knowledge and attitude of high school children toward schizophrenia. A self-report questionnaire was administered with sections containing case vignette-based knowledge and attitude toward schizophrenia. Statistical Analysis Used: Chi-square and “t”-test were done to find the association between demographic characteristics, knowledge level, and attitude. Results: Of 1540 students, about half of all respondents had average knowledge and only 10.5% students had a good knowledge score. Although knowledge level of boys and girls was similar, boys had more positive attitude toward people with schizophrenia as compared to girls. Good knowledge was associated with less distancing with person with schizophrenia. About 45% adolescents believed that people with schizophrenia are more prone to violence. Counseling and psychotherapy were endorsed as helpful compared to antipsychotic drugs and electroconvulsive therapy. Traditional healers were perceived as harmful. The adolescents were more ready to befriend the patient, meet him, and have him in the neighborhood but less ready to work with him or to get him married in the family in the future. Conclusions: There are important knowledge gaps in adolescents. Educational interventions should aim at correcting myths and especially emphasized effective treatment methods.

Keywords: Adolescents, attitudes, India, knowledge, schizophrenia, school


How to cite this article:
Anis SS, Vankar GK, Kansal KR, Jambusarwala TN, Gor VP. Knowledge and attitudes toward schizophrenia among high school adolescents. Ann Indian Psychiatry 2020;4:40-7

How to cite this URL:
Anis SS, Vankar GK, Kansal KR, Jambusarwala TN, Gor VP. Knowledge and attitudes toward schizophrenia among high school adolescents. Ann Indian Psychiatry [serial online] 2020 [cited 2020 Oct 20];4:40-7. Available from: https://www.anip.co.in/text.asp?2020/4/1/40/285505




  Introduction Top


Several studies have concluded that there is a stigmatizing and negative view toward people with schizophrenia around the world which delays its early detection and treatment.[1],[2],[3],[4]

Psychiatric disorders are profoundly stigmatizing disorders despite numerous initiatives to challenge negative stereotypes.[5],[6] Stigma can be understood as a combination of problems of knowledge (ignorance), attitudes (prejudice), and behavior (discrimination).[7] Individuals with mental illness may be subjected to prejudice and discrimination from others and as a result may internalize feelings of devaluation further worsening the situation.[8],[9],[10],[11]

Negative societal responses to people with mental illnesses may be the single greatest barrier to the development of mental health programs worldwide. These negative effects, and the associated human rights issues, are increasingly recognized as a worthy target for social action. A number of programs have been implemented in recent years under the rubric of “anti-stigma programming” to promote greater social equity for people with mental illnesses.[12],[13]

Approximately 10% children and adolescents suffer from psychiatric disorders at any given point of time; however, only one-third receive treatment, leading to personal distress and disadvantage in education, future employment, and social life. Stigmatization right from adolescence for many patients with schizophrenia becomes a major issue.[14]

Stigma, attitude, and belief about mental disorder develop during childhood and adolescence.[15] Intervention targeting this group will increase the treatment seeking behavior of adolescents, and it will enhance treatment compliance. Thus, this age group is appropriate to be targeted for imbibing positive attitude leading to reduction of stigma related to mental disorder, which may reduce the illness burden.[16]

The studies indicate poor schizophrenia literacy among adolescents. For example, in a study of Swedish adolescents, only one-third of the students correctly identified the vignette as a person suffering from schizophrenia and that he needed professional treatment.[17] A Japanese study students explored attitude toward social phobia, depression, and schizophrenia. This study revealed the highest stigma toward schizophrenia.[18] A study of secondary school teachers from Gujarat found that only 30% considered electroconvulsive therapy (ECT) as safe treatment and 50.1% considered that faith healers can help psychiatric patients.[19] A study of nursing students and nursing staff considered faith healers as harmful for treatment of schizophrenia.[20]

There are some studies to reduce stigma related to schizophrenia in adolescents.[21],[22],[23] Recently, many sophisticated educational programs have been conducted to provide basic information on schizophrenia and its associated behaviors to various populations.[24],[25],[26] These studies inspired us to conduct this work targeted at school adolescents, combining the research with an educational intervention. This study aimed to assess the knowledge and attitude toward people with schizophrenia and their correlates in school adolescents of 9th to 12th classes in high schools. We hypothesized that high school adolescents had poor knowledge about schizophrenia, and good knowledge was associated with more positive attitude reflected in less social distance from person with schizophrenia.


  Subjects and Methods Top


This was a descriptive, cross-sectional study to assess the knowledge and attitude toward schizophrenia in school adolescents of classes 9th to 12th.

Instrument: A semi-structured, self-report questionnaire was administered with the following sections:

  1. Demographic details
  2. Case vignette: identification of mental health problem
  3. Attitude toward patient and treatment options
  4. Knowledge and attitude towards people with schizophrenia: the knowledge part consisted of 20 true/false statements, related to epidemiology, causation, clinical features, treatment, and prognosis of schizophrenia, with each correct response carrying score 1 with possible total knowledge score range 0–20. Score 15 or more was arbitrarily considered indicative of good knowledge (>75% correct items). The items were well-accepted facts about schizophrenia. It was used previously in the second author's study on schizophrenia literacy among nursing students and staff.


In addition, the adolescents were asked who and what can help the person with schizophrenia.

Attitude towards the person with schizophrenia was measured on a 5-point scale (certainly ready, probably ready, probably not ready, certainly not ready, and not certain) on adolescents' readiness to live in the neighborhood, to make friends, to work with and to get person married in the family.

After completing the questionnaire, an interactive educational session on the schizophrenia of 60-min duration was conducted. No posttest was taken.

Participants

We conducted the study in 4 schools. Students of classes 9th to 12th were enrolled in the study.

After taking informed consent, students were administered the pro forma in a classroom setting by the 2nd and 3rd year residents in psychiatry. None of the students refused participation, although it was purely voluntary.

This study was ethically approved by the institutional ethics committee. All the institutes were regional language medium, the study instrument was in the same language, and all schools were private schools. Principals of schools were contacted to ensure their cooperation; they gave written permission for the study. The parents were not notified.

Statistical analysis

UpenEpi (Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. www. OpenEpi.com, updated 2013/04/06, accessed 2019/10/15) was used for statistical analysis. Knowledge scores were compared for boys and girls; they were also compared for lower standards (Grade 9–10 and grade 11–12). Comparisons were made for the social distance between boys and girls, lower grades and higher grades, and between those with good knowledge and poor knowledge. Chi-square and “t”-test was done to find the association between demographic characteristics, knowledge level, and attitude. P value was set at 0.05.


  Results Top


Demographic characteristics

As shown in [Table 1], boys were overrepresented in the sample; girls were approximately one-third of boys. Age group was from 13 to 18 years with a mean age of 14.8 (standard deviation [SD] 1.17) years. Maximum students were from 9th standard.
Table 1: Demographic characteristics (n=1540)

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Knowledge about schizophrenia

Knowledge score of the respondents ranged from 0 to 19, with a mean score of 10.8 (SD 3.5). Girls had a score range of 0–19, with mean score 11.2 (3.06) and boys had a score range 0–19 with mean score10.54 (3.69). The difference was not statistically significant.

Only 162 (10.5%) respondents had high knowledge level as defined by score 15 or more.

As shown in [Table 2], more than 50% considered schizophrenia patients to be violent or dangerous; they also considered medicines used in the treatment to be addictive. Sixty percent considered that medications are sleep medications which by improving sleep reduce the features of schizophrenia. 60% also regarded that ECT may cause permanent brain damage. Thus, many myths regarding schizophrenia were prevalent in adolescents.
Table 2: Knowledge about schizophrenia (N=1540)

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Characteristics of adolescents who had good knowledge

There were no gender differences as regards good knowledge level. Younger adolescents aged 13–14 years and those studying in standards 9–10 were significantly overrepresented among students with good knowledge about schizophrenia [Table 3].
Table 3: Demographic characteristics and Knowledge Level

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Perception of adolescents who can help a person with schizophrenia

As shown by [Table 4], maximum students regarded psychiatrists and family doctor to be helpful, around 60% considered that teacher can also be helpful, and around 40%–50% students considered faith healers and religious person to be harmful; but, 18% still considered that they can be helpful. Faith healers were perceived as harmful or having no impact on the treatment of schizophrenia.
Table 4: Perception of students who can help a person with Schizophrenia (% Respondents, n=1540)

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Perception of respondents what can help a person with schizophrenia

As shown in [Table 5], the vast majority of students perceived Yoga and exercise followed by counseling and psychotherapy as useful in the treatment of schizophrenia. Only 22% of adolescents endorsed antipsychotic medication, which is the specific treatment. Around 10% of students responded in favor of ECT which is also an important treatment method. Some of them (1 in 7 students) considered the occasional intake of alcohol to be helpful.
Table 5: Perception of students what can help a person having schizophrenia (% Respondents=1540)

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Adolescent attitude toward schizophrenia

The adolescents were more ready to befriend the patient, meet him, and have him in the neighborhood but less ready to work with him or to get him married in the family in the future [Table 6]. It shows that social acceptance is limited and is present in certain areas only.
Table 6: Measure of social distance with a person having schizophrenia (% Respondents, N=1540)

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Relationship of knowledge and attitude

[Table 7] shows that respondents who had good knowledge had a better attitude toward patients as compared to those who have poor knowledge.
Table 7: Measure of social distance with a person having schizophrenia according to knowledge (% Respondents) (Poor Knowledge=1378, Good knowledge=162)

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Irrespective of the knowledge level, most adolescens were ready to meet and befiend a person with schizophrenia. Those with good knowledge were more ready to live in neighbourhood and work with a person with schizophrenia. Adolescents with good knowledge were also more ready to get a person with schizophrenia married in their own family in future.

Gender and attitude toward schizophrenia

As shown in [Table 8], boys had more positive attitude toward patients of schizophrenia as compared to girls in all aspects.
Table 8: Measure of social distance with person having schizophrenia according to sex (Girls=494, Boys=1036)

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Level of education and attitude toward schizophrenia

On all the parameters of social distance, adolescents studying in classes 9–10 had more positive attitude [Table 9].
Table 9: Measure of social distance with person having schizophrenia according to level of education (Class 9-10, n=866, Class 11-12, n=674)

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  Discussion Top


Adolescent knowledge about schizophrenia

Although the mean knowledge score was slightly higher than 50%, only a few scored 15, i.e., more than 75%. Thus, knowledge about schizophrenia was average. Boys and girls had almost a similar knowledge level. Moreover, there was no difference in knowledge scores between adolescents in higher grades and lower grades. Only studying in higher grade does not automatically increase knowledge about schizophrenia; educational programs are needed for enhancing knowledge about schizophrenia. The lower standard students had better knowledge compared to Std XI–XII despite the latter had exposure to psychology curriculum. This emphasizes that the curriculum needs to be modified to include biological treatments.

The delay in detection of schizophrenia leads to delay in treatment of psychosis is an important issue in the mental health field.[27],[28],[29],[30] According to the studies, 1–2 years is the median duration of the untreated psychosis, which has been associated with delayed remission, increased risk of suicide, substance abuse, and an unfavorable prognosis.[31],[32]

Studies have identified important factors related to delayed detection of schizophrenia.[5],[6],[7],[33] One is a lack of basic knowledge of the symptoms of the disease, and the other important one is stigma.

Providing knowledge about schizophrenia is an important step in preventing delays in diagnosis.[33]

Pang et al. study found 45.5% of Singaporean youth participating in the survey showed misconceptions and negative attitudes toward patients with mental illnesses, demonstrating a clear need for effective stigma reduction campaigns.[34]

Adolescent knowledge about clinical features of schizophrenia

In this study, although auditory hallucinations were recognized as a feature of schizophrenia, only a few identified the poor motivation for work as a feature. The negative symptoms need emphasis in psychoeducation as they may be perceived as intentional and may lead to high expressed emotions contributing o relapses.

If adolescents are having good knowledge of clinical features, they can identify the disorder early, and this can lead to seeking appropriate psychiatric treatment. Failing this, treatment may be delayed with the possibly less desirable outcome, socio-occupational decline, added problems of substance abuse and in some cases suicide.

A common prevalent misconception was that people with schizophrenia were violent reducing their social contacts.[35] In fact, a study concluded that patients are more prone to be victims of violence rather than committing violence themselves.[36]

Almost 45% of students in our study also believed that people with schizophrenia were more prone to violence. Svensson et al. reported that in five of the eight training programs in European medical schools, the majority of the medical students' perceived people with schizophrenia as a danger to others. Students with previous experiences of work in mental health services and students knowing a person with schizophrenia showed more positive attitudes. The study concluded that to remove the prejudice and improve the attitude, personal contact with mentally ill people is required.[36]

Adolescent knowledge about causative factors for schizophrenia

The biological basis of schizophrenia, i.e., neurotransmitter changes was recognized by 59.1% adolescents. This needs further emphasis to understand that the treatment methods of choice are biological.

Adolescent knowledge about treatment of schizophrenia

Only 45.5% correctly knew that antipsychotic drugs were the mainstay of treatment. Half of them considered it addictive and 45.5% knew about the need for continuing the medication for preventing relapse beyond symptomatic improvement. In contrast about two-third of the adolescents considered counseling and psychotherapy as helpful. This may be due to popular strong emphasis in psychology textbooks of Grade XII to psychotherapy while biological treatments are totally excluded.[37] It is to be noted that all Std. XI and XII's students had exposure to the National Council of Educational Research and Training psychology curriculum.

The misconceptions led to refusal or noncompliance to effective treatment measures or choosing potentially less effective treatments.

Only 10% of adolescents considered ECT helpful for schizophrenia; this is not surprising as there are prevalent myths and negative media portrayal. Around 60% of students in the present study responded that ECT may lead to permanent brain damage. Dan et al. showed negative attitude and poor knowledge of the patient as well as relative towards ECT.[38]

Yoga and exercise were considered helpful by a large majority. Traditionally, they are considered useful for a healthy life. Although the practice of Yoga can have positive benefits, there is a danger that many people may consider them as exclusive treatments for a severe, biological disorder like schizophrenia, not seeking more evidence-based biological treatments. More adolescents have preferred general hospital psychiatric unit hospitalization rather than admission in a mental hospital, in tune with modern psychiatric care in a non-restrictive environment. About half of the respondents considered mental hospital inpatient care as harmful.

Adolescent knowledge about who can help patients with schizophrenia

Psychiatrists, general practitioners, clinical psychologists, and teachers were considered helpful by the majority of adolescents. Although teachers are not health professionals, they may be first to recognize features of schizophrenia, especially in school adolescents. Though some studies have found inadequate knowledge and negative attitudes about schizophrenia. For instance, a study of secondary school teachers in Ahmedabad found that 76% of teachers had inadequate knowledge about mental disorders and 63.6% had negative attitudes.[19]

Half of the respondents considered faith healers as harmful for the person with schizophrenia. Large number of people still continue to believe in supernatural causation of mental illness and the faith healer as the person who can treat these disorders. Kishore et al. showed that myth regarding schizophrenia treatment. Kishore et al. showed that myth regarding schizophrenia treatment is still prevalent, more commonly in rural areas as compared to urban areas.[39] Shidhaye and Vankar found that irrespective of diagnosis more than half of their psychiatric patients in outpatients had consulted a traditional healer and one in five patients would recommend a traditional healer for a psychiatric disorder.[40]

Relationship of knowledge about schizophrenia and attitude

The current study found that those who had better knowledge about the disease had more positive attitude towards the persons with schizophrenia. Singh et al. concluded that a significant proportion of patients with schizophrenia experienced stigma, and it was associated with a lower level of functioning; better knowledge about illness led to a decrease in stigma.[41] Stuart and Arboleda-Flórez studied that greater knowledge was associated with less-distancing attitudes.[42] A major study of caregiver stigma was associated with higher levels of positive symptoms of schizophrenia, higher levels of disability, patients' young age, and household education at the secondary school level. Knowledge about schizophrenia was not associated with caregiver stigma.[43]

Many published studies reported that merely increasing knowledge about psychiatric disorders does not have a large impact on attitude for people suffering from psychiatric illness but systematic training can change attitude. Some studies have not found a significant association of knowledge and social distance from persons with schizophrenia.[4],[44],[45]

Gender and level of education: Relation with attitude toward persons with schizophrenia

This study as found more positive attitude towards schizophrenia among boys compared to girls. Those in lower grades had more positive attitudes toward people with schizophrenia.

What to do?

Several Indian studies found correlates of stigmatization of schizophrenia. Grover et al. study found stigma to be experienced more in the early phases of illness; hence, the antistigma programs should focus more on the initial stages to reduce the negative consequences of stigma.[46] It also emphasized that context-specific antistigma messages should be used such as “recovery is possible” and “no-one is to blame” which may be more helpful than focusing on biomedical knowledge alone.[38] Knowledge about schizophrenia may influence the process of stigmatization in both positive and negative ways.[39]

Several studies indicate that young people's attitudes about schizophrenia can be changed. Antistigma projects at the school level could thus be a promising approach to improving public attitudes and to preventing stereotypes from becoming reinforced.[45] For counteracting stereotypes before they arise, targeting children and young people is a central approach in public education and antistigma campaigns.[46],[47],[48] A study from the United States showed that youths with a mental illness are likely to experience misunderstanding and exclusion by peers and it is easier to change the attitude of students as compared to adults.[49] Another systemic review concluded that compared to the adults, the young people accepted children and adolescents with psychiatric disorders.[50]

Previous studies have shown that basic knowledge of schizophrenia is improved by such programs, even though they differ in their content and form from each other.[26],[50],[51],[52],[53],[54],[55] The effective programs can target misinformation and myths related to schizophrenia which can induce a positive behavioral change in the society. Thornicroft et al. have summarized components of effective antistigma programs. They considered that social contact (i.e., interpersonal contact between people with and without the experience of mental illness) is the strongest proven active ingredient to reduce mental illness-related stigma and discrimination; such social contact is most effective in educational settings for young people. The virtual/social media contact may be as effective as direct face-to-face contact.[56] These strategies need to be confirmed in lower and middle-income country settings like India. This will help the patients to live in a place without isolation or discrimination. Along with education, social contact with people with schizophrenia can also lead to a remarkable behavioral change in people.

The study was limited to one city of western India. Multisite study result would be more representative, and the findings can be more generalized.

Ethical statement

This study was approved by Institutional Ethics Committee with reference number IEC/Certi/197/16 obtained on 29th September 2016.

Declaration of Patient Consent

Patient consent statement was taken from each patient as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results / clinical information /image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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