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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 202-207

Knowledge, stigma, and attitude toward mental illness among rural school students


1 Department of Psychiatry, M.P. Shah Medical College and G.G. Hospital, Jamnagar, Gujarat, India
2 Department of Psychiatry, M.P. Shah Medical College, Jamnagar, Gujarat, India
3 Department of Preventive and Social Medicine, M.P. Shah Medical College and G.G. Hospital, Jamnagar, Gujarat, India
4 Dr. M.K. Shah Medical College and Research Center, Ahmedabad, Gujarat, India

Date of Submission25-Jul-2020
Date of Decision08-Sep-2020
Date of Acceptance21-Sep-2020
Date of Web Publication25-Nov-2020

Correspondence Address:
Dr. Parveen Kumar
2nd Floor Department of Psychiatry, Trauma Building, M.P. Shah Medical College, Jamnagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_73_20

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  Abstract 


Background: Mental illnesses have been largely neglected in India due to poor knowledge about various categories of psychiatric disorders. While stigma and discrimination toward people with mental illness is an important barrier to mental health services utilization, timely diagnosis, and treatment, the stigmatizing attitude toward mental illness starts developing at a younger age around 5 years and continuously evolves through adulthood. Aims: The current study aimed to explore the knowledge about mental illness-related disorder, stigma toward mentally ill persons, and help-seeking behavior toward mental illness. Methodology: A total of 3478 students from 9th to 12th class rural school participated in the study. Mental health knowledge of students was assessed using the “Mental Health Knowledge Questionnaire,” and attitude toward persons with mental illness was assessed using the “California Assessment of Stigma Change Scale.” Results: It was observed in our study that in students with higher mental health knowledge about mental illness, students with higher education level, older students, and students with family members affected by mental illness and grossly in females, there were overall fewer stigmas toward mental illness and this group overall believed in possibility of empowerment of mentally ill people. A negative correlation was observed among attribution score with mental health knowledge (r = −0.151) and empowerment score (r = −0.151). Conclusion: The study suggests poor knowledge and understanding about mental illness and has stigmatizing attitude toward persons with mental illness. Students were pessimistic about empowerment and recovery potential of mentally ill persons and also had a negative view toward willingness for treatment.

Keywords: Attitude toward mental illness, mental health knowledge, school students, stigma


How to cite this article:
Kumar P, Tiwari DS, Kanabar BR, Patel VK, Chanpa NB, Vasavada DA. Knowledge, stigma, and attitude toward mental illness among rural school students. Ann Indian Psychiatry 2020;4:202-7

How to cite this URL:
Kumar P, Tiwari DS, Kanabar BR, Patel VK, Chanpa NB, Vasavada DA. Knowledge, stigma, and attitude toward mental illness among rural school students. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Apr 20];4:202-7. Available from: https://www.anip.co.in/text.asp?2020/4/2/202/301440




  Introduction Top


Mental health is an integral and essential component of health. Mental health includes subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one's intellectual and emotional potential. An understanding of mental health and mental functioning is important for complete understanding of the development of mental and behavioral disorders.[1]

Mental health literacy is defined as an “individual's knowledge and beliefs about mental disorders which aid their recognition, management and prevention.” It has different components such as ability to recognize specific disorders, knowledge about risk factors and causes of mental illness, how to seek mental health information, attitude that promotes recognition, and appropriate help-seeking.[2] Mental problems affect everyone, irrespective of age, gender, residence, and living standards, and are of chronic nature and result in a lifelong impact. If they are unrecognized or inappropriately managed, they result in poor quality of life for individuals and their families. Mental health is highly neglected in India.[3]

Epidemiological studies report the prevalence of psychiatric disorders in India varying from 9.5 to 370 in 1000 population.[4] This high prevalence is because people have no knowledge about various categories of psychiatric disorders which include depression, panic disorder, dementia, substance abuse, and schizophrenia.[5]

Stigma and discrimination towards people with mental illness is an important barrier to mental health services utilization, leading to delay in seeking care, timely diagnosis, and treatment, which results in delayed recovery and rehabilitation, and ultimately reduces the opportunity for participation in life.[6] The term stigma is used to refer to an attribute that is deeply discrediting. An attribute that stigmatizes one type of possessor can confirm the usualness of another and therefore is neither creditable nor discreditable as a thing in itself.[7] Stigmas are described on the basis of three conceptual levels: cognitive, emotional, and behavioral, which allow us to separate mere stereotypes from prejudice and discrimination. Stereotypes refer to prefabricated opinions and attitudes toward members of certain groups, such as ethnic or religious groups, whites and blacks, Europeans and Latin Americans, Jews and Muslims, and the mentally ill. The most prominent stereotypes surrounding the mentally ill presume dangerousness, unpredictability, and unreliability; patients with schizophrenia are most affected by such views. Stereotypes are not necessarily wrong or negative; they can also help us to make quick judgments about persons who share specific characteristics. Stereotypes thereby allow us to deal with or adapt to a specific situation without needing more information about the persons involved by adopting different behavior. However, it requires more information than the only stereotype to make a fair and rational judgment about individuals. In case of mental illness, stereotypes become dysfunctional because they activate generalized response pattern rather than customized responses.[8] Negative attitude leads to delay in seeking professional help for the patients, discriminates against patients and their families, and hinders the deserved placement of patients in the society.[9] The stigmatizing attitude toward mental illness starts developing at a younger age around 5 years and continuously evolves through adulthood.[10]

There are few studies in Indian literature that assess attitude and stigma toward mental illness of school students. The current study, therefore, aimed to explore the knowledge about mental illness-related disorder, stigma toward mentally ill persons, and help-seeking behavior toward mental illness.


  Methodology Top


A cross-sectional study was carried to investigate knowledge, attitude, and stigma related toward mentally ill persons in rural school students. Permission from the District Education Officer was taken after explaining the due nature of the study. A list of rural secondary and higher secondary government and government-aided schools was taken from the district education department. There are total 140 schools in all six talukas of Jamnagar district. Out of which, 40 schools were selected by a simple random sampling method. All the students from 9th to 12th standard present on the day of the study were included in the study. Following this, permission from the principals of respective schools was taken by telephonic conversation; date and time were discussed to ensure maximum attendance. After explaining the nature of the study as well as questionnaire given in the scale to students, the level of their understanding was assessed qualitatively by asking questions to some of the students about the study. They were also instructed to contact the investigator immediately in case of doubt in any question while giving response in the questionnaire.

All the students from class 9th to 12th who were present at the time of the study were asked to fill the structured questionnaire containing four important parts: (1) demographic details of students, (2) family history of mental illness, (3) the Mental Health Knowledge Questionnaire (MHKQ), and (4) California Assessment of Stigma Change Questionnaire. Both “MHKQ” and “California Assessment of Stigma Change Scale” were translated into Gujarati and back translated into English by a language expert. Ethical approval was taken from the institutional ethical committee.

Study tools

The Mental Health Knowledge Questionnaire

MHKQ was used to evaluate public knowledge and awareness of mental health. It contains 20 self-administered items. Items 1–16 (the first section) require participants to select “true,” “false,” about statements concerning mental health. For items 1, 3, 5, 7, 8, 11, 12, 15, and 16, a “true” answer corresponded to a 1-point score, while a “false” or “unknown” answer corresponded to a score of 0. By contrast, for items 2, 4, 6, 9, 10, 13, and 14, a “false” answer gave a score of 1, while “true” or “unknown” answers corresponded to a score of 0. Finally, items 17–20 (the second section) are statements concerning previous knowledge about the “four mental health promotion days.” Total scores range from 0 to 20, with higher scores indicating greater knowledge of mental health issues. The Cronbach's coefficient of MHKQ was reported to be 0.69.[11]

The California Assessment of Stigma Change

This is a short battery to assess stigma which contains.

Attribution Questionnaire-9

This nine-item scale comprises single items for each of the nine factors that emerged from path analyses of responsibility and dangerousness: blame, pity, danger, help, fear, avoidance, coercion, and institutionalization. Questions were posed about Harish “a 30 year old man suffering from mental illness”. Research participants responded to individual questions (e.g, “ How dangerous do you think Harish is?”) on a 9 point Likert scale from (1= not at all to 9 = very much). Total Attribution Questionnaire-9 scores range from 9 to 81, with higher scores representing more stigmatizing views toward people with mental illness.

Personal Empowerment Scale

It has a three-item Empowerment Scale (ES) refflecting self-efficacy/self-esteem. A sample item is, “I see people with mental illness as capable people,” to which research participants answered using a 9-point scale of agreement (1 = strongly disagree to 9 = strongly agree). Total scores range from 3 to 27 on this scale with higher scores representing better views of empowerment regarding people with mental illness.

Recovery orientation with a 3-item scale

Recovery orientation with a 3-item scale (RS) consists of a three-factor scale for personal confidence and hope, goal and success orientation, and no domination by symptoms. A sample item is, “People with mental illness can do things as well as most other people,” to which research participants answered using a 9-point scale (1 = strongly disagree to 9 = strongly agree). Total scores range from 3 to 27 on this scale, with higher scores representing better views of recovery.

Care-Seeking Questionnaire

This is a 6-item questionnaire for psychological help-seeking willingness. Participants asked about the level of agreement (1 = strongly disagree to 9 = strongly agree) with statements like, “I would speak to a psychiatrist if I were significantly anxious or depressed.” Scores range from 6 to 54, with higher scores representing more willingness to seek out services. The Cronbach's coefficient was 0.80 for ES, 0.70 for Care-Seeking Questionnaire, and 0.58 for RS.[12]

Statistical analysis

Data entry and analysis was done using Microsoft Excel and Epi Info software (Centers for Disease Control and Prevention (CDC), Piedmont, North Carolina, United State). The sociodemographic profile and family history of mental illness have been expressed in terms of frequency and percentage. Pearson correlation test was used to find the relation between mental health knowledge and attribution score with age of participants and of attribution score with mental health knowledge score and empowerment score. Pearson correlation test was also used to find the relation between education level of participants with mental health knowledge, attribution, empowerment, recovery, and care-seeking scores.


  Results Top


Total 3478 participants participate in our study whose age group ranged from 13 to 18 years with a mean age of 15.52 ± 1.28. There were 9.32% who had a family history of mental illness. [Table 1] shows the demographic details of participants.
Table 1: Demographic details of participants (n=3478)

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The mean mental health knowledge score and attribution score of participants were 11.39 and 42.01, respectively. [Table 2] shows that female participants and participants with family history of mental illness had statistically significant higher mean mental health knowledge score, empowerment score, and recovery score as denoted by independent t-test (P <0.001), while the mean attribution score was significantly lower (P <0.001) than other.
Table 2: Mental health knowledge and attribution, empowerment, recovery, and care (help) seeking score of participants (n=3478)

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However, there was no statistically significant difference found in care-seeking score with age, gender, and education level of participants.

[Figure 1] shows that the correlation of age with mental health knowledge was positive (r = 0.310) and negative (r = −0.203) with attribution score as denoted by Pearson correlation. Both of the relations were found to be statistically significant (P <0.001).
Figure 1: (a) Relation of mental health knowledge with age. (b) Relation of attribution score with age

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[Figure 2] shows a negative correlation attribution score with mental health knowledge (r = −0.151) and empowerment score (r = −0.151) as denoted by Pearson correlation test. Both of the relations were found to be statically significant (P <0.001). As stigma toward mental illness increases, participants' views of empowerment (as capable people) regarding people with mental illness decrease.
Figure 2: (a) Relation between mental health knowledge and attribution score. (b) Relation between empowerment and attribution score

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[Figure 3] showed the correlation of education level of participants with mental health knowledge as positive (r = 0.344) and negative (r = −0.263) with attribution score as denoted by Pearson correlation. Both of the relations were found to be statistically significant (P < 0.001).
Figure 3: (a) Relation of mental health knowledge with education level. (b) Relation of attribution score with education level

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Education level was correlated with empowerment score (r = 0.414) and recovery score (r = 0.394), which was statistically significant (P <0.001), while negatively correlated with care-seeking score (r = 0.010), which was statistically nonsignificant (P = 0.569).


  Discussion Top


We found a relative lack of knowledge as well as stigmatizing attitude of school students toward mentally ill people. Our study shows that female participants have an overall higher mental health knowledge score than male participants. We also found that mental health knowledge increases with age and education level. Those who have had previous experience with family members with mental illness had a better mental health knowledge score. Li et al. in a web-based study from the general population of China found that mental health knowledge increases as education level increases and significantly higher knowledge in the age group of 25–44 years than in age group of >45 years and in those who have had previous contact with mental illness, while they did not find any difference with respect to participants gender.[13] Gureje et al. conducted a study among senior secondary school students of Nigeria which revealed a lack of knowledge and understanding about mental illness.[14]

In our study, school students had a negative attitude toward mental illness and reported mentally ill person as dangerous, felt pity, or tried to stay away from mentally ill people and wanted to put them away in a psychiatric hospital. Similarly, a study conducted by Naeem et al. among medical students in Lahore, Pakistan,[15] Crisp et al. among the adult population,[16] and Parikh et al. in English medium secondary and higher secondary school teachers from Ahmedabad revealed lack of knowledge regarding prevalence, causative factors, symptoms, treatment of mental illness, substantial negativity toward mentally ill patients and considering them as dangerous and unpredictable.[17]

In our study, we also found that female participants had a significantly lower level of stigma toward mentally ill persons. Ng and Chan conducted a study among secondary schools students in Hong Kong,[18] Pinfold et al. in secondary school students of the UK[19] and Watson et al. among high school students from northern suburbs of Chicago[20] found similar results with a more stigmatizing attitude in male participants than females, while Schulze et al. in a study among students from five secondary schools in Leipzig from grade 9–12 did not find any gender difference in stigma toward mental illness. The difference may be possibly due to small sample size.[21] Youssef et al. in a study among 673 college students from the English speaking Caribbean universities reported that females had a more negative attitude to schizophrenia and heroin use as compared to males. This negative attitude may be due to the fact that many people did not think drug addiction as a mental illness but see it as a matter of choice or possibly a moral failing.[22]

In our study, it was observed that participants having more knowledge about mental illness had a significantly lower level of stigma. Similarly, Watson et al. among middle school students of the United States,[23] Pejović-Milovancević et al. among high school students of Serbia,[24] Wahl et al. among middle school students from the US,[25] and Essler et al. among secondary school students of the UK[26] found a positive association between mental health knowledge and understanding with less stigmatizing attitudes toward mental illness.

In our study, it was observed that participants having a family member with mental illness have significantly less stigma. Our results correlated with Penn et al. study in undergraduate students of Nebraska-Lincoln,[27] Alexander and Link in American respondents by telephone,[28] and Corrigan et al. in adult participants from general public,[29] while a study by Ng and Chan among secondary schools in Hong Kong[18] and Corrigan et al. among high school students of southern California[30] found that students with a mentally ill family member associated mentally ill people with greater blame and danger. These findings may have occurred as a result of statistical artifact or lack of understanding about vignette of schizophrenia.

In our study, it was observed that with increasing age and education level in participants, there was a significant reduction in stigma. Mas and Hatim in a study among medical students in university of Malaya, Kuala Lumpur,[31] and Girma et al. in a community-based study conducted at southwest Ethiopia[32] found similar results that as age and education level of respondents increases, stigma score decreases. While a review by Brunton[33] and Wahl et al. found that negative attitudes towards mentally ill start as early as 5 years of age, and that younger children lacked clear conceptualization and understanding about mental illness than older children.[10] A study by Ganesh in general public of southern India reported that participants' knowledge about mental illness was quite poor with participants having negative attitude toward mentally ill people. They found that most people feel uncomfortable in visiting a psychiatrist if they had any emotional problem leading to poor outcomes. This highlights the stigma and lack of awareness toward mental illness.[34]

In this study, it was observed that in students with knowledge about mental illness, older students, students with family members affected by mental illness, students with less stigmatizing attitude, and grossly females believed in possibility of empowerment of mentally ill people. Similarly, Lanfredi et al. in a study among European participants observed self-stigma as a mediator in empowerment toward mental illness,[35] and Lanfredi et al. in a study among 12th-grade students in Italy observed positive attitude, empowerment, and recovery toward mental illness after providing education about mental illness.[36]

Our study did not found any statistically significant difference found in care-seeking score with age, gender, and education level of participants. While Nearchou et al. in a study among secondary school students from Ireland[37] and Parikh et al. in a study among secondary and higher secondary school teachers in Ahmadabad[17] observed that public stigma is a significant predictor of helpseeking. Watson et al. in a study among middle school students in the United States found that a brief educational program increased students' willingness to access treatment toward illness.[23] Pejović-Milovancević et al. in a study among high school students of Serbia observed significantly increased understanding about basic etiological factors leading to mental illness, with participants expressing an increased need to take care of affected peers and helping them in social integration after educational program.[24]


  Conclusion Top


This study provides an assessment of students' knowledge and attitude toward mental illness. Results suggest poor knowledge and understanding about mental illness, with participants considering a mentally ill person as violent and dangerous reflecting a stigmatizing attitude. Students were pessimistic about empowerment and recovery potential of mentally ill persons. Students also had a negative view toward willingness for treatment.

In this study, it was observed that in students with higher knowledge about mental illness, older students, students with family members affected by mental illness, and grossly in females, there was overall less stigma toward mental illness, and this group overall believed in possibility of empowerment of mentally ill people.

Ethical statement

This study was approved by Institutional Ethics Committee with reference number IEC/Certi/46/02/2020 obtained on May7,2020.

Limitations and future scope

The cross-sectional nature of the study precludes any causal interpretations; longitudinal and experimental studies are required to better elucidate causality. Scales' validity and reliability were not available for the Indian population, but a CASC scale was standardized for the Asian population and had good sensitivity. We did not include type, relation, and duration of contact with mental illness. Moreover, hypothetical vignettes were used in the survey and might not truly refflect the actual experience of conceptualizing a problem in real life. Further studies should examine about the impact of antistigma intervention.

Declaration of patient consent

Patient consent statement was taken from each patient as per the Institutional Ethics Committee approval along with consent taken for participation in the study and publication of 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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    Tables

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