Indian Journal of Health Social Work
TRIBAL AND NON TRIBAL ATTITUDE TOWARDS MENTAL ILLNESS
Sarathi Hembram1 & Manisha Kiran2
Correspondence: Sarathi Hembram, e-mail: email@example.com
Background: The mentally ill are often blamed for bringing on their own illness, whereas others may see mentally ill people as victims of unfortunate fate, religious and moral transgression, or even witchcraft. The belief that mental illness is incurable can also be damaging, preventing patients from being referred for appropriate mental health care. Aims: The present study aimed to find out attitudes towards mental illness among tribal and non-tribal population: a comparative study. Materials and methods: The study was a cross sectional carried out in out-patient department of Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS) Kanke, Ranchi . A total of 200 participants (100 tribal and 100 non -tribal participants) were purposively recruited for the present study and applied adapted version of Opinion about Mental Illness Scale. The sample comprised of both male and females in the age range of 20-50 years and educated minimum of primary level. Results & Conclusion: overall there was no significant level of difference revealed among tribal without mental ill patient and non tribal without mental ill patient with regards to attitude towards mental illness. Knowledge of mental illness among the general public was quite poor and suggests the need for strong emphasis on public education to increase mental health literacy among general public to increase awareness and positive attitude of people towards mental illness.
Keywords: Attitudes, mental illness, opinion, tribal, non-tribal
A persistent negative attitude and social rejection of people with mental illness has prevailed throughout history in every social and religious culture. Of all the health problems, mental illnesses are poorly understood by the general public. Such poor knowledge and negative attitude towards mental illness threatens the effectiveness of patient care and rehabilitation. This poor and inappropriate view about mental illness and negative attitude towards the mentally ill can inhibit the decision to seek help and provide proper holistic care. Better knowledge is often reported to result in improved attitudes towards people with mental illness and a belief that mental illnesses are treatable can encourage early treatment seeking and promote better outcomes (Stuart & Arboleda-Florez, 2001). General public’s view about mental illness remains largely unfavourable. The topic of mental illness itself evokes a feeling of fear, embarrassment or even disgust fostering negative attitudes towards mental illness and mentally ill people (Bhugra & Leff, 1993). The mentally ill are often blamed for bringing on their own illness, whereas others may see mentally ill people as victims of unfortunate fate, religious and moral transgression, or even witchcraft. This may lead to denial by both sufferers and their families, with subsequent delays in seeking professional treatment.
Understanding and perceptions about mental illness vary among individuals based on their experience with the illness or their contact with the people affected by it. Recent studies conducted in various cultural contexts indicate that the ancient stigma associated with mental illness is still present in the most part of the population. Mental ill people are irresponsible, unable to control themselves, incurable, irremediably lost for the society, dangerous or a subject of mercy and compassion, living in their own mysterious and isolated world(Corrigan et al., 2001; Mahto et al., 2009; Mehta et al., 2009). These may be further influenced by the individuals’ socio-cultural background. This study aimed to understand the differences in the beliefs about, understanding of, and explanations for mental illness between different population.
Opinion about mental illness plays vital role in long-term care of mentally ill patients. Not only people but patients who are mentally ill also frame a different picture about their illness which can be neutralizing by public’s familiarity with serious mental illness, which subsequently will decrease stigma ( Patrick et al., 2001). An increase of the public negative attitudes toward mentally ill people has been observed in England and Scotland between 1994-2003, in a study conducted by Mehta and his colleagues (2009). In New Zealand, Kazantis et al., (2009) have shown that older participants endorse more authoritarian, social restrictiveness and interpersonal ideology attitudes (assessed with the Opinions about Mental Illness Scale, Cohen & Struening, 1962) in their perception of people with mental illness compared with younger participants.
Attitudes and beliefs about mental illness are shaped by personal knowledge about mental illness, knowing and interacting with someone living with mental illness, cultural stereotypes about mental illness, media stories, and familiarity with institutional practices and past restrictions (e.g., health insurance restrictions, employment restrictions; adoption restrictions) (Corrigan et al., 2004; Wahl, 2003). When such attitudes and beliefs are expressed positively, they can result in supportive and inclusive behaviors (e.g., willingness to date a person with mental illness or to hire a person with mental illness). When such attitudes and beliefs are expressed negatively, they may result in avoidance, exclusion from daily activities, and, in the worst case, exploitation and discrimination.
Attitudes toward mental illness vary among individuals, families, ethnicities, cultures, and countries. Cultural and religious teachings often influence beliefs about the origins and nature of mental illness, and shape attitudes towards the mentally ill. In addition to influencing whether mentally ill individuals experience social stigma, beliefs about mental illness can affect patients’ readiness and willingness to seek and adhere to treatment. Therefore, understanding individual and cultural beliefs about mental illness is essential for the implementation of effective approaches to mental health care. Although each individual’s experience with mental illness is unique, the following studies offer a sample of cultural perspectives on mental illness. People frame a picture about mental illness and mentally ill patients in their mind, which generally guides their behavior, so public must be educated to bring about positive changes in attitudes ( Song et al., 2005).
There was growing awareness about mental illness even in general population and the people were being more receptive of the mentally ill people. A research findings highlighted some major deficits in terms of information and knowledge about mental illness specially in context of Mentally ill person could be easily discriminated in comparison to normal, relatively less awareness in general population in term of unsatisfactory marital relationship and family conflict as a causative factor of mental illness, mentally ill person should not get admitted in hospital until he/she does not harm to any one, mentally ill person should be treated within society (Kumar et al., 2012).
Mental disorders are widely recognized as a major contributor (14%) to the global burden of disease worldwide. World Health Organization (WHO) reported that in 2002,154 million people globally suffered from depression, 25 million people from schizophrenia, 91 million people from alcohol use disorders, and 15 million from drug use disorders. Nearly 25% of individuals, in both developed and developing countries develop one or more mental or behavioural disorders at some stage in their life. Although some nations have been successful in fighting stigma and increasing acceptance of the mentally ill, lack of awareness is very evident in India and other developing countries. Mentally ill people are labelled as “different” from other people and are viewed negatively by others.
Many studies have demonstrated that persons labelled as mentally ill are perceived with more negative attributes and are more likely to be rejected regardless of their behaviour. Stigma remains a powerful negative attribute in all social relations. It is considered an amalgamation of 3 related problems: a lack of knowledge (ignorance), negative attitudes (prejudice), and exclusion or avoidance behaviours (discrimination). Scheff (1986) reported that people who are labelled as mentally ill associate themselves with society’s negative conceptions of mental illness and that society’s negative reactions contribute to the incidence of mental disorder. The social rejection resulting from this may handicap mentally ill people even further. A persistent negative attitude and social rejection of people with mental illness has prevailed throughout history in every social and religious culture. Of all the health problems, mental illnesses are poorly understood by the general public. Such poor knowledge and negative attitude towards mental illness threatens the effectiveness of patient care and rehabilitation. This poor and inappropriate view about mental illness and negative attitude towards the mentally ill can inhibit the decision to seek help and provide proper holistic care. Better knowledge is often reported to result in improved attitudes towards people with mental illness and a belief that mental illnesses are treatable can encourage early treatment seeking and promote better outcomes.
General public’s view about mental illness remains largely unfavorable. The topic of mental illness itself evokes a feeling of fear, embarrassment or even disgust fostering negative attitudes towards mental illness and mentally ill people. The reluctance to seek professional psychiatric help means late presentations are common. The extent to which patients benefit from improved mental health services is influenced not only by the quality and availability of services but also by their knowledge and belief systems. Beliefs about causation and experience may influence patients’ beliefs about effective treatment and may also determine the type of treatment that is sought. Recognition of mental illness is another important determinant of treatment-seeking behaviour. These factors highlight the importance of conducting research to assess public knowledge and attitudes toward mental illness. Only few studies reported regarding knowledge and attitudes of the public toward people with mental illness from India. Hence, the aim of the present study was to assess the knowledge about mental illness and attitude of the public toward people with mental illness.
The propensity of psychiatric patients to cause injury or harm to others and to property is one of the strong stereotype beliefs the Nigerian public holds towards psychiatric patients. Psychiatric patients, especially vagrant psychotics, are seen as worthless, dirty, senseless, dangerous and unpredictable. Moreover, it is the belief of most people in Nigerian society that psychiatric illnesses are afflictions caused by supernatural forces and, as such, require care by traditional and syncratic religious healers, rather than orthodox care. Most Nigerians judge the seriousness of psychiatric illness on behavioural grounds. Therefore, most deviant behavioural manifestations in society equate to psychiatric illness presentation in the involved person. Many African societies believe that psychiatric illness is either the outcome of an abominable familial defect or the ‘handiwork of evil machinations’ (demons, evil spirits). Therefore, these negative beliefs result in psychiatric patients being seen as outcasts and people that should be quarantined. The tribal constitute about 7.53 percent of the total Indian population. Majority of tribal resides in Jharkhand, in the district of Ranchi.
Attitudes and beliefs about mental illness are shaped by personal knowledge about mental illness, knowing and interacting with someone living with mental illness, cultural stereotypes about mental illness, media stories, and familiarity with institutional practices and past restrictions (e.g., health insurance restrictions, employment restrictions, adoption restrictions).The cultural context is important when studying beliefs regarding mental health. The understanding of mental health and the interpretation vary from culture to culture.
In a study conducted by Singh et al. (1992) in an urban areas of Jhansi 238 adults were interviewed to assess their views regarding mental illnesses. Mental illness was not perceived as a serious disease. Cancer was perceived as the most serious disease. Worries, faculty upbringing, overwork were perceived as a mental illness by majority. Early identification signs of mental illness described by them difficult in sleeping, changes in facial expression and feeling of impending mental imbalance. Marital alliance with them was not favored. However, a sympathetic attitude towards mental patients was favored. Avoiding tension, adopting oneself to circumstances, counseling elders was considered as preventive measures against mental illness by majority.
In a study by Jugal et al. (2007) conducted to assess belief regarding attitudes towards patients with mental illness, they observed a number of respondents (24%) who believed that people in contact with the mentally ill, could develop odd behavior. Nearly 70% claimed that they would feel comfortable talking to mentally ill patients. As many as 25% of the respondents said they felt sorry when they saw a mentally ill person. According to 63% respondents, mental disorders were caused solely by unfavorable social circumstances. Some believed that mental illness is God’s punishment (5.2%); a result of poor diet (18.1%) and loss of semen (1.3%). Regarding attitudes towards treatment, it was disheartening to see that 8% of the respondents considered mental illness to be untreatable; further 8% agreed with the attitude that considered psychiatric treatment as being more disabling than the illnesses.
MATERIALS AND METHODS
The study was a cross sectional carried out in out-patient department of Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS) Kanke, Ranchi and two community centers of RINPAS i.e., Khunti and Saraikela community, Jharkhand. Period of data collection was January 2014 to April 2015. Methods: A total of 200 participants were purposively recruited in following two groups of individuals aged between 20-50 years: tribal participants without mental ill patient (group 1, n=100), and non tribal participants without mental ill patient (group 2, n=100). The sample comprised of both male and females educated minimum of primary level. Further participants having mental ill patient in their family or having family history of mental illness were exluded. After explaining about the study in details the given consent form was signed by the participants followed by asked about their beliefs about, understanding of, and attitudes towards mental illness. In this present study Tribes were those participated in the study were Santhals. Mundas, Ho, Oraon, etc.
Socio-demographic data sheet: it is self prepare socio-demographic data sheet to obtain background information of the subjects on different dimensions like age, sex, educational level, family size, type of family, profession, income, occupation etc.
Opinion about mental illness scale (Cohen and Struening, 1962): It was applied to elicit opinion of the tribal and non tribal participants about mental illness. It contains 51 items that measures attitudes, and cause and treatment of mental illness. There are five factors: authoritarianism (the opinion that people with mental illnesses cannot be held accountable for their acts and they should be controlled by society), benevolence (an attitude that could be placed between tolerance and pity/compassion),mental hygiene ideology (the opinion that mental illness is similar to other illnesses and it should be treated adequately by specialists), social restrictiveness (the opinion that mentally ill persons should be restricted in some social domains), and interpersonal etiology (the belief that the real cause of a mental illness is problematic interpersonal relations). Individual responses to each item had 6 alternatives, viz., strongly agree, agree, not sure but probably agree, not sure but probably disagree, disagree, and strongly disagree. Each factor or dimension in the test was defined by a particular group of items. Responses to these items were rated from 1(strongly agree) to 6(strongly disagree) regardless of the items. In computing the factors score, each item received the appropriate no according to the respondent’s position in agree – disagree continuum.
It was done using appropriate statistics, i.e., percentage; and to find out significant differences among tribal participants without mental ill patient and non tribal participants without mental ill patient, chi-square test was used. SPSS version 16.0 was applied for analysis of raw data.
The majority age groups were 40% in tribal participants without mental ill patient and 60 % in non tribal participants without mental ill patient fall within age range of 31-40 years. It shows that majority of the samples were male 83% tribal participants without mental ill patient and 86% non tribal participants without mental ill patient. Participants were female as well as male in both the group of tribal participants without mental ill patient and non tribal participants without mental ill patient respectively. The marital statuses of the participants of tribal without patients The issue of knowing attitudes towards mental illness is very important aspects, as because myths, misconception and inaccurate thought, believes and attitudes towards mental illness severely affect the lives of an individual’s as well as their families with these illness. Many studies shows people suffered with mental illness experience negative attitudes and discrimination at their work places and other areas also as because of stigmatizing thoughts and views about mental illness. There are many studies on attitudes towards mentally ill as well as mental illness of different areas like medical
Table 2 indicates scores on the OMI scale (item wise) by the tribal without mental ill patient and non tribal without mental ill patient. There were observable significant differences among the tribal without mental ill patient and non tribal without mental ill patient regarding the scale items (p<0.05) reflecting the influence of their values and mental health literacy on their attitudes towards mental illness. The chi-square test calculation indicates: significant differences in most of the item wise scale of OMI.
The issue of knowing attitudes towards mental illness is very important aspects, as because myths, misconception and inaccurate thought, believes and attitudes towards mental illness severely affect the lives of an individual’s as well as their families with these illness. Many studies shows people suffered with mental illness experience negative attitudes and discrimination at their work places and other areas also as because of stigmatizing thoughts and views about mental illness. There are many studies on attitudes towards mentally ill as well as mental illness of different areas like medical professionals, students, general public but there are few studies on attitudes of tribal and non tribal individuals towards mental illness.
There is a deficiency in care at the community level; in some countries, it is nonexistent. There are several obstacles to this expansion of community services, the public’s knowledge and attitude regarding mental illness being perceived as a major one. It is reported that the ability to recognize mental disorders is a central part of mental health literacy because it is a prerequisite for appropriate help seeking. The present study revealed that a substantial proportion of the community is had poor knowledge regarding mental illness and only few had average knowledge. More than half of the subjects could mention common mental disorders which reflect the increase prevalence of mental illness in community and influence of media and other sources. Most of respondents had poor knowledge regarding causes of mental illness and believed that mental illness could result from punishment from God. More than half of the respondents had good knowledge on signs and symptoms of mental illness. Deficiency of knowledge about treatment and prognosis of mental illness is persistent in most of the subjects. The possible explanation for the difference in recognition rate is lack of education and information on nature and causes of mental illness in the community. These findings were somehow similar to previous studies. In the present study, negative attitudes towards mental illness were widely held. In item no 1, of OMI scale, mentioned in table 2, signify that “nervous breakdown usually results when people work too hard” it was found that 46% Tribal without mental ill patient agreed with, where as 72 % of non tribal without mental ill patient had disagreed attitudes towards the statement that nervous breakdown usually results when people work too hard. It was found that tribal without mental ill patient had clear-cut opinion whereas non tribal without mental ill patient had also gave clear-cut opinion as disagreed to the statement and could be say that non tribal without mental ill patient had somehow knowledge on cause of mental illness(found significant at 0.000, (p<0.05 level). Most of the studies, when discussing causes of mental health issues, described psychological factors such as unhappiness, low self-esteem, rejection, over thinking, self-downing and blaming, anxiety and worry, and conflicts in familial and other interpersonal relationships. In Item no 2, signify that “Mental illness is an illness like any other illness”. Here the participants of tribal without mental ill patient agreed 53% and non tribal without mental ill patient neutral at 55%. This was found significant at (0.004, p<0.05) level. From this it can be concluded that people tend to avoid such questions and are very uncomfortable with any comments due to lack of knowledge. Item no 3, “most patients in mental hospitals are not dangerous”. Both the group answered neutral, tribal without mental ill patient as well as non tribal without mental ill patient had neutral attitude i.e., 53% and 71% respectively and significant at (0.000, p<0.05 level). Here both the group had neutral attitudes and may be ambivalent in their attitudes towards the nature of hospitalization of the mental ill patient. Item no 5, if patients loved their children more, there would be less mental illness. Both the group tribal without mental ill patient and non tribal without mental ill patient answered as agree 50% and 80% respectively (0.000, p<0.05 level). In item no 7, both the groups had agreed when they were asked about their opinion that “people who are mentally ill let their emotions control them: normal people think things out”. This was found significant at (0.005, p<0.05 level). In this item significant difference was found by (Farina, 1998; Mahto, et al., 2012) but contradict to the opinion to present study.
Item no 9, “when a person has a problem or worry, it is best not to think about it, but keep busy with more pleasant things”. Both the group participants fall in agree i.e., 58% and 83% and significant at (0.000, p<0.05 level). It shows that the people had positive attitude towards mental illness. Similarly, in item no 13, “most mental patient willing to work”. Here both the group has answered as disagreed (34%) and (49%) respectively. It has significant at (0.001, p<0.05 level). Here both the group agreed and it revealed that there is lake of knowledge regarding mental illness. Treatment with psychotherapeutic and psychiatric medicines, and hospitalization following medical treatment, was discussed in many studies. However, there were some findings pointing only to psychiatric and medicinal treatment and not psychological treatment. On contrary, there were findings where participants discouraged professional psychological or psychiatric treatment and advised people not to seek any treatment unless the severity was extremely high. Item no 14, “the small children of patients in mental hospital should not be allowed to visit them”. The group had significant at (0.002, p<0.05 level) though both had answered differently, the tribal without mental ill patient had neutral attitude (36 %) and non tribal without mental ill patient had disagreed (54%). Here the non tribal without mental ill patient had clear- cut opinion towards the item of OMI scale, which was negative attitude, and tribal with metal ill patient had neutral to ambivalent attitude to the mental ill patient behaviors. Item no 21, “people with mental illness should never treated in the same hospital as people with physical illness”. Both the group had agreed (67%) and (83%) respectively. They were significant at (0.026, p<0.005 level). Item no 22 “Anyone who tries hard to better himself deserves the respects of others. Tribal without mental ill patient agree 46% and non tribal without mental ill patient 78 % (0.000, p<0.005 level). Item no 24 “a woman would be foolish to marry a man who has a severe mental illness, even though he seems fully recovered” agree 55% and 82% by both the group. It found that significant at (0.000, p<0.005). In this types of opinion with regards to mental illness and marital life were obviously same where non tribal without mental ill patient were more agree when they were asked about their opinion on item no 24 of OMI scale. Majority of the non-tribal without mental ill patient had 82%. This could be explained on the basis of the understanding that non tribal without mental ill patient are more concerned about their future generation as well as concerned about the female’s marriages and their life partner. In general, Dovido et al., (1985) concluded that people are ambivalent in their attitudes towards individuals with psychological problems and deliberately ignore the issue. In the present study too, ambivalent attitude shows when they were asked about sensitive issues related to person with major psychological problems.
Item no 25, of OMI scale, signify that stated if the children of mentally ill parents were raised by normal parents, they would probably not become mentally ill. It was found that 46% of tribal without mental ill patient and 67% non tribal without mental ill patient disagreed attitude respectively (significant at 0.008, p<0.005). Item no 27, signify that many mental patients are capable of skilled labour, even though in some way they are every disturbed mentally. And tribal without mental ill patient as well as non tribal without mental ill patient had neutral attitude towards mental illness 42% and 59% (0.000, p<0.005) respectively. Here also the participants are ambivalent to the mental illness and tend to ignore the individuals who are recovered from mental illness and avoid the risk of misshapen.
Item no 30, the mental illness of many people is caused by the separation or divorce of their parents during childhood. Neutral attitude found in both the groups of tribal without mental ill patient as well as non tribal without mental ill patient i.e., 58% and 82% (significant at 0.000, p<0.005). The participants of both groups again showed ambivalent attitude by neutral answer and it revealed that positive thought about marital life is present. Similarly in item no 31, state that the best way to handle patients in mental hospital is to keep them behind locked doors. Here the participant of tribal without mental ill patient and non-tribal without mental ill patient were agreed 44% and 51% (significant at 0.039, p<0.005) level by the groups and can be sum up that lack of knowledge regarding hospitalization of a mental patient at mental hospital.
Again in item no 33, the patients of mental hospitals should be allowed more privacy come out opinion with disagree 40% and 56% (significant at 0.025, p<0.005 level) by both the group. Here the participant’s authoritarianism attitude is reflecting and which is a negative attitude towards mental illness.
Item no 35, of OMI scale state that if the children of normal parents were raised by mentally ill parents, they would probably become mentally ill. The response was disagreed by both the group i.e., 39% and 73% respectively and (found significant at 0.000, p<0.005 level). Here the majority of the disagreed response came from non tribal without mental ill patient (73%). They shows positive attitude but may not be due to good knowledge about mental illness. Item no 40, regardless of how you look at it, patients with severe mental illness are no longer really human. In this item there is found significant in attitude towards mental illness though both the groups responses differently were neutral (44%) by the tribal without mental ill patient and disagree (54%) non tribal without mental ill patient (significant at 0.001, p<0.005 level). With this statement the non tribal without mental ill patients participants had strongly opposes have no hope for individuals once who was a mental ill patient. Item no 41, most women who were once patients in mental hospital could be trusted as baby sitters. Agreed attitude by tribal without mental ill patient and non tribal without mental ill patient 61% and 81% respectively (significant at 0.005, p<0.005 level). Both the group avoids the challenges and willing to stay risk free life. Item no 43, college professors are more likely to become mentally ill than are business men. It was found that attitude towards the item was disagreeing by both the group and are 40% and 71% respectively (significant at 0.000, p<0.005 level). It was found that they have clear cut opinion. In the study by Mahto et al., (2009) had also found that male students had disagreed to the statement then female students. Here can be concluded that the participant had clear cut responses and positively attitude towards mental illness. Item no 44, many people who have never been patients in a mental hospital are more mentally ill than many hospitalized mental patients. Disagreed by both the group with 48% and 81% (significant at 0.000, p<0.005 level) tribal without mental ill patient and non tribal without mental ill patient. Here it shows positive attitude towards mental illness by both the group.
Similarly, in item no 45, although some mental patients seem all right, it dangerous to forget for a moment that they are mentally ill. They agreed in with more participants and were 65 % tribal without mental ill patient and 85% non tribal without mental ill patient (significant at 0.004, p<0.005 level). Here they show positive attitude as well as negative attitude towards the mental ill recovered patient. Item no 47, our mental hospitals should be organized in a way that makes the patient feel as much as possible like he is living at home. Both the groups agreed with 68 % and 86% respectively (significant at 0.009, p<0.005 level ). Farina and Felner (1973 ) found that the public tends to be more tolerant of deviant conduct when it is not described using mental illness labels.
Boral et al.(1980) conducted a comparative study of the opinion of relatives of psychiatric patients both the groups stressed hereditary as the main cause of mental illness. Philips (1989) found that the largest increase in rejection rates occurred when a person admitted in mental hospital.
These results can be argued for necessity to understand mental illness in a broad social context. A better understanding of people’s mental model of mental illness as well as a better understanding of the multiple and social dimensions of stigma and misconceptions associated with mental illness will make possible the development of efficient and well targeted anti stigma programs.
This study has its limitations, most of which involve sampling issues. Participants in present study consisted a small number of samples. Therefore, the results of this study may not be representative of the whole tribal and non tribal group.
Future research might consider using a more representative sample, and may attempt to find out the attitude towards mental illness in the non tribal and tribal group.
Overall there were no significant difference emerged among tribal without mental ill patient and non tribal without mental ill patient. But there were many times significant in item wise of OMI scale. Knowledge about mental illness is poor among the subjects in the present study. The majority of the subjects had a negative attitude toward mental illness. Although the entire participants had some amount of exposure into the field in spite of that they responded differently which showed that mental illness is still being stigmatized and is a taboo. The minimal knowledge about mental illness suggests the need for strong emphasis on public education to increase mental health literacy among general public to increase awareness and positive attitude of people towards mental illness.
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Conflict of interest: None
Role of funding source: None