|Year : 2019 | Volume
| Issue : 2 | Page : 173-177
Perceived stigma regarding mental illnesses among rural adults in Vellore, Tamil Nadu, South India
Apoorva Guttikonda1, Aleena M Shajan1, Adeline Hephzibah1, Akhila S Jones1, Jerlyn Susanna1, Sunil Neethu1, Sharon Poornima1, Sarah M Jala1, D Arputharaj1, David John1, Nehemiah Natta1, Dolorosa Fernandes2, Shalini Jeyapaul2, Dimple Jamkhandi2, H Ramamurthy Prashanth2, Anu M Oommen2
1 MBBS Students, Christian Medical College, Vellore, Tamil Nadu, India
2 Community Health Department, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||4-Mar-2019|
Dr. Anu M Oommen
Community Health Department, Christian Medical College, Vellore - 632 002, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Stigma is an important factor that determines whether individuals seek treatment for mental illnesses. Studies assessing public perceptions regarding mental illnesses are scarce in India. This study documents the stigma perceived by a rural population toward patients with mental illness and their families. Materials and Methods: A cross-sectional pilot study was done in five villages, selected by simple random sampling, from a rural block in Vellore, Tamil Nadu. Households in each village were selected by systematic random sampling. From the selected households, 150 subjects aged 18–65 years, without known mental disorders, were chosen by convenience sampling, based on availability. Stigma was assessed using the Devaluation of Consumers Scale (DCS) and Devaluation of Consumer's Families Scale (DCFS). Results: The proportion with high perceptions of stigma associated with mentally ill persons was 63.8%, among the 150 interviewed rural respondents (women: 112, median age: 37 years). The proportion which perceived that there was public stigma toward families of those with mental illnesses was 43.4%. Older respondents (>37 years) had higher perceptions of stigma (odds ratio: 2.07; 95% confidence interval: 1.02–4.20) than others. Conclusion: The high perception of stigma associated with persons who are mentally ill as well as their families needs to be kept in mind while planning interventions to decrease the treatment gap for psychiatric morbidity, especially in rural areas.
Keywords: Mental illnesses, perception, stigma
Key Message: A large proportion of the rural population perceives that there is a high stigma toward those with mental illnesses and their families.
|How to cite this article:|
Guttikonda A, Shajan AM, Hephzibah A, Jones AS, Susanna J, Neethu S, Poornima S, Jala SM, Arputharaj D, John D, Natta N, Fernandes D, Jeyapaul S, Jamkhandi D, Prashanth H R, Oommen AM. Perceived stigma regarding mental illnesses among rural adults in Vellore, Tamil Nadu, South India. Indian J Psychol Med 2019;41:173-7
|How to cite this URL:|
Guttikonda A, Shajan AM, Hephzibah A, Jones AS, Susanna J, Neethu S, Poornima S, Jala SM, Arputharaj D, John D, Natta N, Fernandes D, Jeyapaul S, Jamkhandi D, Prashanth H R, Oommen AM. Perceived stigma regarding mental illnesses among rural adults in Vellore, Tamil Nadu, South India. Indian J Psychol Med [serial online] 2019 [cited 2019 Jul 19];41:173-7. Available from: http://www.ijpm.info/text.asp?2019/41/2/173/252701
CHP 2 Depression Group
| Introduction|| |
Approximately 30% of the world's population suffers from mental and behavioral disorders, of which around 70% does not receive appropriate treatment, with unipolar depression causing the greatest morbidity., According to the National Mental Health Survey 2016, 10.6% of adults in India have “any mental disorder” (excluding tobacco use) and 2.7% have depressive disorders, with a treatment gap of >75% for psychotic disorders and neuroses. The reasons for the treatment gap include low awareness, inaccessible health care, costs, alternative remedies like religious/supernatural, as well as stigma, which is widespread, especially in Asia. Stigma prevents affected people and their families from admitting to or accepting the condition and reduces health-seeking behavior, resulting in a treatment gap. Stigma can be assessed by scales measuring self-stigma, perceived stigma, or public stigma (respondents' beliefs regarding the attitude of others in the community toward people with mental illness or toward their families).
A few studies from Chennai, Kolkata, Karnataka, Delhi, and Maharashtra have assessed public attitudes toward those with mental illness as well as their families.,,,,, The prevalence of perceived stigma varies due to diversities in cultural beliefs, socioeconomic status, and access to healthcare.
This study assessed perceptions of stigma among adults in a rural block in south India, where previous studies have shown high suicide rates, including among adolescents and the elderly.,,,
| Materials and Methods|| |
A cross-sectional pilot study was carried out in Kaniyambadi, a rural block in Vellore district, Tamil Nadu, among those aged between 18 and 65 years, excluding persons with known mental illness. Five clusters (villages) were selected using simple random sampling out of 82 villages. The sample size was calculated to be 150 based on an expected prevalence of 50% perceived stigma and a design effect of 1.5. In each village, 30 households were selected by systematic random sampling. Within each selected household, one adult participant aged between18 and 65 years was included, based on availability and consent (convenience sampling within the household). Perception of stigma was assessed through an interviewer-based questionnaire using the DCS (Devaluation of Consumers Scale) and DCFS (Devaluation of Consumers' Families Scale), translated and pilot tested in Tamil. The DCS assesses perception of stigma toward persons with mental illnesses in terms of community reaction, job prospects and social life, assessing the domains of “status reduction,” “role restriction,” and “friendship refusal,” with an internal consistency/reliability score of 0.82. The DCFS evaluates perceived stigma towards families of those with mental illnesses, in the domains of “community rejection” (looking down on families with mentally ill persons), “causal attribution” (blaming family for the illness), and “uncaring parents” (judging parents with affected children as being less responsible and caring than others), with an internal consistency/reliability score of 0.71–0.77. Knowledge was tested using a vignette (on depression) and assessing whether the case was identified as a mental illness, with the selection of an appropriate course of action.
Statistical analysis was performed using SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL, USA). Categorical variables were expressed as proportions. Mean percentage agreement to the statements indicating perceived stigma was also calculated for the DCS and DCFS scales. To assess factors associated with perceptions of stigma, the responses were scored using a Likert scale of 1–4 and a total score calculated. The median score of the participants was used to categorize as high or low perceptions of stigma. Odds ratios (ORs) were calculated using logistic regression, adjusting for age, sex, education, family history of mental illness, having known someone with a mental illness, and exposure to previous educational messages on mental illness.
The study was approved by the Institutional Review Board and Ethics Committee of the concerned tertiary healthcare institution (IRB min number 10323; dated 5-9-2016). Informed written consent was taken, and confidentiality maintained using unique identifiers.
| Results|| |
Of 160 subjects who were approached, 10 refused to consent to participate. Three-fourths (112) of the 150 participants were women, 82.0% (123) were married, and 93.3% (140) were literate. The median age of the respondents was 37 years. Around one-fourth (23.3%) of the participants had a family member with mental illness, while 50.7% (76) had been previously exposed to awareness programmes/health information on mental illness (newspapers, television, books, pamphlets, etc.).
While 63.8% of the participants perceived that most people devalue persons with mental illnesses, 43.4% felt that most people devalue families of such persons (mean percent agreement with statements indicating stigma, [Table 1]). The percentage of respondents who agreed to individual statements regarding how people devalue a person with mental illness or their families is shown in [Table 1]. While 83.3% felt that a person with serious mental illness was dangerous, 52% felt that having a mental illness was worse than being addicted to drugs. A majority (72%) of respondents felt that people look down on someone who was once a patient in a mental hospital, and 75.3% felt that young women would not marry a man who has been treated for a serious mental disorder.
|Table 1: Perceptions of stigma shown by agreement to statements denoting perceived stigma|
Click here to view
Nearly half (48.7%) said that people blame parents for the mental illnesses of their children and 59.3% felt that people look down on families with a member who is mentally ill [Table 1].
Older respondents (>37 years) were more likely to perceive stigma (64.9%) than younger respondents (44.9%), after adjusting for gender, education, family history of mental illness, or having known someone with a mental illness, OR: 2.07, 95% confidence Interval (CI): 1.02–4.20. There were no gender differences in perceptions of stigma (males: 57.9%, females: 52.9%, P value = 0.577). There was no significant difference in the proportions of perceived stigma between those who had a family history of mental illness (62.9%) compared with others (50.9%), adjusted OR: 1.47 (95% CI: 0.64–3.39), P value = 0.214. There was also no significant difference in perceptions of stigma among those who knew someone with a mental illness, e.g. work colleague or friend (61.5%), compared with others (50.0%), adjusted OR: 1.47 (95% CI: 0.71–3.02), P value = 0.177.
Only 53% identified the case scenario (depression) as a mental illness, and all 80 of them recommended seeking external help. While 28 respondents (35.0%) said that professional health caregivers need to be approached, family and friends were the choices for the source of help for 51 (64%). Of those who identified the vignette as a mental illness, only 49 (61%) were aware of the availability of medications for mental illnesses such as depression. Participants with an education above the eighth grade (median) were more likely to identify the vignette as a mental illness (OR: 2.38, 95% CI: 1.24–4.61).
| Discussion|| |
This community-based pilot study from rural Tamil Nadu documents public perceptions of stigma toward patients with mental illnesses and their families. The strength of the study is that it is a population-based survey, although the generalisability is restricted to similar parts of south India.
Stigma toward mental illnesses is one of the reasons for a “low demand” for mental health care, along with other barriers, such as poor awareness and cultural beliefs. Qualitative findings from the National Mental Health Survey 2016 also pointed to stigma as one reason for poor utilization of health care for mental illnesses.
Almost three-fourths (72%) of the study respondents felt that people look down on those with a history of hospitalization for mental illness, indicating the high stigma associated with serious mental illnesses. This corresponded with a similar study done in Mumbai, where 60.8% of the general population believed the same. In this study from rural Vellore, only 36% felt that employers would be less willing to hire a person with a mental illness as compared with 71.6% in Mumbai. This may reflect differences in socioeconomic status and occupational experiences as it may be less difficult to obtain some form of employment in a rural area than in an urban area, even for those with a mental illness. Thus, role restriction due to mental illness was lower in this rural study, for employment, than the study from urban Mumbai which included a large proportion of armed personnel. However, nearly three-fourths (75.3%) of our rural participants felt that young women would be unwilling to marry a man who has been treated for a serious mental illness. This was higher than the results from an urban study from Chennai and Kolkata, where around half of the respondents believed that young women would be reluctant to date a man who has been admitted for a mental illness.
In this study, 69.3% felt that most people would not accept a person who once had a mental illness as a close friend. This was much higher than Chennai and Kolkata, where only 26.5%–36.1% felt that most people would not accept a former mentally ill patient as a close friend, indicating that friendship refusal due to mental illness, a measure of stigma, is higher in rural settings.
Less than half of our rural respondents (48.7%) felt that parents are blamed for the mental illnesses of their children, whereas nearly 78.4% felt the same in Mumbai.
The overall proportion which perceived that most people devalue persons with mental illnesses was 63.8% in this study, similar to a study in New York among caregivers of patients with serious mental illnesses, of whom 70% perceived that there was public stigma toward patients with mental illnesses.
The lower perception of stigma among younger respondents in this study may reflect education and exposure to mass media and implies changing societal attitudes.
Although this study from Vellore was limited by small study size, purely quantitative methodology, location restricted to a block in rural Tamil Nadu, and over-representation of women due to difficulties with sampling in the community, it highlights the magnitude of stigma as perceived by rural communities toward mental illnesses.
Besides widespread stigma in the general community, studies have also found nonpsychiatric healthcare and paramedical personnel to have stigmatizing attitudes against those with mental illnesses.,, Although in our study there was no significant association between perceptions of stigma and family history of mental illness or contact with someone else with a mental illness, one survey from a teaching hospital among nonpsychiatric medical professionals also found that social contact with an affected person was associated with less socially restrictive attitudes. In view of this barrier of stigmatizing attitudes among healthcare workers, an interventional study aimed at reducing stigma through targeting nonspecialist healthcare workers is being planned in low-resource settings in Nepal.
The World Health Day theme 2017 “Depression: Let's talk,” highlighted the importance of spreading awareness and promoting health-seeking behavior. The WHO campaign was built on the premise that talking about depression would reduce stigma, breaking down barriers, and encouraging people to seek help. Education and social contact with affected people have been found to be the most effective antistigma measures. A review of interventional studies to reduce stigma revealed the paucity of evidence from low and middle-income countries. An interventional study in Karnataka involved educational methods, such as slide shows, discussions, street plays, and printed material, and found a reduction in stigmatizing attitudes postintervention. Further interventional research is needed in India in different locations and cultural settings, with studies aimed at evaluating community-wide educational programs, including formal assessment of changes in public awareness and stigma.
The prevalence of common mental morbidities in India is highest for urban metros, while it is only marginally higher in nonmetros compared with rural areas. Although rural areas have a lower prevalence of mental disorders, the lower educational level may lead to a higher level of public stigma, and consequently to a higher treatment gap in the rural areas. This was shown in a study from Assam, Uttar Pradesh, and Kolkata, in which stigmatizing attitudes toward mental illnesses were higher in the rural areas, indicating the need for intensified educational efforts.
In conclusion, this population-based study from rural Vellore highlights the high magnitude of stigma toward patients with psychiatric illnesses and their families, indicated by almost three-fourths of the respondents feeling that people look down at those with a history of hospitalization for mental illness, as well as their families. Such a high level of public perception of stigma can potentially deter treatment for mental illnesses and needs to be addressed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thornicroft G. Most people with mental illness are not treated. Lancet 2007;70:807-8.
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3: e442.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al
. National Mental Health Survey of India, 2015-16: Prevalence, patterns and outcomes. Bengaluru, National Institute of Mental Health & Neuro Sciences, NIMHANS Publication No. 129, 2016. Available from: http://indianmhs.nimhans.ac.in/nmhs-reports.php
. [Last accessed on 2018 Sep 10].
Lauber C, Rossler W. Stigma towards people with mental illness in developing countries in Asia. Int Rev Psychiatry 2007;19:157-78.
Wei Y, McGrath PJ, Hayden J, Kutcher S. Mental health literacy measures evaluating knowledge, attitudes and help-seeking: A scoping review. BMC Psychiatry 2015;15:291.
Zieger A, Mungee A, Schomerus G, Ta TM, Dettling M, Angermeyer MC, et al
. Perceived stigma of mental illness: A comparison between two metropolitan cities in India. Indian J Psychiatry 2016;58:432-7.
] [Full text]
Pawar AA, Peters A, Rathod J. Stigma of mental illness: A study in the Indian Armed Forces. Med J Armed Forces India 2014;70:354-9.
Vijayalakshmi P, Ramachandra, Nagarajaiah, Reddemma K, Math SB. Attitude and response of a rural population regarding person with mental illness. Dysphrenia- Acad J Psychiatry 2013;4:42-8.
Venkatesh BT, Andrews T, Mayya SS, Singh MM, Parsekar SS. Perception of stigma toward mental illness in South India. J Family Med Prim Care 2015;4:449-53.
] [Full text]
Salve H, Goswami K, Sagar R, Nongkynrih B, Sreenivas V. Perception and attitude towards mental illness in an urban community in south Delhi – A community based study. Indian J Psychol Med 2013;35:154-8.
] [Full text]
Kermode M, Bowen K, Arole S, Pathare S, Jorm AF. Attitudes to people with mental disorders: A mental health literacy survey in a rural area of Maharashtra, India. Soc Psychiatry Psychiatr Epidemiol 2009;44:1087-96.
Prasad J, Abraham VJ, Minz S, Abraham S, Joseph A, Muliyil JP, et al
. Rates and factors associated with suicide in Kaniyambadi Block, Tamil Nadu, South India, 2000-2002 Int J Soc Psychiatry 2006;52:65-71.
Abraham VJ, Abraham S, Jacob KS, Suicide in the elderly in Kaniyambadi block, Tamil Nadu, South India. Int J Geriatr Psychiatry 2005;20:953-5.
Joseph A, Abraham S, Muliyil JP, George K, Prasad J, Minz S, et al
. Evaluation of suicide rates in rural India using verbal autopsies. BMJ 2003;326:1121-2.
Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad J, et al
. Suicides in young people in rural southern India. Lancet 2004;363:1117-8.
Struening EL, Perlick DA, Link BG, Hellman F, Herman D, Sirey JA. Stigma as a barrier to recovery: The extent to which caregivers believe most people devalue consumers and their families. Psychiatr Serv 2001;52:1633-8.
Sathyanath S, Mendonsa RD, Thattil AM, Chandran VM, Karkal RS. Socially restrictive attitudes towards people with mental illness among the non-psychiatry medical professionals in a university teaching hospital in South India. Int J Soc Psychiatry 2016;62:221-6.
Almanzar S, Shah N, Vithalani S, Shah S, Squires J, Appasani R, et al
. Knowledge of and attitudes toward clinical depression among health providers in Gujarat, India. Ann Glob Health 2014;80:89-95.
Pande V, Saini R, Chaudhury S. Attitude toward mental illness amongst urban nonpsychiatric health professionals. Ind Psychiatry J 2011;20:17-20.
] [Full text]
Kohrt BA, Jordans MJD, Turner EL, Sikkema KJ, Luitel NP, Rai S, et al
. Reducing stigma among healthcare providers to improve mental health services (RESHAPE): Protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal. Pilot Feasibility Stud 2018;4:36.
Gronholm PC, Henderson C, Deb T, Thornicroft G. Interventions to reduce discrimination and stigma: The state of the art. Social Psychiatry Psychiatr Epidemiol 2017;52:249-58.
Thornicroft G, Mehta N, Clement S, Evans-Lacko S, Doherty M, Rose D, et al
. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet 2016;387:1123-32.
Dharitri R, Rao SN, Kalyanasundaram S. Stigma of mental illness: An interventional study to reduce its impact in the community. Indian J Psychiatry 2015;57:165-73.
] [Full text]
Jadhav S, Littlewood R, Ryder AG, Chakraborty A, Jain S, Barua M. Stigmatization of severe mental illness in India: Against the simple industrialization hypothesis. Indian J Psychiatry 2007;49:189-94.
] [Full text]