Changing attitude to mental illness among community mental health volunteers in south-western Nigeria

Abstract

Background:

Community-based mental health services may be impaired by stigmatization and social distance towards persons with mental illness. Little is known about the impact of education on the attitude of volunteers for mental health programmes. This study aimed to examine the effect of an educational programme on the attitude of community volunteers towards mental illness.

Methods:

Thirty-one volunteers for a community mental health programme completed the Familiarity with Mental Illness Questionnaire and a modified version of the Bogardus Social Distance Scale (Bogardus, 1925) before and after an educational programme.

Results:

At the end of the educational session, perceived dangerousness was significantly reduced and attitude (social distance) towards persons with mental illness showed significant improvement.

Conclusion:

Attitudes of community volunteers towards persons with mental illness improve with educational programmes. This may lead to improved treatment and care of individuals who are mentally ill.

Keywords

Volunteers Nigeria mental illness social distance attitude education

Introduction

Mental health volunteers play a critical role in symptom recognition, anti-stigma campaigns and rehabilitation of persons with serious mental illness (Mann et al., 2005). Attitudes and beliefs about mental illness contribute to the success of mental health programmes involving non-medical volunteers (Scheerder et al., 2011). In communities where high levels of stigmatization and social distance towards mentally ill persons prevail, mental health services may be impaired (Thornicroft, 2008). Educational programmes have been identified as a major tool for improving public attitude towards persons with mental illness (Brockington, Hall, Levings, & Murphy, 1993; Holmes, Corrigan, Williams, Canar, & Kubiak, 1999; Lauber, Nodt, Faclato, & Rossler, 2002; Link & Cullen, 1986).

Although studies assessing lay public beliefs about mental illness (Adebowale & Ogunlesi, 1999; Kabir, Illiyasu, Abubakar, & Aliyu, 2004) and social distance (Adewuya & Makanjuola, 2008) have been conducted, there is a dearth of information regarding the impact of educational programmes on the attitude of mental health volunteers to mental illness in Nigeria. Interventions targeting non-medical professionals such as community volunteers may be more cost-effective and appropriate in resource-constrained settings (Saraceno & Saxena, 2002; Vijayakumar & Kumar, 2008).

This study aimed to determine if an educational intervention has positive effects on attitudes towards mental illness among volunteers in a rural community setting.

Methodology

This study was part of the evaluation of a community-based mental health education programme in Pakoto, a rural community in Ifo local government, Ogun State, Nigeria. At the centre of the community is a facility that offers spiritual therapy to individuals with mental illness received through an informal network of relatives, friends, religious leaders and sympathizers. Persons requiring further psychiatric care are referred to a mental hospital about 50 km away.

In order to recruit volunteers for the provision of mental health services in the community, public announcements were made at community gatherings and meetings with stakeholders. All those who responded were invited to participate in the training programme. Attitude towards mental illness was assessed before and after a course of six educational sessions conducted by three psychiatrists and a psychologist. Each session lasted one hour and was delivered in the local language (Yoruba) over a period of six weeks. The training was based on a mental health literacy manual for village health workers with modules on causation, clinical features, care and treatment of persons with mental illness. The assessment tool included questionnaires on sociodemographic characteristics, familiarity with mental illness and perceived personal attributes of mental illness (Angermeyer, Beck, & Matschinger, 2003) and a modified Bogardus Social Distance Scale (Bogardus, 1925), which has been used in previous studies in Nigeria (Adewuya &Makanjuola, 2008; Adebowale & Ogunlesi, 1999). The questionnaires were translated into Yoruba (the predominant language of the group) and administered on the first and last day of the programme. Written informed consent was obtained from all the participants and the study was conducted according to the guidelines laid down in the current version of the Declaration of Helsinki. Permission was obtained from the local government authority.

Data were analysed with SPSS version 16 (SPSS, Chicago IL, USA). All responses were scored as 1 (positive responses) or 0 (negative responses). The scores of the Social Distance Scale were reversed so that increasing scores corresponded to increasing social distance. Results were calculated as frequency (%) and mean (M). Wilcoxon signed-rank tests were conducted to determine whether the social distance and perceived personal attributional scores of the volunteers changed after the educational programme. Choices of psychiatric treatment were compared with χ² test. Statistical significance was calculated at p < .05.

Results

A total of 60 volunteers were recruited. Thirty-one respondents completed the questionnaires before and after the educational programme. Those who dropped out of the programme were significantly less likely to have had previous contact with mentally ill individuals (χ² = 6.43, p = .01) or endorse working in the same house (χ² = 6.63, p = .01) with mentally ill persons. The mean age of respondents was 40 years (SD = 10.7). The majority were female (58.1%) aged 40–64 years (58.1%), married (61.3%), had completed secondary education (41.9%) and were employed (64.5%). The respondents were largely individuals involved in pastoral care (46.4%) and artisans (39.2%). Some of the respondents (17.9%) had previously been involved in providing auxiliary nursing care and traditional birth services within the community. The majority had had previous contact with persons with mental illness (83.9%). Sixty-one per cent (61.3%) had a history of caring for a person with mental illness and 32.3% had a family member or friend with mental illness. The mean score on the Social Distance Scale was 2.59 (SD = 1.8) before and 1.24 (SD = 1.7) after the intervention. Mean scores were highest in response to the question ‘Would you like to marry someone with mental illness?’ The scores decreased with situations requiring reduced levels of intimacy. At the end of the educational sessions, respondents were less likely to endorse the negative stereotype of ‘dangerousness’ (p < .001). Also, the attitude (social distance) of respondents towards the mentally ill showed some improvement (p < .05). With respect to help-seeking behaviour, a significant decrease in the proportion endorsing traditional homes as an appropriate treatment centre was observed post-intervention (67.7% vs 33.3%, χ² = 7.22, p = .007) (Table 1).

Table 1.

Perceived personal attributes of the mentally ill and social distance before and after education.

Perceived personal attributes	M		Z	Effect size (r)	p
	Pre	Post
Perceived dangerousness	4.74 (0.57)	2.74 (1.48)	-4.412	0.792	< .001
Perceived dependency	1.61 (0.62)	1.48 (0.63)	-1.633	0.293	.102
Social distance
Can you…
Marry someone who has had a mental illness?	0.90 (0.3)	0.55 (0.5)	-3.317	0.596	.001
Make friends with a mentally ill person?	0.48 (0.51)	0.23 (0.43)	-2.530	0.454	.011
Live in the same house with a mentally ill person?	0.45 (0.51)	0.19 (0.45)	-2.530	0.454	.011
Work in the same house with a mentally ill person?	0.45 (0.51)	0.26 (0.45)	-1.667	0.299	.096
Live on the same street with a mentally ill person?	0.35 (0.49)	0.16 (0.43)	-2.121	0.381	.034
Mean score	2.59 (1.8)	1.24 (1.7)	-3.163	0.568	.002

Choice of treatment	Pre (%)	Post (%)	χ ²		p

Traditional homes	67.7	33.3	7.22		.007
Spiritual centres	80.6	76.7	0.144		.704

Discussion

The impact of education on the attitude of community volunteers towards mentally ill persons was examined in this study. Previous studies have showed that a significant proportion seek mental health care at alternative/unorthodox centres in Nigeria (Adewuya & Makanjuola, 2009; Gureje & Lasebikan, 2006). The significant reduction in the endorsement of traditional homes as appropriate health facilities for mental health treatment agrees with previous studies identifying education as one of the factors influencing help-seeking behaviour (Gulliver, Griffiths, & Christensen, 2010).

The inverse relationship between level of intimacy and desired social distance is consistent with previous findings (Angermeyer & Dietrich, 2006; Gaebel & Baumann, 2003). In this study, reduced attributions of dangerousness and improved attitude towards the mentally ill were observed post-intervention. Attitudinal change has similarly been reported in some studies in western countries (Corrigan et al., 2001; Penn et al., 1994; Pinfold et al., 2003; Wolff, Pathare, Craig, & Leff, 1996). However, no effect on reductions in attribution of dependency was found, suggesting that certain views may be resistant to change (Angermeyer & Dietrich, 2006; Keane, 1990).

Limitations

The limitations of this study include its small, non-random sample and lack of control group. Thus, there is a need to replicate the study in larger samples. Also, longitudinal studies post-intervention may be required to determine if improved attitude corresponds with behavioural change. The strength of the study lies in its interventional nature and the addition it makes to the body of limited research available in this environment.

Conclusion

This study showed that the attitude of community mental health volunteers towards mental illness may change positively following mental health educational programmes. Future training may need to focus more on improving the awareness of the dependency concerns of mentally ill persons. In order to sustain the commitment of the volunteers to the programme, additional initiatives (e.g. incentives) may be required in future programmes. Considering the limited health manpower in developing countries, trained volunteers may play a critical role in delivering mental health interventions. Improving the attitude of volunteers may therefore enhance community-based mental services.

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