Abstract
Background:
Addressing the social stigma of mental illness is of importance in Iraq where mentally ill patients experience the compounded disadvantages of inadequate health services and illness stigma.
Aims:
To study the prevalence and magnitude of the social stigma towards mental illnesses.
Method:
A cross-sectional study has been carried out on 300 male and female participants at shopping malls and public cafes in Baghdad, Iraq. A self-administered questionnaire made data collection. Descriptive, and analytic statics procedure was operated as far as a convenience by using Excel 365 version as a data management tool.
Results:
About (80%) of the respondents revealed a moderate degree of stigmatising attitude towards mental illness with a Likert scale total equivalent score range of (2.34–3.669). About (20%) of respondents showed a low degree of stigmatising attitude towards mental illness, with a Likert scale total equivalent score range of (1–2.339). P-value was highly significant (=0.011798) <0.05 among gender variables while it is not significant among age, income, education, and positive family of mental illnesses. 83% of the respondents prefer the medical management of mental illnesses.
Conclusions:
There were no clear roles of socio-demographic factors in the stigmatic attitude towards mental illnesses. This finding warrants a more in-depth look into the Iraqi community’s cultural, social, and moral contexts.
Introduction
The tendency to stigmatise seems to be a deeply rooted attitude in human nature as a way of responding to people who appear or behave differently. Stigmatisation is based on the fear that those who seem different may behave in threatening or unpredictable ways. It is reduced when it becomes clear that the stigmatised person is unlikely to act in these ways. (Rössler, 2016). Far more than any other type of illness, mental disorders are subject to negative judgements and stigmatisation. Many patients not only have to cope with the often-devastating effects of their disease but also suffer from social exclusion and prejudices. However, stigmatisation and discrimination reached an unfortunate peak during the Nazi reign in Germany when hundreds of thousands of mentally ill people were murdered or sterilised. (Corrigan & Watson, 2002) Stigmatising attitudes towards people with mental disorders are widespread in public and even among mental health professionals. Women and people living in urban areas were more stigmatised. Whereas men experienced more significant discrimination in the job area, women experienced more problems in the family and the social regions. Unlike people with physical disabilities, those with mental disorders are often perceived by the public to be in control of their disabilities and responsible for causing them. The view that ‘weakness’’, ‘laziness’’, or ‘lack of willpower’ contributes to the development of mental disorders has been reported in several countries. Although most states have some provision for disability benefits, people with mental illness are often explicitly excluded from such entitlements. (Knaak et al., 2017) In many cultures, mental illness is much stigmatised, and can, for example, hinder prospects of marriage. In such a culture, the effect of illness on the patient’s view of himself and his future will be quite different from the impact on a patient living in a more tolerant mental disorders (Harrison, 2018). People fear mental illness and they stigmatise those who are affected by it. The reasons for this are complex; they include the notion that people with mental illness cannot control their behaviour, and that they may act in odd, unpredictable, and possibly violent ways. It is incumbent on all those who use psychiatric diagnostic terms that they do so appropriately and judiciously, within the proper context (Reavley et al., 2017). As an outcome of a process, a stigmatised person is considered different from the ‘normal’ people with whom he or she regularly interacts, is viewed negatively, and becomes reduced from ‘a whole and usual person to a tainted and discounted one.’ Stigmatisation also operates on multiple simultaneous levels-intrapersonal (e.g. self-stigma), interpersonal (e.g. relations with others), and structural (e.g. discriminatory, and exclusionary policies, laws, and systems. (Knaak et al., 2017; Sadock et al., 2015). In Iraq, the pattern of mental disorders is escalating in prevalence and severity due to the issues of war-related traumas and displacement, refugees, and the on-going acts of violence by militants, resulting in increased cases of Post-Traumatic Stress Disorder(PSTD), depression, anxiety.(Sharma & Piachaud, 2011) Mental health professional in Iraq are facing the challenge of mitigating the drawback of social stigma where many patients refrain from psychiatric consultation and seek the help of faith or traditional healers; clergymen, sorcerers, or sometimes wizards first or discontinue treatment and follow-up, thus more cases of psychosis, Bi-polar and drug abuse are presented to the psychiatric clinic with severe and complicated conditions because of the stigma. This stigmatised attitude expanded to include the psychiatrists, where many perceive them as (doctors of mads) and the psychiatric medication (brain-damaging drugs), resulting in a tedious effect on the psychiatrists and quality of provided psychiatric services. The stigma of mental illness represents a daily challenge in the mental health field and community in Iraq (Younis et al., 2019). As there were no previous studies carried out to handling stigmatising attitude towards mental illness in the country, this study has been initiated to filling gaps in the knowledge, addressing many questions, and testing the relevant hypothesis
Methods
A cross-sectional simple random selected sample of 300 male and female individuals were invited to complete the survey at their convenience in shopping malls and public cafes during the period of 1st September 2019 to January 2020 in Al-Russafa District in Baghdad. Verbal consent was given to the interviewer (the second author) after explaining the aims of the study and assuring confidentiality. The participants completed the self-administered standard questionnaire consisted of 40 questions and the form of selected socio-demographic variables typed in Arabic language, each question measured by the (5-point Likert scale). Operational definitions of variables and inclusion and exclusion criteria were applied. Descriptive, as well as analytic statically procedures, were operated as far as a convenience by using Excel 365 version as a data management tool. After explaining the aims of the research, oral consent had been taken from each participant. The Ethical and Scientific committee approved the study protocol as one of the research projects required by the Arab Board for Health Specialisations/Iraq. The collected data were submitted to statistical analysis using Microsoft office (version 1904, excel 365). The given responses coded by 5 points Likert scale (strongly agree, agree, neutral, disagree, strongly disagree) the grading of numbers from 1 to 5 indicated a ‘worse’ response of tendency to stigmatise, or in reverse according to the type of question. The asymmetry of categories about a midpoint was considered as equidistant and more like an interval-level measurement. (Maximum–Minimum/n): (5–1/3), the value (1.33) was calculated as an interval value. Maximum refers to the highest, and Minimum refers to the lowest score, while N refers to the number of average categories as follows: Low (1–2.339), Moderate (2.34–3.669), High (3.67–5). Individuals who were <18 years and >75 years did not participate in this study (Derrick & White, 2017).
Results
The study revealed that about (80%) of the respondents showed a moderate degree of stigmatising attitude towards mental illness with a Likert scale total equivalent score range of (2.34–3.669). About (20%) of respondents showed a low degree of stigmatising attitude towards mental illness, with a Likert scale total equivalent score range of (1–2.339). No positive response was identified for the high degree of stigmatic attitude towards the mental illnesses represented by the score’s equivalent range (3.67-5). Among the respondent’s group with a moderate degree of mental illnesses stigmatising attitude, the data reflected that about (66%) were males and (44%) were females; P-value was highly significant (=0.011798) <0.05. The study revealed that almost (60%) of the respondents indicated the critical role of the media in creating a similar attitude towards mental illnesses, and (83 %) of the respondents prefer the medical treatment of psychiatric disorders. These factors were not associated with the degree of stigmatic attitude, as shown in Figures 1–5 as Table 1 below mentioned. There were 252, (88%) respondents, without a personal history of psychiatric disorders, and 33 (12%) respondents, with a personal history of mental disorders.
Frequency distributions according to the level of stigmatising attitude.
Frequency distributions according to the impact of media on stigmatising attitude.
Frequency distribution of positive family history of mental illnesses among respondents.
Frequency distributions of therapeutic modality preferences among the respondents.
Frequency distribution of the effectiveness of the mental health services by respondents.
Association of positive stigmatising attitude with socio-demographic factors.
Discussions
The significance of this study raises from being unique study handling similar interest, there is a scarcity of researches about the stigma of mental disorders in Arab countries, and published data about it in Iraq is almost absent. It has been concluded that about; (12%) of the total respondents revealed a positive family history of mental illnesses, which convey a preliminary impression that mental illnesses are not uncommon findings, but widely prevalent among the population regardless of the types and severity(Dardas & Simmons, 2015) . On the other hand, the 88% of negative family history of mental illnesses group will adequately ensure the unbiased results of stigmatic attitude regarding mental illness, illiterate respondent’s attitude regarding social stigma revealed to be a very small group in the current study has no significant statistical association with social stigma, this finding found to be similar to many other studies findings several comparable studies. (Kadri et al., 2004; Pocock, 2017; Sewilam et al., 2016).The higher percentage (80%) of respondents with moderate degree stigmatising attitude about mental illness was expected among middle eastern countries like Iraq, but the real question was, which segment of the population holds the greatest amount of stigmatisation against mental illnesses. Among respondents, with moderate degree stigmatising attitude about mental illness, there were: 127, (66%) male respondents, and 100 (44%) female respondents. The result of the p-value was (0.011798), and the null hypothesis was rejected, and this relation was considered significant. More male respondents had a moderate degree of stigmatic attitude towards mental illnesses than females. It was obvious that there was no certain age group that holds a stigmatising attitude towards mental illnesses. P-value: 0.632151, (α: 0.05). The group of participants with ‘university education’ were having a moderate degree stigmatising attitude about mental illness was (56%), but the null hypothesis was not rejected due to the top value score of 0.314966. The educational level and stigmatic attitude towards mental illnesses were found to be statistically insignificant, meaning no associations were identified. Similarly, the results related to the socio-economic status (income) were comparable and devoid of any significant findings. P-Value: 0.880012. Almost (62%) of the respondents accused the role of media in affecting their attitude towards the mental illnesses; this may draw the attention towards the possible ways of the judicial use of this potential source, the p-value was (0.3984). About ( 83% )of the study sample, believe that mental illnesses need medical management while 17% trust in traditional spiritual (and religious, faith healers) p-value was (0.99574242). The respondents expressed that stigma arose from series of practical and moral judgments about the person’s ability to fulfil a given role, their moral worth, and their place in the social fabric; such finding is consistent with the results of a previous study in Egypt (Coker, 2005). As for considering the mentally ill patient as (dangerous, unpredictable and undependable) who are unfortunately frequently encountered by the laypeople in the psychiatric institutions (asylums), the findings were contradictory, a high percentage of females (67%) and respondents with university education (76%) which was abolished by the insignificant dependency, (P-value: 0.08262) and (P-value: 0.9985)respectively, likewise findings may resemble, to a great extent, what the Jordanian study abstracted that there was no such role to certain psychiatric diagnosis or diagnoses in stigmatic attitude towards mental illnesses (Hasan & Musleh, 2017). The association of stigma with social rejection has led to the common use of ‘social distance’ scales to measure this construct (Link et al., 1999). These scales offer a quantifiable, comparable way of judging how much distance one would prefer to keep between themselves and a hypothetical person with a given disorder, despite that, this study finding is devoid of similar operational scale to detect exactly the social distance, the findings reflected that, there are unconscious denial about stigma of mental illnesses by getting positive responses to indirect queries that may indicate stigma. The highly negative results (73%, 57%) showed us that the social distance may not be the single most important defining factor regarding stigma of mental illnesses. Social affection on the psychiatric patients and their families; looks not agree with the study of (Kadri et al., 2004) in Morocco which proposed a great familial societal affection, and agreed later on with subsequent researches (Boguñá et al., 2004). Regarding the pathway to care is often shaped by scepticism towards mental health services and the treatments offered, as nearly all of them (92%), think that, these services are inadequate and most of them (61%), were doubtful about its efficiency. This was largely supported by a previous study in a several Asian countries (Lauber & Rössler, 2007).
Study Limitations
Data collected was restricted to malls visitors whom can be special groups of population that cannot represent the general population adequately. The available data was limited to specific geographical districts.
Conclusions
There were no clear roles in stigmatic attitude towards mental illnesses, or even the degrees of stigmatising attitudes, the limited outcomes, highlighted the needs to look beyond socio demographic characteristics of stigmatising attitude qualitative understanding of the phenomena and their cultural deep rooting, and sorting out complexities components of social stigma of mental illnesses within the historical, social and moral contexts of the country. People obviously believe that mental health services, are still inadequate (at quantity and quality paradigms) which may maximise the population stigmatic attitude and impose more difficulties regarding accessing and benefiting from interests. Stigmatising mental illnesses may need wide range investments in national efforts at awareness corner, national cultural contexts and social mobilisations (Nyblade, et al., 2019).
Footnotes
Conflicts of Interests
All authors declared that there are no conflicts of interest.
Ethical issues
Ethical issues have been applied through all stages of the study.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
