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PERCEPTION OF AND ATTITUDE TOWARDS MENTAL ILLNESS AMONG RESIDENTS OF A COMMUNITY IN SOUTH- SOUTH NIGERIA

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Ofonime E. Johnson1, Bibiana M. Benson2

1Department of Community Health, University of Uyo Teaching Hospital, Uyo, Nigeria
2Faculty of Clinical Sciences, University of Uyo, Nigeria

ABSTRACT
Context: The burden of mental illness is increasing steadily and cuts across every community.
Objectives: This study was carried out to determine the perception and attitude towards mental illness among residents of a community in Nigeria.
Study Design: A cross sectional descriptive study was conducted among residents of Obio Offot community in southern Nigeria in June 2016. Participants were selected using cluster sampling method and data collected with semi-structured, interviewer administered questionnaires and analyzed using Statistical Package for the Social Sciences (SPSS) version 20. Level of significance was set at 5%.
Results: A total of 272 respondents participated in the study. The average age of respondent was 29.3 ± 10.14 years, consisting of 52.6% males and 47.4% females. Majority, 72.1% had tertiary education. Almost half of the respondents, 46.0% felt mental illness could not be cured. Various attitudes of the respondents towards the treated mentally ill included shame, 81.3%, unwillingness to share rooms,64.7%, and avoiding all contacts, 41.9%. Majority, 76.5% and 73.5% respectively, considered them as public nuisances and mentally retarded. Identified options of care included psychiatric hospital, 89.3% and church, 72.8%. Unwillingness to share room and perceiving the treated mentally ill as dangerous increased with literacy (p<0.05) The commonest perceived causes of mental illness were substance abuse, 92.3%, brain disease 86.4%  and traumatic events  59.2%.
Conclusion: Despite the high level of literacy among the respondents, there were many stigmatizing attitudes towards the treated mentally ill.  A multi dimensional approach is needed towards ensuring social acceptance of the treated mentally ill.
Key words: Mental illness, community, perception, stigma, attitude, Nigeria

INTRODUCTION
Mental health is an essential and integral component of health. It is a state of emotional and psychological well-being in which an individual is able to use his or her cognitive and emotional capabilities, function in society and meet the ordinary demands of everyday life. 1Mental illness on the other hand refers to disorders generally characterised by deregulation of mood, thought and /or behaviour.2 The burden of mental illness continues to increase over time. Globally, an estimated 350 million people suffer from depression, 21 million from schizophrenia and other psychosis, 60 million from bipolar affective disorders and 47.5 million from dementia.3 This growing burden amounts to huge cost in terms of human misery, disability and economic loss. 4In Nigeria, the prevalence of mental illness is reported at 20% and with a population of 140 million, with less than 100 psychiatrists, the ratio of psychiatrist to population is 1:1.4million.5
Studies have shown that people suffering from mental illness experience stigmatization in many communities.6-11 The condition is often perceived as frightening, shameful, and incurable, while the mentally ill are characterised as dangerous, unpredictable, unstable, untrustworthy, incompetent and helpless in the community.7,8,10,11 Stigma generally lowers their access to resources and opportunities such as housing and employment and leads to diminished self esteem and greater isolation and hopeless life.8 In all, public stigma towards mental illness matters as it sets the context in which individuals in the community respond to the onset of mental health problems, clinicians respond to individual who come for treatment and public policy about mental illness is crafted.12
Research done suggests that poor knowledge of the cause of mental illness especially an attribution to supernatural causation as well as very negative view of person with mental illness is consequentially characterized by intolerance of even basic social contact with people known to have such illness.7 The most common perceived causes of mental illness reported in studies include substance misuse, possession by evil spirit, punishment from God, trauma, stress and hereditary.6,13,14
Community attitude and beliefs play a role in determining help seeking behaviour and successful treatment of the mentally ill. 14In Nigeria, the strong spiritual connotation attributed to mental illness often results in treatment being commonly sought from prayer houses before considering psychiatric hospitals.15 Interestingly, educational interventions that frame the aetiology of mental illness as having a largely biological or genetic component have been shown to counter certain forms of stigma.16,17 Direct contact with person with mental illness also appears to be a critical component in stigma reduction.18
There has been limited research in the area of perception and attitude towards people with mental illness among community members in Akwa Ibom State. The study was conducted to determine perception of and attitude towards people with mental illness in a community in Uyo, Akwa Ibom State.

METHODOLOGY

Study Area
The study was carried out in Obio Offot, a community in Uyo Local Government Area of Akwa Ibom State, located in the coastal southern part of Nigeria. Uyo had a projected population of 413,381 in 2015.19

Study Population
The study was carried out among adults in Nung Akpe, one of the five villages in Obio Offot Community in Uyo Local Government Area of Akwa Ibom State.

Inclusion criteria
Residents of Obio Offot Community in Uyo Local Government Area who were above 18 years were included in the study.

Exclusion criteria
Mentally retarded persons, those less than 18 years and temporary visitors to the study area were excluded from the study.

Study Design
A cross sectional descriptive study was carried out among residents of Obio Offot community.

Sample Size Determination
The formula for descriptive study was used, with p of 0.2 being the prevalence in a target population estimated to have mental illness in a previous study20and a 95% confidence interval set at 1.96 with an acceptable margin of sampling error of 0.05. The calculated minimum sample size was 246. To compensate for improperly filled questionnaires, a non-response rate of 10% (24.6) was added to the minimum sample size. This brought the total sample size to 270.6. However, for the purpose of this study, 300 adults were enrolled in the study.

Sampling Method and Data Collection
Obio Offot Community is made up of five villages in clusters. One of the villages was chosen by simple random sampling method and two eligible persons were administered the questionnaire in each household. Data was collected using a semi-structured, interviewer administered questionnaire which sought information on the respondent’s socio demographic characteristics, knowledge about mental illness, perceived causes of mental illness, attitude towards treated mentally ill person, practice of care of people with mental illness and acceptability of mental health facilities. Seven undergraduate medical students were involved in data collection as research assistants. The questionnaires were translated into the local language for those who didn’t understand English. Data collection lasted for a period of eight days in June 2016.

Data Management
The data obtained was analyzed with the Statistical Package for the Social Sciences (SPSS) version 20. Analysis was carried out using descriptive statistics (Frequency, proportions, means and standard deviation to summarize variables). Chi square test was used to test the significance of association between variables. Level of significance was set at 5%.

Ethical Considerations
Ethical clearance for this study was obtained from the Akwa Ibom State Health Research Committee and permission to conduct the research was received from the community head. Each respondent’s consent was obtained after the objectives of the study and the rights of the respondents were clearly spelt out. In order to ensure confidentiality and anonymity, serial numbers and not names were used.

RESULTS

PERCEPTION-OF-AND-ATTITUDE-TOWARDS-T1
Out of 300 respondents who were enrolled in the study, 272 participated to the end giving response rate of 90.7%. The average age of respondent was 29.3 ± 10.14 years. A total of 143 (52.6%) males and 129 (47.4%) females participated in the study. Majority, 72.1% had tertiary education. (Table 1)

PERCEPTION-OF-AND-ATTITUDE-TOWARDS-T2
Two hundred and fifty five (93.8%) respondents believed there was a lot of stigma associated with mental illness. However, 204(75.0%) believed that living a normal life in the community would help a person with mental illness after treatment, while 181(66.5%) believed that mental illness could be treated outside the hospital. One hundred and twenty five (46.0%) however said that mental illness could not be cured. (Table 2)

PERCEPTION-OF-AND-ATTITUDE-TOWARDS-T3
The various attitudes of the respondents towards the treated mentally ill included shame, 81.3%, unwillingness to share a room,64.7%, and avoiding all contact 41.9%. Majority, 76.5% said the treated mentally ill were public nuisances, while 200 (73.5%) believed they tended to be mentally retarded. (Table 3)

PERCEPTION-OF-AND-ATTITUDE-TOWARDS-T4
Two hundred and forty three (89.3%) of respondents believed that the mentally ill should be cared for in the psychiatric hospital, while 72.8% believed they should be taken to church.(Table 4)

PERCEPTION-OF-AND-ATTITUDE-TOWARDS-T5
Majority of those with tertiary education, 189 (96.4%) said the treated mentally ill were stigmatized (p<0.05). There was a significant association between educational level and unwillingness to share a room, avoiding contact with the treated mentally ill and considering them as dangerous. These negative attitudes increased with literacy (p<0.05). Even though it was not statistically significant, a higher proportion of those with tertiary education, 146 (74.5%) said the treated mentally ill tended to be mentally retarded (p>0.05).  (Table 5)

PERCEPTION-OF-AND-ATTITUDE-TOWARDS-Chart1
Two hundred and fifty one (92.3%) respondents felt that substance abuse was a major cause of mental illness, while 235(86.4%) attributed the cause to brain disease and  59.2% believed that traumatic events could cause mental illness.(Fig 1)

DISCUSSION
This study was carried out in a local community in southern Nigeria. Despite the high literacy of the respondents, their attitude and beliefs portrayed poor knowledge about mental illness. Many believed that mental illness could not be cured and the treated mentally ill tended to be regarded as mentally retarded. Similar studies reported poor knowledge about mental illness and this had no association with their level of education.7,21,22
Majority of respondents in the present study had negative attitude towards the treated mentally ill as close to two-thirds reported unwillingness to share a room and most said they would be ashamed of a family member diagnosed with mental illness. Similar finding was reported in a study in India, where 55% were ashamed to mention that anyone in their family had mental illness.22 Such attitude could lead to unwillingness to seek medical treatment for the affected relative. A study in China on the contrary reported that treated psychosis was viewed relatively benignly.23This would help in reintegrating such people into the community more easily.
Although many of the respondents in the present study believed that mental illness could be treated, majority felt the mentally ill still had some imbalance in the mind despite treatment.  Similarly, in a study done in Cameroon among university students, only 39.5% believed that mental illness could be treated.21This may explain the lack of acceptance and stigmatization of the treated mentally ill in the community. Such attitude fuels the myth that mental illness is lifelong, hopeless and deserving of revulsion.24A survey done in a Nigerian teaching hospital on stigmatising attitudes towards the mentally ill revealed that 82.7% of the respondents were of the opinion that the mentally ill should be denied individual rights while 51.0% were opposed to having mentally ill patients living in their neighbourhood.6 On the contrary, an Indian community which had positive perception regarding treatment outcome of mental illness was reported to have kind and non- stigmatizing attitude towards the mentally ill. Stress was viewed by them as the commonest cause of mental illness.25 Studies have shown that stigma towards the mentally ill is deep rooted in various socio demographic factors.26,27 The extent of such stigma varies according to the cultural and sociological backgrounds of such society.13
In the present study, higher educational level did not seem to improve attitude towards the treated mentally ill. Unwillingness to share room and perceiving the treated mentally ill as dangerous significantly increased with literacy. Similar finding was reported in Ethiopia where college or university students had a higher belief that people with mental illness were threats to the society and should be avoided.28In contrast, a study done in Northern Nigeria reported that literacy was found to be significantly associated with positive attitude towards the mentally sick,14while a study in Oman found no relationship between beliefs of the respondents and educational level.13These differences in study findings suggest that other factors, such as the local beliefs also affect the individual’s attitude towards mental illness.
Studies have shown that educating people alone about mental illness may not automatically lead to improvement in their attitudes towards the mentally ill.29,30 This suggests that a multi dimensional approach is needed towards ensuring social acceptance of the treated mentally ill. One strategy which contributed to improved attitude in New Zealand was advertisement involving the stories of well known and famous people who had experienced mental illness.31
In the present study, substance abuse was the commonest perceived cause of mental illness, followed by brain disease and traumatic events. Psychoactive substance use commonly comes to the mind of many people as the cause of mental illness, especially if a young adult is affected as most substances are commonly sold in communities in the raw and refined forms. This assumption affects people’s sympathy and acceptance of the mentally ill. In a similar study in a teaching hospital in southern Nigeria, 89.4% thought it could result from abuse of drugs, 82.7% traumatic events, and 68.3% genetics.6 On the contrary, in a study in Western Nigeria, over 90% thought mental illnesses could result from punishment from God.7 This belief leads to intolerance of even basic social contacts with people known to have such illnesses.
Concerning the choice of care of the mentally ill in the present study, most respondents believed that psychiatric hospital was the best place for treatment, followed by church. In contrast, respondents in Enugu identified prayer house as the first choice for treatment (34.5%), followed by psychiatric hospital (32%).15In both studies, prayer houses were highly considered because of the spiritual connotation given to mental illness. A study on the treatment seeking behaviour of mentally ill patients in a rural area of India reported that the modality of treatment was significantly influenced by the perception of illness and the attributed cause.32
In the present study, though up to three quarters of the respondents said integrating the treated mentally ill into the community would help in recuperation, they still gave the option of institutional care probably due to fear of violence or relapse of the mentally ill. This implies that community based treatment may not be fully accepted in the study area. In a study in Oman, majority preferred that facilities for psychiatric care should be located away from the community.13Long term custodial care and isolation from the community have been suggested to be the sequel to rejection by the family.33In contrast a study done in Taiwan reported a high level of tolerance of rehabilitation in the community.27Community beliefs about mental illness seems to vary from place to place.

CONCLUSION
Despite the high literacy level of the respondents in this study, their perception of those diagnosed and treated of mental illness did not reflect adequate understanding of mental illness. Hence, there was stigmatization and negative attitude towards such persons. Awareness campaigns and seminars should be organised by mental health professionals and other stakeholders to community members and the public in general to sensitize them about the treated mentally ill so that they can be better accepted and allowed to carry out their activities without fear of harassment.

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