Ellaisha Samari|Esmond Seow|Boon Yiang Chua|Hui Lin Ong|Edimansyah Abdin|Siow Ann Chong|Mythily Subramaniam
Stigma towards people with mental disorders: Perspectives of nursing students
Institute of Mental Health|Institute of Mental Health|Institute of Mental Health|Institute of Mental Health|Institute of Mental Health|Institute of Mental Health|Institute of Mental Health
singapore nursing students relatively low endorsements stigmatizing attitudes towards people mental disordersthose clinical placements relatively higher stigmatizing attitudes versus withoutnursing students attitudes towards people mental disorders varies according type disorders stigma towards people mental disorders highly prevalent often leads negative impact lives alonso et al 2008alonso j buron bruffaerts r posadavilla j lepine j et alassociation perceived stigma mood anxiety disorders results world mental health surveysacta psychiatrica scandinavica 2008 118 305314httpsdoiorg101111j16000447200801241xcrossref pubmed scopus 170 google scholar corrigan watson 2006corrigan pw watson paradox selfstigma mental illnessclinical psychology science practice 2006 9 3553httpsdoiorg101093clipsy9135crossref google scholar according world health organization 2001world health organization world health report mental health new understanding world health organization new hope geneva2001httpwwwwhointwhr2001enwhr01enpdfua1google scholar stigma signifies mark shame disgrace disapproval negative consequences stigmatizing attitudes include rejected discriminated excluded participating number different areas society furthermore stigmatized affects psychological wellbeing development people mental disorders also acts significant barrier seeking accessing adherence treatment link phelan 2006link b phelan j stigma public health implicationsthe lancet 2006 367 528529httpsdoiorg101016s0140673606681841abstract full text full text pdf pubmed scopus 0 google scholar prior research studies generally revealed continued misconceptions mental disorders amongst various populations review population studies angermeyer dietrich 2006angermeyer dietrich public beliefs attitudes towards people mental illness review population studiesacta psychiatrica scandinavica 2006 113 163179httpsdoiorg101111j16000447200500699xcrossref pubmed scopus 743 google scholar found significant proportion public unable recognize specific mental disorders respective causes also perceived people mental disorders unpredictable dangerous perceptions contributed increasing desire distance people mental disorders notably research also shown presence hierarchy stigma within mental disorders diagnoses stigmatizing attitudes directed towards people schizophrenia compared mental disorders mood anxiety disorders griffiths et al 2006griffiths km nakane christensen h yoshioka k jorm nakane h stigma response mental disorders comparison australia japanbmc psychiatry 2006 6httpsdoiorg1011861471244x621crossref google scholar stigmatizing attitudes towards people mental disorders restricted uninformed members general public healthcare professionals also endorse stereotypical beliefs people mental disorders jorm korten jacomb christensen henderson 1999jorm af korten ae jacomb pa christensen h henderson attitudes towards people mental disorder survey australian public health professionalsaustralian new zealand journal psychiatry 1999 33 7783httpsdoiorg101046j14401614199900513xcrossref pubmed scopus 263 google scholar ross goldner 2009ross c goldner e stigma negative attitudes discrimination towards mental illness within nursing profession review literaturejournal psychiatric mental health nursing 2009 16 558567httpsdoiorg101111j13652850200901399xcrossref pubmed scopus 249 google scholar stigmatizing attitudes amongst mental healthcare professionals act barriers seeking treatment hence need broken essentially healthcare professionals especially nurses play key role mental healthcare system harborne jones 2008harborne g jones supplementary prescribing new way working psychiatrists nursespsychiatric bulletin 2008 32 136139httpsdoiorg101192pbbp107016311crossref scopus 6 google scholar frontline healthcare responsible bulk direct care patients baker richards campbell 2005baker j richards campbell nursing attitudes towards acute mental health care development measurement tooljournal advanced nursing 2005 49 522529httpsdoiorg101111j13652648200403325xcrossref pubmed scopus 44 google scholar profound effect therapeutic relationship well treatment outcomes patients interact furthermore given high contact experience patients nurses well positioned ameliorate stigmatizing attitudes amongst public happell 2005happell b mental health nursing challenging stigma discrimination towards people experiencing mental illnessinternational journal mental health nursing 2005 14 1httpsdoiorg101111j14400979200500339xcrossref pubmed scopus 15 google scholar harbouring negative views towards people mental disorders may thus challenging would influence way nurses view patients nature work enarsson sandman hellzen 2007enarsson p sandman p hellzen preservation order use common approach among staff toward clients longterm psychiatric carequalitative health research 2007 17 718729httpsdoiorg1011771049732307302668crossref pubmed scopus 17 google scholar may affect role advocate reducing stigma also hinder development therapeutic relationship patients kameg mitchell clochesy howard suresky 2009kameg k mitchell clochesy j howard v suresky j communication human patient simulation psychiatric nursingissues mental health nursing 2009 30 503508httpsdoiorg10108001612840802601366crossref pubmed scopus 59 google scholar therefore nursing education placements carry great responsibilities shaping attitudes held nursing students towards people mental disorders providing enough depth exposure theoretical practical knowledge positive attitude towards mental health nursing could expected would subsequently prepare nursing profession mental health field happell 1999happell b wants psychiatric nurse novice student nurses interest psychiatric nursingjournal psychiatric mental health nursing 1999 6 479484httpsdoiorg101046j13652850199900249xcrossref pubmed scopus 46 google scholar whether nursing students eventually pursue career psychiatric nursing areas nursing would likely encounter patients mental disorders practice front thus imperative nurses positive attitude towards patients mental disorders furthermore discovering extent stigma fundamental gaining insights current stereotypes could subsequently addressed clarified nursing education placements ultimately understanding nursing students attitudes would aid shaping nursing education singapore twentyone accredited nursing programmes december 2015 singapore nursing board 2016singapore nursing board annual report 2015httpwwwhealthprofessionalsgovsgcontentdamhprofsnbdocspublicationssnb20annual20report202015203020aug202016pdfdate 2016google scholar including degree nursing diploma nursing others mental health nursing curriculum differs across programmes based objectives set students nonetheless nursing students across programmes required complete mental health module subsequently undergo clinical placement mental health facility nursing students typically undergo placements tertiary psychiatric hospital span two weeks inpatient ward setting acute care long stay ward recent populationwide study explored extent stigmatizing attitudes towards people mental disorders singapore subramaniam et al 2016subramaniam abdin e picco l pang shafie vaingankar j et alstigma towards people mental illness components perspective multi ethnic singaporeepidemiology psychiatric sciences 2016 112httpsdoiorg101017s2045796016000159crossref google scholar previous study compared attitudes amongst nursing students across different types mental disorders examined extent stigma amongst nursing students singapore towards people mental disorders furthermore limited number studies examined nursing students attitudes towards people mental disorders across various types mental disorders asia study could thus contribute dearth research region using vignette approach present study aims examine extent overall stigma towards people mental disorders depression obsessive compulsive disorder ocd schizophrenia dementia alcohol abuse well ii examine factors correlate stigma dimensions amongst nursing student population singapore crosssectional study online web survey tool questionpro used collect data sample nursing students singapore ethical approval granted national healthcare group domain specific review board singapore target population included students four public nursing institutions singapore permissions granted corresponding institutions mass email invitations sent nursing students invite partake study enclosed email link directed potential participants online portal screening questions asked assess suitability study included participants course study nationality academic year institution participation quota based institutions academic years order eligible study participants nursing students enrolled public nursing institution singapore recruitment period april 2016 july 2016 singapore citizen permanent resident meet inclusion criteria received automatic email notifying ineligibility study met inclusion criteria directed online consent form participation voluntary clicking agree button participants indicated willingness participate study upon completion participants reimbursed inconvenience fee participants randomly assigned one five vignettes describing person mental disorder alcohol abuse ii dementia iii depression iv ocd v schizophrenia vignettes adapted used prior studies depression schizophrenia vignettes adapted jorm et al 1997jorm af korten ae jacomb pa christensen h rodgers b pollitt p mental health literacy survey publics ability recognize mental disorders beliefs effectiveness treatmentmedical journal australia 1997 166 182186crossref pubmed scopus 1109 google scholar alcohol abuse dementia ocd vignettes adapted subramaniam et al 2016subramaniam abdin e picco l pang shafie vaingankar j et alstigma towards people mental illness components perspective multi ethnic singaporeepidemiology psychiatric sciences 2016 112httpsdoiorg101017s2045796016000159crossref google scholar participants asked indicate attitudes towards person described assigned vignette using two different scales personal perceived scale depression stigma scale dss griffiths christensen jorm evans groves 2004griffiths km christensen h jorm af evans k groves c effect webbased depression literacy cognitivebehavioural therapy interventions stigmatizing attitudes depression randomised controlled trialbritish journal psychiatry 2004 185 342349crossref pubmed scopus 498 google scholar social distance scale sds link phelan bresnahan stueve pescosolido 1999link b phelan j bresnahan stueve pescosolido b public conceptions mental illness labels causes dangerousness social distanceamerican journal public health 1999 89 13281333httpsdoiorg102105ajph8991328crossref pubmed google scholar depression stigma scale dss griffiths christensen jorm evans groves 2004griffiths km christensen h jorm af evans k groves c effect webbased depression literacy cognitivebehavioural therapy interventions stigmatizing attitudes depression randomised controlled trialbritish journal psychiatry 2004 185 342349crossref pubmed scopus 498 google scholar two subscales personal perceived stigma developed measure stigma towards people mental disorders subscale nine items asks respondents personal stigma scale beliefs others attitudes perceived stigma scale towards person described depression vignette although originally designed measure stigma towards depression scale also used measure stigma towards disorders described relevant vignettes eight nine items personal stigma scale used study excluding one item would vote politician knew mental disorder ratings item measured 5point likert scale 1 strongly agree 2 agree 3 neither agree disagree 4 disagree 5 strongly disagree higher scores suggest stigmatizing attitude cronbachs personal stigma scale 0647 social distance scale sds link phelan bresnahan stueve pescosolido 1999link b phelan j bresnahan stueve pescosolido b public conceptions mental illness labels causes dangerousness social distanceamerican journal public health 1999 89 13281333httpsdoiorg102105ajph8991328crossref pubmed google scholar used assess respondents selfreported willingness contact person depicted vignette specifically respondents rated willingness 1 move next door person vignette 2 spend evening socialising person 3 make friends person 4 work closely job person 5 person marry family ratings item measured 4point scale 1 definitely unwilling 2 probably unwilling 3 probably willing 4 definitely willing lower scores suggest greater social distance desired respondents cronbachs scale 0827 similar vignettebased approach measurement tool used previous populationbased study conducted subramaniam et al 2016subramaniam abdin e picco l pang shafie vaingankar j et alstigma towards people mental illness components perspective multi ethnic singaporeepidemiology psychiatric sciences 2016 112httpsdoiorg101017s2045796016000159crossref google scholar singapore factor analysis done measurement tools suggested twofactor structure depression stigma scale weaknotsick dangerousunreliable consistent study done yap mackinnon reavley jorm 2014yap mackinnon reavley n jorm measurement properties stigmatizing attitudes towards mental illness results two community surveysinternational journal methods psychiatric research 2014 23 4961httpsdoiorg101002mpr1433crossref pubmed scopus 77 google scholar onefactor structure social distance scale social distance first dimension weak sick comprised three items ps1ps3 items describe problem person depicted vignette experiencing form personal weakness within hisher control opposed medical condition subsequent four items ps4 ps5 ps6 ps8 formed second dimension dangerousunpredictable items describe person depicted vignette one dangerous best avoided third dimension social distance comprised five items social distance scale sd1sd5 loaded strongly single factor following aforementioned populationbased study total score three dimensions calculated summing items dimension dangerousunpredictable dimension item ps7 problem like vignette would tell anyone excluded calculation 5 items social distance factor reversed coded summed together higher scores dimension represent stigmatizing attitudes towards mental illness ibm spss statistics version 23 used conduct statistical analyses study mean standard error mean calculated continuous variables frequencies percentages calculated categorical variables descriptive analyses items personal perceived stigma scale recoded grouped three categories agree neither agree disagree agree items agree strongly agree combined agree disagree strongly disagree combined disagree items social distance scale recoded binary responses willing unwilling items definitely willing willing combined willing definitely unwilling unwilling combined unwilling ttests oneway anova tests conducted identify differences mean scores three stigma dimensions across variables gender ethnicity education level monthly household income clinical placement experience lectures psychiatry type vignette administered whether family friends ever problems similar person described vignette multivariate linear regressions also conducted examine associations aforementioned variables stigma dimensions towards people mental disorders listwise deletion used handle missing data statistically significant results reported p 005 500 nursing students 83 male 417 female aged 16 35 years old 201 sd 31 completed study table 1 presents sociodemographic characteristics participantstable 1sociodemographic characteristics study samplenagemean 201 yearssd 31gendermale83166female417834ethnicitychinese287574malay134268indian60120others1938current educationdegree100200diploma others400800average monthly household income per capita past 1 yearbelow sgd2000158316sgd2000 5999248496sgd6000 above94188clinical placement experienceyes303606no197394lecturesyes424848no76152vignette typedepression100200ocd100200alcohol abuse100200dementia100200schizophrenia100200family close circle friends ever problems similar person described vignetteyes125250no375750 open table new tab seen table 2a percentage difference participants agree disagree item within weak sick dimension shows larger number participants endorsed stigmatizing attitudes items ps1 compared items ps2 ps3 specifically participants agreed people problem like x could get better wanted ps1772 however participants less likely agree problem like x sign personal weakness ps223 xs problem real medical illness ps3172table 2aitem endorsement depression stigma scale personal stigmadisagreeneither agree disagreeagreennnweak sick dimensionps1 people problem like x could get better wanted to479467134386772ps2 problem like xs sign personal weakness219438166332115230ps3 xs problem real medical illness28256413226486172dangerousunpredictable dimensionps4 people problem like xs dangerous others26152214629293186ps5 best avoid people problem like xs dont also get problem412824631262550ps6 people problem like xs unpredictable107214158316235470ps7 problem like xs would tell anyone232464161322107214ps8 would employ someone knew problem like x22745418136292184 open table new tab table 2a also shows larger number participants endorsed stigmatizing attitudes items ps6 compared rest items within dangerousunpredictable dimension specifically participants agreed people problem like xs unpredictable ps6470 however participants less likely agree person described vignette dangerous others ps4186 best avoided order avoid contracting disorder ps55 also less likely agree would tell someone similar problem ps7214 would employ someone problem ps8184 table 2b reports endorsement stigmatizing statements social distance dimension reports percentage participants either willing unwilling make social contact person described vignette item scale general larger percentage participants willing social contact saying willing move next door sd1748 spend evening sd2726 make friends sd3882 work closely job someone mental disorder sd4698 however social interaction participants unwilling engage person mental disorder marry family sd566 unwillingtable 2bitem endorsement social distance scale social distancesocial distance dimensionunwillingwillingnnsd1 willing would move next door x126252374748sd2 willing would spend evening x137274363726sd3 willing would make friends x59118441882sd4 willing would x start working closely job151302349698sd5 willing would x marry family330660170340 open table new tab descriptive values three established dimensions stigma weak sick dangerousunpredictable social distance across sociodemographic groups reported table 3 higher mean scores denote higher level stigma three dimensionstable 3descriptive statistics stigma dimensions sociodemographic factorsweak sickdangerousunpredictablesocial distancemeanahigher mean scores denote higher level stigmasep valuemeanahigher mean scores denote higher level stigmasep valuemeanahigher mean scores denote higher level stigmasep valueoverall90100096103200119112260117gender male88400220045210482031905451075902910075 female90400110102880128113190127ethnicity chinese86900126000010216016103421130701600082 malay96790171106340214108730202 indian92670286100170354112500351 others82110527106320636124210520average monthly household income per capita past 1 year sgd200091710169002510304021603511086702010058 sgd2000599991050130104560166114920170 sgd6000 above8468024799890280111280265current education degree7920024200009860024400531107002410506 diploma others92770100104350135112650133clinical placement experience yes91090121018510528016000301143601500026 no88480158100000173109040185attended psychiatry lecture yes90450099034210276013003831121001250746 no87890312105660300113160325vignette type depression9200023400159680022900001071002700000 ocd8860019590000246105300246 alcohol abuse95600206112700287117600239 dementia86100233107000247110300252 schizophrenia88000196109500254121000269family close circle friends ever problems similar person described vignette yes8584022200119808023800131030402430000 no91470104104910137115330130a higher mean scores denote higher level stigma open table new tab multivariate linear regression analyses reported table 4 shows correlates variables predicting three factors stigma mentioned participants malay 0578 p 005 received depression 0597 p 005 alcohol abuse 0759 p 005 vignette significantly associated higher weak sick scores pursuing degree nursing 1175 p 005 whose family close circle friends ever problems similar person described vignette 0457 p 005 significantly associated lower weak sick scores participants pursuing degree nursing 0639 p 005 attended psychiatry lectures 0916 p 005 lower dangerousunpredictable scores male participants 0711 p 005 received dementia vignette 0817 p 005 whose family close circle friends ever problems similar person described vignette 1003 p 005 significantly associated lower social distance scores interestingly participants presented either depression 1072 p 005 1019 p 005 ocd vignette 1879 p 005 1495 p 005 associated lower dangerousunpredictable scores social distance scores participants attended clinical placements 0822 p 005 0730 p 005 associated significantly higher dangerousunpredictable social distance scorestable 4multivariate linear regression analyses variables predicting stigma dimensionsweak sickdangerousunpredictablesocial distance95 confidence intervalp value95 confidence intervalp value95 confidence intervalp valuegender male020606980286041200920510069407640711130701150020 femalerefrefrefethnicity malay057801311025001102210326076904280525106700170058 indian030502890899031305601287016701310356107603630331 others063615960323019303380837151305721158000523210051 chineserefrefrefaverage monthly household income per capita past 1 year sgd2000016603800711055100860582075408010367102802940276 sgd20005999016703350669051303450270096002710287032208950355 sgd6000 aboverefrefrefcurrent education degree117516760674000006391253002600410452105801550144 diploma othersrefrefrefclinical placement experience yes040400360845007208220283136100030730019712640007 norefrefrefattended psychiatry lecture yes015907560437060009161646018600140719144200040051 norefrefrefvignette type depression059700101184004610721790035400041019173003080005 ocd010704650678071418792579118000001495218708030000 alcohol abuse075901861331001003080394100903890272096604220442 dementia002706100555092700320745068109300817152301120023 schizophreniarefrefreffamily close circle friends ever problems similar person described vignette yes045708890025003805211050000800541003152604790000 norefrefref open table new tab main purpose study examine extent overall stigma towards people mental disorders depression ocd schizophrenia dementia alcohol abuse factors significantly correlated stigma dimensions amongst nursing student population singapore general results study encouraging showed evidence relatively low endorsement stigmatizing attitudes towards people mental disorders within nursing student population fact compared larger singapore population subramaniam et al 2016subramaniam abdin e picco l pang shafie vaingankar j et alstigma towards people mental illness components perspective multi ethnic singaporeepidemiology psychiatric sciences