Stigma and Discrimination Against People with Mental Illness: Findings from North-Central Nigeria

Transcription

1 ORIGINAL PAPER Stigma and Discrimination Against People with Mental Illness: Findings from North-Central Nigeria Adeyemi SO, Abiola T, Solomon KJ Department of Medical Services, Federal Neuropsychiatric Hospital, Barnawa-Kaduna, Nigeria Abstract Background: Stigma has been described as social disadvantages being experienced by people with mental illness. This usually come in the triad of ignorance, prejudice and discrimination and has been identified as a universal phenomenon. Specific studies on psychiatric stigma that were carried out in Nigeria were mainly outside the Northern part of the country. Hence, the present study aimed at assessing the level of stigma and discrimination in Kaduna, a major city in North Central Nigeria using Stip-9. We also aim to validate the English version of this German instrument as the English translation used in this study has no reported psychometric properties. Methods: The participants are a group of factory workers who were approached to fill the study instruments during an anti-stigma educational activity. The instruments comprised a socio-demographic questionnaire and Stig-9. Mean scores of respondents on Stig-9 were used to group them into high or low stigma. Cronbach s alpha and factorial analysis were done to determine the validity of the measuring scales. Results: Participants variables significantly contributing to high perceived stigma are female gender and being less than 31 years in age. The internal consistency of Stig-9 is moderately high (r=0.718). Scree plot reveals that Stig-9 is made up of 3 factors that relates to discrimination, emotional reactions and labeling. Conclusion: Our study shows that the participants who were females and less than 31 year-old had high level of perceived stigma. The internal reliability of Stig-9 is moderately high and comprises of three factorially derived subscales relating to discrimination, negative emotions and labeling. These findings supported Stig-9 as a valid short measure of stigma and identified variables to target in planning stigma interventions. Keywords: Stigma, Discrimination, Stig-9 Psychometric, Mental Illness, North-Central Nigeria

2 Introduction The social disadvantages being experienced by people with mental illness has been described by Thornicroft and colleagues as the outcome triad of ignorance, prejudice and discrimination 1. These triad of problems summed up as stigma were initially speculated to be uncommon in non-western societies 2. However, studies from non- Western societies showed that negative beliefs and behaviours toward mental illness are not only a Euro-American phenomenon but a universal one 3-9. These studies showed stigma to be high in varying groups of people: from the service providers and service users within the hospital settings to people in the community implementing their acquired negative socialization towards people utilizing mental health services. Studies on psychiatric stigma among medical personnel and trainees had been reported to be equally high and at times higher than that found among community members and both are higher than that anticipated by the mental health service users Specific studies on psychiatric stigma that were carried out in Nigeria were mainly outside the Northern part of the country 6-9. These Nigerian studies explored the knowledge base of the participants and found this to be often erroneous (e.g. preternatural or supernatural factors as the causes of mental illness) and contributory to the derogatory attitudes and actions these faulty knowledge breed in term of prejudices (e.g. low utilization of available modern treatments) and discriminations (e.g. not allowing people with mental illness to live within the community). One of these Nigerian studies that utilized objectively structured Community Attitudes towards the Mentally Ill (CAMI) scale to determine the level of public stigma against people with mental illness reported high stigma on all the four subscales of CAMI 7. With the dearth of research on mental health stigma from Northern Nigeria and particularly using standardized measuring scales, we deemed it necessary to study the level of stigma and discrimination among group of factory workers during an antistigma educational activity in Kaduna, a major city in North Central Nigeria. The current study utilized the brief Stig-9 scale which should be less time consuming and easier to administer unlike the 40-item lengthy CAMI scale. We also aim to provide psychometric properties of the English version of this German instrument as the English translation used in this study has no reported psychometrics 11,12. Methods Setting, sample and procedure The study was conducted among Nigerian National Petroleum Commission (NNPC) refinery staff in Kaduna, north western Nigeria. Kaduna is considered the third major cosmopolitan city after Lagos. The study was carried out during an educational activity in The study instruments were given to all the participants in the training program. Before any participants were asked to fill the study instruments, a verbal informed consent was obtained from them. The participants were also told that participation was voluntary and that responses were anonymous. From all the participants that were approached for their informed consent, 481 participants gave their consent and filled the study instruments. Measures The measure comprised two parts, with the first documenting the socio-demographic

3 characteristics of the respondents and the second part was Stig-9. The Stig-9 was developed by Gierk and colleagues 11 as a nine-item measuring scale that assessed the participants expectations of negative social responses to be meted out to people with psychiatric disorders. Each item is scored on four point likert scale from disagree, somewhat disagree, somewhat agree to agree. The total minimum score obtainable is 0 and 27 is the maximum sum score 12. High score corresponds to high expectation of stigma and discrimination from the society that socialized them. Stig-9 has high internal consistency with a reported Cronbach s alpha of 0.9 for the German version 11. The Stig-9 also exists as an English version with no known psychometric validation available from the search of the authors 11,12. Statistical analysis All data collected were analyzed with SPSS version 21. Frequency tables were used to show the distribution of the sociodemographics of the respondents. The Stig-9 scores were grouped into high or low using the respondents mean score as the cut off mark. The Cronbach s alpha was calculated for the Stig-9 to determine its internal consistency. Student t-test was carried out to determine which of the sociodemographic variables were related to high level of stigma. Factorial analysis was also done on Stig-9 to determine if it is made up of more than one component of perceived stigma. All results were determined as significant if the p-value is less than 0.05, two tailed. Results The sociodemographic variables of participants according to their scores on the STIG-9 scale are presented in Table 1. We report the participants mean age as (standard deviation (SD) 11.83) years and most of them are males (68.1%), of Christian religion (60.9%) and having over 12 years of formal education (91.7%). Participants aged 30 years and below recorded higher stigma scores against people with mental illness, and this is statistically significant. Also significant with high scores is the female gender. The religious and educational statuses of the participants did not significantly contribute to the observed results. Table 1. Sociodemographic variables of participants according to their scores on Stig-9 Scale (N=481) STIG-9 SCORES Test Statistics Age Group (years) Low scorers [218 (%)] High Scorers [263 (%)] Chi-Square p-value < 31 years 86 (38.2) 139 (61.8) years and above 132 (51.6) 124 (48.4) Mean age (SD) (11.83) years Gender Male 165 (50.3) 163 (49.7) Female 53 (34.6) 100 (65.4) Religion Christianity 125 (42.7) 168 (57.3) Islam 93 (49.5) 95 (50.5) Educational Status

4 Some formal 20 (50.0) 20 (50.0) education Nil formal 198 (44.9) 243 (55.1) education SD: Standard Deviation Table 2 reports the mean scores of participants according to their sociodemographics. Statistically contributing to higher mean scores are being less than 31 years in age and female gender. Although being a Christian and having a tertiary education recorded higher mean stigma score, these are not found to be statistically significant. Table 2. Mean score distribution of Stig-9 according to participants socio-demographics (N=481) Stig-9 Test Statistics Age Grouping Mean Score Standard Deviation t-test p-value <31 years < years and above Overall Gender Male <0.001 Female Religion Christianity Islam Educational Status Some formal education Nil formal education According to table 3, the Cronbach s alpha score is and this falls into the acceptable and moderately high range. Moderate correlations were noted between items: 3 and 6 (0.495); 7 and 8 (0.476); 7 and 9 (0.402); and 8 and 9 (0.409) implying that these items may be measuring similar construct. Table 3. Stig-9 inter-item correlation and reliability score (N=481) Stig

5 Cronbach s Alpha = Since the Stig-9 was an adapted translation from German into English, we carried out a factorial analysis on our result to test further the applicability of this instrument. A Scree plot analysis reveals that this instrument has 3 components (with Eigen value greater than 1) and these are fixed into the factorial analysis. The Kaiser-Meyer OIlkin (KMO) measure of sampling adequacy was supporting the need for factorial analysis. The Bartlett s Test of Sphericity is significant (p<0.001 at Chi-Square value of ) and rejects the assumption that the intercorrelation matrix of these items is an identity matrix. The results of the oblique rotations are shown in Table 4 when factor loading is greater than Figure 1. The scree plot of STIG-9 showing the monotonically descending Eigen values

6 Five items loaded onto Factor 1 and all of them relate to reported mental illness stigma perceived as social loss and/or discrimination 13. The expectations and experiences from this perception confer the status stereotypes and structural discriminations meted out to people who have mental health challenges. This factor is hence tagged The perceived status loss/discrimination associated with mental illness. The two items that load onto Factor 2 identify the negative emotional reactions of the perceiver onto the mentally ill 13. Similarly, it identifies the emotional distress experience by people with mental illness from the public stigma. This factor is hereby called The emotional reactions of mental illness stigma. The items for Factor 3 represent the unhelpful negative cognitions arising from the perceived status loss/discrimination and associated with consequent emotional distress 13. This factor is described as The preoccupied negative cognition from the experience of separation and labeling. Table 4. A principal axis factor analysis with Promax (oblique) rotation of the 9 likert scale questions of STIG-9 Component I think that most people do not even take a look at an application from someone who has been treated for a mental illness do not enter into a relationship with someone who has been treated for a mental illness consider mental illness to be a sign of personal weakness feel uneasy when someone who has been treated for a mental illness moves into the neighbourhood 4... think badly of someone who has been treated for a mental illness 6... hesitate to entrust their child with someone who has been treated for a mental illness hesitate to do business with someone who has been treated for a mental illness 1... take the opinion of someone who has been treated for a mental illness less seriously 2 consider someone who has been treated for a mental illness to be dangerous. Eigen Value Percentage of total Variance Number of Test Measure Overall goodness of fit indices: χ 2 = (df = 24; p < 0.01); χ 2 /df = 2.359; goodness of fit index (GFI) =.974; adjusted goodness of fit index (AGFI) = 0.951; normed fit index (NFI) = 0.925; Tucker-Lewis fit index (TLI) = 0.932; comparative fit index (CFI) = 0.955; root mean square error of approximation (RMSEA) = O.053; p-value of close fit (PCLOSE) = Extraction Method: Principal Component Analysis (Promax with Kaiser Normalization)

7 Discussion This study find stigma to be high among participants who are less than 31 years in age and belonging to the female gender. This may be reflecting findings from the wider three states study in southern Nigeria 6 identifying their respondents as majorly belonging to the young age group and of predominant female population. Associated and not included in our study is the participants attribution on the causes of mental illness. We speculated that our participants attributions on this will be close to that of previous studies in sub- Saharan Africa 6,14 that identified substance abuse, supernatural reasons and psychological trauma as the three leading causes of mental illness. The influence of education in our study is very weak, but it does corresponds to 6-9, 14 previous findings in sub-saharan Africa and other parts of the world 2-5 that higher education does come with a slightly reduced level of stigma towards people with mental illness. All the above supported the well documented effects of stigma dissuading the mentally challenged from seeking treatment in a health facility. It also reflects the community resentment people with mental illness were faced with judging that more than half of our study sample scored high on stigma towards people with mental illness. The moderately high Cronbach s alpha showed that this German instrument adapted into English is reliable. The moderate inter item correlations also show that some of the items are measuring towards similar stigma constructs. Hence, the three factors were identified as being related to discrimination, negative emotional reactions and labeling respectively 13. Labeling is the creation of undesirable names that described in a stereotypic manner the salient suffering people with mental illness are facing 13. This is both on the mind and in the behavior of the stigmatizers and the stigmatized. When such labels lead to a social loss, disadvantages, devaluations, rejections or exclusion it becomes discrimination 13. The emotional responses to such discriminatory behavior are termed emotional reactions 13. These are usually played out from the stigmatizers as them vs. us, and from the stigmatized as shame, anger, fear, alienation or embarrassment. Despite our moderate sample size, this study did come with a major limitation. This was our inability to carry out concurrent and divergent validity, as we did not coadminister similar/related measures of stigma to the participants. Also, our result should be interpreted with caution for our sample is based on convenience and from one place of work. Hence it cannot be generalized to all population in Northern Nigeria. Conclusion We presented findings on a group of factory workers attitude towards people with mental illness. Our study shows that the participants who were females and less than 31 year-old had high level of perceived stigma. The internal reliability of Stig-9 is moderately high and comprises of three factorially derived subscales related to discrimination, negative emotional reactions and labeling. All these supported Stig-9 as a valid short measure of stigma and identified variables to target in planning stigma interventions. References 1. Thornicroft G., Brohan E., Kassam A. and Lewis-Holmes E. Reducing stigma and discrimination: Candidate

8 interventions. International Journal of Mental Health Systems; 2008, 2:3. 2. Fabrega Jr,H. Psychiatric stigma in non- Western societies. Compr Psychiatry, 1991; 32: Naeem F., Ayub M., Javed Z., Irfan M., Haral F. and Kingdon D. Stigma and psychiatric illness. A survey of attitude of medical students and doctors in Lahore, Pakistan. J Ayub Med Coll Abbottabad, 2006; 18(3). 4. Ahmedani B. K. Mental Health Stigma: Society, Individuals and the Profession. Journal of Social Work Values and Ethics, 2011; 8(2). 5. Ghanean H., Nojomi M. and Jacobsson L. Internalized stigma of mental illness in Tehran, Iran. Stigma Research and Action, 2011; vol. 1 (1): Gureje O., Lasebikan V. O., Ephraim- Oluwanuga O., Olley B. O. and Kola L. Community study of knowledge of and attitude to mental illness in Nigeria. Br J Psychiatry, 2005; 186: Ukpong D. I. and Abasiubong F. Stigmatizing attitudes towards the mentally ill: A survey in a Nigerian university teaching hospital. South African Journal of Psychiatry, 2010; Vol. 16 (2). 8. Adewuya A. O. and Makanjuola R. O. Social distance towards people with mental illness amongst Nigerian university students. Soc Psychiatry Psychiatr Epidemiol, 2005; 40(11): Adewuya A. O. and Makanjuola R. O. Social distance towards people with mental illness in southwestern Nigerian. Aust N Z J Psychiatry, 2008; 42(5): Byrne P. Challenging healthcare discrimination: Commentary on Disrimination against people with mental illness. Advances in Psychiatric Treatment, 2010; 16: Gierk B., Murray AM, Kohlmann S., & Leo B. Measuring the Perceived stigma of mental illness with Stig-9: A reconceptualisation of the Perceived Devaluation-Discrimination Scale. Available on: atik/downloads/klinik-psychosomatikpsychotherapie/gierk_poster_dkpm_2 013.pdf; (accessed on ). 12. Stig-9. Available from: (accessed on ). 13. Link B. G., Yang L. H., Phelan J. C. and Collins P. Y. Measuring Mental Illness Stigma. Schizophr Bull, 2004; 30(3): Crabb J., Stewart R. C., Kokota D., Masson N., Chabunya S. and Krishnadas R. Attitudes towards mental illness in Malawi: a crossectional survey. BMC Public Health, 2012; 12:541. Corresponding Author Tajudeen Abiola Department of Medical Services, Federal Neuropsychiatric Hospital, Barnawa-Kaduna, Nigeria abiolatob@yahoo.com