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Table of Contents
Year : 2018  |  Volume : 5  |  Issue : 4  |  Page : 140-144

Community attitude toward the mentally ill and its related factors in Kashan, Iran

1 Department of Public Health, School of Public Health, Kashan University of Medical Sciences, Kashan, Iran
2 Department of Statistics and Epidemiology, School of Public Health, Kashan University of Medical Sciences, Kashan, Iran
3 Determinants of Health (SDH) Research Center, Kashan University of Medical Sciences, Kashan, Iran

Date of Web Publication3-Jan-2019

Correspondence Address:
Dr. Ali Fakhri
Social Determinants of Health (SDH) Research Center, Kashan University of Medical Sciences, Kashan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/iahs.iahs_11_18

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Aims: Today, the prevalence of mental disorders is increasing. In Iran, more than 20% of people suffer from mental problems too. Despite all scientific developments in diagnosis and treatment of the mentally ill patients, presenting psychotherapy service is still facing some problems because of the negative attitudes which require more investigation. The current research aims to study the attitudes of Kashan city population about the mentally ill and the contributing factors. Materials And Methods: In this study, the samples were chosen randomly at two levels among health posts and their covered population in Kashan city (364 samples). Community Attitudes toward the Mentally Ill questionnaire was used for data collecting. The data were analyzed by SPSS software and statistical tests. Findings: Most of the participants had a positive attitude toward the mentally ill (with the mean of 3.66 from 5 score and standard deviation of 0.37). Attitude of women and higher-educated people were, respectively, better than men (PV < 0.01) and lower-educated people (PV < 0.01). There was no meaningful difference between attitude toward the mentally ill and employment, and there was no meaningful correlation between the attitude score and age either. Conclusion: The results confirm the role of education on the positive attitude of people toward the mentally ill. The positive attitude can show the appropriate awareness of people on these lines.

Keywords: Attitude, stigma, the mentally ill

How to cite this article:
Jalali N, Tahan S, Moosavi SG, Fakhri A. Community attitude toward the mentally ill and its related factors in Kashan, Iran. Int Arch Health Sci 2018;5:140-4

How to cite this URL:
Jalali N, Tahan S, Moosavi SG, Fakhri A. Community attitude toward the mentally ill and its related factors in Kashan, Iran. Int Arch Health Sci [serial online] 2018 [cited 2022 Jan 23];5:140-4. Available from: http://www.iahs.kaums.ac.ir/text.asp?2018/5/4/140/249373

  Introduction Top

Considering conceptual framework of social determinants of health, one of the intermediary determinants of health is psychosocial factors that are in the form of influencing factors on mental health.[1] Today, mental health disorders concern authorities in the health system at the global level.[2] According to the WHO, at least 52 million people in the world are affected by severe mental illness and 150 million by the mild type. There are growing mental disorders in developing countries. In Iran as a developing country, more than 20% of people suffer from mental disorders.[3],[4] Mental patients and their families face some social problems such as discrimination, labeling, stereotyping, separation, and status loss because of negative attitude toward the mentally ill called stigma.[5],[6]

The affected persons with stigma are subject to decreasing self-esteem.[7] Stigma can lead to a decrease in the quality of life, refusing to take medicine and follow-up, worsening the patient's illness, and causing family damage.[8],[9],[10] Stigma and discrimination have harmful effects on people's lives so they have been considered by the WHO.[2],[11] Studies show that stigma is more in men, younger people, poor people, and more pious people.[12] At the same time, it is also argued that information and experience about the illness and possibility of controlling it are very effective on attitude.[13]

The attitude of special groups such as students toward the mentally ill has been investigated and reported in Iran.[14],[15],[16],[17],[18] However, the prevalence of mental disorders in Iran is high, so the health transformation plan recently emphasized on presenting mental health services, training mental health, and developing active participation of people.[19] Considering these conditions and also interdependence of successful services and the attitude, the assessment of the attitude seems important.[15] However, few studies have assessed the community attitude in the last decades in Iran including different results;[20],[21],[22] for example, Kheirabadi et al. studied the attitude of people in Sanandaj toward the mentally ill in 1997 that shown positive attitude in the 70% of cases, but Omidvari et al. study carried out in 2007, however, indicates stigma views in the 66% of participants.[20],[21]

To investigate attitude toward the mentally ill, various questionnaires are designed and used in Iran,[15],[16],[20],[21] often focusing on special groups such as students.[14],[15],[16],[17],[18] The community attitude toward the mentally ill (CAMI)[23] is a questionnaire used in some countries to assess community nurses and even students' attitude toward the mentally ill[24],[25],[26],[27], but in Iran, it has been used only to assess nursing students' attitude.[28] According to the previous studies, Kashan is a city with high prevalence of the mentally illness (29%).[29] Thus, the aim of the present study is to investigate community attitude toward the mentally ill using CAMI questionnaire in this city. We hope that patients could get some help through suitable intervention for removing stigma after determining the community attitude and predicting the behavior of people so that the pain they endure is limited to the pain resulting from their illness.

  Materials and Methods Top

This cross-sectional study was conducted on adult Iranian inhabitants (people above 18-years-old) covered by health posts in Kashan city in 2016. Based on the mean rate of 34% of positive attitude reported in an Iranian source[20] and considering the Cochrane formula with confidence interval of 95% and error margin of 5%, the number of needed participants amounted to 345. Sampling was conducted in two steps; first from all 32 health posts of Kashan and then randomly from the covered population of the selected health posts. The participants (364 samples) were identified from health posts' records, and then the questionnaires were completed in person under the supervision of researchers. We excluded people who are reluctant or unable to collaborate. The collecting tool was CAMI questionnaire. The aim of the study was the investigation of the current attitude of the community which includes two parts; the first includes demographic features and the second is 40 attitude questions in the form of the 5-points Likert scale from 1 to 5, respectively, for strongly agree, agree, no idea, disagree, and strongly disagree. In this questionnaire, the attitude includes four dimensions; authoritarianism evaluates the authoritarian domination without any emotions. In this view, the mental patients are low-class groups that need to be assisted. Second is benevolence attitude showing kindness and loving originated from religion and humanism rather science. Third, the mental health ideology based on the idea that mental illness is like physical illnesses. The basis is medical pattern which is adjusted to psychiatric issues and focused on individual adaptability. Fourth is the social restrictiveness that shows a belief that considers mental patient as a threat for society, especially family, believing that his/her actions should be limited whether in hospital or after discharge.[23] The construct validity of original questionnaire has been verified by factor analysis.[30] This questionnaire has been translated to Persian and used by the Iranian researchers.[28] The content of questionnaire is presented to 10 psychologists or highly educated people to study the validity. Considering Polit method including acceptable level of I-content validity index and S-content validity ratio, the questionnaire was adjusted and reached the threshold of 0.78 and 0.9, respectively.[31]

In order to assess the reliability, it was presented to thirty people to complete and then the Cronbach's alpha (α = 0.84) was measured.

Data were analyzed using SPSS 11.5 (SPSS Inc., Chicago, IL) after collecting it. Descriptive statistics including frequency, mean, and standard deviation of studied variables are measured and significance of difference by contributing factors, that is, gender, education level, age, marital status, and employment was analyzed using statistical tests of Kolmogorov–Smirnov, one-way ANOVA, and t-test.

  Findings Top

In order to achieve a sample of 345 persons, the questionnaire was distributed between 380 persons. Three hundred and sixty-four questionnaires were fully completed (rate = 96%) and analyzed. Two hundred and thirty-two persons (63.7%) were women and 132 (36.3%) were men. The average age was 35.14 and ranged 18–75. Two hundred and seventy-eight (76.4%) were married and 86 (23/6%) were single. Based on education level, 147 persons (40.4%) were above diploma.

The results indicate that the mean score of attitude toward the mentally ill in Kashan was 3.66 with the standard deviation of 0.37 and in its four dimensions, that is, authoritarianism, benevolence, social restrictiveness, and mental health ideology was 3.37, 3.83, 3.57, and 3.75, respectively [Figure 1]. The mean attitude score of the married toward the mentally ill in general and in dimensions of authoritarianism, benevolence, social restrictiveness, and mental health ideology of community is higher than that of singles but is not statistically significant (PV > 0.05) [Table 1].
Figure 1: Mean score of community attitude toward mentally ill totally and by its dimensions in Kashan in 2016

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Table 1: Mean and standard deviation of attitude toward mental illness in Kashan in 2016 by gender

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The comparison of the mean score of attitude toward the mentally ill shows that women have a higher score than men significantly in general attitude and in two dimensions of authoritarianism and social restrictiveness (PV < 0.05). In general, the score in benevolence dimension is higher than other dimensions in both genders [Table 2].
Table 2: Mean and standard deviation of attitudes toward mental illness in Kashan in 2016 by education

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There was a significant difference between mean score in general attitude and also authoritarianism dimension of high- and low-educated participants (PV < 0.01) so that the attitude of people above diploma was better than below diploma. People with higher education in three dimensions including benevolence, social restrictiveness, and mental health ideology have higher score than other people below diploma, but the difference is not significant (PV > 0.05). Because of the significant differences of gender and education in attitude score in general, the relationship between gender and education level was studied; the tests did not verify a significant relationship between gender and education (PV > 0.05) [Table 3]. Mutual effect on two variables on the attitude was also studied, and with PV = 0.826 it was not significant.
Table 3: Mean and standard deviation of attitudes toward mental illness in Kashan in 2016 by employment

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The average attitude score of nonemployed people in social restrictiveness dimension was more significant than in employed people, while the difference in general attitude and also other dimensions were not significant [Table 4].
Table 4: Mean and standard deviation of attitudes toward mental illness in Kashan in 2016 by marital status

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By analysis of correlation coefficient between age and attitude in different dimensions and also general attitude, it was determined that the correlation was not significant.

  Discussion Top

Considering the cutoff point of 3,[20] the results indicated that the attitude toward the mentally ill in general and in its dimensions is positive in our study. That is, the studied group has a less negative attitude toward the mentally ill. The attitude in different societies is not the same and in societies at low socioeconomic level, stigma is seen more than others.[24] For example, in the study of stigma in African countries, average stigma score to the mentally ill in all attitude dimensions whether benevolence, authoritarian, social restrictiveness, or mental health ideology have been at high level and the stigma is widely used to the mentally ill and ignored individual rights with the mentally ill.[32],[33]

The study of knowledge and attitude of people in Tehran toward the mentally ill conducted by another tool shows stigma views and negative stereotype tending to social distance in most participants in the survey.[20] In the study of attitude in Kurdistan, however, the studied cases did not have a negative attitude toward the mentally ill and most had positive attitude.[21]

Better attitude of highly educated people is another finding of this study (PV < 0.01). Other studies verified the reverse relationship between stigma to the mentally ill and education level too.[32] Studies show that people with high social status and academic education have less negative attitude.[24] Increase of educational level and completing the psychiatric course improves the medical students' attitude, so positive correlation between age and improvement in attitude are attributed to relationship between high education level and information.[15]

It should be noted that in our study, the correlation between age and attitude was not verified. This negative correlation is not opposed to the previous point because more analysis shows that in our study there is no significant relationship between age and education.[34] This is verified that aging and an increase in the interaction with patients improve the attitude as well as increasing the awareness; for instance, an increase in education level leads to the same result. Furthermore, there is a need for more study about whether positive attitude is obtained from higher education or increase in awareness. It seems that education has positive effect on people's attitude and can cause changes in culture and false customs in some societies and remove some stereotype and superstitions about the mentally ill. People with higher education believe in superstitions less than others and training is more effective on the highly educated people.

There was a significant difference between women and men in attitude (PV < 0.01) so that the average attitude score in women was better than that of men and it was significant in two dimensions of authoritarian and social restrictiveness. Some studies show that women have more positive attitude.[24],[33] Other studies have shown no gender differences.[35],[36],[37]

The significant difference between gender and education on the attitude score leads to this assumption that two variables have mutual effects that means in our study women have high education and their attitude is originated in education, while statistical tests did not show significant relationship between gender and education. Studies have mentioned variables such as humanitarian attitude or attitude about the treatability of mental illnesses as influencing factors,[38],[39] but other contextual factors could influence the attitude score too.[40] Other sources discuss that biologic and genetic differences may contribute to some of the psychological and behavioral differences, we observe between two genders.[41] However, further studies are needed to assess these hypotheses.

The limitation of this study is in its limited implementation in a district and the problem of generalizing its results to other populations as well as the limitation of analyzing of other effective and relative factors affecting the attitude toward mentally ill. Other limitation is excluding reluctant people from the study because the negative attitude of them to collaborate in the study can be attributed to their negative attitude to other areas so introduce bios in the results.

  Conclusion Top

The findings of this study emphasize the role of social factors and particularly education level on the health issue. However, the attitude of educated people was positive showing the good awareness of those people in these areas. However, it is felt that more effort is needed in the health system to increase the attitude score. Acceptance and social support of mental patients are some of the most fundamental needs in the treatment process and negative attitude and avoiding mental patients can be barriers to improving their health, so it is necessary that decision-makers take effective actions to design and implement plans to improve the attitudes. Exerting suitable laws and taking advantage of media, particularly the state media, can help the health system. Positive attitude in women toward the mentally ill originating in emotions could be considered, meaning that in training of the community besides stating the positive effects of positive attitude toward mentally ill, triggering human emotions could be emphasized.


We extend our gratitude and appreciation to that venerable Research Deputy of Kashan University of Medical Sciences.

Ethical permission

Ethical permission was granted by the Ethics Committee on Biological Sciences of the Kashan University of Medical Sciences; code IR. KAUMS. REC.1395.51.

Financial support and sponsorship

This study was implemented under the financial support of the Research Deputy of Kashan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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