Attitudes toward the mentally ill among community health-related personnel in South Korea.

BACKGROUND AND AIMS: Prejudice and negative attitudes toward mental illness are major obstacles in the rehabilitation and functional recovery of patients. The objective of this study was to evaluate the attitudes of health-related personnel toward mentally ill patients in a local urban community in South Korea.
MATERIALS AND METHODS: In total, 401 participants (men, 132; women, 269; mean age, 37.3 ± 9.5 years) were recruited. The participants were health-related personnel in a district of Seoul, who were recruited from three different workplaces: a local administration office, a public health center, and a community welfare center. Sociodemographic data were gathered, and the community attitudes toward the mentally ill (CAMI) inventory were administered. Comparisons of the CAMI subscales were conducted among participants using statistical analysis.
RESULTS: Community welfare center workers showed more authoritarianism and social restriction and less community mental health ideology than the other two groups. Among the demographic variables, a shorter working career, higher education, female gender, and younger age were also related to a more negative attitude toward mentally ill patients.
CONCLUSION: Community health-related personnel who have contact with patients with mental illness should be encouraged to have a fair, hospitable, and open-minded attitude. It is advisable for these workers to receive interventions such as regular educational programs early in their careers.

INTRODUCTION

Public mental health services for severe psychiatric illness are changing from long-term institutionalization to short-term hospital admission. In addition, community-based rapid resocialization has been emphasized.[1] The aim of this policy is to reduce long-term admission to mental hospitals and the degeneration of social function by prolonged isolation from society.[2] Therefore, the proactive role of community support systems has been increasingly emphasized. Unfortunately, negative attitudes, such as prejudice and stigmatization, are still widespread among community residents. These factors can be major obstacles for the social adaptation of the mentally ill.[3] Social stigma is defined as a set of negative attitudes and beliefs that the public adopts toward patients with mental illness.[4] Given its burden, the World Health Organization has recommended launching public awareness campaigns to overcome stigma and discrimination.[56]

Several studies have been performed to investigate the attitudes toward the mentally ill among various groups of community residents.[7891011] Most studies have revealed associations between negative attitudes toward the mentally ill and certain populations, such as older people, individuals with a lower education level, opinion leaders, and community residents. However, the results have not been consistent due to the possible effects of cultural differences or the demographic composition of each community. The objective of this study was the investigation of the attitudes toward the mentally ill among workers at three mental health-related organizations using the community attitudes toward the mentally ill (CAMI) inventory.[12]

MATERIALS AND METHODS

Participants

A total of 401 participants were recruited in this study. The participants comprised 132 men (33%) and 269 women with a mean age of 37.3 ± 9.5 years. The participants were all community health-related personnel in Sungbuk-gu (an administrative district of Seoul, South Korea; estimated total population: 495,000) and were divided into three groups according to the type of organization in which they were employed: administrative offices (district office, police station, and community service center, n = 162, M:F = 68:94, age = 39.9 ± 8.5 years), health centers (n = 129, M: F = 35:94, age = 39.5 ± 9.9 years), and community welfare centers (n = 120, M:F = 29:81, age = 30.5 ± 6.7 years). Administrative offices register the mentally ill and provide economic support such as medical aid from the local government. Health centers provide services such as vaccination or medical treatment for low-income groups. Community welfare centers are nongovernmental organizations for people in the community with low socioeconomic status. They offer programs for community residents, such as vocational and social skill training programs.

The inclusion criterion was employment as community health-related personnel in Sungbuk-gu, and the exclusion criterion was a refusal to participate in the study. It was conducted as a part of a community mental health survey organized by a community mental health center and local health center.

We explained the meaning and goal of the study to the participants and obtained their written informed consent. The study protocol and ethics were reviewed and approved by the Institutional Review Board of the institution with which the authors were affiliated.

Interview process

A trained interviewer administered the interview survey after fully informing potential participants about the purpose of the research during visits to their workplaces. The interview lasted approximately 20 min. After the interview, the participants received compensation worth approximately 3 USD.

Sociodemographic data

We gathered data including gender, age, type of workplace, work experience, education level, religion, and job position.

Community attitudes toward the mentally ill inventory

The study used the Korean version of the CAMI inventory that was developed by Taylor and Dear.[71213] The CAMI includes four subscales: authoritarianism (AU), benevolence (BE), social restrictiveness (SR), and community mental health ideology (CMHI). AU refers to a view of the individual with mental illness as someone inferior who requires coercive handling. BE implies a sympathetic view of individuals with mental illness based on humanistic and religious principles. SR involves the belief that individuals with mental illness should be restricted in their social functions. CMHI involves the acceptance and integration of individuals with mental illness in the community. The scale includes 40 items that are rated on a 5-point Likert scale from 1 (strongly agree) to 5 (strongly disagree) and is organized into the four subscales. Each subscale is composed of ten items, with five items each on positive and negative attitudes. Lower scores indicate more negative attitudes in AU and SR and more positive attitudes in BE and CMHI. To elaborate, low scores indicated that participants are authoritative, socially restrictive, benevolent, and aware of CMHI, respectively. Cronbach's alpha values of the Korean version of the CAMI have been reported as 0.57 for AU, 0.64 for BE, 0.72 for SR, and 0.84 for CMHI. Cronbach's alphas in this study were similar: 0.56 for AU, 0.59 for BE, 0.79 for SR, and 0.67 for CMHI. During the validation study of the Korean version of CAMI, successful back-translation was performed, and test-retest reliability was assessed.[13]

Statistical analysis

To identify the differences in the four CAMI subscales according to the participants' workplace, gender, age, educational background, religion, and work experience, independent t-tests and one-way ANOVAs were conducted with a statistical significance level of P = 0.05 as the parametric tests. All statistical analyses were performed using the predictive analysis software version 17.0 (Chicago, Illinois, USA).

RESULTS

General characteristics

The percentage of women was highest in the community welfare centers, with percentages of female workers in administrative offices, health centers, and community welfare centers being 58%, 72%, and 73%, respectively. The percentage of women among public officials in South Korea is 49.4%.[14] There are more women employed in lower grades. In health centers, workers include nurses, physiotherapists, pathologists, and others; women comprise a large percentage.[15] In community welfare centers, 75.1% are women in South Korea. Therefore, the female majority observed in this study is relatively well representative of South Korean worker distribution in these contexts.[16]

The mean age varied by workplace and was lower in the community welfare centers than in the other two organizations, (mean ages = 39.9 ± 8.5 vs. 39.5 ± 9.9 vs. 30.5 ± 6.7 years in the administrative offices, health centers, and community welfare centers, respectively F = 46.5 P < 0.001). The distribution of education levels was as follows: high school degree, n = 55; college degree, n = 296; and graduate degree, n = 50. The proportion of individuals with a college or graduate degree was largest among community welfare center workers. Work experience ranged from 1 month to 33 years, with mean work tenure of 8.6 ± 8.6 years. The average working career was shorter among community welfare center workers (mean working time in months: administrative offices, health centers, community welfare centers = 144 ± 107 vs. 107 ± 100 vs. 41 ± 44 months, F = 40.4, P < 0.001) [Table 1].

Table 1

Socio-demographic characteristics of the participants

Attitudes toward the mentally ill

The overall mean scores of all participants assessed by the CAMI subscales were 23.9 ± 3.6 for AU, 37.2 ± 3.7 for BE, 27.0 ± 4.8 for SR, and 33.7 ± 4.0 for CMHI.

Community welfare center workers showed more authoritative attitudes than workers in the other two institutions (F = 11.5 P < 0.001) and more strongly favored restricting the social functions of the mentally ill (F = 16.5, P < 0.001). Moreover, they had more negative beliefs about CMHI (F = 10.6, P < 0.001) [Table 2].

Table 2

Comparison between each organization and the mean scores in the CAMI subscales

Regarding demographic variables, women showed more authoritative attitudes (F = 1.7, P < 0.001), and participants younger than 30 years were more authoritative than participants older than 40 years (F = 6.5, P < 0.001). In addition, younger participants believed that individuals with mental illness should be restricted in their social functions (F = 12.9, P < 0.001) and showed a negative attitude toward CMHI (F = 4.5, P < 0.001).

The level of education also affected the attitudes of the participants. Highly educated participants with a college or graduate degree showed more authoritative attitudes (F = 4.8, P < 0.001). A short working career (<2 years) was related to negative attitudes toward the mentally ill; these participants were more authoritative (F = 5.9, P < 0.001), favored social restriction (F = 6.3, P < 0.001), and did not place value in CMHI (F = 3.9, P < 0.001). However, there were no differences in attitude according to religion [Table 3].

Table 3

Comparison between each socio-demographic variable and the mean scores in the CAMI subscales

DISCUSSION

Participants who worked at a community welfare centre, had <2 years' work experience, were female, were aged younger than 30 years, or had a relatively high level of education (college or graduate degree) showed more negative attitudes overall. However, the interpretation of these results requires caution. Community welfare center workers were younger, were more highly educated, and had a shorter working career; the lowest men versus women ratio was also observed in this group. It is possible that demographic factors affected the results more than did the workplace or the opposite.

Similarly, attitudinal biases have been reported in previous studies. In studies among community residents, more negative attitudes were observed among older individuals and those with a lower education level.[7891017] In contrast, younger participants showed more negative attitudes in the present study. This has been attributed to lack of knowledge about mental illness.[18] Those findings could be considered consistent with the current results if examined from an alternative perspective. Most of the participants were between 20 and 40 years of age. Although we did not collect data regarding previous experience with individuals with mental illness, we assumed that a younger age and shorter work career would indicate less experience and contact with the mentally ill. The duration of education alone cannot be regarded sufficient to determine the level of mental health knowledge. Moreover, changes in the education level of the general population, in recent years, should be considered when comparing the current study to the previous ones. The tertiary advancement rate (the share of high school graduates advancing to tertiary education) rose from 33% in 1990 to a peak of 84% in 2008 in South Korea.[19] The current results suggested that demographic data such as age, gender, and work experience were more associated than the place of work and could be determining variables.

Women are usually more empathetic than men and can show more emotional reactions toward individuals with mental illness, in both positive and negative ways.[20] In this study, female workers' negative attitudes might be due to fear and the need to avoid unknown dangers. Age could also be a common significant factor influencing the attitudes toward mental illness, and it could offer an explanation for previously reported inconsistent results based on job, religion, or social status.[21] Moreover, an Indian study showed that less experienced and female doctors had negative perceptions of mental illness.[22] Based on this assumption, the need for appropriate educational or support programs related to mental illness could be important for individuals who have recently started their career in civil service. Negative attitudes could be effectively reduced by educational or other interventions.[223] The experience gradually obtained through work might be insufficient for the rapid social readjustment of individuals with mental illness.

The study had several limitations. First, we examined only demographic variables, including gender, age, religion, education level, duration of working career, and type of organization. Other potentially influential factors were excluded, such as previous experience with the mentally ill, a family history of mental illness, personality traits, and other variables. Second, the current study had no control group. We limited our sample to health-related personnel and compared their attitudes. Our aim was to identify weaknesses in the community mental health system.

CONCLUSION

The negative perceptions and biases of civil officials and public health-related personnel, who play pivotal roles in community mental health services, are critical and can interfere with the care and rehabilitation of the mentally ill. Age and gender could play a role in increasing or decreasing negative attitudes toward the mentally ill. Regular educational programs should be provided to civil officials and health-related workers in the early period of their working careers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.