Behavior of general population toward mentally ill persons in Digital India: Where are we?

BACKGROUND: We aimed to find out the overall reported and intended behavior of the general population of India toward mentally ill persons.
MATERIALS AND METHODS: Participants were included in an online survey using a nonprobability snowball sampling technique. After taking informed consent, sociodemographic details were recorded, and the "Reported and Intended Behaviour Scale" was administered.
RESULTS: Out of 818 responses, 684 responses were eligible for study after exclusion. The mean age (standard deviation) of the study population was 31.01 (7.79) years. Maximum participants reported that they did not live (76.6%), did not work (75.7%), did not live nearby (66.4 %), or have not had a close friend (79.8%) with mental health problems. However, most individuals neither agreed nor disagreed to live (48.5%), work (38%), and live nearby (42.7%) a mentally ill person, but maximum individuals strongly agreed to continue a relationship with a friend having mental health problems (34.5%). There were 77.5% males and 32.2% healthcare workers. Regarding intended behavior, there was a significant difference between healthcare workers and persons other than these as well as between males and females. Participants who had previous interaction with the mentally ill person were more willing to interact with the same.
CONCLUSION: Most people do not intend to have stigmatized behavior toward mentally ill persons. Healthcare workers and males have less negative social reactions toward mentally ill persons in different domains of life. However, there is still a need to intensify awareness about mental health. Copyright:

One in four persons is affected by mental health problems in their life time. By 2030, depression would be the leading cause of disease burden globally.[1] A study on the burden of mental disorders across the states of India revealed that one in seven people of India was affected with psychiatric disorders up to 2017. The proportional contributions of psychiatric disorders to the total disease burden in India have doubled since 1990.[2]

The WHO revealed that three out of four people with mental illness do not receive any treatment for the same.[1] Poor awareness about symptoms of psychiatric disorders, prejudice, and negative behavior toward people of mental health problems, lack of knowledge about treatment availability, and its benefits of seeking treatment are leading causes for the high treatment gap.[3] The discriminatory attitude of healthcare workers toward mentally ill persons was also a matter of concern. Stigmas attached in our society along with low perceived need for psychiatric care are challenges to the mental healthcare services.[4]

A study in India revealed high prevalence of stigma toward mentally ill persons among females and people with higher income.[5] Another study collected data from five metropolitan cities of India regarding perceived stigma and discrimination toward mentally ill persons. It revealed higher level of stigma among females. In different cultural and societal norms, gender differences are also accountable for perceived stigma toward persons with mental health problems. Females have important roles in family and making a social system of cultural norms.[6]

To ensure universal accessibility, equality, and affordability of mental healthcare and preserving the rights of people with mental illness, the National Mental Healthcare Policy of India 2014 and Mental Healthcare Act 2017 were enacted.[78] The role of family and community is important in destigmatization, reducing discrimination in mental healthcare services, increasing awareness, and promoting mental healthcare services.[9] In India, community-based programs have also been implemented as they have the potential to reduce the treatment gap for mental health problems.[10]

Stigma attached to persons with mental illness makes them more vulnerable to significant loss of self-esteem, self-stigmatization, reduced job opportunities, and social exclusion.[11] Stigma in mental health is defined in the domains of knowledge, attitude, and behavior. Knowledge refers to experience with a person having mental health problems. Attitude of general population toward mentally ill persons is characterized by their thoughts and emotions such as fear and mistrust. Behavior toward person with mental disorders refers to discriminatory actions in the form of rejection and avoidance of mentally ill persons.[12] The predetermined attitude and stigma attached in our society lead to hindrance in help-seeking behavior of mentally ill persons.

This is the era of digitization where most of the information is available on digital media. Maximum people have access to digital media and easily get information about mental health problems. Therefore, this study was undertaken to estimate and determine the current behavior of general population toward mentally ill persons in India, after implementation of multiple strategies to reduce the treatment gap and discrimination.

MATERIALS AND METHODS

It was a cross-sectional study on the population of India with access to internet. An online Google Form was developed by using a semi-structured questionnaire of sociodemographic details and a questionnaire of “Reported and Intended Behaviour Scale (RIBS).”[13] An informed consent was incorporated in this Google Form. Full confidentiality was assured and no details of unique identifiers such as name were collected. Clearance was taken from the institutional ethical committee (IEC) of the tertiary health care center. After taking clearance from IEC, the link of Google Form was circulated through WhatsApp, emails, and other social media by using snowball sampling technique. Every person is connected to others through digital media in the current era of digitalization. The participants were asked to forward the link to as many persons as possible. On receiving and opening of the link, the participants were auto directed to the Google Form. On opening, the Google Form gave relevant information about the survey and principal investigator to have trust in the survey. After giving informed consent, they were asked to fill up the questionnaire. A set of questions appeared sequentially. After answering all the questions, the participants were asked to submit the survey online. This study was started on May 6, 2020, and data were collected from across various states of India till June 6, 2020.

The semi-structured questionnaire collected common sociodemographic details and also information about history of mental illness in the individual and his family. After collecting the sociodemographic details, “RIBS” questionnaire was administered. The RIBS is a scale to measure the mental health stigma-related behavior and is feasible to use with large populations. It contains eight items which measures behavior of persons toward mentally ill persons in various life domains: living with, working with, living nearby with, and continuing a relationship with a close friend with a mental health problem. Item–retest reliability based on weighted kappa is ranged from 0.62 to 1.0. For internal consistency, Cronbach's alpha achieved from 0.72 to 0.81, if each item was eliminated from the scale. The RIBS has substantial internal consistency and test–retest reliability.[13] The RIBS has two subsets of questions. First subset (items 1–4) assesses reported behavior toward person with mental illness regarding present and past life events. These items are answered as “yes” or “no” or “don't know.” Second subset (items 5–8) measures intended (future) behavior of persons toward a person with mental health problems. These items are scored on a Likert scale (1–5) ranging from strongly disagree, slightly disagree, neither agree nor disagree, slightly agree, to strongly agree. It also has a “don't know” option scored as 3. A higher score indicates more positive intended behavior and less stigmatization. Participants who were aged 18–60 years, literate enough to read English language, and willing to participate in study were considered as inclusion criteria. Individuals having history of mental illness, having history of cognitive deficits, and who refused to give informed consent were excluded from the study.

Descriptive/inferential statistics were used to estimate the proportions of the study and to determine the association between reported and intended behavior with other variables of the study by using Mann–Whitney test and Kruskal–Walis test for ordinal data and ANOVA for parametric data in IBM SPSS (version 20) software (IBM India Pvt Ltd., Pune, Maharashtra, India). The level of significance was set as P < 0.05.

RESULTS

A total of 818 respondents participated in the survey. A total of 684 respondents were included in the study after consideration of inclusion and exclusion criteria. The mean age of the participants was 31.01 ± 7.79 years. Maximum numbers of participants were 30–39 years of age group, male, Hindu by religion, upper middle class socioeconomic status, married, of urban residential area, and professional by occupation [Table 1]. The participants belonged to 22 states or union territories of India, with maximum responses from Uttar Pradesh [Figure 1]. Out of 684 participants, 42.7% were professionals or postgraduates, 45% were graduates, and 12.3% educated up to higher secondary education. 32.2% were healthcare workers.

Table 1

Sociodemographic details

	Frequency, n (%)
Age group (years)
18-29	284 (41.5)
30-39	314 (45.9)
40-49	74 (10.8)
50-60	12 (1.8)
Gender
Male	530 (77.5)
Female	154 (22.5)
Religion
Hindu	610 (89.2)
Muslim	30 (4.4)
Sikh	16 (2.3)
Others (Jain/Buddhism/atheist/Christian)	28 (4.1)
Socioeconomic class
Upper lower	112 (16.4)
Lower middle	152 (22.2)
Upper middle	212 (31.0)
Upper	208 (30.4)
Occupation
Professional	298 (43.6)
Semi-professional	94 (13.7)
Arithmetic skill jobs	72 (10.5)
Skilled worker	34 (5.0)
Semi-skilled worker	10 (1.5)
Unskilled worker	6 (0.9)
Unemployed	170 (24.9)
Residential area
Urban	422 (61.7)
Semi-urban	138 (20.2)
Rural	124 (18.1)
Marital status
Married	428 (62.6)
Unmarried	256 (37.4)

Figure 1

Study population with color gradient: Lowest (red) to highest (green) population

It is estimated that approximately 70% of study population never has had interacted or any experience with persons having mental health problems [Table 2]. As per the past and present experiences of the study population, future behavior was also estimated. It was found that maximum study population neither agreed nor disagreed to live with (48.5%), work with (38%), and live nearby (42.7%) to a person with mental health problems, but 34.5% strongly agreed to continue a relationship with friends having mental illness [Table 3].

Table 2

Estimated experiences of general population in relation to people who have mental health problems

Questions	Responses
	Yes, n (%)	No, n (%)	Don’t know, n (%)
1. Are you currently living with, or have you ever lived with, someone with a mental health problem?	110 (16.1)	524 (76.6)	50 (7.3)
2. Are you currently working with, or have you ever worked with, someone with a mental health problem?	100 (14.6)	518 (75.7)	66 (9.6)
3. Do you currently have, or have you ever had, a neighbor with a mental health problem?	150 (21.9)	454 (66.4)	80 (11.7)
4. Do you currently have, or have you ever had, a close friend with a mental health problem?	108 (15.8)	546 (79.8)	30 (4.4)

Table 3

Estimated intended behavior of general population in relation to people who have mental health problems

Questions	Responses
	Strongly disagree, n (%)	Slightly disagree, n (%)	Do not know/neither agree nor disagree, n (%)	Slightly agree, n (%)	Strongly agree, n (%)
5. In the future, I would be willing to live with someone with a mental health problem	126 (18.4)	52 (7.6)	332 (48.5)	84 (12.3)	90 (13.2)
6. In the future, I would be willing to work with someone with a mental health problem	140 (20.5)	62 (9.1)	260 (38.0)	100 (14.6)	122 (17.8)
7. In the future, I would be willing to live nearby to someone with a mental health problem	112 (16.4)	58 (8.5)	292 (42.7)	124 (18.1)	98 (14.3)
8. In the future, I would be willing to continue a relationship with a friend who developed a mental health problem	78 (11.4)	34 (5.0)	210 (30.7)	126 (18.4)	236 (34.5)

It is determined that healthcare workers in the study population has significantly higher RIBS score for overall intended behavior in comparison to other (nonhealthcare) participants of the study population. The score for male is significantly higher than female in the domains of live with, work with, and live nearby to a mentally ill person, but there is no significant difference between male and female regarding intended behavior of willing to continue a relationship with a friend who developed a mental health problem. The intended behavior score of the age group of 40–60 years is significantly higher than age group of 18–39 years in the domains of work with, live nearby, and willing to continue a relationship with a friend who developed a mental health problem, but both age groups do not have any significant different opinion regarding living with mentally ill person. There is no significant different opinion between married and unmarried with respect to live with, work with, and live nearby, but married were more willing to keep the friendship with mentally ill person [Table 4].

Table 4

Determination of intended behavior of study population toward people having mental health problems in different domains using Mann-Whitney test

	n	Mann-Whitney U-value (P)
		Question-5	Question-6	Question-7	Question-8
Population type
Healthcare workers	220	40,708.000 (0.001)*	39,158.000 (0.001)*	44,986.000 (0.009)*	37,742.000 (0.001)*
Others (nonhealthcare)	464
Gender
Male	530	34,596.000 (0.002)*	34,794.000 (0.004)*	35,248.000 (0.007)*	38,616.000 (0.290)
Female	154
Age (years)
18-39	596	25,862.000 (0.823)	22,718.000 (0.035)*	20,822.000 (0.001)*	21,380.000 (0.004)*
40-60	88
Marital status
Married	428	50,754.000 (0.085)	54,148.000 (0.792)	52,122.000 (0.264)	48,096.000 (0.005)*
Unmarried	256

*Significant difference (P<0.05)

The study population was also divided into three groups bases on responses (Yes, No, and Don't know) of first subset of questionnaire (items 1–4) of RIBS. The participants who responded “Yes” to any of the first 4 questions comprised Group 1. Those who responded “No” comprised Group 2 and those who responded “Don't know” comprised Group 3. The participants who have had experience with mentally ill persons (Group 1) are more willing to live with, work with, live nearby, and continue a relationship with a friend having mental health problems in comparison to participants who never had experience with mentally ill persons (Group 2). This study found a significant difference (P < 0.05) between Group 1 and Group 2 regarding overall intended behavior, but no significant difference (P > 0.05) was found between Group 1 and Group 3 or Group 2 and Group 3.

It is found that higher secondary educated persons are more willing to live with mentally ill person in comparison to graduate and postgraduate educated persons. However, there is no different opinion among these people with respect to work with, live nearby, and willing to continue a relationship with a friend having mental health illness. The upper socioeconomic class is more willing in compared with other class regarding keeping friendship with a person having mental health problems. Otherwise, there is no significant difference among socioeconomic classes in other domains of intended behavior [Table 5].

Table 5

Determination of intended behavior of study population toward people having mental health problems in different domains using Kruskal-Wallis test

	n	χ2 (P)
		Question 5	Question 6	Question 7	Question 8
Education
Postgraduate/professional degree	292	6.121 (0.047)*	3.639 (0.162)	1.678 (0.432)	2.185 (0.335)
Graduate	308
Higher secondary (11th-12th class)	84
Socioeconomic class
Upper lower	112	6.862 (0.076)	3.386 (0.336)	8.185 (0.052)	23.694 (0.001)*
Lower middle	152
Upper middle	212
Upper	208

*Significant difference (P<0.05)

DISCUSSION

The participants were asked about interactions and predetermined actions in the domains of living with, work with, living nearby, and continuation of friendship with person having mental health problems. A person's attitude or intended behavior may not reflect his/her actual behavior.[12] Self-reported view can be biased according to expectations of our society. Our society influences our view toward mentally ill persons (social desirability bias). People get influenced by cultural norms and values, and their actions may vary from their beliefs or thoughts.[14] We found that maximum participants were not sure about predetermined actions or behavior in the domains of living with, work with, and living nearby. It may reflect a possible dichotomy in their intended and actual behavior. It may be possible that they do not want to live their daily life with person having mental health problems, but they may not be able to avoid this due to social desirability. Maximum participants were however willing to continue friendship with mentally ill persons because having interaction with them is their choice. Possibly, they can easily break off the relationship and can easily avoid the situation.

Education about mental illness as well as regular interaction with mentally ill persons leads to a positive attitude toward them.[1516] Healthcare workers work regularly with the live experience with persons having mental health problems. This is the concept of social contact and knowledge about mental illness which reduces stigma.[1516] Apart from knowledge, the motivation and determination of persons also determine the stigmatized attitude of them. It is supported by studies which suggested that most of individuals have negative attitude toward mentally ill persons, regardless of their knowledge about mental illness.[17] We found that healthcare workers have less discriminatory behavior toward mentally ill persons in comparison to others. Therefore, possibly, healthcare workers have more determination and motivation for destigmatization toward mentally ill persons apart from knowledge about mental disorders.

The present study found that overall intended behavior of men was less stigmatizing or discriminatory in comparison to women. In support of our study, few other studies have also shown that women in the community have more discriminatory attitude toward mental disorders.[1819] The study by Bener and Ghuloum found that women are afraid to talk about it and believe that it is family matter which should not be disclosed. Overall, attitude, knowledge, and beliefs were more positive in men in comparison to women.[18] In contrast, a study revealed that females were more open-minded and positive to prointegration but also avoidant and fearful in comparison to males toward mentally ill persons.[20]

Literature revealed that individuals with <40 years of age were more willing to interact with mentally ill persons.[21] It was also found that open-mindedness and positive to prointegration increase with age toward persons having mental illness.[20] Students get the most misinformation regarding the mental health knowledge. Therefore, the student population was priority group for mental health education.[22] We also found that younger population was more stigmatized in comparison to older age group. There may be a possibility that older age group population has wider contact and exposure in community, hence having more positive attitude toward people with mental illness.

It is mentioned that people who had previous relationship with mentally ill persons were more willing to interact with persons having mental health problems.[21] However, direct (face-to-face) contact was more successful in comparison to indirect (mass media) contact to reduce the mental health stigma.[23] However, media coverage regarding mental health issues is an important factor in shaping and reflecting attitude of general population toward mentally ill persons and mental illness.[24] It was found that message conveyed by mass media may have negative impact on general population. Persons with mental illness are often represented in media as dangerous and living in mental asylum, which has led to negative perception of general population toward mentally ill person.[25] Apart of these, contacts with person having mental illness to reduce stigma are competing ideas. It does not guarantee an improvement in stigmatizing attitude.[2627] However, the present study suggests that contact with mentally ill persons possibly reduce stigma toward them. Few studies reported that right information regarding mental health and reducing discrimination against persons with mental health problems may enhance positive attitude toward them and help-seeking behavior of them.[28] Therefore, in this digital era, positive information on media about mental health will be substantial enough to achieve positive attitude and behavior of general population.

Interpersonal contact and causal attributions are two most common approaches to reduce the stigma toward mental health. Individuals who have interpersonal contact in the form of more experience, familiarity, and contact with mentally ill persons tend to have less discriminatory and negative behaviors. If individuals believe that the cause of mental health problems is attributable to flaws of mentally ill persons and their character, then mentally ill persons are judged responsible for their situation and then they are more likely to experience discriminatory behavior, to be avoided and segregated. In contrast, if individuals believe that the illness is due to medical/genetic cause or due to stress and accidents (e.g., head injury), then they are less likely to experience discriminatory behavior or stigma.[2529]

CONCLUSION

We conclude that despite multiple programs and policies targeting destigmatization in this digital era, as well as ensuring accessibility of effective mental healthcare services to mentally ill persons, the positive change in attitude and behavior of general population toward mentally ill persons has not reached at expected levels. However, in view of social desirability, overall, they have started having positive behavior toward them. There is a need for well-coordinated public education regarding mental health and also a need for antistigma programs which facilitate familiarity with mentally ill persons and their mental health problems.

Limitations of the study

The present study has some limitations in the form of limited number of participants for a national-level study and social desirability bias rather than actual practices. Majority of participants were from Uttar Pradesh; hence, the findings may not be generalized to all over India due to diversity of different cultures and norms. There were no respondents with below secondary education. Individuals who do not have access to digital media, literate persons in other languages, or illiterate persons were other limiting factors.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.