Awareness and attitude about mental illness in the rural population of India: A mixed method study

Abstract

Context:

Recent systematic review and meta-analysis of public attitudes have shown that despite improvements in mental health literacy, public attitudes and desire for social distance with mental illnesses have remained stable over time.

Aims:

To assess the awareness and attitude of the rural community towards mental disorders using the CAMI scale.

Materials and Methods:

This mixed method study was conducted under the ICMR-STS grant scheme after IEC approval. It included administration of a pre-tested questionnaire adapted from CAMI scale on 196 adults aged 18-60 years from an adopted village in the field practice area of medical college along with 8 in-depth interviews of key people in the same community. Thematic analysis was done for the qualitative part whereas for the quantitative part, Pearson's correlation coefficient, independent t-test, ANOVA and Kruskall-wallis test were used.

Results:

Age was positively correlated with the attitude of authoritarianism, social restrictiveness, CMHI and showed a negative correlation with attitude of benevolence. Females showed higher scores for authoritarianism and social restrictiveness. There was a statistically significant difference between APL and BPL groups for authoritarianism attitude towards the mentally ill (P value = 0.02) and CMHI (P value = 0.033). It was observed that with increase in the education levels there was a rise in the mean score of the values for the attitude of benevolence but the difference wasn’t statistically significant (P > 0.05). Thematic analysis of the key informant interviews suggested various perceptions of the community regarding mental illness, available options for management, current practices of the community and what can be done further to improve facilities for mental health.

Conclusions:

People in the community have a varied perspective to mental illnesses which has changed for the better over time but community still approaches quacks first which warrants the need for more awareness. For this, feasibility and effectiveness of increasing involvement of females from the community in health-related decisions can be explored further. We recommend further awareness generation in the younger generation with community-based research on perceptions of the community about mental health. This will provide more practical and feasible solutions to complement the national mental health program.

INTRODUCTION

Mental illness is a universal and common health problem.[1] At any point of time, it is present in about 10% of the adult population worldwide.[2] These illnesses not only cause a substantial economic loss in terms of gross national product (GNP) loss but also have hidden social costs. Social costs can include the emotional burden of looking after disabled family members, diminished quality of life for careers, social exclusion, stigmatization, and loss of future opportunities for self-improvement.[3]

The idea that mental disease is incurable or self-inflicted can be harmful as well, as it prevents sufferers from receiving the right mental health care.[4] Adverse attitude toward psychiatry and psychiatrists has been observed among medical professionals,[5] which could be another hindrance in providing adequate mental health services. Communities tend to show stigmatizing behavior towards people with mental illness (PWMI). As a result, PWMI and their family members find it challenging to maintain their day-to-day social interactions. It causes delays in treatment-seeking and, as a consequence, the cure and rehabilitation process.[6] A community's understanding and its attitude towards PWMI matters because it acts as a reinforcing agent for preventive, treatment-seeking, and drug compliance.[7,8]

A recent systematic review and meta-analysis of public attitudes has shown that despite improvements in mental health literacy, public attitudes and desire for social distance with mental illnesses have remained stable over time.[9] To know the reason why such stigma persists, we need to assess the attitude of the community, which has a powerful influence on the behavior of the people. This attitude can be assessed by using the scale for measuring community attitude towards the mentally ill (CAMI) scale.

Studies of attitudes towards mental disorders are relatively scarce in the Indian population, even though stigmas cannot be denied. The establishment of primary health centers (PHCs) has helped improve the affordability and accessibility of healthcare, to some extent, for some conditions. However, it has been largely ineffective in addressing the needs of people suffering from or at risk of noncommunicable disorders, including mental disorders.[4]

Thus, through this mixed method study, we attempted to assess the awareness and attitude of the rural community towards mental disorders. Understanding the attitude of the community will help us identify focus areas for our mental health interventions.

MATERIALS AND METHODS

The present study is a mixed method study conducted in an adopted village under the village adoption scheme. Adults in the age group 18–60 years residing in the village were considered as study participants for administering the pretested questionnaire adapted from the CAMI scale. Those adults who were known cases of mental disorders or those with active medical comorbidities were excluded from our study.

For the quantitative part of the study, a total sample size of 196 was calculated using OpenEpi software version 3.01, considering a 50% prevalence of mental illness, 7% error, 95% confidence interval, and design effect of 1. These 196 participants were identified by simple random sampling using the data available through the Health and Demographics Surveillance System (HDSS) of the institute as the data frame. Participation was offered to 212 participants, out of which 16 either refused consent, expired, or were not available during data collection (nonresponse rate of 7.54%). This study was conducted over a period of 2 months (July–August 2022) under the Indian Council of Medical Reasearch - Short Term Studentship (ICMR-STS) scheme.

After ethics committee approval, the study was initiated, and a list of all adult population from HDSS was obtained through the proper channel. A unique number was allotted to all the eligible people from the list. A computer software was used to identify the random numbers required for selecting the study participants. Once identified, these participants were paid home visits, and a study tool was administered to understand their attitude toward people with mental illness (PWMI) after obtaining verbal consent for the same. The data collection tool for assessing the attitudes of the community was adapted from the CAMI scale (interview rated).[10,11] The English version of CAMI was used, and the interviews were conducted in the local language (Marathi). The interviewer who conducted all the interviews was guided regarding the administration of the scale by a practicing psychiatrist who is one of the co-authors in the study, and the interviewer is fluent in the local language spoken in the region. The CAMI scale has 40 questions and includes four subsets (each consisting of 10 questions): authoritarianism, benevolence, social restrictiveness, and community health ideology. Along with these, sociodemographic details like age, gender, education, occupation, and socioeconomic status were also enquired.

For every subset, five of the 10 statements on each scale expressed a positive sentiment with reference to the underlying concept, and the other five were negatively coded. The statements were sequenced in 10 sets of four, and within each set, the statements were ordered by scale — authoritarianism, benevolence, social restrictiveness, and community mental health ideology (CMHI). This sequencing was done to minimize the possibilities of response set bias.[12] The response format for each statement was the standard 5-point Likert scale: strongly agree, agree, neutral, disagree, and strongly disagree. Many such visits were done to receive the data, which was collected and stored in the KoBo Toolbox. Regarding the interpretation of the CAMI scale, higher scores for authoritarianism and social restrictiveness subscales indicate an unfavorable attitude, whereas higher scores for benevolence and CMHI indicate a favorable attitude towards a person with mental illness.

The qualitative component included conducting in-depth interviews with eight purposively selected key members from the community. These interviews were conducted in the vernacular language after obtaining verbal consent from the respondents and were audio-recorded. Field notes were also taken by the interviewer to note any nonverbal cues or important observations. All the interviews were then transcribed and analyzed. These key members of the community were identified from those providing healthcare [Two Accredited Social Health Activists (ASHAs), two Anganwadi Workers (AWWs), an Auxiliary Nurse Midwife (ANM), and a Multi-purpose Worker (MPW)], who had authority and were living in the village for a long time (sarpanch) and one who held a position of respect, was consulted by the community for various issues (school teacher). These participants were contacted, and an appropriate date and time, according to their convenience, was requested for the interview. The participants were met and were briefed about the interview and the objectives of the study. After taking audio consent for the audio recording and for participation in the research, the participant was interviewed, ensuring his/her privacy.

Data Analysis

Quantitative analysis

The data was collected in the KoBo Toolbox and was tabulated using the same. The data was then assessed for normalcy of its distribution using the Kolmogorov–Smirnov test. Since the data had a nonnormal distribution, it was analyzed by nonparametric tests using SPSS (Statistical Package for the Social Sciences) version 23 (developer- IBM, New York).

For quantitative variables in the study, which were nonnormally distributed, the Mann–Whitney U test was used to compare the two groups, whereas for the normally distributed variables, an independent t-test was used. Analysis of variance (ANOVA) and Kruskal–Wallis test were used for comparing the following four subsets in more than one group.

• Authoritarian

• Benevolence

• Social restrictiveness

• Community mental health ideology

Qualitative analysis

Transcripts were prepared for each interview. Thematic analysis was done of these transcripts, and themes and codes were identified. The coding was done manually by two different authors independently, and overall analysis was reported based on mutual consensus. The overall analysis was reviewed by a third author. No external coder was involved. An inductive approach was used to generate the codes and themes presented in the study. Verbatims were identified for the themes and have been mentioned in the results section. The field notes and observations were also incorporated while drawing inferences from the interviews.

Ethical Considerations

The study was conducted only after prior approval from the institutional ethics committee (Reference number: IEC/COMMED/117/2022 dated 11/06/2022). After briefing the participants about the purpose and objectives of the study, verbal consent was taken from the participants, both the respondents of the CAMI scale as well as the key-informant interviews, ensuring the confidentiality of their records.

RESULTS

Demographic Characteristics

The demographic characteristics have been mentioned in Table 1. Overall, 196 subjects were selected from the HDSS data frame through simple random selection and were interviewed for the response to the CAMI scale. The mean age for the participants was 39 years (±21). The study had a nearly equal proportion of males (51%) and females (49%). Half of all participants belonged to the above poverty line (APL) category, one-third (33.67%) belonged to below poverty line (BPL), and the remaining (16.33%) belonged to the Antyodayee category. The education background varied from an education level below the 10^th class to graduate and above. Nearly one-third (34.6%) were farmers or working as farm laborers, followed by housewives (17.3%), people employed in service industries (7.6%), and 3.5% of them were students and unemployed people in each category. Regarding the religion of the participants, 78.1% followed the Hindu religion, 15.3% were Buddhists, and 6.6% belonged to other religious groups (adivasi) [Table 1].

Table 1.

Sociodemographic characteristics of the study population

Variable	n=196, n (%)
Mean age (S.D)	39.56 (±12.82)
Median age (Range)	42 years (18–60)
Sex
Male	100 (51)
Female	96 (49)
Ration card
APL	98 (50)
BPL	66 (33.67)
Antyodayee	32 (16.33)
Education
Below 10th	76 (38.7)
10th	36 (18.3)
12th	39 (19.8)
Graduate and above	45 (22.9)
Religion
Hindu	153 (78.1)
Buddhist	30 (15.3)
Other (adivasi)	13 (6.6)
Occupation
Housewife	34 (17.3)
Self-employed (farmer/business)	68 (34.6)
Employed (govt./private)	15 (7.6)
Labourer	65 (33.1)
Unemployed	7 (3.5)
Student	7 (3.5)

APL=Above poverty line, BPL=Below poverty line, SD=Standard deviations, govt.=Government

Attitude of the Participants

Table 2 suggests the mean scores of all four subsets of attitude along with their standard deviation (S.D). The mean score for the attitude of authoritarianism was 29.26 (±3.77). For benevolence, the mean score of the participants in the general population was 34.78, with a S.D of 4.59. The mean score for social restrictiveness was 27.47, with a S.D of 5.64. CMHI was assessed in the participants, and the mean score for CMHI was observed to be 32.09 (±6.56).

Table 2.

Attitude of study participants towards mental illness

Subset of attitude	Mean (S.D)
Authoritarianism	29.26 (±3.77)
Benevolence	34.78 (±4.59)
Social restrictiveness	27.47 (±5.64)
CMHI	32.09 (±6.56)

CMHI=Community mental health ideology, S.D=Standard deviations

Factors Associated with Subsets of Attitude

We have presented the results studied to report the association between various variables under study and subsets of attitude in Table 3. Age was positively correlated with the attitude of authoritarianism, social restrictiveness, and CMHI and showed a negative correlation with the attitude of benevolence. Females showed higher scores for authoritarianism and social restrictiveness, whereas males had higher scores for benevolence and CMHI. The mean values for the attitudes of authoritarianism were found to be higher in the participants following Hinduism (29.35). All the other attitudes had higher mean values in the participants following Buddhism (P > 0.05).

Table 3.

Factors associated with subsets of attitude

Variable	Statistical parameter	Authoritarianism	Benevolence	Social restrictiveness	Community mental health ideology (CMHI)
Age
	Test value	0.133a	−1.31a	0.0.085a	0.002a
	P	0.063	0.068	0.238	0.972
Sex
Male	Mean (±S.D)	28.95±3.84	35.06±4.56	27.12±5.45	32.66±6.74
Female	Mean (±S.D)	29.58±3.69	34.48±4.64	27.84±5.84	31.48±6.34
	Test value	1.17b	−0.876 b	4481c	−1.26b
	P	0.245	0.382	0.424	0.209
Religion
Hindu	Mean (±S.D)	29.35±3.76	34.85±4.43	27.26±5.39	31.90±6.64
Buddhist	Mean (±S.D)	28.68±3.91	34.45±5.51	28.58±6.88	33.23±6.21
	Test value	0.524d	0.11d	7.28e	0.645d
	P	0.593	0.896	0.296	0.526
Economic class
APL	Mean (±S.D)	29.98±3.63	35.00±4.16	27.96±5.33	30.92±7.05
BPL	Mean (±S.D)	28.35±3.95	35.12±5.49	26.55±6.52	32.94±6.03
Antyodayee	Mean (±S.D)	28.91±3.45	33.41±3.60	27.88±4.42	33.94±5.44
	Test value	3.97d	1.74d	0.451e	3.47d
	P	0.02*	0.178	0.798	0.033*
Education
Illiterate	Mean (±S.D)	30.45±3.80	33.64±5.89	27.55±6.59	33.73±3.98
Below primary	Mean (±S.D)	27.25±5.68	38.00±2.45	24.50±4.93	34.50±3.32
Primary	Mean (±S.D)	29.27±3.47	33.93±3.81	28.03±4.95	31.70±6.79
Secondary	Mean (±S.D)	29.66±4.31	34.73±4.11	27.98±5.46	31.18±7.64
Higher secondary	Mean (±S.D)	29.04±3.45	35.28±5.44	26.32±5.99	32.80±6.26
Graduate	Mean (±S.D)	29.46±4.14	36.23±5.10	28.54±7.17	31.85±5.65
Postgraduate	Mean (±S.D)	25.25±1.26	39.25±3.30	25.75±7.80	34.00±4.55
	Test value c	1.25d	1.84d	0.64e	0.536d
	P	0.281	0.094	0.424	0.781

^aPearson's r correlation, ^bIndependent Samples t-test, ^cMann–Whitney U test, ^dANOVA, ^eKruskal–Wallis test, SD=Standard deviation

The ration card was used as a means to compare the socioeconomic status of the participants, dividing the participants majorly into APL and BPL. There was a statistically significant difference between APL and BPL groups for authoritarianism attitude towards the mentally ill (F statistic = 3.97, P = 0.02) and CMHI (F statistic = 3.47, P = 0.033) [Table 3]. Table 3 also suggests that the attitude of authoritarianism was the most in the illiterate participants (30.45). It was observed that with the increase in education levels, there was a rise in the mean score of the values for the attitude of benevolence, but the difference between the groups was not statistically significant (P > 0.05). However, the differences in mean scores in the education groups were also not significant statistically in either of the four subsets of the CAMI scale (P > 0.05).

Qualitative Analysis

Thematic analysis of the interview transcripts was conducted, and we are reporting the findings in Table 4. To emphasize the importance of each first-order code, we have mentioned the number of interviewees who gave statements suggesting the code and have mentioned the verbatims for each code. The perspective of the community regarding mental illness included the causes, symptoms, causes of discrimination, and changing perception over the past several years. The community primarily attributed mental illness to two key factors: excessive thinking and challenging economic circumstances. The symptoms frequently exhibited by individuals with mental illness, as reported, include overthinking, altered behavior, and self-isolation.

Table 4.

Thematic analysis of interview transcripts

Codes	Description
Higher order	Perspective regarding mental illness
Second order	Cause for mental illness	Symptoms		Cause for discrimination		Change of perspective over time
First-order (number of interviewees who endorsed a code)	Overthinking (6 out of 8)	Overthinking (6 out of 8)		Society is unwilling to accept for marriage because of PWMI family member (1 out of 8)		More aware about diseases due to the increased involvement of females (2 out of 8)
	Poor economic condition (3 out of 8)	Being alone constantly (3 out of 8)		Lack of a caretaker for the treatment because of PWMI's behavior (2 out of 8)		Population's thought process is changing (1 out of 8)
	Poor economic condition (3 out of 8)	Any behavior other than normal (all interviewees)		PWMI are ridiculed by peers (5 out of 8)		Increased mental stress in pandemic (2 out of 8)
		Not coming out of home (2 out of 8)		Attitude of the family members about mental illness (3 out of 8)		Younger population being exposed to the internet (2 out of 8)
		Not coming out of home (2 out of 8)		Hesitation for giving jobs; Social acceptance only for normal behavior (5 out of 8)		People aware about symptoms of mental illness (5 out of 8)
				Those with better economic status get rehabilitated easily (3 out of 8)		Financial crisis but still have responsibilities (2 out of 8)
				Those with better economic status get rehabilitated easily (3 out of 8)		Financial crisis but still have responsibilities (2 out of 8)
Verbatims	“Many of their families living in the village don’t have a good economic condition so this means that many of them in one way or other are more prone to develop mental illness.” (ASHA 1)	“when people tend to notice that some person is being alone, not talking to anyone, keeps to himself and remains at home they do think that something is wrong with the person” (Teacher 1)		“… the people who are coming to see her for marriage, even if they get to know that her mother is mentally ill they will reject her for marriage, even though she is educated, she is independent because they believe that this illness can be inherited …” (ANM)		“More and more women coming out of their homes, more and more women joining self-help groups. What they’re doing is they are themselves getting independent, getting empowered they’re not being enclosed in their homes. So they know about these illness.” (AWW 1)
Codes	Description
Higher order	Management options opted by the community			Practices regarding mental illness		What can be done
Second order	Quackery	Facility-based organizations	Community-based awareness activities	Unsupportive practices	Supportive practices	Support from the health system	Contribution by the community
First-order (number of interviewees who endorsed a code)	Prevalence of superstitions (all interviewees)	People aware about Govt./Private Hospitals (all interviewees)	Prerna Prakalp for farmers in crises (3 out of 8)	Lack of awareness causes superstitions (7 out of 8)	Proper family support (1 out of 8)	More projects should be conducted (2 out of 8)	Increase awareness by programs and surveys (5 out of 8)
			Shibirs at subcenter, health promotion activities by ASHA (4 out of 8)	People feel better when they visit a temple (2 out of 8)	Friends support (1 out of 8)
	Fear of judgment (3 out of 8)	Low awareness regarding NGO (7 out of 8)	Free check-ups and treatment (5 out of 8)	Not a single objective test to detect MI (1 out of 8)	Sympathy from a few community members (2 out of 8)
				Messages for not ridiculing PWMI and Counselling Sessions by ASHA, AWW (5 out of 8)	Avoiding PWMI due to fear of getting/feeling hurt (4 out of 8)	Training courses should be created for counseling PWMI (2 out of 8)	A day in school dedicated to awareness of mental ailments (2 out of 8)
	Absence of doctors in rural areas (2 out of 8)	Not required because of low number of cases (1 out of 8)	Kishori Shakti Yojana by AWW (2 out of 8)	Inappropriate behavior by people around PWMI (4 out of 8)			Special messages delivered during gatherings (4 out of 8)
Verbatims	Poverty (2 out of 8) Information about mental illness received by medical College based activity (5 out of 8) People can be screened in community-led clinics (1 out of 8) Various people-led activities to involve everyone (4 out of 8)	Important people in the community know the names if need be (1 out of 8) Hiding signs of Mental illness like staying alone, not opening up (2 out of 8)				Referred patients receive treatment by the government (all interviewees)	SHGs inclusion to spread awareness (2 out of 8)
			React according to stage of illness (1 out of 8)	Medicines can be given by health workers (3 out of 8)	Social Rehabilitation through inclusiveness, schemes and proper communication with PWMI (1 out of 8)
					Economic rehabilitation be creating vocational training centers or providing them jobs (1 out of 8)
	“What happens is in many rural areas where no doctors are there or don’t reach out regularly their people won’t prefer to go to the doctors instead, they go to the tantric and all”.(MPW).	“They are present which when called will surely come to the village for this very purpose, just to name a few there are foundations like the Naam foundation, the Aadhar foundation and other foundations working for this purpose.” (Sarpanch)	“I try to spread awareness in the society. They should not make fun of such people, behave normally with them as they do with a normal person. but they have seen that such people returned back to the hospital in six months because of the way the community behaves with them”.(ANM)	“Then they say they have seen some change in the patient for a while after going to the Mandir. Then when it's (mental health) bad they come to us, we need to talk to them without judging them in any way.”	“…people are somewhat sympathetic towards the mental ill…”	“We don’t get any specialized training for counselling of such people or we don’t have any access to such medications which are to be given for these diseases.” (ASHA 1)	“We also tell them about various signs or various symptoms that you can observe and save someone living near you or someone who is living at your home who may be suffering from mental illness….”

ASHA=Accredited social health activists, ANM=Auxiliary nurse midwife, MPW=Multipurpose worker, AWW=Anganwadi workers, PWMI=People with mental illness

Also, individuals facing mental illness encounter discrimination from their own families. They endure ridicule from peers as well as discrimination from society. Employment opportunities become scarce, making rehabilitation even more challenging. The individuals from higher socioeconomic backgrounds find it comparatively easier to facilitate the recovery of their affected family. There has been a shift in public perception, primarily driven by increased awareness campaigns and the active involvement of women in society. Also, it was suggested that people have become more conscious about their mental health, particularly in the aftermath of the pandemic.

The various management options chosen by the community, as suggested during the interviews, included quackery, treatment in facility-based organizations, and community-based organizations. The community still prefers going to the quacks first as they believe in superstitions. Many people fear judgment from others if they go to the hospital for mental illness. People are aware of various government and private hospitals, but they do visit them if they are pushed by the healthcare workers. The community has low awareness about nongovernmental organizations (NGOs) working for this cause as there is less felt need for the same, but if the need arises, they know which these NGOs are. ASHA and AWW conduct community-based awareness initiatives and provide guidance to families. The government health system has undertaken many projects like the Prerna Prakalp and health camps conducted at the level of subcenters to spread various messages. Inclusion in mental health is also done under Kishori Shakti Yojana for teenagers. Monthly visits by the medical students under the village adoption scheme have helped to increase awareness and disease identification.

Societal practices regarding mental illness are affected by the level of awareness about the illness and the lack of a definitive diagnostic test, which reduces trust in hospitals. Individuals exhibit supportive behaviors; some display appropriate conduct around those with mental illness, while others offer sympathy, facilitating their reintegration into society. However, certain members of the community believe in superstitions. People avoid talking to PWMI for fear of not getting an appropriate response. People also make fun of PWMI and remind them of their illness, thus leading to PWMI hiding signs of mental illness. According to community members, the healthcare system could provide more comprehensive support and suggested more research in this field. They also felt the need for training courses to counsel PWMI and to train healthcare workers for providing medicines.

More awareness can also be generated through programs, surveys, dedicated mental health awareness days in schools, and disseminating messages during various social gatherings. The inclusion in self-help groups has not only empowered women but also facilitated their economic rehabilitation, ensuring smoother reintegration into society. Other suggestions for improvement included the community's help to health workers in spreading awareness during social gatherings via the inclusion of self-help groups (SHGs). Social rehabilitation should also be promoted by local authorities. Counselling sessions can also be introduced for social rehabilitation. The community also expressed the need for various jobs, or vocational training centers should be established to make PWMI economically independent.

DISCUSSION

Mental health is an urgent concern even in India, as every sixth Indian needs mental health help, as reported by a recent National Mental Health Survey.[13] There are various myths and beliefs about mental illness prevalent not only in the rural population but also in the medical professionals.[2] Thus, this study was conducted with the intention to address this concern by assessing the awareness and attitude towards mental illness in the rural population of India.

Attitude and behavior

Our findings were similar to a study conducted in 1981[13] and in India in 2016,[14], where, in their community-based study, they also found that older residents reported less considerate attitudes towards persons with mental illness. These observations are similar to the results of another study on public attitudes toward the mentally ill, which found that social distance for the mentally ill increased among the older individuals.[15]

However, a study conducted on the general population in Sweden[16] suggests that as people age, their open-mindedness and pro-integration attitudes relative to persons with mental illness also increase, whereas attitudes representing CMHI decreased, which was not observed in our study. One reason for this variation may be that older people who tend to exhibit more negative attitudes towards persons with mental ill health in spite of their life experiences is because they are more likely to be conventional and to reject odd behavior.[12,14] Another reason for these differences in various countries may be the cultural variations in how the community members treat each other and coexist.

Other studies demonstrated that younger people generally have more favorable attitudes toward mental illness.[17,18] This could be due to the younger generation having a more flexible attitude, which is influenced by media as well as education, whereas the older age groups generally carry more rigid attitudes, making them impermeable to change.[19]

Our study suggests that participants from APL families have a more authoritarian and social restrictive attitude towards the PWMI. These results are inconsistent with studies from Ethiopia[20] and Singapore[21], suggesting that people with lower incomes are more likely to have unfavorable attitudes. It has been hypothesized to get negative social, psychological, and economic skills against the effect of hardship, which would keep the negative attitude. One reason for this difference may be the comparatively lower sample size in our study and the difference of sampling since these studies considered participants from all over the country.

No significant correlation was established between gender and behavior in our study; however, in a Swedish study, females showed fear and social distance as opposed to men.[16] Some other studies demonstrated that women have less social restrictiveness, prejudice, and misconceptions.[21] Further research is needed to test this association.

A study from India (2008) suggested no significant findings with religion and attitudes, which is in line with our results. It was considered that religion initially predicted attitudes; however, it was found that there was no difference between the various religions, demonstrating that attitudes are similar among people from all religions.[19] However, another study from Jordan suggests that stigma about mental illness is associated with how religious the community members are.[22] However, since all religions are not included in our study, the effect of religion on attitude towards mental illness needs to be studied further.

Studies conducted in Lebanon,[21] indicate that knowledge was not a predictor of attitude towards mental health and problems. Contrary to this, studies done in Saudi Arabia, Lebanon, and Gimbi town Ethiopia, have shown a positive correlation of knowledge and attitudes with mental health problems.[21] This could not be assessed in our study as our objectives focused only on the awareness and attitude of the participants and not on their knowledge per se.

Perception of mental illness by family members and their beliefs has been shown to be important criteria that determine their attitudes and behaviors. Previous studies have shown that having experience and familiarity with PWMI leads to more benevolence, reduces socially restrictive attitudes[14], and higher CAMI scores than those without it. In other cases, however, having experience with someone suffering from mental illnesses establishes negative attitudes.[23]

Studies indicate that occupational status is associated with a favorable attitude towards PWMI, where employed people may have more exposure to awareness of mental health problems, which may improve their perceptions and attitudes toward mental illness.[24] Studies conducted in Singapore show that being unemployed is associated with higher tolerance and support for community care.[22] In our study, occupation was not included for analysis of association as occupations in our study population were too diverse. Enough samples for unemployed participants were not available, making it nonfeasible to compare the employed and unemployed participants to draw out conclusions.

Qualitative

Although mental health is an integral component of total health, in many countries, it has been a largely neglected field. The international direction is to focus on a community-based model of mental health service delivery. There are several factors affecting the expansion of community services, of which the public's knowledge and attitude regarding mental illness being perceived as a major one.[25] This is also supported by a study from Delhi, which suggests that the presence of family members during psychiatric consultations and views towards lithium were discovered to be important determinants of adherence.[26]

In our study, where various in-depth interviews were conducted, it was observed that due to the basic treatment path for any individual who is suspected of having a mental illness is that they approach quacks, then the health workers in the community who refer them further to the hospital. As discussed earlier, there are various reasons why the rural population would believe more in them as compared to the hospitals. Health workers have to convince people to visit a hospital as well as make the people accept that they have visited a quack before. This task also involves rapport building as they have to convince the people and spread awareness without strongly challenging their beliefs, which might make them look bad in the community and hamper the progress of health in all directions.

It has been observed that there has been a change in the thinking of the young population, which can be seen presently not only in India but also throughout the world, as a result of the awareness-spreading activities of the health workers. This may have been due to the fact that the younger population has a more flexible attitude, which gets influenced by media and education, whereas the older age groups generally carry rigid attitudes, making them impermeable to change.[27] For government and nonprofit professional organizations to promote depression literacy among the general population, there is a need to develop reliable and approachable internet materials in regional languages like Hindi.[28] This also implies that we may be working in the right direction by focusing more on spreading awareness in the younger population. As suggested by the interviewees, this can be achieved by having a day at school dedicated to this specific purpose and including this in the Kishori Shakti Yojana, where teenagers could be sensitized about the same.

Another important change over time that was seen was the increased involvement of the females in the village, which may have led to increased awareness in them, which was not observed in earlier times. This can be exploited further by using various SHGs, which can be used to spread awareness and make females independent as a whole instead of being limited to household work.

Limitations of the Study

The results from the current study depict the status of mental health in the rural community in our area, and these perceptions might not be the same for the other population. The current study considered only the broad category of mental illness. The attitudes of the community may vary among different subcategories of mental illness, but such an assessment was beyond the scope of this study. Also, translation of the CAMI scale into the local language using the World Health Organization (WHO) methodology would have ensured a greater degree of standardization. Some important factors like mental health knowledge, family members with mental illness, etc., affecting attitudes could not be assessed. This was a cross-sectional study and hence cannot determine causality or assess the change in attitudes over time. No lay community members or family members of PWMI were interviewed, etc., We acknowledge that the lack of use of software and an external coder for verification is a limitation of our study.

CONCLUSION

People in the community have varied perspectives on mental illnesses and PWMI, which has changed over time. The community still approaches quacks first instead of a doctor, which warrants the need for more awareness in the community regarding mental illness. For the same, the feasibility and effectiveness of increasing the involvement of females from the community in health-related decisions can be explored further. The participants holding an APL card had a more authoritarian and socially restrictive attitude towards PWMI when compared to BPL participants. Key people from the community enumerated various ways in which they feel we can increase awareness in the community. We recommend further the need to focus on raising awareness in the younger generation along with community-based research on perceptions of the community about mental health with a better understanding of the community's perspectives. This will help us come up with more practical and feasible solutions to complement the national mental health program and ultimately improve overall mental health and well-being.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.