Abstract
Background:
The community misunderstands mental illness, resulting in stigmatizing attitudes toward persons with mental illness. High mental health literacy (MHL) among Accredited Social Health Activists (ASHA) workers can help spread mental health awareness to the community. The study aimed to assess the attitudes of ASHA workers toward the mentally ill.
Method:
A cross-sectional survey was conducted among ASHA workers in the city of Ahmedabad using the Community Attitude toward Mentally Ill (CAMI) scale – Gujarati version. Census sampling was used to collect data from ASHA workers at various Urban Health Centers (UHC). We analyzed 265 responses.
Results:
The mean (SD) of authoritarianism (AU), benevolence (BE), social restrictiveness (SR), and community mental health ideology (CMHI) subscales were 29.77(3.35), 35.33(3.78), 34.55(3.49), and 37.15(4.42), respectively (a higher mean suggests a negative attitude in the AU and SR subscales and a positive attitude in the BE and CMHI subscales).
Conclusion:
Although ASHA workers displayed goodwill and a welcoming attitude on the BE and CMHI subscales, they showed negative and stigmatizing attitudes on certain items of the AU and SR subscales. This necessitates a widespread mental health education campaign and training program for them.
Keywords: Stigma, mental illness, ASHA workers, CAMI scale
Key Messages:
ASHA workers displayed stigmatizing attitudes toward persons with mental illness in many areas of the CAMI scale, especially in the SR and AU subscales. Therefore, training them is much needed.
Mental health is very important for the sustainable development goals of any country. 1 In India, around 14.3% of the population suffers from various types of mental illness. 2 Usually, the person with mental illness (PWMI) faces stigma. This stigma delays treatment-seeking, lowers self-esteem, contributes to disruption in family relationships, and affects employability.3,4 Often, three related problems contribute to the stigma: lack of knowledge (ignorance), negative attitudes (prejudice), and exclusion or avoidance behaviors (discrimination).5,6 To fight against stigma, we need to improve mental health literacy (MHL). MHL has three major components: recognition, knowledge, and attitude. Mental health awareness campaigns have yielded positive outcomes.7,8 Community services can promote mental health awareness, reduce stigma and discrimination, and support recovery and social inclusion.9,10 India is a predominantly rural country, as most of its population (around 72%) lives in rural areas. The District Mental Health Program (DMHP) was initiated for community-based mental health services. 5 At the community level, we have around 8 lakh Accredited Social Health Activist (ASHA) workers who are well-integrated into the community in which they live. They are supposed to be trained in such a way that they can become a bridge between the community and the public health system. Therefore, they can also play a crucial role in promoting mental health awareness, supporting the families of people with PWMI, addressing the stigma, identifying major health problems, and supervising the medications for PWMI. They are the ones through whom we can deliver mental health services to India’s rural population.5,11–13 As a potential resource for the delivery of mental healthcare, it is important to analyze the knowledge, perceptions, and attitudes of the ASHA workers toward PWMI so that their training needs can be identified. Our study’s objective was to assess ASHA workers’ attitudes toward the PWMI using the Gujarati version of the Community Attitude toward the Mentally Ill (CAMI) scale. 14
Methods
Participants and Procedures
A cross-sectional study was done among the ASHA workers of the city of Ahmedabad to assess their attitudes toward PWMI. Ahmedabad Municipal Corporation (AMC) provided us a list of Urban Health Centers (UHC) to spread awareness regarding mental health among the ASHA workers posted there. Several ASHA workers of each UHC needed to be trained by the Psychiatry Departments of different medical colleges. Out of around 80 UHCs, our institute received a list of 20. Therefore, all authors and the residents of the Psychiatry Department went to these 20 UHCs in January–February 2021. Before training the ASHA workers, data collection was done regarding their attitudes. The purpose of the study was informed, and written informed consent was taken from those who agreed to participate. As we included all ASHA workers of these 20 UHCs, the data collection is called as census. The Institutional Ethics Committee approved the study.
Study Instruments
The study questionnaire comprised socio-demographic datasheet and the CAMI scale – Gujarati version.
CAMI Scale – Gujarati Version: This was derived from the original CAMI scale, a 40-item questionnaire developed by Taylor et al. 15 It has four subscales: authoritarianism (AU), benevolence (BE), social restrictiveness (SR), and community mental health ideology (CMHI). One of the previous studies from the same region was based on the CAMI scale-Gujarati version and measured the scale’s reliability. The alpha coefficients of the AU, BE, SR, and CMHI subscales were found to be 0.34, 0.62, 0.63, and 0.57, respectively. 14 Thus, the reliability of all subscales was good except in the case of the AU. Therefore, the current study did not focus on measuring reliability and validity. In each category, five of the ten statements expressed a positive sentiment regarding the underlying concept, and the other five were negatively worded. For example, in the AU category, five statements expressed a pro-authoritarian sentiment, and five were anti-authoritarian. The response format for each statement was the standard Likert five-point labeled scale: Strongly Agree/Agree/Neutral/Disagree/Strongly Disagree. All responses were converted from words to numbers. Pro-questions were converted as follows: Strongly Agree=5 and Strongly Disagree=1. Anti-questions were converted the opposite way: Strongly Agree=1 and Strongly Disagree=5. The questions in each subscale are formed in such a way that a higher score or mean suggests a negative attitude in the AU and SR subscales and a positive attitude in the BE and CMHI subscales. The possible range of the mean is 1–50. Therefore, the mean value being more toward 50 in the BE and CMHI subscales suggests a positive attitude, while the mean value being more toward 1 in the AU and SR subscales suggests a positive attitude. In all subscales, a mean score near 25 suggests a mixed response. The original scale has no cut-off score that suggests positive or negative attitudes.14,15 We define them arbitrarily.
Statistical Analysis
The analysis was done using Microsoft Excel 2019. The participants with missing data were excluded from the study. The frequency was calculated for pro and anti-items of all four subscales. The mean and standard deviation (SD) were calculated for the total score of each subscale.
Results
A total of 300 responses were received; of which, 35 were discarded as the information provided was inadequate, leaving 265 completed questionnaires for final analysis. All respondents were females. Their mean (SD) age was 40.3 (7.4) (range 23–63 years), 233 (87.9%) were married, 93 (53.1%) had studied up to secondary, 97 (36.6%) had a monthly income of more than ₹17,755, 232 were Hindu (87.5%), and 147 (55.5%) came from joint families (Table 1).
Table 1.
Socio-Demographic Characteristics of ASHA Workers ( N = 265).
| Variable | Characteristic | n (%)/Mean (SD) |
| Marital Status | Married | 233 (87.9) |
| Other (widow, divorced, married but separated, and unmarried) | 32 (12.1) | |
| Years of Education | Secondary | 93 (35.1) |
| Higher secondary | 120 (45.3) | |
| Other (graduate, postgraduate, and double degree) | 52 (19.6) | |
| Monthly Income (in rupees) | >17755 | 97 (36.6) |
| ≤17755 | 168 (63.4) | |
| Domicile | Urban | 249 (94) |
| Rural | 16 (6) | |
| Religion | Hindu | 232 (87.5) |
| Others | 33 (12.5) | |
| Family Type | Joint | 147 (55.5) |
| Nuclear | 118 (44.5) | |
| Age | – | 40.3 (7.4) |
ASHA: Accredited Social Health Activist.
AU Subscale
The ASHA workers showed a positive attitude in the last three items, a mixed attitude in the middle three items, and a negative attitude in the rest. The item with the most positive attitude was “The best way to handle the mentally ill is to keep them behind locked doors” (88.7% disagreed). The items with the most negative attitude were “Mental patients need the same kind of control and discipline as a young child.” (75.8% agreed) and “There is something about the mentally ill that makes it easy to differentiate them from normal people.” (74.3% agreed, Table 2).
Table 2.
Attitudes on the Authoritarianism Subscale ( N = 265).
| Items | % endorsing an unfavorable response (rated as 4 and 5) on itemc |
| Mental patients need the same kind of control and discipline as a young child.a | 75.8% |
| There is something about the mentally ill that makes it easy to differentiate them from normal people.a | 74.3% |
| Mental illness is an illness like any other.b | 59.6% |
| As soon as a person shows signs of mental disturbance, he should be hospitalized.a | 55.8% |
| One of the main causes of mental illness is a lack of self-discipline and willpower.a | 52.8% |
| Mental hospitals are an outdated means of treating the mentally ill.b | 51.7% |
| Less emphasis should be placed on protecting the public from the mentally ill.b | 49.0% |
| The mentally ill should not be treated as outcasts of society.b | 20.4% |
| Virtually anyone can become mentally ill.b | 17.0% |
| The best way to handle the mentally ill is to keep them behind locked doors.a | 11.3% |
aPro-authoritarian belief; bAnti-authoritarian belief; cStrongly agree or agree with a response on pro-authoritarian belief or Strongly disagree or disagree on an anti-authoritarian belief.
BE Subscale
In the first seven items, positive attitude was shown; in one item, there was a mixed attitude; and the attitude toward the last two items was negative. The item with the most positive attitude was “We have the responsibility to provide the best possible care for the mentally ill” (92.1% agreed). The item with the most negative attitude was “There are sufficient existing services for the mentally ill” (21.1% agreed, Table 3).
Table 3.
Attitudes on the Benevolence Subscale ( N = 265).
| Items | % endorsing favorable response (rated as 4 and 5) on itemc |
| We have the responsibility to provide the best possible care for the mentally ill.a | 92.1% |
| We need to adopt a far more tolerant attitude toward the mentally ill in our society.a | 90.9% |
| The mentally ill are a burden on society.b | 89.4% |
| The mentally ill do not deserve our sympathy.b | 80.0% |
| Increased spending on mental health services is a waste of tax money.b | 78.5% |
| It is best to avoid anyone who has mental problems.b | 74.7% |
| The mentally ill have for too long been the subject of ridicule.a | 58.5% |
| Our mental hospitals seem more like prisons than like places where the mentally ill can be cared for.a | 53.9% |
| More tax money should be spent on the care and treatment of the mentally ill.a | 29.0% |
| There are sufficient existing services for the mentally ill.a | 21.1% |
aPro-BE belief; bAnti-BE belief; cStrongly agree or agree with a response on pro-BE belief or strongly disagree or disagree on an anti-BE belief.
SR Subscale
Positive attitudes were shown for the last eight items. The first two items received a mixed response. The item with the most positive attitude was “The mentally ill should be isolated from the rest of the community” (only 5.7% agreed). The item with the most negative attitude was “Most women who were once patients in a mental hospital can be trusted as babysitters” (only 49.4% agreed, Table 4).
Table 4.
Attitudes on the Social Restrictiveness Subscale ( N = 265).
| Items | % endorsing an unfavorable response (rated as 4 and 5) on itemc |
| Most women who were once patients in a mental hospital can be trusted as babysitters.b | 50.6% |
| The mentally ill are far less of a danger than most people suppose.b | 47.2% |
| The mentally ill should not be given any responsibility.a | 43.4% |
| No one has the right to exclude the mentally ill from their neighborhood.b | 39.6% |
| A woman would be foolish to marry a man who has suffered from mental illness, even though he seems fully recovered.a | 24.5% |
| The mentally ill should not be denied their individual rights.b | 23.4% |
| Anyone with a history of mental problems should be excluded from taking public office.a | 19.6% |
| I would not want to live next door to someone who has been mentally ill.a | 18.1% |
| Mental patients should be encouraged to assume the responsibilities of normal life.b | 17.0% |
| The mentally ill should be isolated from the rest of the community.a | 5.7% |
aPro-SR belief; bAnti-SR belief; cStrongly agree or agree with a response on pro-SR belief or strongly disagree or disagree on anti-SR belief.
CMHI Subscale
On nine out of the ten items, more than half of the participants had a positive attitude. On the item “Having mental patients living within residential neighborhoods might be good therapy, but the risks to residents are too great,” almost half of them showed negative attitude (Table 5).
Table 5.
Attitudes on the CMHI Subscale ( N = 265).
| Items | % endorsing a favorable response (rated as 4 and 5) on itemc |
| The best therapy for many mental patients is to be part of a normal community.a | 84.9% |
| Locating mental health facilities in a residential area downgrades the neighborhood.b | 83.0% |
| As far as possible mental health services should be provided through community-based facilities.a | 80.0% |
| Residents have nothing to fear from people coming into their neighborhood to Obtain mental health services.a | 77.0% |
| Residents should accept the location of mental health facilities in their neighborhood to serve the needs of the local community.a | 76.6% |
| Local residents have good reason to resist the location of mental health services in their neighborhood.b | 76.6% |
| Mental health facilities should be kept out of residential neighborhoods.b | 68.3% |
| It is frightening to think of people with mental problems living in residential neighborhoods.b | 67.5% |
| Locating mental health services in residential neighborhoods does not endanger local residents.a | 63.0% |
| Having mental patients living within residential neighborhoods might be good therapy, but the risks to residents are too great.b | 55.8% |
aPro-CMHI belief; bAnti-CMHI belief; cStrongly agree or agree with a response on pro-CMHI belief or Strongly disagree or disagree on anti-CMHI belief. CMHI: community mental health ideology.
The mean (SD) scores of AU, BE, SR, and CMHI subscales were 29.77(3.35), 35.33(3.78), 34.55(3.49), and 37.15(4.42), respectively. As the mean score is more toward 50 in BE and CMHI subscales and less toward one in AU and SR subscales, we can say that ASHA workers showed a more positive attitude on the BE and CMHI subscales compared to AU and SR.
Discussion
Several studies in India and worldwide had detected gaps in knowledge about and stigma toward PWMI.14,16,17 Around 72% of the Indian population live in rural areas where the Indian health system has sub-centers (SC) and primary health centers (PHC). The psychiatrist of DMHP has to train medical officers (MO) of PHCs, and the MO has to train Auxiliary Nurse Midwife (ANM) of SC. Ultimately, the ANM of SC has to train the ASHA workers in village areas. Thus, the infrastructure for delivering mental health services is ready, and ASHA workers are supposed to be trained to become a bridge between the community and the public health system. 5 As a potential resource for delivering mental healthcare, it is important to analyze ASHA workers’ knowledge about, perceptions of, and attitudes toward PWMI. 18 This was the reason for conducting our study. As per our best knowledge, no previous study on ASHA workers has used the CAMI scale. Our overall results are promising. ASHA workers displayed goodwill and a welcoming attitude toward the PWMI by showing a positive attitude on the BE and CMHI subscales. However, there are certain items of the AU and SR subscales on which they showed negative and stigmatizing attitudes.
AU measures the participants’ way of looking at mental illness as a disease, looking at PWMI, knowledge of how it develops, and how PWMI should be handled. A higher mean value here indicates a negative attitude toward PWMI. As we did not find any studies conducted on ASHA workers using the CAMI scale, we compared our findings with other populations. We compared our data with sociology, psychology, and medical students in one Indian study; a common population in one Lebanese study and one National Health Service (NHS) survey; and one Nigerian study on the staff of a teaching hospital. Our study means (29.77) were less compared to two studies among Indian (31.71) and Lebanese (32.74) populations.14,19 Our study focused on individual items: 55.84% of ASHA workers believed that immediate hospitalization is mandatory if someone shows symptoms of mental illness. Compared to our study, 51.5% of participants agreed on the same in another Indian study, while in the NHS survey, only 21% agreed on the same, and in the Nigerian study, 62% agreed on the same.14,17,20 On another item, 74.33% of ASHA workers believed that something about the mentally ill makes it easy to differentiate them from normal people. In the other Indian study, 55.8% agreed on the same, while in the NHS survey, only 22% agreed on the same, and in the Nigerian study, 75% agreed on the same.14,17,20 These two items showed negative attitudes in the current study, the other Indian study, and the Nigerian study, while more positive attitudes were seen in the NHS survey. In our study, almost half of the participants endorsed a negative attitude on six items of the AU subscale. Therefore, based on the above data, we can say that ASHA workers still have poor knowledge about mental illness and believe that patients with mental illness require coercive handling.
BE suggests a paternalistic and sympathetic view toward PWMI; a higher mean value here indicates goodwill toward PWMI. Our study mean (35.33) was higher compared to the Indian study (20.95) and lesser compared to the Lebanese study (36.75).14,19 Among the unfavorable items, only 29.05% of ASHA workers believed that more tax money should be spent on the care and treatment of the mentally ill. Compared to our study, 75.6%, 87.5%, and 94.4% of participants agreed on the same in the Indian study and two Nigerian studies, respectively.14,17,21 Therefore, these studies found a more positive attitude than ours for this particular item. On another item, 25.29% of ASHA workers believed it is best to avoid anyone with mental health problems. Compared to our study, 33.5%, 16.3%, and 23.3% of participants agreed on the same in the Indian study and the two Nigerian studies, respectively.14.17,21 This shows somewhat positive attitudes in the current and Nigerian studies and less positive attitudes in the other Indian study for this particular item. In our study, almost half of the participants endorsed a positive attitude on six items of the BE subscale. Based on the above data, we can conclude that the ASHA workers have an overall positive attitude on the BE subscale; however, there are a few items where we need to work more to improve the attitude.
SR views mentally ill patients as a threat to society; a higher mean value here indicates less social openness toward PWMI. Our study mean (34.55) was lower compared to the Indian study (37.12) and almost similar to the Lebanese study (34.34).14,19 Among the unfavorable items, 24.52% of ASHA workers believed that a woman would be foolish if she married a man who has had mental illness, even though he seems fully recovered. Compared to our study, 22.1% agreed on the same in the other Indian study, while 13% agreed on the same in the NHS survey, and in the Nigerian study, only 6.7% agreed on the same.14,17,20 This shows positive attitudes in the NHS survey and the Nigerian study for this particular item. On another question, 23.39% of ASHA workers believed that PWMI were denied their rights. Compared to our study, 74.1%, 82.7%, and 6.5% of participants agreed on the same in the other Indian study and the two Nigerian studies, respectively.14,17,21 This shows positive attitudes in our study and one Nigerian study for this particular item. In our study, on most of the items, endorsement of a negative response was chosen by less than half of the participants. Therefore, based on these data, we can say that ASHA workers have a more social openness toward PWMI overall; however, there are a few areas in which more work is needed to change the attitude.
CMHI concerns the acceptance of PWMI and the services provided to them in the society in which they live. A high mean value in this category indicates community inclusiveness and, thereby, a more positive attitude toward PWMI. Our study mean (37.15) was higher compared to the other Indian study (22.18) and the Lebanese study (33.19), which suggests a more positive attitude among the ASHA workers.14,19 Even among unfavorable items, only 31.60% of ASHA workers believed mental health facilities should be outside the local residential areas. Compared to our study, 48.2%, 39.4%, and 69.1% of participants agreed on the same in the other Indian study and the two Nigerian studies, respectively.14,17,21 This shows that ASHA workers have a more positive outlook than the participants in those studies. In our study, on 9 out of 10 items of the CMHI subscale, more than half of the participants had a positive attitude. Therefore, the overall result indicates that ASHA workers had more community inclusiveness.
We found limited studies analyzing knowledge and perception of mental illness in ASHA workers. As described above, those studies also got similar results.18,22 Although ASHAs did not support isolating PWMI from society, a restrictive attitude was observed regarding marriage, childbearing, and babysitters. Apart from this, almost 75% of ASHA workers reported that they could identify PWMI with a few characteristic behaviors. This might be because they have only come across severe forms of mental illness and do not have enough knowledge about other milder forms. Our findings are consistent with an earlier published study conducted on healthcare providers, including ASHA workers, in the Haryana district. 22
ASHA workers were still pessimistic regarding careers, job opportunities, and responsibilities among PWMI, as 43.4% ASHA workers still believe that “The mentally ill should not be given any responsibility” and 19.6% still believe that “Anyone with a history of mental problems should be excluded from taking public office”. These findings are consistent with earlier published studies.22–24 This restrictive, pessimistic, and negative attitude of ASHA workers can hinder the successful implementation of DMHP. Therefore, there is an urgent need to create awareness and address the stigma about mental illness among all stakeholders in DMHP, including ASHA workers. Studies have suggested that the integration of some form of a mental health training curriculum generally improves attitudes, knowledge, motivation, and support toward PWMI, so such training sessions should be done regularly for all stakeholders in DMHP.22,25,26
Limitations
First, the Gujarati version of the CAMI subscale has face validity only. Second, the internal consistency of the AU subscale of the Gujarati version was low (the alpha coefficient is 0.34). However, it could be explained by the low alpha coefficient of the original AU subscale, which is around 0.1–0.2 lower than the other subscales of the original CAMI scale. Third, though we mentioned that we found positive attitudes on the BE and CMHI and negative attitudes on the AU and SR subscales, there are no pre- define cut-off values that suggested this; we decided it on an arbitrary basis only. Fourth, the generalizability of our study is a little less as we took a sample from the Ahmedabad district only; it would have been better if we had assessed the attitude of ASHA workers from various other districts of Gujarat, especially from rural areas. Lastly, our study was cross-sectional in nature. Therefore, future studies in this area should include a focused group discussion following the initial assessment to understand the qualitative component, such as personal opinions and biases that influence the stigmatizing view toward PWMI.
Conclusion
This study is relevant as it describes the attitude toward PWMI of frontline healthcare workers and community leaders responsible for the success of DMHP in India. Our overall results are promising. ASHA workers displayed goodwill and a welcoming attitude toward the PWMI by showing good results on the BE and CMHI subscales. However, there are certain items on the AU and SR subscales in which they showed negative and stigmatizing attitudes. Future training of ASHA workers under the DMHP has the potential to change their negative and conflicting attitudes toward PWMI, and such training should be focused on stigma in relation to knowledge gaps. This may help in improving the delivery of mental health care services at the community level.
Acknowledgments
We express our gratitude toward other junior residents of psychiatry department of our college who helped us collect data and took lectures from ASHA workers to improve their knowledge regarding various mental illnesses. We also express our gratitude toward Dr. Jagdish Verma, Department of Psychiatry, PSMC, Karamsad, for providing valuable inputs.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author received no financial support for the research, authorship and/or publication of this article.
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