Attitudes of undergraduates towards mental illness : A comparison between nursing and business management students in India

August 2013 Vol. 19 No. 3 SAJP 66 Worldwide, despite growing evidence of the importance of mental health for economic, social and human capital, people with mental health problems, mental health services and professionals, and even the very concept of mental health, receive negative publicity and are stigmatised in public perceptions.[1-3] Today, the focus of psychiatric care is on de-institutionalisation: this depends on a number of key conditions, of which tolerance and non-discrimination are among the most important.[4] As in other parts of the world, the prevalence of mental disorders in India is high.[5] It is estimated that at least 58/1 000 Indians have a mental illness and about 10 million suffer from severe mental illness. [6-8] In India, 90% of people with psychiatric illnesses live with their families, and opinion about mental illness plays a vital role in their long-term care within the family and community. Further, a positive attitude towards mental illness is a prerequisite for the provision of holistic care.[9] However, persistent negative attitudes and the social rejection of people with mental illness have prevailed throughout history.[10] Studies show that people with mental illness face widespread stigmatisation, discrimination, violence, neglect and avoidance, and that negative attitudes towards them are widespread among the general public.[11-15] Lack of awareness about mental illness encourages discrimination and stigmatisation.[16] However, cross-sectional studies show that members of the public who have more knowledge about mental illness are less likely to endorse stigmatising attitudes.[15] Every section of society has its unique way of perceiving mental illness, particularly the young generation and college-going students. Colleges may be the best place to develop a comprehensive mental health programme, because the attitude and values of college-going students tend to influence society the most.[17] Thus, understanding the attitudes and beliefs about people with mental illness among undergraduate students is a fundamental step in addressing the negative attitudes so often reported in studies.[15] A handful of studies have explored the attitudes among healthcare students and the effectiveness of Attitudes of undergraduates towards mental illness: A comparison between nursing and business management students in India

training programmes. [18]However, limited research is available regarding students' attitudes towards mental illness.Hence, the current study specifically aimed to examine the differences in attitudes towards mental illness of undergraduates studying nursing and those studying towards a Bachelor of Business Management (BBM).Because BBM students do not receive knowledge about the mental illness through clinical experience or course curriculum, it was hypothesised that a difference would be found between their attitudes and those of nursing students.

Methods
The study was carried out among undergraduate women from selected colleges of nursing and graduate women's colleges in Bangalore, India from April to June 2011.

Participants
A non-probability convenience sample with a quantitative descriptive method was used.Selection criteria for participants required that they be nursing or BBM students in the third year and fourth year of their course and willing to participate.There were no exclusion criteria.A total of 288 students were enrolled in the study, but 20 questionnaires were subsequently discarded as they were incomplete.Hence, 268 completed questionnaires (148 nursing students and 120 BBM students) were analysed.

Instruments Demographic data survey instrument
The demographic form elicited information on five aspects of the participants' background: age, family's monthly income, place of residence, and history of personal contact with mental illness.

Questionnaires
The Attitude Scale for Mental Illness (ASMI) [19] is a valid and reliable self-report that measures respondents' attitude to mental illness.It uses 34 items divided into six broad conceptual sub-scales: • Benevolence, or paternalistic and sympathetic views • Separatism, or attitude to discrimination • Stereotyping, or the degree of social distance maintained from the mentally ill • Restrictiveness, or perception of the mentally ill as a threat to society • Pessimistic prediction, or level of prejudice towards mental illness • Stigmatisation, or discriminatory behaviour towards those with mental illness.
Respondents are given the choice of 5 Likert scale responses (totally disagree = 1, almost totally disagree = 2, sometimes agree = 3, almost totally agree = 4, totally agree = 5) based on their feelings towards each of the 34 items.The study also used the original version of the Opinions about Mental Illness in the Chinese Community (OMICC) questionnaire, [19] in English.

Procedure
Both the ASMI and OMICC questionnaires were distributed to batches of students separately at various times, in a group setting in a common place such as the lecture halls.One author (PV) verbally explained the aims and method of the research and how to complete the questionnaires.The willing participants then completed both questionnaires in about 20 minutes.

Ethical considerations
Permission was obtained from the administrators of the colleges where the study was conducted.Participants were informed of the study's aims and procedures so that they could decide if they were willing to participate.It was explicitly explained that students' responses would have no influence on their semester exams.After students agreed to participate verbally the researcher gave them the confidential questionnaire.Data collection tools contained no identifying information and thus kept individual responses confidential.

Statistical analysis
The data were analysed using statistical software and results were presented in narratives and tables.Descriptive (frequency and percentage) and inferential statistics (chi-square test) were used to interpret the data.Statistical significance was assumed at p<0.05.

Results
A total of 268 undergraduate women participated.The results of comparative analysis of the responses to the ASMI scale of nursing students versus BBM students are listed in Table 1.On the Separatism sub-scale, more nursing students (n=128, 86.5%) than BBM students (n=86, 71.7%) disagreed with the statement: 'If a mental health facility is set up in my street or community, I will move out of the community' (χ 2 =16.503, p<0.002).Similarly, more than half the nursing students (n=79, 53.4%) compared with 40% (n=48) of BBM students agreed that they were not afraid of treated mentally ill people (χ 2 =15.279, p<0.004).Only 34.5% (n=51) of nursing and 21.6% (n=26) of BBM students agreed that the law should allow a spouse to file for divorce when the other spouse is mentally ill (χ 2 =11.892, p<0.018).More nursing (n=26, 17.6%) than BBM students (n=15, 12.5%) disagreed with the statement that people with mental illness tend to be violent (χ 2 =14.215, p<0.007) and dangerous (χ 2 =17.808, p<0.001).More nursing (n=101, 68.2%) than BBM students (n=58, 48.3%) felt that people with mental illness who are being treated are not more dangerous than normal people (χ 2 =16.284, p<0.003).
Different attitudes were observed among nursing and BBM students on the Stereotyping sub-scale: 39.1% (n=58) of nursing students compared with 15.8% (n=19) of BBM students disagreed with the statement, 'It is easy to identify those who have a mental illness' (χ 2 =30.094, p<0.000).Only 22.3% (n=33) of the nursing and 11.6% (n=14) BBM students stated that 'people with mental illness cannot be easily identified by their behaviour (χ 2 =3.892, p<0.008).A significant difference was observed in the reactions of nursing and BBM students to the statement 'People with mental illness have a lower IQ' (χ 2 =70.689,Nursing and BBM students responded similarly to statements in the Restrictiveness sub-scale.However, 76.3% (n=113) of nursing students compared to 52.5% (n=63) of BBM students agreed that the 'mentally ill should be able to have children' (χ 2 =24.531, p<0.000).

Discussion
The current study indicates that nursing students generally hold more positive attitudes towards all aspects of mental illness than BBM students.It is likely that the attitudes of nursing students and other health professionals may be more positive than those of BBM students and the general public, since they have fieldwork experience and are interested in working within mental health.Nursing and other healthcare students are knowledgeable about mental health, have a greater awareness of mental health issues, and are trained in skills that enable them to cope with challenging behaviour displayed by mentally ill patients and to provide them with care.][24] Similarly, a study on occupational therapy students reported that they were positively influenced towards persons with disabilities after having contact with disabled persons through fieldwork. [25]Furthermore, a multicentre university programme that surveyed 456 students from various departments reported that they developed less stigmatising attitudes after a course on mental illness. [26]owever, not all healthcare students exhibit this positive attitude towards mental illness.A recent investigation, which explored student nurses' attitudes towards psychiatric/mental health nursing as a career, found that students were negative about the prospect of working in this area. [27]The authors concluded that this was a direct result of negative attitudes towards mental health service users.Another study, which examined the impact of the psychiatric curriculum on the attitude of Indian undergraduate medical students and interns, found that the participants were more negatively disposed towards accepting the autonomy and independence of the mentally ill and in considering them as part of the larger unaffected community. [28]t is integral to recognise the value of changing attitudes and perceptions to promote equality and inclusion for people with mental illness.There is a need to educate all students about mental health disorders, through interventions such as discussions, talks, and awareness sessions in class and tutorials.A recent study examined the effects of three strategies for changing stigmatising attitudes about schizophrenia and other severe mental illnesses among 152 randomly selected college students: (i) education (which replaces myths about mental illness with accurate conceptions); (ii) contact (which challenges public attitudes about mental illness through direct interactions with persons who have these disorders); and (iii) protest (which seeks to suppress stigmatising attitudes about mental illness). [29]The researchers found that contact stimulated more positive changes in ideas about targeted psychiatric disabilities, i.e. depression and psychosis, than education did.Other research also provided strong evidence that contact with the mentally ill reduced stigmatised attitudes among the general population. [30]Another study explored the factors which might influence the willingness of teenage students to address mental health concerns: results suggested that reducing stigma through mental health education is crucial. [31]Further, outreach programmes that are designed to enhance college students' help-seeking attitudes and intentions, and to reduce stigmas, were effective in increasing participants' positive attitudes toward counselling and decrease their self-stigma associated with counselling immediately after the programme. [32]n this study, nursing students had less restrictive, more benevolent attitudes than BBM students.The majority agreed that people with mental illness can have children and acknowledged their need for job opportunities.Stigma related to mental illness is an international concern, and research is needed to understand its basis, mechanisms and consequences in order to formulate means by which stigma and its impact may be ameliorated. [33]Stigma diminishes self-esteem and robs people of social opportunities such as employment or accommodation. [34]Perhaps unfortunately, in the present study many nursing students felt that people with mental illness should not disclose their illness to others.These findings could be attributed to nursing students' awareness of how the impact of stigma can pervade the lives of people with mental health problems in many different ways.
The present study has certain limitations.As the participants were selected through purposive sampling and were primarily women, gender differences could not be examined.The results are therefore not generalisable and are not directly comparable to most other studies.Furthermore, given that attitudes toward mental illness are culturally and socially sensitive, caution is required when comparing results across different contexts.The study lacked a qualitative component, which may have provided more personal data regarding students' attitudes and understanding of mental illness.However, despite these limitations, we believe this study contains important findings for researchers as well as practitioners working in the field of mental health.

Conclusion
This study revealed that nursing students exhibited a significantly more positive attitude towards mental illness compared to BBM students.Efforts must be made to improve the attitudes of college students not in contact with mental illness, through raising awareness of mental health issues, providing educational sessions, and making time for discussion.Hence, the researchers strongly suggest the curriculum be revised to incorporate educational sessions about mental illness, in order to combat stigma and discrimination, and potentially promote the human rights of the mentally ill.

Table 1 . Participants' response to the Attitude Scale for Mental Illness (ASMI) questionnaire Variable Response Education χ 2 -value df
Even after a person with mental illness is treated, I would still be afraid to be around them