Soc Psychiatry Psychiatr Epidemiol (2014) 49:771–780 DOI 10.1007/s00127-013-0775-y
ORIGINAL PAPER
Community attitudes and social distance towards the mentally ill in South Sudan: a survey from a post-conflict setting with no mental health services Touraj Ayazi • Lars Lien • Arne Eide • Elizabeth Joseph Shadar Shadar • Edvard Hauff
Received: 21 January 2013 / Accepted: 3 October 2013 / Published online: 18 October 2013 Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose This study investigates attitudes and social distance towards the mentally ill in a post-conflict, lowincome country. Methods A cross-sectional community survey (n = 1,200) was conducted in South Sudan. Associations between various sociodemographic variables and attitudes toward/social distance from the mentally ill were investigated.
T. Ayazi (&) E. Hauff Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, Blindern, 0318 Oslo, Norway e-mail: [email protected] E. Hauff e-mail: [email protected] L. Lien National Center for Dual Diagnosis, Innlandet Hospital Trust, Furnesvegen 26, 2380 Brumunddal, Norway e-mail: [email protected] L. Lien Faculty of Public Health, Hedmark University College, P.O. Box 400, 2418 Elverum, Norway A. Eide SINTEF, Technology and Society, P.O. Box 124, Blindern, 0314 Oslo, Norway e-mail: [email protected] E. J. S. Shadar Ahfad University for Women, P.O. Box 167, Omdurman, Sudan e-mail: [email protected] E. Hauff Division of Mental Health and Addiction, Department of Research and Development, Oslo University Hospital, Ulleval, Kirkeveien 166, Building 20, 0407 Oslo, Norway
Results The regression analysis showed that lower levels of education were positively associated with social distance, and Christian or Muslim beliefs, compared with traditional beliefs, were negatively associated with social distance. Familiarity with mental illness or psychological distress was not significantly associated with social distance. Participants who endorsed community-oriented attitudes (rather than hospital/drug-oriented attitudes) about health care for the mentally ill were more likely show a decreased social distance. Participants who believed that the mentally ill were dangerous had higher scores on the social distance scale. Conclusions A high level of stigma towards the mentally ill exists in South Sudan, especially in the rural areas. Alongside efforts to build up mental health services in South Sudan, the existing stigma needs to be addressed. Information regarding the role of the community both in preventing mental illnesses and in service delivery should be prioritised. Keywords Stigma Social distance Post-conflict South Sudan
Introduction The negative impacts of stigma on people with mental illness are well documented [1, 2]. Stigma is defined as ‘‘the endorsement of a set of prejudicial attitudes, negative emotional responses, discriminatory behaviors, and biased social structures toward members of a subgroup’’ [3]. Attribution theory is one of the models used to explain stigma. Stereotypes (generalised assumptions) about people with mental illness are activated by cues, such as encountering a person with mental illness. These
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stereotyped attitudes result in behavioural reactions or discriminative behaviour [4]. Two aspects of stigma, negative attitudes and social distance, are frequently used in the study of stigma and as indicators of discriminatory behaviour [5–9]. The current study aims to investigate the level of stigma towards the mentally ill in a post-conflict, low-income country. The vast majority of studies on stigma have been conducted in high-income countries [2]. Previous studies on the pattern of mental health outcomes suggest a better prognosis for the severely mentally ill in low-income countries, an assumption that has been taken as evidence of a lower level of stigma towards the mentally ill in these countries [10, 11]. The notion of ‘better prognosis’ has since been challenged [12], and the supposedly generalised tolerant and supportive attitude towards the mentally ill has been questioned. Subsequently, there has been an increase in recent years in the number of studies from low-income counties. Lauber and Ro¨ssler’s [13] review of studies in Asian countries showed broad tendencies of stigmatisation and discrimination of people with mental illness. In subSaharan Africa, surveys on the attitudes of the general public [14] and students [15] in Nigeria towards the mentally ill indicated a high level of stigmatisation; a study in rural Ethiopia [16] also showed that relatives of individuals with mental illness commonly experience stigmatisation. Similar results, showing an extensive amount of stigma, have been replicated in surveys in recent studies in Zambia [17], Ghana [18] and Malawi [19]. Various studies have examined the factors that influence social distance (the willingness to engage in relationships of varying intimacy with a person [20]). Sociodemographic factors such as older age, sex, lower level of education and social class have been associated with increased social distance towards people with mental illness [20–22]. Contact with people with mental disorders decreased social distance towards the mentally ill [23]; participants who were familiar with mental illness (based on scores on an index of familiarity with mental illness) also showed a reduced level of social distance towards the mentally ill [5]. The influence of attitudes towards the mentally ill on social distance has also been a focus of stigma-related studies. For instance, accepting the biomedical model of mental illness increased the degree of social distance [20], as did perceiving the mentally ill to be dangerous [24] and unpredictable [25, 26]. A comparative study of students in several countries (Australia, Belgium, Estonia, Finland, India and Latvia) [27] found that although the levels of stigma were similar, the determinants of social distance differed between the countries. The role of culture on the expression of stigmatising attitudes was also asserted in Lauber and Ro¨ssler’s [13] review of studies on stigma in
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Asian countries. In summary, cultural and contextual specificity of the determinant of stigma is evident [2, 28]. South Sudan is one of the most impoverished countries in the world [29]. In addition to economic hardship, the country has experienced a 21-year period of armed conflict that ended in 2005 and eventually resulted in the creation of the Republic of South Sudan in 2011. Previous studies from South Sudan [30, 31] have indicated high levels of trauma exposure and psychological distress in the general population. The health facilities in South Sudan are scant [29] and mental health services are non-existent. In many low-income countries, the scarce mental health services are hospital based [32] and most commonly centred in hospitals established during the colonial era. There are, however, no psychiatric hospitals in South Sudan. Since the signing of the Peace Agreement in 2005, a small number of severely ill patients have been referred or admitted to the psychiatric hospital in Khartoum (the capital city of neighbouring Sudan, 1,000 km from South Sudan). This tortuous pathway was not available during the war. Mental health services provided in the general hospitals in larger towns consist of the prescription of sedative drugs. The majority of studies on stigma in low-income countries are conducted in settings with at least minimal mental health services. The present survey provides an opportunity to study public attitudes towards the mentally ill in a post-conflict setting with no mental health services. The World Health Organisation (WHO) recommends the development of community-based mental health services in low-income countries [33]. While the implementation process of community mental health services in lowincome settings has been studied [34], public attitudes towards community-oriented versus hospital/drug-oriented mental health services for the mentally ill have received less attention. A better understanding of public attitudes is valuable in planning mental health programmes with regard to increasing access and use of mental health services, and developing relevant public educational programmes. The current study aimed to examine two dimensions of stigma towards the mentally ill in South Sudan: attitudes that represent prejudice or negative stereotypes and social distance. More specifically, the aims of the present study were to: • •
•
Examine community attitudes and social distance towards the mentally ill. Investigate factors that predict the participants’ endorsement of stereotypical beliefs about the mentally ill. Examine factors predicting social distance towards the mentally ill.
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Methods
Instruments
A cross-sectional community survey was conducted in the Greater Bahr el Ghazal region of South Sudan in 2010. The sample frame was the general population of four states in the Greater Bahr el Ghazal region. A multistage random cluster sampling method was used. A total of 30 administrative units (‘bomas’) within the four states constituted the survey clusters, with a corresponding running cumulative population size for each boma. The population data were based on the Sudan 2008 census [35] and were considered the most accurate population data available. The bomas were of different population sizes. The cluster selection was proportional to the relative population size of each boma to ensure that each boma had the same probability of selection. Nine bomas were selected randomly as the study sites. We estimated the design effect at 2 to compensate for cluster randomisation and the sample size was increased to double. In the next stage, the ‘spin-the-pen’ method from the WHO Expanded Programme on Immunization [36] was used for household selection: the approximate geographical centre of the area was identified and then one household was selected at random along an imaginary line connecting the centre to the periphery. Subsequent households were then selected by visiting every third closest household. Within each selected household, individuals who were 18 years or older and who gave informed consent to participate in the study were assigned a number. A card was drawn at random from a deck of cards with corresponding numbers. The randomly selected household member was then interviewed. Individuals who were not able or declined to give informed consent, or who were visibly intoxicated, were excluded from the study. The participants were interviewed by health personnel (five women and six men) from the area who were familiar with the cultural traditions and the local languages. They participated in two rounds of training workshops before the data collection, during which the cultural acceptability of the interview protocol was also discussed. The research instruments were available in both English and Arabic, but the main language used was Arabic. Each household was approached by both a male and a female interviewer to ensure the interviewer’s sex would match that of the participant. In cases in which psychopathology needing urgent treatment was identified, the interviewer referred the individual to an associated health provider. In total, 1,236 households were contacted, from which 1,200 participants were recruited. The response rate was 95 %. Response rates tend to be particularly high in low-income countries [37, 38]. Ethical clearance was obtained from the Research Department of the Ministry of Health of the Government of South Sudan and the Norwegian Regional Committee for Medical Research.
A questionnaire consisting of sociodemographic questions, including those pertaining to sex, age, marital status, religion, education, employment situation and household income, was administered to all participants. Because of the high influx of returnees to the region of study [39], the participants were also asked whether they were returnees. A returnee was defined as a person who had left his/her place of origin (regardless of the reason), but who had since returned to his/her place of origin. Attitudes towards people with mental illness were assessed using six statements; participants were asked whether they agreed or disagreed with each statement. Social distance was assessed by another six questions that represented different social interactions with various degrees of intimacy. Participants were asked to indicate their willingness to interact with people with mental illness in these social situations. We calculated a score for each participant’s reported social distance. The score was obtained by adding up the participant’s responses on the six items on social distance. Scores ranged from 0 to 6 with a higher score representing a greater expressed social distance. Both sets of questions were used by Stuart and Arboleda–Flo´rez [40] and have subsequently been used in other studies on social distance in different countries [14, 41, 42] and in the World Psychiatric Association’s stigma reduction programme [43, 44]. The internal consistency of the social distance questions and the attitude questions was measured by Cronbach’s alpha, and the values were 0.86 and 0.80, respectively. Familiarity with mental illness was assessed by asking participants about their own experience with mental illness and whether they had a family member/ friend with mental illness. The General Health Questionnaire (GHQ-28) was used to assess psychological distress. The GHQ-28 is a screening instrument that is widely used to detect psychological distress in the general population, in community settings and in non-psychiatric clinical settings, such as primary care or community care [45]. It has been used in various populations and cultural settings [46], including Sudan [47]. For each item four response possibilities are available (‘not at all’, ‘no more than usual’, ‘rather more than usual’ and ‘much more than usual’). Scores on the GHQ-28 were calculated by applying a binary scoring method: The two least symptomatic answers were scored 0 and the two most symptomatic answers scored 1 (0-0-1-1). For instance, if a participant answered that he or she has been getting edgy and bad-tempered ‘not at all’ or ‘no more than usual’, the item was scored 0, whereas if the response was ‘rather more than usual’ or ‘much more than usual’ the item was scored 1. A cutoff of 5 or higher was used to indicate psychological distress [45].
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Statistical analysis Data analyses were conducted using SPSS (PASW) 20.0. Frequency distributions were used to describe the characteristics of the participants and to obtain the overall responses to items eliciting the attitudes and the degree of social distance towards the mentally ill. We created a combined variable called ‘attitude towards health care of the mentally ill’ by taking the aggregate value of three attitude items related to health care of the mentally ill: ‘‘people with mental illness can be successfully treated outside hospital, in the community’’; ‘‘people with mental illness need prescription drugs to control their symptoms’’ and ‘‘people with mental illness can be successfully treated without drugs, by using family care or social intervention’’. This new variable was categorical with the following three values: ‘community-oriented attitude’, ‘hospital/drug-oriented attitude’ and ‘combined attitude’. Participants with ‘community-oriented attitude’ agreed with the statements ‘‘people with mental illness can be successfully treated outside hospital, in the community’’ and ‘‘people with mental illness can be successfully treated without drugs, by using family care or social intervention’’ and disagreed with the statement ‘‘people with mental illness need prescription drugs to control their symptoms’’. The ‘hospital/drug-oriented attitude’ group agreed with the statement ‘‘people with mental illness need prescription drugs to control their symptoms’’ and disagreed with the other two statements. The ‘combined attitude’ group included the other six possible combinations of the aforementioned attitude statements. To examine the participant characteristics that predicted various attitudes towards the mentally ill, a set of separate logistic regression analyses was conducted and odd ratios were estimated. The exposure variables were the sociodemographic factors of sex, age, urban/rural setting, religion, marital status, level of education, employment status, monthly family income and being a returnee. Familiarity with mental illness and psychological distress were also considered to be exposure variables. The outcome variables were each of the statements that represented the different attitudes towards people with mental illness and the combined variable ‘‘attitude towards health care of the mentally ill’’. Using a backward elimination logistic regression, all the above-mentioned exposure variables were entered into the model at the first stage of the analysis. The non-significant exposure variables were removed after regression was conducted. This process was repeated, allowing only significant exposure variables at the end of each stage, until the final model with only significant independent variables was obtained. In a separate analysis, a linear regression model (backward elimination) was applied to determine the relationship
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between exposure variables and social distance (continuous variable). All the exposure variables were entered into the regression model at the first step. The exposure variables were sex, age, urban/rural setting, religion, marital status, level of education, employment status, monthly family income and being a returnee (sociodemographic variables), familiarity with the mentally ill, own psychological distress (measured by GHQ-28) and attitudes about people with mental illness (four different attitudes). At the next step, the nonsignificant exposure variables were eliminated and the analysis was run with significant exposure variables. The final model contained only the exposure variables that were significantly associated with social distance.
Results Table 1 shows the sociodemographic characteristics of the participants. Most participants were married (65.9 %). In terms of education, 36.2 % of the participants reported having no formal education. The majority of the participants (63 %) reported a monthly household income of less than US$ 200. High levels of psychological distress were reported by the majority of the participants. Table 2 shows the participants’ responses to statements about social interaction with the mentally ill. The more intimacy the social interaction demanded, the higher the degree of social distance reported. For instance, 41.6 % were afraid of having a conversation with a person who had a mental illness while about 90 % would be unwilling to marry a person with a mental illness. Participants’ attitudes about people with mental illness are also presented in Table 2. About 80 % of the participants believed that people with mental illness are dangerous. About 37 % believed that people with mental illness can be treated outside hospitals and 85 % believed medication is required to control the symptoms of mental illness. We explored the association between the participants’ various characteristics and the endorsement of a certain attitude. Table 3 summarises three logistic regression analyses: the participants from urban areas, those who were self-employed and those who were familiar with mental illness (had a family member/friend with mental illness) were more likely to believe that the mentally ill ‘‘tend to be less intelligent than others’’. Participants from rural settings, those with a low level of education and those who were self-employed were more likely to believe that people with mental illness ‘‘suffer from an evil spirit or are possessed’’. Low level of education, familiarity with mental illness and having a lower degree of psychological distress increased the likelihood of believing that individuals with mental illness are dangerous. Concerning participants’
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Table 1 Characteristics of participants Variable
N (%)
Table 2 Number (proportion) of participants agreeing with various attitudes towards people with mental illness/health care of mentally ill N (%)
Sex Male
660 (55.4)
Female
510 (43.6)
Urban/rural setting
Feel ashamed if someone in your family was diagnosed with a mental disorder
365 (30.4)
Feel afraid to have a conversation with someone who has a mental disorder
499 (41.6)
Urban
934 (77.8)
Rural
266 (22.2)
Upset or disturbed about working on the same job as someone with a mental disorder
534 (44.6)
18–25
308 (26.0)
Unable to maintain a friendship with someone who has a mental disorder
642 (53.6)
26–35
391 (33.1) 395 (33.4)
Feel upset or disturbed about rooming with someone with a mental disorder
562 (47.0)
36–50
89 (7.5)
Unwilling to marry someone with a mental disorder
Age (years)
[50 Marital status Single
320 (27.2)
Married
774 (65.9)
No longer married
81 (6.9)
Religion Christian
1,061 (88.9)
People with mental illness: Can be successfully treated outside hospital, in the community Tend to be less intelligent than others Need prescription drugs to control their symptoms 1,156 (89.3)
445 (37.1) 707 (59.0) 1,019 (85.1)
Muslim
40 (3.5)
Can be successfully treated without drugs, by using family care or social intervention
Traditional beliefs
84 (7.3)
Suffer from an evil spirit or are possessed
642 (53.6)
Are dangerous to the public because of violent behaviour
971 (80.9)
Education Secondary school or higher
387 (32.8)
Primary school
359 (30.4)
Did not attend school
434 (36.3)
Employment Paid work
291 (26.0)
Self-employment
484 (43.2)
Student
144 (12.9)
Homemaker Retired Unemployed
67 (6.0) 23 (2.1) 111 (9.9)
Household monthly income US$ \200
553 (63.1)
200–500
209 (23.9)
500–1,000
85 (9.7)
[1,000
29 (3.3)
Returnee No
781 (68.4)
Yes
386 (33.1)
Family member/friend with mental illness No
689 (62.5)
Yes
414 (37.5)
Psychological distress No (GHQ *\5) Yes (GHQ C5)
481 (40.1) 719 (49.9)
* Psychological distress: General Health Questionnaire-28 (GHQ)
attitudes on health care of the mentally ill, participants with primary education endorsed a more community-oriented attitude than those with no formal education [beta = 0.11; 95 % CI (0.04–0.09)]. Psychological distress was also
439 (36.7)
Number (proportion) adopting attitude towards health care of mentally ill* Community-oriented attitude
358 (29.9)
Hospital/drug-oriented attitude Combined attitude
488 (40.7) 353 (29.4)
* A combined variable based on participants’ scores on the three following statements: ‘‘people with mental illness can be successfully treated outside hospital, in the community’’; ‘‘people with mental illness need prescription drugs to control their symptoms’’; ‘‘people with mental illness can be successfully treated without drugs, by using family care or social intervention’’
positively associated with a community-oriented attitude [beta = 0.11; 95 % CI (0.04–0.09)]. Living in a rural setting [beta = -0.34; 95 % CI (–0.26 to -0.18)] and holding traditional beliefs (rather than Christian beliefs) [beta = -0.12; 95 % CI (-0.18 to -0.07)] were negatively associated with community-oriented attitudes and favoured hospital/drug-oriented care (not displayed in the tables). Table 4 displays factors predicting social distance. Having a lower level of education was associated with increased social distance. Participants in the Christian or Muslim faith were less likely to show increased social distance than participants with traditional beliefs. Participants who held a community-oriented attitude about health care for the mentally ill were more likely to show decreased social distance. Participants who believed that the mentally ill were dangerous had higher scores on the social distance scale. Familiarity with mental illness or
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Table 3 Results of three logistic regression analyses (backward): variables associated with adopting different attitudes towards people with mental illness (dichotomous) Adjusted OR (95 % CI) Tend to be less intelligent than others Urban/rural setting
Rural
1
Education
Urban Secondary or higher
5.73 (3.89–8.43)* 1
No formal education
1.73 (1.17–2.56)*
Employment Familiarity
Paid work
1
Self-employed
1.59 (1.78–2.36)*
No
1
Yes
1.54 (1.14–2.07)*
Suffer from an evil spirit or are possessed Urban/rural Education
Employment
Urban
1
Rural
2.11 (1.41–3.14)*
Secondary or higher
1
Elementary
2.95 (1.86–4.69)*
No formal education
2.01 (1.35–2.99)*
Paid work
1
Self-employed
1.98 (1.32–2.97)*
Are dangerous to the public because of violent behaviour Education Secondary or higher 1
Familiarity Psychological distress
Elementary
2.30 (1.55–3.41)*
No formal education
1.83 (1.25–2.70)*
No
1
Yes
1.46 (1.04–2.06)*
High
1
Low
1.72 (1.21–2.44)*
* p \ 0.05 Psychological distress: GHQ score [5 = high
psychological distress was not significantly associated with social distance. It is also noteworthy that holding the belief that mentally ill persons are possessed or less intelligent was not significantly associated with social distance.
Discussion This study is the first investigation of community attitudes towards the mentally ill in South Sudan. The majority of participants favoured a hospital/drug-oriented health care approach rather than community and family care. Christians and Muslims were more likely than participants with traditional beliefs to favour community-oriented care. Participants from urban areas and those with some education (compared with those who had never attended school) were more likely to believe in family and social intervention rather than the use of hospital/drug-oriented care.
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This study set out with the aim of exploring variables predicting social distance towards the mentally ill. Attitudes towards mental health care were significantly associated with the level of social distance; the more one agreed with hospital/drug-oriented care, the greater the social distance that was expressed. Given the lack of mental health services in the form of medication and hospitalisation in the region, it is less likely that the abovementioned attitudes are rooted in the participants’ own experiences (i.e. direct personal participation or observation). It is reasonable to argue that the participants were more likely to be familiar with/exposed to the medication and hospital/drug-oriented treatment through their experiences within somatic health care services and extrapolated these to mental illness. Following the attribution theory, encountering individuals with mental illness may trigger the attitude that the behaviour of the mentally ill individual is unpredictable and can only be contained with the help of external aid, such as medication. The succeeding reaction can then be to ensure a safe distance from the mentally ill. Another explanation is that the participants who believed that the mentally ill needed modern medicine or needed to be admitted to the hospital were expressing the difficulty they experience in dealing with the mentally ill. The participants’ expressed hospital/drug-oriented attitude may also be understood as a voiced desire or a need to have access to these facilities especially because many of participants may not be familiar with any alternative health care for the mentally ill. Participants who believed that individuals with mental illness are dangerous were understandably also more likely to express a higher degree of social distance than participants who did not hold this belief. Perceived dangerousness of the mentally ill, which is a commonly held stereotypical belief, is activated when people encounter cues that they associate with mental illness. The behavioural responses that follow (e.g. the desire to establish a distance) can be characterised as a reaction to that stereotypical belief. The perceived dangerousness of the mentally ill is a widespread attitude, and its impact on public stigma has been well studied [48, 49]. Other African studies also support the influence of perceived dangerousness on increased desire for social distance [14]. The high level of expressed social distance towards the mentally ill observed in our study is comparable with findings from other African countries. For instance, a Nigerian study, applying the same set of questions to assess social distance, found that 82 % of respondents would not marry someone with a mental illness and 62.2 % would be disturbed about sharing a room with someone with a mental illness [14]. In a similar survey in Malawi, the corresponding results were 81 and 59 % [19]. The reported social distance towards people with schizophrenia in
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Table 4 Result of backward linear regression analysis with social distance as the dependent variable (continuous) Predictor
Model 1 b (CI 95 %)
Sex (male)
-0.05 (-0.28 to 0.24)
Age
-0.32 (-0.17 to 0.07)
Rural residency
-0.01 (-0.38 to 0.29)
Level of education: primary (reference: no formal education)
-0.06 (-0.54 to -0.05)*
-0.09 (-0.61 to -0.13)*
Level of education: secondary or higher (reference: no formal education)
-0.13 (-0.83 to -0.06)*
-0.13 (-0.75 to -0.27)*
Employment: self-employed (reference: paid work)
0.70 (-0.62 to 0.57)
Employment: student (reference: paid work)
0.78 (-0.03 to 0.90)
Employment: homemaker (reference: paid work)
-0.07 (-1.19 to 0.05)
Employment: retired (reference: paid work)
-0.05 (-1.50 to 0.19)
Employment: unemployed (reference: paid work)
0.06 (-0.06 to 0.91)
Household monthly income US$: 200–500 (reference: \200)
-0.01 (-0.34 to 0.30)
Household monthly income US$: 500–1,000 (reference: \200)
0.00 (-0.45 to 0.47)
Household monthly income US$: [1,000 (reference: \200)
-0.01 (-0.73 to 0.64)
Returnee
0.11 (-0.13 to 0.62)
Religion: Muslim (reference: Christian)
-0.03 (-0.67 to 0.46)
Religion: Traditional beliefs (reference: Christian)
0.09 (0.22 to 1.62)*
Marital status: Married (reference: single)
0.84 (-0.20 to 0.81)
Marital status: Married (reference: no longer married) High level of psychological distress (GHQ score [5)
0.38 (-0.43 to 0.72) 0.02 (-0.17 to 0.32)
Familiar with mental illness
-0.01 (-0.28 to 0.23)
Agree that ‘‘the mentally ill tend to be less intelligent than others’’
0.04 (-0.09 to 0.42)
Agree that ‘‘the mentally ill suffer from an evil spirit or are possessed’’
0.05 (-0.06 to 0.43)
Agree that ‘‘the mentally ill are dangerous to the public because of violent behaviour’’
0.15 (0.35 to 0.96)
‘Community-oriented’ attitude towards mental health care
Model 2 b (CI 95 %)
1.79 (0.92 to 1.73)*
0.18 (0.62 to 1.11)*
-0.19 (-1.77 to -0.89)
-0.29 (-2.42 to -1.70)*
R2 = 0.31
R2 = 0.43
* p \ 0.05 b (beta): standardised regression coefficients, adjusted
studies from high-income countries, using the same set of questions, showed much lower tendencies [40, 42]. Few sociodemographic factors were significantly associated with social distance. Urban or rural residency was not significantly associated with expressing social distance towards the mentally ill in our study. This is in line with a study conducted in Nigeria [14]. According to Angermeyer and Dietrich’s review of the stigma-related literature [2], a limited number of studies have examined the influence of urban-rural differences on the degree of social distance/ stigma and the results are inconsistent. Having a higher level of education was found to be inversely associated with social distance, which is consistent with other studies. Reviews of the literature [2, 6] suggest a weak influence of the level of education on social distance and a weak explanatory power of sociodemographic factors in general [2]. Participants’ familiarity with mental illness was not significantly associated with social
distance. Contact with individuals with mental illness (familiarity) has been found to be associated with reduced social distance in most previous studies [6], although several studies have found that familiarity with mental illness has no significant influence on social distance [2]. It has been suggested that the quality of the contact rather than the contact per se may influence the level of stigma [50]. No significant association was found between the participants’ level of psychological distress and their desired social distance towards the mentally ill, which is in accordance with the result of a previous study [51]. This study demonstrates that it was possible to conduct a community survey under very difficult circumstances. For example, there was a lack of proper infrastructure, making it difficult to reach some of the sampling areas, and the security of the situation had to be carefully and continuously monitored. We believe that these results based on the randomised sample of the study can be considered
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generalisable to the Greater Bahr el Ghazal states and possibly to the whole country. Data from this study will be analysed further and made available to the health authorities in South Sudan to be used in the further development of the health services in the country. A clear implication of this study is first of all to meet the need for mental health literacy programmes in the region. Such programmes should provide information about mental illness, including information about the various types of treatment for the mentally ill. They should pay special attention to rural areas and people with low levels of education. More research is needed to better understand the community’s ways of managing mentally ill individuals and the use of traditional as well as modern (general hospital and dispensary) services for treating mental illnesses. This study had some limitations. Being a cross-sectional study, it cannot provide a cause and effect relationship between the studied demographic variables and attitudes on the one hand and social stigma on the other. Furthermore, we relied on self-report measures to assess the level of social distance rather than actions, which may influence the validity of the results. It has been suggested that people may report a certain level of social distance but act differently when faced with the real situation [51]. An additional limitation was the lack of operationalisation of the concept of mental illness. The term ‘mental illness’, as used in our study, is a broad concept. Studies show that the level of stigma varies according to the type of mental illness [52]. Despite these limitations, our findings, based on data from a post-conflict setting with virtually no history of modern mental health services, highlight the extreme vulnerability of the mentally ill. Not only are they vulnerable because of their low socioeconomic position and their limited access to treatment services [53], but they are also exposed to stigma.
Conclusion A high level of stigma towards the mentally ill exists in South Sudan, especially in the rural areas. Further research is needed in order to investigate the role of the community both in preventing mental illnesses and in service delivery. Alongside efforts to build up mental health services in South Sudan, the existing stigma needs to be addressed. Community awareness campaigns have been recommended in combating stigma [54]. However, the impact of such public awareness campaigns have proven to be difficult to assess [55, 56]. Relying solely on awareness campaigns is not sufficient in attitude/behavioural changes and providing effective services is believed to be an effective way of reducing stigma [57]. We believe identifying, training and assisting potential advocacy persons in the local
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communities is a valuable step towards working against stigma. Community and religious leaders should be invited to contribute to such processes. There is a great need for further evidence on the effect of mental health training programmes in low-income countries. Thus, such a training programme for community leaders and primary health care personnel in South Sudan should include a research component if implemented [58]. Reducing the socioeconomic vulnerability amongst mentally ill, for instance by providing greater employment opportunities, will contribute to minimising stigmas against the mentally ill [59]. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
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ORIGINAL PAPER
Community attitudes and social distance towards the mentally ill in South Sudan: a survey from a post-conflict setting with no mental health services Touraj Ayazi • Lars Lien • Arne Eide • Elizabeth Joseph Shadar Shadar • Edvard Hauff
Received: 21 January 2013 / Accepted: 3 October 2013 / Published online: 18 October 2013 Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose This study investigates attitudes and social distance towards the mentally ill in a post-conflict, lowincome country. Methods A cross-sectional community survey (n = 1,200) was conducted in South Sudan. Associations between various sociodemographic variables and attitudes toward/social distance from the mentally ill were investigated.
T. Ayazi (&) E. Hauff Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, Blindern, 0318 Oslo, Norway e-mail: [email protected] E. Hauff e-mail: [email protected] L. Lien National Center for Dual Diagnosis, Innlandet Hospital Trust, Furnesvegen 26, 2380 Brumunddal, Norway e-mail: [email protected] L. Lien Faculty of Public Health, Hedmark University College, P.O. Box 400, 2418 Elverum, Norway A. Eide SINTEF, Technology and Society, P.O. Box 124, Blindern, 0314 Oslo, Norway e-mail: [email protected] E. J. S. Shadar Ahfad University for Women, P.O. Box 167, Omdurman, Sudan e-mail: [email protected] E. Hauff Division of Mental Health and Addiction, Department of Research and Development, Oslo University Hospital, Ulleval, Kirkeveien 166, Building 20, 0407 Oslo, Norway
Results The regression analysis showed that lower levels of education were positively associated with social distance, and Christian or Muslim beliefs, compared with traditional beliefs, were negatively associated with social distance. Familiarity with mental illness or psychological distress was not significantly associated with social distance. Participants who endorsed community-oriented attitudes (rather than hospital/drug-oriented attitudes) about health care for the mentally ill were more likely show a decreased social distance. Participants who believed that the mentally ill were dangerous had higher scores on the social distance scale. Conclusions A high level of stigma towards the mentally ill exists in South Sudan, especially in the rural areas. Alongside efforts to build up mental health services in South Sudan, the existing stigma needs to be addressed. Information regarding the role of the community both in preventing mental illnesses and in service delivery should be prioritised. Keywords Stigma Social distance Post-conflict South Sudan
Introduction The negative impacts of stigma on people with mental illness are well documented [1, 2]. Stigma is defined as ‘‘the endorsement of a set of prejudicial attitudes, negative emotional responses, discriminatory behaviors, and biased social structures toward members of a subgroup’’ [3]. Attribution theory is one of the models used to explain stigma. Stereotypes (generalised assumptions) about people with mental illness are activated by cues, such as encountering a person with mental illness. These
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stereotyped attitudes result in behavioural reactions or discriminative behaviour [4]. Two aspects of stigma, negative attitudes and social distance, are frequently used in the study of stigma and as indicators of discriminatory behaviour [5–9]. The current study aims to investigate the level of stigma towards the mentally ill in a post-conflict, low-income country. The vast majority of studies on stigma have been conducted in high-income countries [2]. Previous studies on the pattern of mental health outcomes suggest a better prognosis for the severely mentally ill in low-income countries, an assumption that has been taken as evidence of a lower level of stigma towards the mentally ill in these countries [10, 11]. The notion of ‘better prognosis’ has since been challenged [12], and the supposedly generalised tolerant and supportive attitude towards the mentally ill has been questioned. Subsequently, there has been an increase in recent years in the number of studies from low-income counties. Lauber and Ro¨ssler’s [13] review of studies in Asian countries showed broad tendencies of stigmatisation and discrimination of people with mental illness. In subSaharan Africa, surveys on the attitudes of the general public [14] and students [15] in Nigeria towards the mentally ill indicated a high level of stigmatisation; a study in rural Ethiopia [16] also showed that relatives of individuals with mental illness commonly experience stigmatisation. Similar results, showing an extensive amount of stigma, have been replicated in surveys in recent studies in Zambia [17], Ghana [18] and Malawi [19]. Various studies have examined the factors that influence social distance (the willingness to engage in relationships of varying intimacy with a person [20]). Sociodemographic factors such as older age, sex, lower level of education and social class have been associated with increased social distance towards people with mental illness [20–22]. Contact with people with mental disorders decreased social distance towards the mentally ill [23]; participants who were familiar with mental illness (based on scores on an index of familiarity with mental illness) also showed a reduced level of social distance towards the mentally ill [5]. The influence of attitudes towards the mentally ill on social distance has also been a focus of stigma-related studies. For instance, accepting the biomedical model of mental illness increased the degree of social distance [20], as did perceiving the mentally ill to be dangerous [24] and unpredictable [25, 26]. A comparative study of students in several countries (Australia, Belgium, Estonia, Finland, India and Latvia) [27] found that although the levels of stigma were similar, the determinants of social distance differed between the countries. The role of culture on the expression of stigmatising attitudes was also asserted in Lauber and Ro¨ssler’s [13] review of studies on stigma in
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Asian countries. In summary, cultural and contextual specificity of the determinant of stigma is evident [2, 28]. South Sudan is one of the most impoverished countries in the world [29]. In addition to economic hardship, the country has experienced a 21-year period of armed conflict that ended in 2005 and eventually resulted in the creation of the Republic of South Sudan in 2011. Previous studies from South Sudan [30, 31] have indicated high levels of trauma exposure and psychological distress in the general population. The health facilities in South Sudan are scant [29] and mental health services are non-existent. In many low-income countries, the scarce mental health services are hospital based [32] and most commonly centred in hospitals established during the colonial era. There are, however, no psychiatric hospitals in South Sudan. Since the signing of the Peace Agreement in 2005, a small number of severely ill patients have been referred or admitted to the psychiatric hospital in Khartoum (the capital city of neighbouring Sudan, 1,000 km from South Sudan). This tortuous pathway was not available during the war. Mental health services provided in the general hospitals in larger towns consist of the prescription of sedative drugs. The majority of studies on stigma in low-income countries are conducted in settings with at least minimal mental health services. The present survey provides an opportunity to study public attitudes towards the mentally ill in a post-conflict setting with no mental health services. The World Health Organisation (WHO) recommends the development of community-based mental health services in low-income countries [33]. While the implementation process of community mental health services in lowincome settings has been studied [34], public attitudes towards community-oriented versus hospital/drug-oriented mental health services for the mentally ill have received less attention. A better understanding of public attitudes is valuable in planning mental health programmes with regard to increasing access and use of mental health services, and developing relevant public educational programmes. The current study aimed to examine two dimensions of stigma towards the mentally ill in South Sudan: attitudes that represent prejudice or negative stereotypes and social distance. More specifically, the aims of the present study were to: • •
•
Examine community attitudes and social distance towards the mentally ill. Investigate factors that predict the participants’ endorsement of stereotypical beliefs about the mentally ill. Examine factors predicting social distance towards the mentally ill.
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Methods
Instruments
A cross-sectional community survey was conducted in the Greater Bahr el Ghazal region of South Sudan in 2010. The sample frame was the general population of four states in the Greater Bahr el Ghazal region. A multistage random cluster sampling method was used. A total of 30 administrative units (‘bomas’) within the four states constituted the survey clusters, with a corresponding running cumulative population size for each boma. The population data were based on the Sudan 2008 census [35] and were considered the most accurate population data available. The bomas were of different population sizes. The cluster selection was proportional to the relative population size of each boma to ensure that each boma had the same probability of selection. Nine bomas were selected randomly as the study sites. We estimated the design effect at 2 to compensate for cluster randomisation and the sample size was increased to double. In the next stage, the ‘spin-the-pen’ method from the WHO Expanded Programme on Immunization [36] was used for household selection: the approximate geographical centre of the area was identified and then one household was selected at random along an imaginary line connecting the centre to the periphery. Subsequent households were then selected by visiting every third closest household. Within each selected household, individuals who were 18 years or older and who gave informed consent to participate in the study were assigned a number. A card was drawn at random from a deck of cards with corresponding numbers. The randomly selected household member was then interviewed. Individuals who were not able or declined to give informed consent, or who were visibly intoxicated, were excluded from the study. The participants were interviewed by health personnel (five women and six men) from the area who were familiar with the cultural traditions and the local languages. They participated in two rounds of training workshops before the data collection, during which the cultural acceptability of the interview protocol was also discussed. The research instruments were available in both English and Arabic, but the main language used was Arabic. Each household was approached by both a male and a female interviewer to ensure the interviewer’s sex would match that of the participant. In cases in which psychopathology needing urgent treatment was identified, the interviewer referred the individual to an associated health provider. In total, 1,236 households were contacted, from which 1,200 participants were recruited. The response rate was 95 %. Response rates tend to be particularly high in low-income countries [37, 38]. Ethical clearance was obtained from the Research Department of the Ministry of Health of the Government of South Sudan and the Norwegian Regional Committee for Medical Research.
A questionnaire consisting of sociodemographic questions, including those pertaining to sex, age, marital status, religion, education, employment situation and household income, was administered to all participants. Because of the high influx of returnees to the region of study [39], the participants were also asked whether they were returnees. A returnee was defined as a person who had left his/her place of origin (regardless of the reason), but who had since returned to his/her place of origin. Attitudes towards people with mental illness were assessed using six statements; participants were asked whether they agreed or disagreed with each statement. Social distance was assessed by another six questions that represented different social interactions with various degrees of intimacy. Participants were asked to indicate their willingness to interact with people with mental illness in these social situations. We calculated a score for each participant’s reported social distance. The score was obtained by adding up the participant’s responses on the six items on social distance. Scores ranged from 0 to 6 with a higher score representing a greater expressed social distance. Both sets of questions were used by Stuart and Arboleda–Flo´rez [40] and have subsequently been used in other studies on social distance in different countries [14, 41, 42] and in the World Psychiatric Association’s stigma reduction programme [43, 44]. The internal consistency of the social distance questions and the attitude questions was measured by Cronbach’s alpha, and the values were 0.86 and 0.80, respectively. Familiarity with mental illness was assessed by asking participants about their own experience with mental illness and whether they had a family member/ friend with mental illness. The General Health Questionnaire (GHQ-28) was used to assess psychological distress. The GHQ-28 is a screening instrument that is widely used to detect psychological distress in the general population, in community settings and in non-psychiatric clinical settings, such as primary care or community care [45]. It has been used in various populations and cultural settings [46], including Sudan [47]. For each item four response possibilities are available (‘not at all’, ‘no more than usual’, ‘rather more than usual’ and ‘much more than usual’). Scores on the GHQ-28 were calculated by applying a binary scoring method: The two least symptomatic answers were scored 0 and the two most symptomatic answers scored 1 (0-0-1-1). For instance, if a participant answered that he or she has been getting edgy and bad-tempered ‘not at all’ or ‘no more than usual’, the item was scored 0, whereas if the response was ‘rather more than usual’ or ‘much more than usual’ the item was scored 1. A cutoff of 5 or higher was used to indicate psychological distress [45].
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Statistical analysis Data analyses were conducted using SPSS (PASW) 20.0. Frequency distributions were used to describe the characteristics of the participants and to obtain the overall responses to items eliciting the attitudes and the degree of social distance towards the mentally ill. We created a combined variable called ‘attitude towards health care of the mentally ill’ by taking the aggregate value of three attitude items related to health care of the mentally ill: ‘‘people with mental illness can be successfully treated outside hospital, in the community’’; ‘‘people with mental illness need prescription drugs to control their symptoms’’ and ‘‘people with mental illness can be successfully treated without drugs, by using family care or social intervention’’. This new variable was categorical with the following three values: ‘community-oriented attitude’, ‘hospital/drug-oriented attitude’ and ‘combined attitude’. Participants with ‘community-oriented attitude’ agreed with the statements ‘‘people with mental illness can be successfully treated outside hospital, in the community’’ and ‘‘people with mental illness can be successfully treated without drugs, by using family care or social intervention’’ and disagreed with the statement ‘‘people with mental illness need prescription drugs to control their symptoms’’. The ‘hospital/drug-oriented attitude’ group agreed with the statement ‘‘people with mental illness need prescription drugs to control their symptoms’’ and disagreed with the other two statements. The ‘combined attitude’ group included the other six possible combinations of the aforementioned attitude statements. To examine the participant characteristics that predicted various attitudes towards the mentally ill, a set of separate logistic regression analyses was conducted and odd ratios were estimated. The exposure variables were the sociodemographic factors of sex, age, urban/rural setting, religion, marital status, level of education, employment status, monthly family income and being a returnee. Familiarity with mental illness and psychological distress were also considered to be exposure variables. The outcome variables were each of the statements that represented the different attitudes towards people with mental illness and the combined variable ‘‘attitude towards health care of the mentally ill’’. Using a backward elimination logistic regression, all the above-mentioned exposure variables were entered into the model at the first stage of the analysis. The non-significant exposure variables were removed after regression was conducted. This process was repeated, allowing only significant exposure variables at the end of each stage, until the final model with only significant independent variables was obtained. In a separate analysis, a linear regression model (backward elimination) was applied to determine the relationship
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between exposure variables and social distance (continuous variable). All the exposure variables were entered into the regression model at the first step. The exposure variables were sex, age, urban/rural setting, religion, marital status, level of education, employment status, monthly family income and being a returnee (sociodemographic variables), familiarity with the mentally ill, own psychological distress (measured by GHQ-28) and attitudes about people with mental illness (four different attitudes). At the next step, the nonsignificant exposure variables were eliminated and the analysis was run with significant exposure variables. The final model contained only the exposure variables that were significantly associated with social distance.
Results Table 1 shows the sociodemographic characteristics of the participants. Most participants were married (65.9 %). In terms of education, 36.2 % of the participants reported having no formal education. The majority of the participants (63 %) reported a monthly household income of less than US$ 200. High levels of psychological distress were reported by the majority of the participants. Table 2 shows the participants’ responses to statements about social interaction with the mentally ill. The more intimacy the social interaction demanded, the higher the degree of social distance reported. For instance, 41.6 % were afraid of having a conversation with a person who had a mental illness while about 90 % would be unwilling to marry a person with a mental illness. Participants’ attitudes about people with mental illness are also presented in Table 2. About 80 % of the participants believed that people with mental illness are dangerous. About 37 % believed that people with mental illness can be treated outside hospitals and 85 % believed medication is required to control the symptoms of mental illness. We explored the association between the participants’ various characteristics and the endorsement of a certain attitude. Table 3 summarises three logistic regression analyses: the participants from urban areas, those who were self-employed and those who were familiar with mental illness (had a family member/friend with mental illness) were more likely to believe that the mentally ill ‘‘tend to be less intelligent than others’’. Participants from rural settings, those with a low level of education and those who were self-employed were more likely to believe that people with mental illness ‘‘suffer from an evil spirit or are possessed’’. Low level of education, familiarity with mental illness and having a lower degree of psychological distress increased the likelihood of believing that individuals with mental illness are dangerous. Concerning participants’
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Table 1 Characteristics of participants Variable
N (%)
Table 2 Number (proportion) of participants agreeing with various attitudes towards people with mental illness/health care of mentally ill N (%)
Sex Male
660 (55.4)
Female
510 (43.6)
Urban/rural setting
Feel ashamed if someone in your family was diagnosed with a mental disorder
365 (30.4)
Feel afraid to have a conversation with someone who has a mental disorder
499 (41.6)
Urban
934 (77.8)
Rural
266 (22.2)
Upset or disturbed about working on the same job as someone with a mental disorder
534 (44.6)
18–25
308 (26.0)
Unable to maintain a friendship with someone who has a mental disorder
642 (53.6)
26–35
391 (33.1) 395 (33.4)
Feel upset or disturbed about rooming with someone with a mental disorder
562 (47.0)
36–50
89 (7.5)
Unwilling to marry someone with a mental disorder
Age (years)
[50 Marital status Single
320 (27.2)
Married
774 (65.9)
No longer married
81 (6.9)
Religion Christian
1,061 (88.9)
People with mental illness: Can be successfully treated outside hospital, in the community Tend to be less intelligent than others Need prescription drugs to control their symptoms 1,156 (89.3)
445 (37.1) 707 (59.0) 1,019 (85.1)
Muslim
40 (3.5)
Can be successfully treated without drugs, by using family care or social intervention
Traditional beliefs
84 (7.3)
Suffer from an evil spirit or are possessed
642 (53.6)
Are dangerous to the public because of violent behaviour
971 (80.9)
Education Secondary school or higher
387 (32.8)
Primary school
359 (30.4)
Did not attend school
434 (36.3)
Employment Paid work
291 (26.0)
Self-employment
484 (43.2)
Student
144 (12.9)
Homemaker Retired Unemployed
67 (6.0) 23 (2.1) 111 (9.9)
Household monthly income US$ \200
553 (63.1)
200–500
209 (23.9)
500–1,000
85 (9.7)
[1,000
29 (3.3)
Returnee No
781 (68.4)
Yes
386 (33.1)
Family member/friend with mental illness No
689 (62.5)
Yes
414 (37.5)
Psychological distress No (GHQ *\5) Yes (GHQ C5)
481 (40.1) 719 (49.9)
* Psychological distress: General Health Questionnaire-28 (GHQ)
attitudes on health care of the mentally ill, participants with primary education endorsed a more community-oriented attitude than those with no formal education [beta = 0.11; 95 % CI (0.04–0.09)]. Psychological distress was also
439 (36.7)
Number (proportion) adopting attitude towards health care of mentally ill* Community-oriented attitude
358 (29.9)
Hospital/drug-oriented attitude Combined attitude
488 (40.7) 353 (29.4)
* A combined variable based on participants’ scores on the three following statements: ‘‘people with mental illness can be successfully treated outside hospital, in the community’’; ‘‘people with mental illness need prescription drugs to control their symptoms’’; ‘‘people with mental illness can be successfully treated without drugs, by using family care or social intervention’’
positively associated with a community-oriented attitude [beta = 0.11; 95 % CI (0.04–0.09)]. Living in a rural setting [beta = -0.34; 95 % CI (–0.26 to -0.18)] and holding traditional beliefs (rather than Christian beliefs) [beta = -0.12; 95 % CI (-0.18 to -0.07)] were negatively associated with community-oriented attitudes and favoured hospital/drug-oriented care (not displayed in the tables). Table 4 displays factors predicting social distance. Having a lower level of education was associated with increased social distance. Participants in the Christian or Muslim faith were less likely to show increased social distance than participants with traditional beliefs. Participants who held a community-oriented attitude about health care for the mentally ill were more likely to show decreased social distance. Participants who believed that the mentally ill were dangerous had higher scores on the social distance scale. Familiarity with mental illness or
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Table 3 Results of three logistic regression analyses (backward): variables associated with adopting different attitudes towards people with mental illness (dichotomous) Adjusted OR (95 % CI) Tend to be less intelligent than others Urban/rural setting
Rural
1
Education
Urban Secondary or higher
5.73 (3.89–8.43)* 1
No formal education
1.73 (1.17–2.56)*
Employment Familiarity
Paid work
1
Self-employed
1.59 (1.78–2.36)*
No
1
Yes
1.54 (1.14–2.07)*
Suffer from an evil spirit or are possessed Urban/rural Education
Employment
Urban
1
Rural
2.11 (1.41–3.14)*
Secondary or higher
1
Elementary
2.95 (1.86–4.69)*
No formal education
2.01 (1.35–2.99)*
Paid work
1
Self-employed
1.98 (1.32–2.97)*
Are dangerous to the public because of violent behaviour Education Secondary or higher 1
Familiarity Psychological distress
Elementary
2.30 (1.55–3.41)*
No formal education
1.83 (1.25–2.70)*
No
1
Yes
1.46 (1.04–2.06)*
High
1
Low
1.72 (1.21–2.44)*
* p \ 0.05 Psychological distress: GHQ score [5 = high
psychological distress was not significantly associated with social distance. It is also noteworthy that holding the belief that mentally ill persons are possessed or less intelligent was not significantly associated with social distance.
Discussion This study is the first investigation of community attitudes towards the mentally ill in South Sudan. The majority of participants favoured a hospital/drug-oriented health care approach rather than community and family care. Christians and Muslims were more likely than participants with traditional beliefs to favour community-oriented care. Participants from urban areas and those with some education (compared with those who had never attended school) were more likely to believe in family and social intervention rather than the use of hospital/drug-oriented care.
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This study set out with the aim of exploring variables predicting social distance towards the mentally ill. Attitudes towards mental health care were significantly associated with the level of social distance; the more one agreed with hospital/drug-oriented care, the greater the social distance that was expressed. Given the lack of mental health services in the form of medication and hospitalisation in the region, it is less likely that the abovementioned attitudes are rooted in the participants’ own experiences (i.e. direct personal participation or observation). It is reasonable to argue that the participants were more likely to be familiar with/exposed to the medication and hospital/drug-oriented treatment through their experiences within somatic health care services and extrapolated these to mental illness. Following the attribution theory, encountering individuals with mental illness may trigger the attitude that the behaviour of the mentally ill individual is unpredictable and can only be contained with the help of external aid, such as medication. The succeeding reaction can then be to ensure a safe distance from the mentally ill. Another explanation is that the participants who believed that the mentally ill needed modern medicine or needed to be admitted to the hospital were expressing the difficulty they experience in dealing with the mentally ill. The participants’ expressed hospital/drug-oriented attitude may also be understood as a voiced desire or a need to have access to these facilities especially because many of participants may not be familiar with any alternative health care for the mentally ill. Participants who believed that individuals with mental illness are dangerous were understandably also more likely to express a higher degree of social distance than participants who did not hold this belief. Perceived dangerousness of the mentally ill, which is a commonly held stereotypical belief, is activated when people encounter cues that they associate with mental illness. The behavioural responses that follow (e.g. the desire to establish a distance) can be characterised as a reaction to that stereotypical belief. The perceived dangerousness of the mentally ill is a widespread attitude, and its impact on public stigma has been well studied [48, 49]. Other African studies also support the influence of perceived dangerousness on increased desire for social distance [14]. The high level of expressed social distance towards the mentally ill observed in our study is comparable with findings from other African countries. For instance, a Nigerian study, applying the same set of questions to assess social distance, found that 82 % of respondents would not marry someone with a mental illness and 62.2 % would be disturbed about sharing a room with someone with a mental illness [14]. In a similar survey in Malawi, the corresponding results were 81 and 59 % [19]. The reported social distance towards people with schizophrenia in
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777
Table 4 Result of backward linear regression analysis with social distance as the dependent variable (continuous) Predictor
Model 1 b (CI 95 %)
Sex (male)
-0.05 (-0.28 to 0.24)
Age
-0.32 (-0.17 to 0.07)
Rural residency
-0.01 (-0.38 to 0.29)
Level of education: primary (reference: no formal education)
-0.06 (-0.54 to -0.05)*
-0.09 (-0.61 to -0.13)*
Level of education: secondary or higher (reference: no formal education)
-0.13 (-0.83 to -0.06)*
-0.13 (-0.75 to -0.27)*
Employment: self-employed (reference: paid work)
0.70 (-0.62 to 0.57)
Employment: student (reference: paid work)
0.78 (-0.03 to 0.90)
Employment: homemaker (reference: paid work)
-0.07 (-1.19 to 0.05)
Employment: retired (reference: paid work)
-0.05 (-1.50 to 0.19)
Employment: unemployed (reference: paid work)
0.06 (-0.06 to 0.91)
Household monthly income US$: 200–500 (reference: \200)
-0.01 (-0.34 to 0.30)
Household monthly income US$: 500–1,000 (reference: \200)
0.00 (-0.45 to 0.47)
Household monthly income US$: [1,000 (reference: \200)
-0.01 (-0.73 to 0.64)
Returnee
0.11 (-0.13 to 0.62)
Religion: Muslim (reference: Christian)
-0.03 (-0.67 to 0.46)
Religion: Traditional beliefs (reference: Christian)
0.09 (0.22 to 1.62)*
Marital status: Married (reference: single)
0.84 (-0.20 to 0.81)
Marital status: Married (reference: no longer married) High level of psychological distress (GHQ score [5)
0.38 (-0.43 to 0.72) 0.02 (-0.17 to 0.32)
Familiar with mental illness
-0.01 (-0.28 to 0.23)
Agree that ‘‘the mentally ill tend to be less intelligent than others’’
0.04 (-0.09 to 0.42)
Agree that ‘‘the mentally ill suffer from an evil spirit or are possessed’’
0.05 (-0.06 to 0.43)
Agree that ‘‘the mentally ill are dangerous to the public because of violent behaviour’’
0.15 (0.35 to 0.96)
‘Community-oriented’ attitude towards mental health care
Model 2 b (CI 95 %)
1.79 (0.92 to 1.73)*
0.18 (0.62 to 1.11)*
-0.19 (-1.77 to -0.89)
-0.29 (-2.42 to -1.70)*
R2 = 0.31
R2 = 0.43
* p \ 0.05 b (beta): standardised regression coefficients, adjusted
studies from high-income countries, using the same set of questions, showed much lower tendencies [40, 42]. Few sociodemographic factors were significantly associated with social distance. Urban or rural residency was not significantly associated with expressing social distance towards the mentally ill in our study. This is in line with a study conducted in Nigeria [14]. According to Angermeyer and Dietrich’s review of the stigma-related literature [2], a limited number of studies have examined the influence of urban-rural differences on the degree of social distance/ stigma and the results are inconsistent. Having a higher level of education was found to be inversely associated with social distance, which is consistent with other studies. Reviews of the literature [2, 6] suggest a weak influence of the level of education on social distance and a weak explanatory power of sociodemographic factors in general [2]. Participants’ familiarity with mental illness was not significantly associated with social
distance. Contact with individuals with mental illness (familiarity) has been found to be associated with reduced social distance in most previous studies [6], although several studies have found that familiarity with mental illness has no significant influence on social distance [2]. It has been suggested that the quality of the contact rather than the contact per se may influence the level of stigma [50]. No significant association was found between the participants’ level of psychological distress and their desired social distance towards the mentally ill, which is in accordance with the result of a previous study [51]. This study demonstrates that it was possible to conduct a community survey under very difficult circumstances. For example, there was a lack of proper infrastructure, making it difficult to reach some of the sampling areas, and the security of the situation had to be carefully and continuously monitored. We believe that these results based on the randomised sample of the study can be considered
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generalisable to the Greater Bahr el Ghazal states and possibly to the whole country. Data from this study will be analysed further and made available to the health authorities in South Sudan to be used in the further development of the health services in the country. A clear implication of this study is first of all to meet the need for mental health literacy programmes in the region. Such programmes should provide information about mental illness, including information about the various types of treatment for the mentally ill. They should pay special attention to rural areas and people with low levels of education. More research is needed to better understand the community’s ways of managing mentally ill individuals and the use of traditional as well as modern (general hospital and dispensary) services for treating mental illnesses. This study had some limitations. Being a cross-sectional study, it cannot provide a cause and effect relationship between the studied demographic variables and attitudes on the one hand and social stigma on the other. Furthermore, we relied on self-report measures to assess the level of social distance rather than actions, which may influence the validity of the results. It has been suggested that people may report a certain level of social distance but act differently when faced with the real situation [51]. An additional limitation was the lack of operationalisation of the concept of mental illness. The term ‘mental illness’, as used in our study, is a broad concept. Studies show that the level of stigma varies according to the type of mental illness [52]. Despite these limitations, our findings, based on data from a post-conflict setting with virtually no history of modern mental health services, highlight the extreme vulnerability of the mentally ill. Not only are they vulnerable because of their low socioeconomic position and their limited access to treatment services [53], but they are also exposed to stigma.
Conclusion A high level of stigma towards the mentally ill exists in South Sudan, especially in the rural areas. Further research is needed in order to investigate the role of the community both in preventing mental illnesses and in service delivery. Alongside efforts to build up mental health services in South Sudan, the existing stigma needs to be addressed. Community awareness campaigns have been recommended in combating stigma [54]. However, the impact of such public awareness campaigns have proven to be difficult to assess [55, 56]. Relying solely on awareness campaigns is not sufficient in attitude/behavioural changes and providing effective services is believed to be an effective way of reducing stigma [57]. We believe identifying, training and assisting potential advocacy persons in the local
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communities is a valuable step towards working against stigma. Community and religious leaders should be invited to contribute to such processes. There is a great need for further evidence on the effect of mental health training programmes in low-income countries. Thus, such a training programme for community leaders and primary health care personnel in South Sudan should include a research component if implemented [58]. Reducing the socioeconomic vulnerability amongst mentally ill, for instance by providing greater employment opportunities, will contribute to minimising stigmas against the mentally ill [59]. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
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