Attitudes and beliefs about mental illness among relatives of patients with schizophrenia

Abstract

Background: Schizophrenia is a mental disease with inability to differentiate real from unreal. In many African cultures a traditional view on mental disease results in stigma, negative attitudes, and ignorance of the patient and their symptoms.

Objective: To explore the different attitudes and beliefs amongst relatives of patients having schizophrenia.

Method: Cross-sectional survey among relatives of patients with schizophrenia treated at Butabika Mental Hospital, Kampala, Uganda. 

Results: A total of 44 were included. 30% believed schizophrenia to be a brain disease, 32% thought the cause was supernatural. The majority (80%) thought that schizophrenia can be treated and preferably in hospitals (91%); 66% felt the best way to reduce schizophrenia was to pray to God, and many stated that being with the patients (73%) or letting them be part of the community (80%) was good ways of helping the patients.  

Conclusion: Beliefs about supernatural causes of schizophrenia and stigmatizing are still present in Uganda. However among participants many had positive attitude towards letting the patients be part of community. Education of the communities could be a way of improving the awareness of mental disorders and the role that the community play in recovery from mental illness.

Keywords: schizophrenia, mental illness; stigma; attitudes; beliefs

Introduction

Schizophrenia is a mental disorder characterized by abnormal social behaviour and failure to recognize reality.  Symptoms include delusions, disordered thoughts and speech, hallucinations, poverty of speech, lack of ability to enjoy things, poor motivation, and lack of desire to form relationships [1].

The causes include genetic factors (8-10% risk if a first degree relative has schizophrenia), environmental, substance abuse, and socioeconomic.

Approximately 24 million people worldwide suffer from schizophrenia with a prevalence rate of 0.5-1% across racial and socioeconomic factors. The disease resulted in 20,000 deaths in 2010 due to neglect and lack of basic treatment [2]. Africa is a low resource continent with many predisposing factors such as substance abuse like khat and few diagnosing and treating facilities. The low number of specialists in the psychiatric field makes the diagnosis and treatment of mental diseases difficult.

Many African families have traditional views about schizophrenia resulting in stigmatisation and negative attitudes which may delay treatment and cause worse outcomes [3,4].  These are passed down the generations in spite of available modern explanations [5].

The purpose of the study was to explore the different attitudes and beliefs among relatives of patients having schizophrenia.

Method

The research was conducted at Butabika Hospital, Kampala, Uganda. The study was cross-sectional using a 24-item self-administered questionnaire developed using items from the following:

• Questionnaire developed for the World Psychiatric Association Program to Reduce Stigma and Discrimination because of Schizophrenia [6]
• The Fear and Behavioral Intentions toward the mentally ill (FABI) questionnaire [7]
• The Community Attitudes to Mental Illness (CAMI) scale [8].

Participants were relatives of patients with schizophrenia aged 18 years or above, either accompanying the patient as an in-patient or out-patient.

Chi-square tests were used to compare the answers based on sociodemographic characteristics. This was used to identify any significant differences in responses among men and women, between two educational levels (primary/secondary versus tertiary), and two different areas of living (rural and urban). The analysis was done using Stata version 12 and Microsoft excel.

Results

Forty-four relatives completed the questionnaire. Socio-demographic characteristics are presented in Table 1. The cause of schizophrenia was believed by participants to be: brain disease (30%), evil spirit (15%), drug/alcohol abuse (14%), witchcraft (11%), genetic (11%), poverty (9%), or a curse (6%).

Table 1. Socio-demographic characteristics of the participants

Characteristic	n	%
Total	44	100
Gender
Male	19	43
Female	25	57
Age
<20	5	11
20-<40	21	48
40-<60	12	27
≥60	6	14
Relationship to patient
Parent	12	27
Sibling	11	25
Spouse	3	7
Son/daughter	10	23
Other	8	17
Education
Primary	18	41
Secondary	19	43
Tertiary	7	16
Residence
Rural	30	68
Town	14	32
Religion
Christian	37	84
Muslim	5	11
Other	2	5

Table 2 shows that 80% of the participants believed that treatment of schizophrenia is possible and 45% believed that it can be inherited but many (27%) were unsure and declared that they did not know.  Over 90% believed that hospital is the best place for treatment, 5% believed in witch doctors, and 5% stated that church could be the best place for help.   No one believed in going to traditional healers or ancestors. Table 2 sets out the various perceptions that schizophrenia arises as a punishment (43%), and also lists the “treatment” options e.g. praying (66%) to God. Tables 3 and 4 describes additional attitudes.

Table 2. Beliefs about schizophrenia

Beliefs	Gender				Education			Residence
	Total	Male	Female		Primary/    secondary	Tertiery		Town	Rural
		n (%)	n (%)	p-value	n (%)	n (%)	p-value	n (%)	n (%)	p-value
	n (%)	n=19	n=25		n=27	n=7		n=30	n=14
Treatment of schizophrenia is possible
Strongly agree	16 (36)	8 (42)	8 (32)	0.84	13 (35)	3 (43)	0.69	11 (37)	5 (36)	0.39
Agree	19 (43)	7 (37)	12 (48)		16 (43)	3 (43)		15 (50)	4 (29)
Disagree	1 (2)	1 (5)	0 (0)		1 (3)	0 (0)		1 (3)	0 (0)
Strongly disagree	0 (0)	0 (0)	0 (0)		0 (0)	0 (0)		0 (0)	0 (0)
Dont know	8 (18)	3 (16)	5 (20)		7 (19)	1 (14)		3 (10)	5 (36)
The best place for treatment is
Witch doctors	2 (5)	2 (11)	0 (0)	0.24	2 (5)	0 (0)	0.66	2 (7)	0 (0)	0.54
Traditional healers	0 (0)	0 (0)	0 (0)		0 (0)	0 (0)		0 (0)	0 (0)
Hospital	40 (91)	16 (84)	24 (96)		33 (89)	7 (100)		27 (90)	13 (93)
Ancestors burial places	0 (0)	0 (0)	0 (0)		0 (0)	0 (0)		0 (0)	0 (0)
Church	2 (5)	1 (5)	1 (4)		2 (5)	0 (0)		1 (3)	1 (7)
Other	0 (0)	0 (0)	0 (0)		0 (0)	0 (0)		0 (0)	0 (0)
Schizophrenia is a punishment from the following
God	8(18)	1(5)	7(28)	0.24	8(22)	0(0)	0.60	5(17)	3(21)	0.53
Ancestors	4(9)	2(11)	2(8)		3(8)	1(14)		3(10)	1(7)
Wrong doing	4(9)	1(5)	3(12)		4(11)	0(0)		2(7)	2(14)
Drug abuse	9(20)	3(16)	6(24)		8(22)	1(14)		5(17)	4(29)
It is not a punishment	19(43)	12(63)	7(28)		14(38)	5(71)		15(50)	4(29
Rich people cannot become mentally ill
Strongly agree	5(11)	2(11)	3(12)	0.26	4(11)	1(14)	0.31	4(13)	1(7)	0.16
Agree	8(18)	2(11)	6(24)		8(22)	0(0)		7(23)	1(7)
Disagree	14(32)	5(26)	9(36)		13(35)	1(14)		9(30)	5(36)
Strongly disagree	10(23)	7(37)	3(12)		6(16)	4(57)		6(20)	4(29)
Dont know	7(16)	3(16)	4(16)		6(16)	1(14)		4(13)	3(21)
What can be done to stop/reduce schizophrenia
Respect ancestors	5(11)	1(5)	4(16)	0.053	5(14)	0(0)	0.49	3(10)	2(14)	0.11
Pray to God	29(66)	12(63)	17(68)		23(62)	6(86)		22(73)	7(50)
Wealth	3(7)	0(0)	3(12)		3(8)	0(0)		3(10)	0(0)
Avoid curse	4(9)	4(21)	0(0)		4(11)	0(0)		1(3)	3(21)
Other	3(7)	2(11)	1(4)		2(5)	1(14)		1(3)	2(14)
Schizophrenia can be inherited
Strongly agree	5(11)		4(16)	0.12	5(14)	0(0)	0.70	4(13)	1(7)	0.89
Agree	15(34)		8(32)		12(32)	3(43)		9(30)	6(43)
Disagree	5(11)		3(12)		4(11)	1(14)		4(13)	1(7)
Strongly disagree	7(16)		2(8)		6(16)	1(14)		5(17)	2(14)
Dont know	12(27)		8(32)		10(27)	2(29)		8(27)	4(29)

When asked how the family can help the patient the great majority (89%) suggested taking the patient to the hospital. A larger proportion (32%) suggested talking to the patients, while small numbers recommended isolation, discipline, and to lock in the patient.

Table 3. Attitude towards schizophrenia

Attitude	Gender				Education			Residences
	Total	Male	Female		Primary/     Secondary	Tertiary		Town	Rural
		n(%)	n(%)	p-value	n(%)	n(%)	p-value	n(%)	n(%)	p-value
	n(%)	n=19	n=25		n=27	n=7		n=30	n=14
Schizophrenic people should not be living with people and spend money like other family members
Strongly agree	9(20)	3(16)	6(24)	0.31	9(24)	0(0)	0.69	8(27)	1(7)	0.97
Agree	12(27)	5(26)	7(28)		9(24)	3(43)		5(17)	7(50)
Disagree	12(27)	6(32)	6(24)		8(22)	4(57)		10(33)	2(14)
Strongly  disagree	7(16)	4(21)	3(12)		7(19)	0(0)		5(17)	2(14)
Don’t know	4(9)	1(5)	3(12)		4(11)	0(0)		2(7)	2(14)
The best treatment for schizophrenic patients is to be part of normal community
Strongly agree	13(30)	3(16)	10(40)	0.64	12(32)	1(14)	0.94	11(37)	2(14)	0.27
Agree	22(50)	14(74)	8(32)		16(43)	6(87)		13(43)	9(64)
Disagree	4(9)	0(0)	4(16)		4(11)	0(0)		3(10)	1(7)
Strongly disagree	2(5)	1(5)	1(4)		2(5)	0(0)		1(3)	1(7)
Don’t know	3(7)	1(5)	2(8)		3(8)	0(0)		2(7)	1(7)
Being together with schizophrenic patient is best way to improve their health
Strongly agree	13(30)	6(32)	7(28)	0.95	11(30)	2(29)	0.46	10(33)	3(21)	0.35
Agree	19(43)	9(47)	10(40)		15(40)	4(57)		13(43)	6(43)
Disagree	5(11)	2(11)	3(12)		5(14)	0(0)		3(10)	2(14)
Strongly disagree	2(5)	1(5)	1(4)		2(5)	0(0)		1(3)	1(7)
Don’t know	5(11)	1(5)	4(16)		4(11)	1(14)		3(10)	2(14)

 

Figures 1 and 2 show who the participants thought should care for the patient with the majority (in both education and location groups) thought it should be the family, followed by the government (particularly in rural areas). Smaller numbers answered ‘God’, or the patients themselves. None in the tertiary education group suggested that ‘God’

 

Figure 1. Who should be responsible for proper care of the schizophrenic patient? By percentage of participants, comparing primary/secondary with tertiary education.

 

Figure 2. Who should be responsible for proper care of the schizophrenic patient? By percentage of participants, comparing town and rural residence.

Discussion

This study has demonstrated different stigmatizing attitudes and beliefs among the relatives of schizophrenic patients attending hospital.  It was found that a large proportion of the participants still endorsed culturally accepted causations of schizophrenia such as evil spirits, curses, and witchcraft.  Compared with other studies in rural areas we found a lower percentage of participants believing in supernatural causes of schizophrenia [4,9,10]. Our results highlighted a variety of biological factors, supernatural causes, and alcohol and drug abuse.

Most participants believed that schizophrenia could be treated (80%) and that the best place for this is hospital (91%). But it must be re-emphasised that our patients were hospital based and may not reflect opinion in the out-of -hospital population. Certainly other studies in rural settings found that traditional methods such as consulting wise men or traditional healers were preferred over hospital treatment [9].  Nevertheless we still found a significant number in our study who thought that schizophrenia was a punishment.

The wealthier you are was considered by over half of the participants as a protection against schizophrenia; this may be related in some way to the level of education. Several other studies have found that traditional medicine and supernatural forces play a very important part in the beliefs about schizophrenia, also among health professionals [4, 11].

There was a strange mismatch of the attitude towards living with people with schizophrenia. Almost half did not think that patients should be living in the community and spend money like other people but 80% believed that the best treatment is to be part of community. This needs further investigation.

This is small study and hence some of the numerical differences might have reached significance with greater number.

Conclusion

Beliefs about supernatural causes of schizophrenia and stigmatizing, negative attitudes towards people with mental disorders are still present in Uganda due to lack of enough awareness in the population regardless of residential areas. However, a large proportion of the participants felt that the best place for treatment of the patient would be the community and there seems to be a willingness to include the patients in the community although education about the disease, symptoms, and how to best help the patient is needed. Community awareness could be conducted as an education on the known bio-psycho-social basis of mental disorders and the role that community and social inclusion play in recovery from mental illness.

Conflict of interest: All authors have declared that there is no conflict of interest.

Funding: No financial assistance or grants were solicited or obtained during the course of preparing this article.

References

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10. Adebowale T, Oqunlesi A. Beliefs and knowledge about aetiology of mental illness among Nigerian psychiatric patients and their relatives. Afr J Med Med Sci 1999; 28: 35–41.
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In South Sudan the options for treatment and care of mentally ill is very limited with no psychiatric hospitals and few psychiatric medications available. According to a 2016 report by Amnesty International only two psychiatrists are practicing in the country. Additionally health personnel have very little training and knowledge regarding mental illness and even if they had no accessible treatment options are available. The great majority of patients will therefore be entirely depended on their family and for many the stigmatization and lack of facilities will result in prison. While there is no easy and simple way to solve the issues community education regarding the more common mental diseases is extremely important to reduce stigmatization. Likewise clinical guidelines for diagnosing and treatment must be made available for health personnel. See  Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders.

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