INTRODUCTION:

Global attempts to improve health continue to ignore mental health. Mental illness is on the rise worldwide, affecting 970 million people globally¹ causing severe health dangers, social, human rights, and economic consequences². The Eastern Mediterranean countries (EMC) demonstrated a high prevalence of mental problems. A large-scale study of regional residents in the EMC has revealed that the average person experiences emotional distress between 15.6% and 35.5% of the time, more than the complex emergencies witnessed. In addition, the prevalence estimates for psychiatric diseases in EMC over 12 months varied widely from 11.0–40.1%³. It is a widespread misconception to believe that people suffering from mental illness are more likely to to engage in criminal behaviour, act violently, and be antagonistic to others⁴. It was supported by the global study of mental illness stigma⁵ which presented that 7-8% and 15-16% of the respondents in developed and developing countries considered PMI more violent and dangerous. People with mental illness (PWMI) often become the victims of stigma, prejudice, negative attitudes, and discrimination, causing fear, social isolation, and exclusion⁶.

Stigma is a source of shame that distinguishes a person from others. Discrimination and stigma have far-reaching and widespread negative consequences on mental health, creating obstacles for those with mental illness to receive treatment⁷. Ignorance, prejudice, and discrimination combine to form stigma, delay therapy, and force people to seek unprofessional solutions impeding the efficient administration of mental health services all over the globe^7,8. For example, a study by Pawar and colleagues⁹ in the Indian Armed Forces showed that approximately 90% and 84% of PMI admitted to being stigmatized and discriminated against for mental issues, respectively. In addition, there is a wide range of stigmatizing attitudes, behaviours, and perspectives on mental health care among Arabs¹⁰. Several Arab countries have reported a global prevalence of prejudice against people with PMI^8,10-14.

Stigma can significantly impact all aspects of a person's life with a mental ailment. The PWMI experiencing public stigma are often denied employment and decent housing and are even subjected to rejection from family members and friends¹⁵. The prevailing fear that the mentally ill patient would harm others and themselves would create self-stigma in the PWMI, leading to social isolation, low self-esteem, mistrust¹⁵, feelings of shame, agreeing with generalizations about mental illness, and having a sour outlook on life and low empowerment¹⁶. On the other hand, stigma followed by discrimination significantly negatively affects self-esteem and trust^{17,18, 19}. Stigmatizing would force the PMI to live under the pressure of people's expectations or compromise in matters dealing with his life's routines²⁰.

Other than the general public and family members^8,21,22healthcare professionals^22,23,24, stakeholders²⁵and students²⁶especially nursing students^27,28and medical students²⁹ are also significant source of societal shame, holding a varied level of stigma and mixed views of those who have a mental illness, globally^30,31 and locally^8,14 causing reluctant to seek help. Numerous studies conducted on the general public have found that people in rural communities in Southern India have a negative to ambivalent attitude towards those who suffer from mental illness^32,33,34,35. Many Indian carers of the family of patients with mental illness rated the mental condition as a moderate to high burden and distressing^36,37,38. If carers and other family members have a negative view of people with mental illness, it can be the source of stigma^39,40,41. A survey of mental health workers' attitudes and understanding of ECT treatment found that the vast majority (55%) had at least average knowledge and a positive attitude (82%) toward treating their mentally ill patients. However, similar research conducted in Puducherry, India, found that most carers for patients with mental illness had inadequate information and a relatively supportive mindset towards mental illness⁴⁰. Furthermore, there was a strong correlation between the caregiver's level of education and their relationship with the patient who was mentally ill⁴¹. Among the student population, In Turkey, for instance, the study discovered a balance of positive and negative views regarding mental illness among nursing students¹⁹. Similar findings were found in European countries, which showed that Portuguese nurses' sentiments were highly positive, whereas Lithuanian nurses' opinions were quite negative³¹. Negative attitudes among healthcare students have also been reported in several studies^{15,16,27,29,42}. Therefore being ignorant and lacking knowledge has caused such disparity in the views of different health professionals⁴³. However, being knowledgeable about mental disorders has significantly lowered the stigmatizing attitude among nursing students necessitating immediate anti-stigma measures to discuss unfavorable views about patients with mental illness^16,44.

Furthermore, a positive outlook towards mental illness was also expressed in several studies^4,2745. Despite negative stereotypical beliefs, cross-sectional research of nursing students in Saudi Arabia by Shammari²⁷ found an overall good attitude towards the patient with mental illness. Another study conducted in India showed a positive attitude among nursing students⁴⁵.

Since nursing students are crucial to the healthcare industry, the stigma surrounding mental illness has real-world consequences for nursing education. However, if students of health professions, such as doctors and nurses, hold negative views, it could hinder their ability to advocate for reducing stigma and impede therapeutic contact with the PMI and mental health care team⁴⁵. As a result, mistreatment of the patient with mental illness and neglect from the healthcare teams, will in turn, affect the mental quality of life, leading to further discrimination and stigma in the healthcare team itself^{18, 27}. Mentally ill patients must be treated with empathy and compassion by building an excellent therapeutic rapport. A therapeutic patient-nurse relationship demands a favourable attitude among nurses. Therefore strategies to combat the stigmatizing attitudes are urgently needed and should be promoted right way in health professional courses⁷.

The mental health course is one of the core courses in the undergraduate nursing curriculum taught at different years of study across the globe. One of the nursing colleges in Gujarat, India, conducted a study comparing nursing students' perspectives on mental illness between their first and fourth years of study and discovered that first-year students were more authoritarian than their fourth-year counterparts. The positive outlook, however, was found to be significantly higher among fourth-year students than first-year students at the .001 level of significance²⁸. In Oman, a course on mental health nursing is given in the fourth year of nursing school. It is a three-credit course (actual 45 hours) with a practicum of 2 credits, equivalent to 90 hours of actual clinical teaching. Nursing students have predetermined ideas or views about mentally ill patients⁴⁵. Students must be informed and instructed to respect and care with dignity, empathy, and compassion toward the mentally ill patient. It is possible if they harbour a positive attitude towards PMI. Exploring the views of student nurses regarding stigmatized attitudes toward mental illness would worldwide scope for the nursing practice⁴⁵. This research aimed to assess nursing students' perspectives on mental illness and compare these perspectives based on demographic variables.

MATERIALS AND METHODS:

Study design:

This study employed a quantitative, non-experimental, descriptive-comparative methodology to compare the perspectives of first-, second-, and third-year nursing students on mental illness.

Sample:

The nursing students at the undergraduate level who were not exposed to mental health courses from one of the branches of Oman College of Health Sciences, Oman, were recruited to the study.

Sampling technique and size:

The investigators selected individuals based on their proximity and availability of access using a non-probability convenience sampling strategy. Using Slovin's approach, a sample size was calculated with a 95% confidence level and a 5% margin of error. The total sample size was 177 instead of the anticipated 155, with a non-response rate of 10%. Students studying year four were excluded since the level four students took the mental health course during the data collection time.

Instrument and data collection:

A pre-validated tool, "Attitude Scale towards Patients with Mental Illness-Singapore Version" (AMI-SV), developed by Yuan et al.²², was used in this study and was administered to the participants as an online-based survey. AMI-SV has 20 items to be rated on a 5-point Likert scale (1 being strongly disagreed, to 5 being strongly agreed) and was grouped into four main factors: social distancing (three statements); tolerance/support community care (nine statements); social restrictiveness (three statements); prejudice and misconceptions (five statements). A lower score in the first, third, and fourth factors and a higher second-factor score were described as having a positive attitude towards PWMI. The tool was reliable, with acceptable reliability scores of 0.791, 0.735, 0.663, and 0.671 for the first, second, third, and fourth factors reported by the original author²². The demographic profile of the students, such as age, gender, marital status, year of study and history of family or relative having a mental disease, and history of direct contact with the mentally ill patient, were collected. Piloting was done before the main study with 17 samples. No methodological issues were addressed during the pilot study; hence, the researcher proceeded to the main study. Over two weeks, responses were collected via a Google Survey Form. Students were given a participant information sheet outlining the study's purpose, benefits, and risks before any data collection, encouraged to participate voluntarily, and allowed to withdraw from the study if they felt it was necessary.

Data analysis:

Using SPSS (Statistical Package for the Social Science) package 23.0 Version, extracted data from the Google survey form were computed using descriptive (frequency distribution, percentage, mean, median, and standard deviation) and advanced statistics (ANOVA and t-test).

Ethical Consideration:

The Oman College of Health Sciences Ethical and Approval Committee approved the study (MOH/OCHS/REC/2021/12). After receiving permission from their individual college Associate Dean, students were invited to participate in the study by the branch's research focal point.

Table 4: ANOVA/t-test for finding the significant difference in the stigmatizing attitudes among students based on the demographic variables.

Demographic variables

Social distancing

Tolerance/support for community care

Social restrictiveness

Prejudice and misconception

M ± SD

F-value/

P-value

M ± SD

F-value/

P-value

M ± SD

F-value/

P-value

M±SD

F-value/

P-value

Age

18-19

20-21

22-23

2.80±.916

2.57±.841

2.78±1.05

1.423

(p=0.244)

4.84±0.550

4.59±0.671

4.51±0.742

3.036

(p=0.051)

2.55±0.872

2.37±0.789

2.51±0.971

0.785

(p=0.458)

3.16±0.617

3.05±0.534

3.07±0.579

0.675

(p=0.511)

Gender

Female

Male

2.60±0.894

2.97±0.852

2.127

(p=0.039) *

4.61±0.648

4.80±0.724

1.327

(p=0.193)

2.31±.770

3.06±0.908

4.130

(p=0.000)*

3.04±0.537

3.31±0.634

2.200

(p=0.034)*

Marital Status

Married

Single

3.50±0.577

2.638±0.893

2.914

(p=0.054)

4.53±0.246

4.64±0.669

0.835

(p=0.450)

3.33±0.384

2.41±0.835

4.535

(p=0.013*)

2.90±0.200

3.08±0.567

1.683

(p=0.164)

Academic year

Year one

Year two

Year three

8.40±2.632

7.43±2.574

7.98±2.800

1.962

(p=0.144)

42.85±5.832

41.46±4.793

40.72±6.905

2.043

(p=0.133)

7.585±2.31

6.61±2.294

7.64±2.820

3.033

(p=0.051)

15.707±2.816

15.074±2.386

15.344±3.149

0.764

(p=0.468)

Family members/ relatives with MI

Yes

2.65±0.906

2.6±0.844

0.350

(p=0.728)

4.66±0.682

4.52±0.520

1.196

(p=0.239)

2.42±0.855

2.52±0.739

0.606

(p=0.549)

3.12±0.569

2.90±0.487

1.892

(p=0.067)

History of contact with PMI

Yes

2.68±0.857

2.61±0.955

0.596

(p=0.552)

4.61±0.723

4.67±0.558

0.593

(p=0.554)

2.44±0.826

2.42±0.863

0.124

(p=0.901)

3.12±0.572

3.02±0.543

1.128

(p=0.261)

Furthermore, data in Table 4 shows the ANOVA/t-test results showing attitude factors based on the demographic profile. Attitudes toward social distancing (p=.039), Social restrictiveness (p=.000), and prejudice and misconception (p=.034) gender-wise varied significantly, demonstrating lower mean scores among females indicating positive attitude for factor one (M±SD=2.60±.894); three (M±SD=2.31±.770); and four (M±SD=3.04±.537) than their counterparts males (M±SD=2.97±.852); (M±SD=3.06±.908); (M±SD=3.31±.634). In addition, the difference between the attitudes of single and married pupils toward social restrictiveness was statistically significant (p=.013). The remaining demographic variables did not demonstrate any significant differences in attitude factors.

DISCUSSION:

The present study was the baseline enquiry to explore nursing students' attitudes toward PWMI. It was the first of its kind in the current setting in Oman. Previous studies in Oman comprised a more general population, relatives of mentally ill patients, mental health professionals, and a relatively small number of general student population^8,14. Unlike the other studies done across the globe that included primarily medical and nursing students and mainly evaluated the influence of mental health courses on the attitudes towards PMI, our study was a novel attempt that compared the stigmatizing attitude toward PWMI among the groups of nursing students year I, II and III studying in one of the branches of OCHS. This study used the questionnaire that was the Singapore version of the AMI scale with 20 items measuring the views towards four attitude factors such as 1) Social distancing, 2) Tolerance/support community care, 3) Social restrictiveness, and 4) Prejudices and misconception²². The positive attitudes toward mental illness are determined if the subject's median score were less in factors one, two, and four and higher in factor two.

In the present study, median scores for factors one, two, three, and four were 8, 42, 7, and 15, respectively, and were utilized to compare the scale elements by academic year; we found that students were more likely to have positive views about social distancing (95; 53.7%), social restrictiveness (97; 54.8%), and prejudice and misperception (99; 55.9%) than support for community care (92; 52%). The above interpretations are consistent with a study conducted in Singapore to explore attitudes toward mental illness²² and several other studies worldwide^4,27,45. However, stereotyped and stigmatizing attitudes were also prevalent in many studies^15-16,27,44 that contradicted the present study results. However, Poreddi⁴⁵ supported our findings, demonstrating a less stigmatized attitude among nurses.

Our study hypothesis was to identify a statistically significant difference in views regarding mental illness based on the study year. The study findings showed no significant difference (p>.05) for all of the attitude factors among nursing students based on the year of the study (Table 3). Though there was no significant difference between groups, second-year students had the lowest mean scores for social distancing, social restrictiveness, and prejudice and misperception, indicating favourable attitudes toward PWMI. In contrast, the first-year nursing students had higher mean scores for social distancing, prejudice, and misconceptions than second and third-year students. This indicates senior students had favorable attitudes towards social distancing, social restrictiveness, and prejudice and misconception; however, year one students were more favourable in their attitudes towards' tolerance/support for community care' than their senior counterparts. These findings were supported by several studies^19,45. Our results were incongruent with a study conducted in Singapore that investigated the stigmatizing attitude toward mental illness patients among medical and nursing students that showed a significant difference between the groups (p<0.05)²². However, one study finding showed congruency with our results, presenting no significant difference between first and third-year students based on their year of study. According to the survey results regarding beliefs about mental health, almost half of the students thought that PMWIs were either mentally sick or crazy. When comparing the two groups on the perception of mental illness, there were no significant differences (p =.12)⁴⁶. Furthermore, exposure to the mental health course could affect the attitude toward mental illness. According to Rodríguez-Almagro's study⁴⁴, students' stigma against mental illness will likely reduce as they progress via various nursing education levels, owing to their training during the study. For example, the stigma levels were moderate among 359 nursing students in their degree course and were significantly lower among the third and 4^th-year students after receiving the mental health training and among students whose family members have a mental illness⁴⁴. So the clarity concerning this finding is lacking as this study did not attempt to see the effectiveness of the mental health courses in determining the attitude. The fact that first-year students had a favourable attitude toward tolerance and supported community care while the senior students demonstrated a negative attitude toward the same factor needs further investigation. However, the absence of a significant difference in the attitude levels among all students would lead to the understanding that students have some awareness and have been exposed to similar facts and figures on mental health via other means, such as media.

The mental health course was introduced in the fourth year as per Oman's nursing curriculum, and the fourth-year students were undertaking that course. Therefore 4^th, fourth-year students were excluded from the study. Students in the year one to three have no prior exposure to mental health disorders and no contact with PWMI during their clinical experience in the previous semesters either. The existence of an almost equal number of students overall with mixed responses of positive and negative attitudes may be attributed to cultural differences unlike across the globe. For instance, Oman is one of the Arab countries that believe that mental health is due to God's punishment as the evil spirit's influence⁸. On the other hand, nursing students are part of the health system, and they emerge into the health care system by showing a positive attitude among nursing students, indicating openness to mental views, which would help render positive care and outcome.

The majority of nursing students in this survey were between the ages of 20 and 21, and women outnumbered men by a ratio of 83.6% to 16.4%. In Arab countries like Oman enrollment for nursing profession is higher among females as nursing is a female-dominated profession, hence the number of female students recruited for the study is justifiable. Gender significantly influenced their views towards social distancing and social restrictiveness. Females were more favourable toward social distancing and social restrictiveness. They felt that mentally ill patients should not be isolated but allowed to interact socially and not be burdened by society. These findings contradicted the findings of Sari et al.¹⁵,who validated in their study that gender does not influence the attitude level among nursing students toward the patient with mental disease.

Regarding other demographic factors, however, there was no significant variation in attitude scores except the marital status, where singles were more tolerant and supportive of community care than to married students. These findings are incongruent with several studies^15,22,27.For example, Yuan and colleagues²² found that Singaporeans' attitudes about people with mental illness varied significantly by race, marital status, educational level, and where they lived in the country. A previous study done in Oman among the general public also showed a significant difference in attitude based on age⁸. A similar study in Spain showed disgrace was higher among understudies with a family history of patients with mental ailment⁴⁴. It is rationalized in several studies that the varied stigmatizing attitudes can be attributed to the cultural environment, organizational structure, urban or rural living, and significant contact with PMI. ^{14, 31}

CONCLUSION:

Overall, undergraduate nursing students have a positive outlook on mental illness. In particular, they regard positively the concepts of "social distancing," "social restrictiveness," and "prejudice and misconception.” However, "tolerance/support for community care" was evaluated negatively, highlighting the need to increase students' awareness and exposure to these concepts during their early years of baccalaureate nursing education. Mental health is a global health concept to be appreciated, thereby sensitizing students toward mentally ill patients. Mixed responses to the study's factors among the students in different years of the study call for anti-stigma strategies to enhance the tolerance towards mentally ill patients and become aware of the prevailing social stigma around mentally ill patients and the health professionals rendering mental healthcare services and appreciating one's mental well-being.

It is further recommended that the study can be reproduced to study the attitude and perceptions of healthcare professional students towards mental health before and after the introduction of mental health courses to propose the necessary anti-stigma strategies to improve the attitude towards mental illness. Awareness programs and anti-stigma campaigns can further enhance their knowledge and shape their attitude toward mental illness. Subsequently, students need to be encouraged to educate the general public or their community since the student population is considered a part of the general population. Thus stigma and discrimination toward mentally ill patients are minimized. Nursing students need to have early exposure to Mental Health Nursing practicum, enhance communication, and recognize their feelings and emotions to provide optimum patient care with empathy.

Since this study is just a snapshot of how nursing students felt about mental illness at one point in time, it cannot show how their attitudes have changed over time. A representative sample from more than one OCHS branch would have strengthened the external validity of the findings. Hence generalization is limited to the participants under study. The social desirability factor must have influenced the findings as a tool was administered through the year coordinators, and frequent request was made to fill out the survey for the year coordinators to reach the desired sample size.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

The researchers acknowledge the authors of the instrument²² used in this study for allowing them to use it in our study. Also, thank the subjects who participated in the study.

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Received on 09.07.2023 Modified on 12.09.2023

Asian J. Nursing Education and Research. 2023; 13(4):241-248.

DOI: 10.52711/2349-2996.2023.00051

Factor	Mean	SD	Median
Social distancing	7.966	2.686	8
Tolerance/ Support for community care	41.729	5.962	42
Social Restrictiveness	7.305	2.515	7
Prejudice and Misconception	15.396	2.807	15