Mental health stigma and attitudes to psychiatry among Bangladeshi medical students

Stakeholder perspectives of mental healthcare services in Bangladesh, its challenges and opportunities: a qualitative study

This study explores Bangladesh's mental health services from an individual- and system-level perspective and provides insights and recommendations for strengthening it's mental health system. We conducted 13 in-depth interviews and 2 focus group discussions. Thirty-one participants were recruited using a combination of purposive and snowball sampling methods. All interviews and group discussions were audio-recorded and transcribed, and key findings were translated from Bengali to English. Data were coded manually and analysed using a thematic and narrative analysis approach. Stakeholders perceived scarcity of service availability at the peripheral level, shortage of professionals, weak referral systems, lack of policy implementation and regulatory mechanisms were significant challenges to the mental health system in Bangladesh. At the population level, low levels of mental health literacy, high societal stigma, and treatment costs were barriers to accessing mental healthcare. Key recommendations included increasing the number of mental health workers and capacity building, strengthening regulatory mechanisms to enhance the quality of care within the health systems, and raising awareness about mental health. Introducing measures that relate to tackling stigma, mental health literacy as well as building the capacity of the health workforce and governance systems will help ensure universal mental health coverage.

An Examination of Barriers to Accessing Mental Health Care, and Their Association with Depression, Stress, Suicidal Ideation, and Wellness in a Bangladeshi University Student Sample

BACKGROUND

The mental health burden is high and rising among Bangladeshi university students. Understanding barriers to mental healthcare and how barriers impact mental health outcomes may inform the development of targeted interventions to decrease barriers and improve access to care.

AIMS

This study identifies barriers to mental healthcare and their association with mental health outcomes in a Bangladeshi university student sample.

METHODS

We conducted a cross-sectional survey (n = 350) on stigma-related, attitudinal, and instrumental barriers to accessing mental healthcare among Bangladeshi university students. We examined the association between stigma and non-stigma (i.e., attitudinal and instrumental) barriers with four mental health outcomes: suicidal ideation, depression, high perceived stress, and wellness.

RESULTS

Attitudinal barriers were the most reported barriers. Stigma-related barriers were significant for individuals who had experienced suicidal ideation (aOR = 2.97, p = 0.001), not for individuals with depression. Non-stigma-related barriers were significant for individuals who had experienced depression (aOR = 2.80, p = 0.011).

CONCLUSIONS

The current work advances our understanding of how to improve access to mental healthcare among university students in Bangladesh. Stigma-related barriers were particularly salient for individuals who experienced suicidal ideation. Further study is needed on how stigma may impact access to care distinctly for different mental health problems among Bangladeshi university students.

A qualitative exploration of university student perspectives on mindfulness-based stress reduction exercises via smartphone app in Bangladesh

Purpose

Mental health problems are proliferating, and access to mental health care is difficult due to barriers imposed by the COVID-19 pandemic in low-income countries such as Bangladesh. University students are susceptible to mental health concerns, given their unique stressors (i.e., academic pressure, new social environment). Mindfulness techniques can promote mental health , yet their acceptability has not been examined among Bangladeshi university students. These techniques can be used on a digital app, to decrease barriers to use.Qualitative methods were used to examine the acceptability of mindfulness among university students in Bangladesh. In-depth interviews (n = 12) were conducted to examine student reactions to linguistically (Bangla) and culturally adapted mindfulness exercises. Thematic analysis generated three themes (1) previous experience with mindfulness (2) positive responses to and (3) improvements to mindfulness exercises.

Results

The results showed favourable attitudes towards the mindfulness content; students expressed positive psychological and physiological reactions. Students welcomed the concept of using these exercises on an app and felt it could overcomepast barriers to help-seeking.

Conclusions

This evidence suggests the value of exploring the acceptability of an app with mindfulness exercises for mental health promotion through a larger-scale pilot study in university students in Bangladesh.

The prevalence of feeding and eating disorders symptomology in medical students: an updated systematic review, meta-analysis, and meta-regression

PURPOSE

Medical students have a higher risk of developing psychological issues, such as feeding and eating disorders (FEDs). In the past few years, a major increase was observed in the number of studies on the topic. The goal of this review was to estimate the prevalence risk of FEDs and its associated risk factors in medical students.

METHODS

Nine electronic databases were used to conduct an electronic search from the inception of the databases until 15^th September 2021. The DerSimonian-Laird technique was used to pool the estimates using random-effects meta-analysis. The prevalence of FEDs risk in medical students was the major outcome of interest. Data were analyzed globally, by country, by research measure and by culture. Sex, age, and body mass index were examined as potential confounders using meta-regression analysis.

RESULTS

A random-effects meta-analysis evaluating the prevalence of FEDs in medical students (K = 35, N = 21,383) generated a pooled prevalence rate of 17.35% (95% CI 14.15-21.10%), heterogeneity [Q = 1528 (34), P = 0.001], τ² = 0.51 (95% CI 0.36-1.05), τ = 0.71 (95% CI 0.59-1.02), I² = 97.8%; H = 6.70 (95% CI 6.19-7.26). Age and sex were not significant predictors. Body mass index, culture and used research tool were significant confounders.

CONCLUSION

The prevalence of FEDs symptoms in medical students was estimated to be 17.35%. Future prospective studies are urgently needed to construct prevention and treatment programs to provide better outcomes for students at risk of or suffering from FEDs.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

Medical students’ attitudes toward psychiatry in Indonesia

Nearly two-thirds of psychiatric patients are reluctant to seek help from healthcare professionals due to stigma, discrimination, and negligence that evolve around the community, including healthcare providers. Future health professionals should have a positive attitude toward psychiatry and patients with mental health problems. Thus, it is vital to identify medical students’ attitudes toward psychiatry as future healthcare providers. The authors conducted a cross-sectional study by using online questionnaires of “Perceptions of Psychiatry” in Faculty of Medicine Universitas Indonesia, with first- and fourth-year students (before psychiatric rotation), as well as fifth-year students and alumni (after psychiatric rotation). Out of 250 questionnaires distributed, 224 subjects responded, with a response rate 89.6%. Chi-square or fisher analysis was conducted to know the correlation between gender and attitudes towards psychiatry. The frequency distribution method was applied to identify the degree of stigmatization from respondents. A mix of positive and negative perceptions towards psychiatry was identified. The overall response was favorable to both before and after psychiatric rotation groups. Differences in perceptions between male and female psychiatry students as a discipline and career were statistically significant. Correcting misapprehension and removing the stigma on psychiatry during medical education might decrease the stigma in the psychiatric field and patients.

Motivations Toward Using Digital Health and Exploring the Possibility of Using Digital Health for Mental Health in Bangladesh University Students: Cross-sectional Questionnaire Study

Background

Digital health is efficacious for the management and prevention of mental health (MH) problems. It is particularly helpful for the young adult population, who appreciate the autonomy digital health provides, and in low-income countries, where the prevalence of MH problems is high but the supply of professionals trained in MH is low.

Objective

The objectives of this study are 2-fold: to determine whether university students in Bangladesh find using digital health for MH promotion acceptable and to examine motivational factors for using digital health for MH.

Methods

This study used a cross-sectional survey to examine the likelihood that university students in Bangladesh (n=311) would use different forms of digital health platforms for MH promotion and assessed drivers of intention to use and actual use of digital health generally and digital health for MH through the lens of the Technology Acceptance Model. The results provided evidence that the university student population in Bangladesh is likely to use digital health to promote their MH.

Results

Social influence (adjusted odds ratio [aOR] 1.68, 95% CI 1.40-2.01; P<.001), ease of use (aOR 1.85, 95% CI 1.35-2.53; P<.001), and perceived usefulness (aOR 4.12, 95% CI 1.79-9.51; P=.001) of digital health were found to be significant drivers of the intention to use general digital health, and having an intention to use digital health (aOR 2.10, 95% CI 1.17-3.78; P=.01) had the greatest influence on actual use of digital health. Social influence (aOR 1.71, 95% CI 1.43-2.04; P<.001), perceived usefulness (aOR 8.92, 95% CI 4.18-19.04; P<.001), and use of general digital health (aOR 2.16, 95% CI 1.18-3.97; P=.01) were associated with higher intention to use digital health for MH. The use of general digital health (aOR 4.19, 95% CI 2.37-7.41; P<.001) was associated with the actual use of digital health for MH, as were greater non–stigma-related barriers to using traditional clinical MH services (aOR 2.05, 95% CI 1.10-3.80; P=.02).

Conclusions

Overall, we see that the use of digital health for MH is acceptable in this population and can be helpful for students who perceive barriers to receiving traditional care. We also gain insight into how to promote the intention to use digital health, which in turn promotes the actual use of digital health.

Motivations and barriers for clinical mental health help-seeking in Bangladeshi university students: a cross-sectional study

BACKGROUND

University and college students are vulnerable to developing depressive symptoms. People in low-income countries are disproportionately impacted by mental health problems, yet few studies examine routes to accessing clinical services. Examining motivation and barriers toward seeking clinical mental health services in university students in Bangladesh is important.

METHOD

Using a cross-sectional survey (n = 350), we assess the relationship between the constructs of autonomy, relatedness, and competency toward using clinical mental health practices (i.e. using professional resources, taking medication) with (1) positive views, (2) perceived need, and (3) use of clinical mental health services among Bangladeshi university students.

RESULTS

Results showed that the perceived need for mental health support was the predictor of the largest magnitude (aOR = 4.99, p = 0.005) for using clinical services. Having a positive view of clinical services was predictive of clinical service use (aOR = 2.87, p = 0.033); however, that association became insignificant (p = 0.054) when adjusting for the perceived need for mental health care. Of the SDT constructs, social influences were predictive of perceiving a need for mental health support, and mental health knowledge was predictive (aOR = 1.10, p = 0.001) of having a positive view of clinical mental health care.

CONCLUSION

Our findings show that knowledge of mental health is associated with positive views of mental health services, and that higher levels of stress and the presence of people with mental health problems are associated with the perception of a need for mental health care, which is ultimately responsible for using the services.

Exploring challenges in mental health service provisions for school-going adolescents in Sri Lanka

Schools provide an ideal setting for early, accessible intervention according to research conducted in developed countries for adolescents experiencing adverse mental health (MH). Many schools in South Asia, however, lack structured and standardized school counselling services. Research indicates that where services do exist, students are reluctant to access them due to perceived high risks and low benefits in MH help seeking. This paper explores the challenges experienced in MH provision from the perspective of school counsellors. A qualitative approach was chosen, and three main themes emerged from the data using the thematic analysis: negative perceptions of MH and counselling, the unwillingness to invest in MH services, and the challenges inherent in the system itself. The findings reveal cultural implications behind these challenges and suggest grassroots level initiatives that can be implemented within schools to reduce the barriers to service provision without the need for legislative changes at a national level.

Impact of Service User Video Presentations on Explicit and Implicit Stigma toward Mental Illness among Medical Students in Nepal: A Randomized Controlled Trial

This study evaluated the impact of didactic videos and service user testimonial videos on mental illness stigma among medical students. Two randomized controlled trials were conducted in Nepal. Study 1 examined stigma reduction for depression. Study 2 examined depression and psychosis. Participants were Nepali medical students (Study 1: n = 94, Study 2: n = 213) randomized to three conditions: a didactic video based on the mental health Gap Action Programme (mhGAP), a service user video about living with mental illness, or a control condition with no videos. In Study 1, videos only addressed depression. In Study 2, videos addressed depression and psychosis. In Study 1, both didactic and service user videos reduced stigma compared to the control. In Study 2 (depression and psychosis), there were no differences among the three arms. When comparing Study 1 and 2, there was greater stigma reduction in the service user video arm with only depression versus service user videos describing depression and psychosis. In summary, didactic and service user videos were associated with decreased stigma when content addressed only depression. However, no stigma reduction was seen when including depression and psychosis. This calls for considering different strategies to address stigma based on types of mental illnesses. ClinicalTrials.gov identifier: NCT03231761.

Geographic distribution and determinants of mental health stigma in central Mozambique

PURPOSE

This study describes patterns of community-level stigmatizing attitudes towards mental illness (MI) in central Mozambique.

METHODS

Data for this study come from a representative community household survey of 2933 respondents ≥ 18 years old in Manica and Sofala Provinces, Mozambique. Six MI stigma questions represented primary research outcomes. Bivariate and multivariable analyses examined the relationship between key explanatory factors and each stigma question. Spatial analyses analyzed the smoothed geographic distribution of responses to each question and explored the association between geographic location and MI stigma controlling for individual-level socio-demographic factors.

RESULTS

Stigmatizing attitudes towards MI are prevalent in central Mozambique. Analyses showed that males, people who live in urban places, divorced and widowed individuals, people aged 18-24, people with lower education, people endorsing no religion, and people in lower wealth quintiles tended to have significantly higher levels of stigmatizing attitudes towards MI. Individuals reporting depressive symptoms scored significantly higher on stigmatizing questions, potentially indicating internalized stigma. Geographic location is significantly associated with people's response to five of the stigma questions even after adjusting for individual-level factors.

CONCLUSION

Stigmatizing attitudes towards MI are common in central Mozambique and concentrated amongst specific socio-demographic groups. However, geographic analyses suggest that structural factors within communities and across regions may bear a greater influence on MI stigma than individual-level factors alone. Further implementation science should consider focusing on identifying the most significant modifiable structural factors associated with MI stigma in LMICs to inform the development, testing, and optimization of multi-level stigma prevention interventions.

The impact of a psychiatry clinical rotation on the attitude of South African final year medical students towards mental illness

BACKGROUND

Stigmatising attitudes of health care professionals towards mental illness can impede treatment provided for psychiatric patients. Many studies have reported undergraduate training to be a critical period for changing the attitudes of medical students, and one particularly valuable intervention strategy involves time spent in a clinical psychiatric rotation. In South Africa, medical students are exposed to a clinical rotation in psychiatry but there is no evidence to show whether this has an effect on attitudes toward mental illness.

METHODS

This prospective cohort study involved a convenience sample of 112 South African medical students in their 5th or 6th year of undergraduate training. This sample attended a 7-week psychiatry rotation. The Attitudes to Mental Illness Questionnaire (AMIQ) was used to assess students' attitudes toward mental illness before and after the clinical rotation which includes exposure to a number of psychiatric sub-divisions and limited didactic inputs.

RESULTS

There was a significant improvement (p < 0.01, t-test) in the students' attitude toward mental illness following the psychiatric rotation. Females displayed a more positive attitude towards mental illness at the end of the rotation compared to males. The participants' attitude significantly deteriorated for the non-psychiatric vignette describing diabetes (< 0.01, t-test).

CONCLUSIONS

Our findings suggest that clinical training and exposure to a psychiatric setting impacts positively on medical students' attitude towards mental illness, even when this training does not include any focused, didactic anti-stigma input.

Perceptions of mental illness etiology and treatment in Saudi Arabian healthcare students: A cross-sectional study

OBJECTIVES

Cultural beliefs often affect people's attitude toward mental illness and their help-seeking behavior. Belief in superstitious causes of mental illness can lead to seeking help from non-medical practitioners, which might hinder treatment. This study aimed to explore the perception of mental illness and help-seeking behavior among healthcare students.

METHODS

A cross-sectional study carried out on a sample of 400 randomly selected undergraduate health professional students in Riyadh. Data collection involved two self-administered questionnaires: the causes and treatment routes for a female vignette with psychosis and the General Health Questionnaire-28.

RESULTS

The mean age of participants was 20.9 years, and 68.2% were male. Although participants reported a lack of personal history of mental illness (81.9%), female participants were more likely to disclose psychological distress as measured by General Health Questionnaire-28 (67.6%). Mental illness (47.2%) was chosen as the main reason for the problem depicted by the female vignette. General Health Questionnaire-28 scores for "caseness" did not affect perception about psychosis versus non-caseness. Factor analysis produced four dimensions for causes of psychosis: "social," "psychobiological," "superstitious," and "socially undesirable"; and two treatment routes: "clinical" versus "social interventions." Male participants leaned toward social factors for the cause of psychosis and were more likely to endorse social interventions for treatment.

CONCLUSION

Healthcare students in Riyadh remained supportive of a biomedical approach toward the causation and treatment of mental illness. The use of religious practices as an adjunct was apparent. Students, especially females, were prone to experience more psychological distress.

Mental illness stigma among medical students and teachers

BACKGROUND

Medical school curriculum contributes to future doctors' attitude formation towards people with mental illness.

AIM

The purpose of this study was to compare stigmatizing attitudes between medical students and faculty, analyse stigmatizing attitudes among students from different years of study and identify factors predicting stigma.

METHODS

A cross-sectional study with the use of scales measuring attitudes and social distance was designed. Online questionnaires were distributed to all students and teachers at a medical faculty in the Czech Republic.

RESULTS

The response rate was 32.1% ( n = 308) among students and 26.7% ( n = 149) among teachers. Teachers had a greater prevalence of stigmatizing attitudes than students. Increased tolerant attitudes in students were detected after the fourth year, that is, following introduction to psychiatry. Preferred specialization in psychiatry and attending two psychiatry courses predicted more tolerant attitudes. Among both students and teachers, men possessed more stigmatizing attitudes towards people with mental illness. Age was an important predictor of stigmatizing attitudes among teachers.

CONCLUSION

Educators should pay closer attention to the role of medical psychology and communication training implementation, which may be beneficial to improving skills and increasing medical students' self-esteem and feeling of competence throughout their psychiatry rotation.

The psychometric characteristics of the revised depression attitude questionnaire (R-DAQ) in Pakistani medical practitioners: a cross-sectional study of doctors in Lahore

Background

Depression is common mental health problem and leading contributor to the global burden of disease. The attitudes and beliefs of the public and of health professionals influence social acceptance and affect the esteem and help-seeking of people experiencing mental health problems. The attitudes of clinicians are particularly relevant to their role in accurately recognising and providing appropriate support and management of depression. This study examines the characteristics of the revised depression attitude questionnaire (R-DAQ) with doctors working in healthcare settings in Lahore, Pakistan.

Methods

A cross-sectional survey was conducted in 2015 using the revised depression attitude questionnaire (R-DAQ). A convenience sample of 700 medical practitioners based in six hospitals in Lahore was approached to participate in the survey. The R-DAQ structure was examined using Parallel Analysis from polychoric correlations. Unweighted least squares analysis (ULSA) was used for factor extraction. Model fit was estimated using goodness-of-fit indices and the root mean square of standardized residuals (RMSR), and internal consistency reliability for the overall scale and subscales was assessed using reliability estimates based on Mislevy and Bock (BILOG 3 Item analysis and test scoring with binary logistic models. Mooresville: Scientific Software, 55) and the McDonald’s Omega statistic. Findings using this approach were compared with principal axis factor analysis based on Pearson correlation matrix.

Results

601 (86%) of the doctors approached consented to participate in the study. Exploratory factor analysis of R-DAQ scale responses demonstrated the same 3-factor structure as in the UK development study, though analyses indicated removal of 7 of the 22 items because of weak loading or poor model fit. The 3 factor solution accounted for 49.8% of the common variance. Scale reliability and internal consistency were adequate: total scale standardised alpha was 0.694; subscale reliability for professional confidence was 0.732, therapeutic optimism/pessimism was 0.638, and generalist perspective was 0.769.

Conclusions

The R-DAQ was developed with a predominantly UK-based sample of health professionals. This study indicates that this scale functions adequately and provides a valid measure of depression attitudes for medical practitioners in Pakistan, with the same factor structure as in the scale development sample. However, optimal scale function necessitated removal of several items, with a 15-item scale enabling the most parsimonious factor solution for this population.

The attitudes and beliefs of Pakistani medical practitioners about depression: a cross-sectional study in Lahore using the Revised Depression Attitude Questionnaire (R-DAQ)

BACKGROUND

Mental disorders such as depression are common and rank as major contributors to the global burden of disease. Condition recognition and subsequent management of depression is variable and influenced by the attitudes and beliefs of clinicians as well as those of patients. Most studies examining health professionals' attitudes have been conducted in Western nations; this study explores beliefs and attitudes about depression among doctors working in Lahore, Pakistan.

METHODS

A cross-sectional survey conducted in 2015 used a questionnaire concerning demographics, education in psychiatry, beliefs about depression causes, and attitudes about depression using the Revised Depression Attitude Questionnaire (R-DAQ). A convenience sample of 700 non-psychiatrist medical practitioners based in six hospitals in Lahore was approached to participate in the survey.

RESULTS

Six hundred and one (86 %) of the doctors approached consented to participate; almost all respondents (99 %) endorsed one of various biopsychosocial causes of depression (38 to 79 % for particular causes), and 37 % (between 13 and 19 % for particular causes) noted that supernatural forces could be responsible. Supernatural causes were more commonly held by female doctors, those working in rural settings, and those with greater psychiatry specialist education. Attitudes to depression were mostly less confident or optimistic and less inclined to a generalist perspective than those of clinicians in the UK or European nations, and deterministic perspectives that depression is a natural part of aging or due to personal failings were particularly common. However, there was substantial confidence in the efficacy of antidepressants and psychological therapy. More confident and therapeutically optimistic views and a more generalist perspective about depression management were associated with a rejection of supernatural explanations of the origin of depression.

CONCLUSIONS

Non-psychiatrist medical practitioners in Pakistan hold a range of views about the causes of depression, with supernatural explanations held by more than a third. Depression attitudes appear less positive than among UK and European clinicians, with the notions that depression is due to a lack of stamina and will-power and a natural part of growing old being especially commonly held; more positive attitudes appear to be associated with a rejection of supernatural explanatory models of depression.