Highlights
- •Singapore nursing students have relatively low endorsements of stigmatizing attitudes towards people with mental disorders.
- •Those with clinical placements had relatively higher stigmatizing attitudes versus those without.
- •Nursing students’ attitudes towards people with mental disorders varies according to the type of disorders.
Stigma towards people with mental disorders is highly prevalent and often leads to negative impact on their lives (
Alonso et al., 2008
; Corrigan and Watson, 2006
). According to The World Health Organization, 2001
, stigma signifies a ‘mark of shame, disgrace, or disapproval’. The negative consequences of stigmatizing attitudes include ‘being rejected, discriminated against and excluded from participating in a number of different areas of society’. Furthermore, being stigmatized not only affects the psychological well-being and development of people with mental disorders, but also acts as a significant barrier to seeking, accessing and adherence to treatment (Link and Phelan, 2006
).Prior research studies have generally revealed continued misconceptions about mental disorders amongst various populations. In their review of population studies,
Angermeyer and Dietrich, 2006
found that a significant proportion of the public were unable to recognize specific mental disorders and their respective causes. They also perceived people with mental disorders as unpredictable and dangerous. These perceptions contributed to increasing desire to distance themselves from people with mental disorders. Notably, research has also shown the presence of a hierarchy of stigma within mental disorders diagnoses where more stigmatizing attitudes are directed towards people with schizophrenia as compared to other mental disorders such as mood or anxiety disorders (Griffiths et al., 2006
).- Griffiths K.M.
- Nakane Y.
- Christensen H.
- Yoshioka K.
- Jorm A.
- Nakane H.
Stigma in response to mental disorders: A comparison of Australia and Japan.
BMC Psychiatry. 2006; 6https://doi.org/10.1186/1471-244x-6-21
Stigmatizing attitudes towards people with mental disorders are not restricted to only uninformed members of the general public. Healthcare professionals also endorse stereotypical beliefs about people with mental disorders (
Jorm, Korten, Jacomb, Christensen and Henderson, 1999
; - Jorm A.F.
- Korten A.E.
- Jacomb P.A.
- Christensen H.
- Henderson S.
Attitudes towards people with a mental disorder: A survey of the Australian public and health professionals.
Australian and New Zealand Journal of Psychiatry. 1999; 33: 77-83https://doi.org/10.1046/j.1440-1614.1999.00513.x
Ross and Goldner, 2009
). These stigmatizing attitudes amongst mental healthcare professionals can act as barriers to those seeking treatment and hence need to be broken down. Essentially, healthcare professionals, especially nurses, play a key role in the mental healthcare system (- Ross C.
- Goldner E.
Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature.
Journal of Psychiatric and Mental Health Nursing. 2009; 16: 558-567https://doi.org/10.1111/j.1365-2850.2009.01399.x
Harborne and Jones, 2008
). Being on the frontline of healthcare, they are responsible for the bulk of direct care for patients (Baker, Richards and Campbell, 2005
) and have a profound effect on the therapeutic relationship as well as treatment outcomes of patients with whom they interact. Furthermore, given their high contact and experience with patients, nurses are well positioned to ameliorate stigmatizing attitudes amongst the public (Happell, 2005
). Harbouring negative views towards people with mental disorders may thus be challenging as these would influence the way nurses view their patients and the nature of their work itself (- Happell B.
Mental health nursing: Challenging stigma and discrimination towards people experiencing a mental illness.
International Journal of Mental Health Nursing. 2005; 14: 1https://doi.org/10.1111/j.1440-0979.2005.00339.x
Enarsson, Sandman and Hellzen, 2007
), which may not only affect their role as an advocate in reducing stigma, but also hinder the development of therapeutic relationship with patients (Kameg, Mitchell, Clochesy, Howard and Suresky, 2009
).Therefore, nursing education and placements carry great responsibilities in shaping the attitudes that are held by nursing students towards people with mental disorders. By providing enough depth and exposure to theoretical and practical knowledge, a more positive attitude towards mental health nursing could be expected. This would subsequently prepare them for a nursing profession in the mental health field (
Happell, 1999
). Whether nursing students eventually pursue a career in psychiatric nursing or other areas of nursing, they would most likely encounter patients with mental disorders. Being on the practice front, it is thus imperative that nurses have a positive attitude towards patients who have mental disorders. Furthermore, discovering the extent of stigma is fundamental to gaining insights into the current stereotypes that could subsequently be addressed and further clarified during nursing education and placements. Ultimately, an understanding of nursing students' attitudes would aid in shaping nursing education.- Happell B.
Who wants to be a psychiatric nurse? Novice student nurses' interest in psychiatric nursing.
Journal of Psychiatric and Mental Health Nursing. 1999; 6: 479-484https://doi.org/10.1046/j.1365-2850.1999.00249.x
Singapore has twenty-one accredited nursing programmes as of December 2015 (
Singapore Nursing Board, 2016
), including degree in nursing, diploma in nursing, and others. Mental health nursing curriculum differs across programmes based on the objectives they have set out for their students. Nonetheless, nursing students across these programmes are required to complete a mental health module and subsequently undergo a clinical placement in a mental health facility. Nursing students typically undergo their placements in a tertiary psychiatric hospital for a span of two weeks in an inpatient ward setting – acute care or long stay ward.While a recent population-wide study explored the extent of stigmatizing attitudes towards people with mental disorders in Singapore (
Subramaniam et al., 2016
), there is no previous study that compared attitudes amongst nursing students across different types of mental disorders and examined the extent of stigma amongst nursing students in Singapore towards people with mental disorders. Furthermore, a limited number of studies have examined nursing students' attitudes towards people with mental disorders across various types of mental disorders in Asia. This study could thus contribute to the dearth of this research in this region.Using a vignette approach, the present study aims to (i) examine the extent of overall stigma towards people with mental disorders (depression, obsessive compulsive disorder (OCD), schizophrenia, dementia and alcohol abuse) as well as to (ii) examine factors that correlate with the stigma dimensions amongst the nursing student population in Singapore.
Methodology
Design and sample
In this cross-sectional study, an online web survey tool QuestionPro® was used to collect data from a sample of nursing students in Singapore. Ethical approval was granted by the National Healthcare Group Domain Specific Review Board in Singapore. The target population included students from four public nursing institutions in Singapore. Once permissions were granted from the corresponding institutions, mass email invitations were sent to these nursing students to invite them to partake in the study. Enclosed in the email was a link that directed potential participants to an online portal where screening questions were asked to assess their suitability for the study. These included participants' course of study, nationality, academic year and institution. Participation quota was based on institutions and academic years. In order to be eligible for the study, participants had to be nursing students who were enrolled in a public nursing institution in Singapore during the recruitment period (April 2016 to July 2016) and be a Singapore citizen or permanent resident. Those who did not meet the inclusion criteria received an automatic email notifying them of their ineligibility for this study. Those who met the inclusion criteria were directed to the online consent form. Participation was voluntary. By clicking on the ‘agree’ button, participants indicated their willingness to participate in this study. Upon completion, participants were reimbursed with an inconvenience fee.
Participants were randomly assigned to one of five vignettes describing a person with a mental disorder - (i) alcohol abuse, (ii) dementia, (iii) depression, (iv) OCD or (v) schizophrenia. Vignettes were adapted from those used in prior studies – ‘depression’ and ‘schizophrenia’ vignettes were adapted from
Jorm et al., 1997
while ‘alcohol abuse’, ‘dementia’ and ‘OCD’ vignettes were adapted from Subramaniam et al., 2016
. Participants were then asked to indicate their attitudes towards the person described in the assigned vignette using two different scales – the personal and perceived scale of Depression Stigma Scale (DSS) (Griffiths, Christensen, Jorm, Evans and Groves, 2004
) and the ‘Social Distance Scale’ (SDS) (Link, Phelan, Bresnahan, Stueve and Pescosolido, 1999
).Instruments
The Depression Stigma Scale (DSS) (
Griffiths, Christensen, Jorm, Evans and Groves, 2004
) which has two subscales (personal and perceived stigma) was developed to measure stigma towards people with mental disorders. Each subscale has nine items and asks respondents about their own (personal stigma scale) or their beliefs about others' attitudes (perceived stigma scale) towards the person who was described as having depression in the vignette. Although originally designed to measure stigma towards depression, the scale can also be used to measure stigma towards other disorders as described in the relevant vignettes. Eight out of the nine items of the personal stigma scale were used in this study, excluding one item “I would not vote for a politician if I knew they had a mental disorder”. Ratings for each item were measured on a 5-point Likert scale (1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, 5 = strongly disagree). Higher scores suggest a more stigmatizing attitude. Cronbach's α for the personal stigma scale was 0.647.The Social Distance Scale (SDS) (
Link, Phelan, Bresnahan, Stueve and Pescosolido, 1999
) was used to assess respondents' self-reported willingness to have contact with the person depicted in the vignette. Specifically, respondents rated their willingness to 1. move next door to the person in the vignette; 2. spend an evening socialising with the person; 3. make friends with the person; 4. work closely on a job with the person; and 5. have the person marry into the family. Ratings for each item were measured on a 4-point scale (1 = definitely unwilling, 2 = probably unwilling, 3 = probably willing, 4 = definitely willing). Lower scores suggest greater social distance desired by respondents. Cronbach's α for this scale was 0.827.A similar vignette-based approach and measurement tool was used in a previous population-based study conducted by
Subramaniam et al., 2016
in Singapore. Factor analysis done on these measurement tools suggested a two-factor structure of the depression stigma scale (‘weak-not-sick’ and ‘dangerous-unreliable’), consistent with a study done by Yap, Mackinnon, Reavley and Jorm, 2014
, and a one-factor structure for social distance scale (‘social distance’). The first dimension ‘weak not sick’, comprised three items (PS1–PS3). These items describe the problem which the person depicted in the vignette is experiencing as a form of personal weakness that is within his/her control as opposed to it being a medical condition. The subsequent four items (PS4, PS5, PS6 and PS8) formed the second dimension ‘dangerous/unpredictable’. These items describe the person depicted in the vignette as one who is dangerous and whom is best avoided. The third dimension ‘social distance’ comprised all the five items from the social distance scale (SD1–SD5) which loaded strongly into a single factor. Following the aforementioned population-based study, the total score for each of the three dimensions were calculated by summing all the items in each dimension. For ‘dangerous/unpredictable’ dimension, item (PS7) ‘if I had a problem like [vignette] I would not tell anyone’ was excluded from the calculation. All 5 items from the ‘social distance’ factor were reversed coded before they were summed together. Higher scores for each dimension represent more stigmatizing attitudes towards mental illness.- Yap M.
- Mackinnon A.
- Reavley N.
- Jorm A.
The measurement properties of stigmatizing attitudes towards mental illness: Results from two community surveys.
International Journal of Methods in Psychiatric Research. 2014; 23: 49-61https://doi.org/10.1002/mpr.1433
Statistical analyses
IBM SPSS Statistics Version 23 was used to conduct all statistical analyses in this study. Mean and standard error of mean were calculated for continuous variables while frequencies and percentages were calculated for categorical variables. For descriptive analyses, items on the personal and perceived stigma scale were recoded and grouped into three categories; agree, neither agree nor disagree and agree (items ‘agree’ and ‘strongly agree’ were combined into ‘agree’ while ‘disagree’ and ‘strongly disagree’ were combined into ‘disagree’), while items on the social distance scale were recoded as binary responses; willing and unwilling (items ‘definitely willing’ and ‘willing’ were combined into ‘willing’ and ‘definitely unwilling’ and ‘unwilling’ were combined into ‘unwilling’).
T-tests and one-way ANOVA tests were conducted to identify differences in mean scores on all three stigma dimensions across these variables: gender, ethnicity, education level, monthly household income, clinical placement experience, lectures on psychiatry, type of vignette administered and whether family or friends ever had problems similar to the person described in the vignette. Multivariate linear regressions were also conducted to examine the associations of the aforementioned variables with each of the stigma dimensions towards people with mental disorders. Listwise deletion was used to handle missing data. All statistically significant results were reported at p < 0.05.
Results
500 nursing students (83 male, 417 female) aged between 16 and 35 years old (M = 20.1, SD = 3.1) completed the study. Table 1 presents the sociodemographic characteristics of the participants.
Table 1Sociodemographic characteristics of the study sample
| n | % | ||
|---|---|---|---|
| Age | Mean = 20.1 years | ||
| SD = 3.1 | |||
| Gender | Male | 83 | 16.6 |
| Female | 417 | 83.4 | |
| Ethnicity | Chinese | 287 | 57.4 |
| Malay | 134 | 26.8 | |
| Indian | 60 | 12.0 | |
| Others | 19 | 3.8 | |
| Current education | Degree | 100 | 20.0 |
| Diploma and others | 400 | 80.0 | |
| Average monthly household income per capita over the past 1 year | Below SGD2000 | 158 | 31.6 |
| SGD2000 - 5999 | 248 | 49.6 | |
| SGD6000 and above | 94 | 18.8 | |
| Clinical placement experience | Yes | 303 | 60.6 |
| No | 197 | 39.4 | |
| Lectures | Yes | 424 | 84.8 |
| No | 76 | 15.2 | |
| Vignette Type | Depression | 100 | 20.0 |
| OCD | 100 | 20.0 | |
| Alcohol abuse | 100 | 20.0 | |
| Dementia | 100 | 20.0 | |
| Schizophrenia | 100 | 20.0 | |
| Family or close circle of friends ever had problems similar to person described in the vignette | Yes | 125 | 25.0 |
| No | 375 | 75.0 |
‘Weak not sick’ dimension and its pattern of endorsement
As seen in Table 2a, percentage difference between participants who ‘agree’ and ‘disagree’ to each item within the ‘weak not sick’ dimension shows that a larger number of participants endorsed stigmatizing attitudes on items ‘PS1’ as compared to items ‘PS2’ and ‘PS3’. Specifically, more participants agreed that ‘people with a problem like X could get better if they wanted to (PS1–77.2%). However, participants were less likely to agree that ‘a problem like X is a sign of personal weakness (PS2–23%) and ‘X’s problem is not a real medical illness' (PS3–17.2%).
Table 2aItem endorsement of the Depression Stigma Scale – personal stigma.
| Disagree | Neither agree nor disagree | Agree | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| ‘Weak not sick’ dimension | ||||||
| PS1. People with a problem like X could get better if they wanted to. | 47 | 9.4 | 67 | 13.4 | 386 | 77.2 |
| PS2. A problem like X's is a sign of personal weakness. | 219 | 43.8 | 166 | 33.2 | 115 | 23.0 |
| PS3. X's problem is not a real medical illness. | 282 | 56.4 | 132 | 26.4 | 86 | 17.2 |
| ‘Dangerous/unpredictable’ dimension | ||||||
| PS4. People with a problem like X's are dangerous to others. | 261 | 52.2 | 146 | 29.2 | 93 | 18.6 |
| PS5. It is best to avoid people with a problem like X's so that you don't also get this problem. | 412 | 82.4 | 63 | 12.6 | 25 | 5.0 |
| PS6. People with a problem like X's are unpredictable. | 107 | 21.4 | 158 | 31.6 | 235 | 47.0 |
| PS7. If I had a problem like X's I would not tell anyone. | 232 | 46.4 | 161 | 32.2 | 107 | 21.4 |
| PS8. I would not employ someone if I knew they had a problem like X. | 227 | 45.4 | 181 | 36.2 | 92 | 18.4 |
‘Dangerous/unpredictable’ dimension and its pattern of endorsement
Table 2a also shows that a larger number of participants endorsed stigmatizing attitudes on items ‘PS6’ as compared to the rest of the items within the ‘dangerous/unpredictable’ dimension. Specifically, more participants agreed that ‘people with a problem like X’s are unpredictable’ (PS6–47.0%). However, participants were less likely to agree that the person described in the vignette was dangerous to others (PS4–18.6%) and should be best avoided in order to avoid contracting the same disorder (PS5–5%). They were also less likely to agree that they would not tell someone if they had a similar problem (PS7–21.4%) and would not employ someone with such a problem (PS8–18.4%).
‘Social distance’ dimension and its pattern of endorsement
Table 2b reports the endorsement of stigmatizing statements in the ‘social distance’ dimension. It reports the percentage of participants who were either ‘willing’ or ‘unwilling’ to make social contact with the person described in the vignette for each item on the scale. In general, a larger percentage of participants were willing to have social contact by saying that they were willing to: move next door to (SD1–74.8%), spend an evening with (SD2–72.6%), make friends with (SD3–88.2%) and work closely on a job with someone who has a mental disorder (SD4–69.8%). However, the social interaction that participants were most unwilling to engage in was having the person with a mental disorder marry into their family (SD5–66% were unwilling).
Table 2bItem endorsement of the Social Distance Scale – social distance.
| ‘Social distance’ dimension | Unwilling | Willing | ||
|---|---|---|---|---|
| n | % | n | % | |
| SD1. How willing would you be to move next door to X? | 126 | 25.2 | 374 | 74.8 |
| SD2. How willing would you be to spend an evening with X? | 137 | 27.4 | 363 | 72.6 |
| SD3. How willing would you be to make friends with X? | 59 | 11.8 | 441 | 88.2 |
| SD4. How willing would you be to have X start working closely with you on a job? | 151 | 30.2 | 349 | 69.8 |
| SD5. How willing would you be to have X marry into your family? | 330 | 66.0 | 170 | 34.0 |
Stigma dimensions
Descriptive values of the three established dimensions of stigma – ‘weak not sick’, ‘dangerous/unpredictable’ and ‘social distance’ – across sociodemographic groups are reported in Table 3. Higher mean scores denote higher level of stigma for all three dimensions.
Table 3Descriptive statistics of stigma dimensions by sociodemographic factors.
| Weak not sick | Dangerous/unpredictable | Social distance | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Mean | S.E. | p value | Mean | S.E. | p value | Mean | S.E. | p value | |
| Overall | 9.010 | 0.096 | 10.320 | 0.119 | 11.226 | 0.117 | |||
| Gender | |||||||||
| Male | 8.840 | 0.220 | 0.452 | 10.482 | 0.319 | 0.545 | 10.759 | 0.291 | 0.075 |
| Female | 9.040 | 0.110 | 10.288 | 0.128 | 11.319 | 0.127 | |||
| Ethnicity | |||||||||
| Chinese | 8.690 | 0.126 | 0.000 | 10.216 | 0.161 | 0.342 | 11.307 | 0.160 | 0.082 |
| Malay | 9.679 | 0.171 | 10.634 | 0.214 | 10.873 | 0.202 | |||
| Indian | 9.267 | 0.286 | 10.017 | 0.354 | 11.250 | 0.351 | |||
| Others | 8.211 | 0.527 | 10.632 | 0.636 | 12.421 | 0.520 | |||
| Average monthly household income per capita over the past 1 year | |||||||||
| Below SGD2000 | 9.171 | 0.169 | 0.025 | 10.304 | 0.216 | 0.351 | 10.867 | 0.201 | 0.058 |
| SGD2000–5999 | 9.105 | 0.130 | 10.456 | 0.166 | 11.492 | 0.170 | |||
| SGD6000 and above | 8.468 | 0.247 | 9.989 | 0.280 | 11.128 | 0.265 | |||
| Current education | |||||||||
| Degree | 7.920 | 0.242 | 0.000 | 9.860 | 0.244 | 0.053 | 11.070 | 0.241 | 0.506 |
| Diploma and others | 9.277 | 0.100 | 10.435 | 0.135 | 11.265 | 0.133 | |||
| Clinical placement experience | |||||||||
| Yes | 9.109 | 0.121 | 0.185 | 10.528 | 0.160 | 0.030 | 11.436 | 0.150 | 0.026 |
| No | 8.848 | 0.158 | 10.000 | 0.173 | 10.904 | 0.185 | |||
| Attended psychiatry lecture | |||||||||
| Yes | 9.045 | 0.099 | 0.342 | 10.276 | 0.130 | 0.383 | 11.210 | 0.125 | 0.746 |
| No | 8.789 | 0.312 | 10.566 | 0.300 | 11.316 | 0.325 | |||
| Vignette type | |||||||||
| Depression | 9.200 | 0.234 | 0.015 | 9.680 | 0.229 | 0.000 | 10.710 | 0.270 | 0.000 |
| OCD | 8.860 | 0.195 | 9.000 | 0.246 | 10.530 | 0.246 | |||
| Alcohol abuse | 9.560 | 0.206 | 11.270 | 0.287 | 11.760 | 0.239 | |||
| Dementia | 8.610 | 0.233 | 10.700 | 0.247 | 11.030 | 0.252 | |||
| Schizophrenia | 8.800 | 0.196 | 10.950 | 0.254 | 12.100 | 0.269 | |||
| Family or close circle of friends ever had problems similar to person described in the vignette | |||||||||
| Yes | 8.584 | 0.222 | 0.011 | 9.808 | 0.238 | 0.013 | 10.304 | 0.243 | 0.000 |
| No | 9.147 | 0.104 | 10.491 | 0.137 | 11.533 | 0.130 | |||
a Higher mean scores denote higher level of stigma.
Multivariate linear regression analyses reported in Table 4 shows the correlates of variables predicting the three factors of stigma mentioned above. Participants who were Malay (β = 0.578, p < 0.05), received the ‘depression’ (β = 0.597, p < 0.05) or ‘alcohol abuse’ (β = 0.759, p < 0.05) vignette were significantly associated with higher ‘weak not sick’ scores while those pursuing a degree in nursing (β = −1.175, p < 0.05) and those whose family or close circle of friends ever had problems similar to person described in the vignette (β = −0.457, p < 0.05) were significantly associated with lower ‘weak not sick’ scores. Participants pursuing a degree in nursing (β = −0.639, p < 0.05) and those who had attended psychiatry lectures (β = −0.916, p < 0.05) had lower ‘dangerous/unpredictable scores’. Male participants (β = −0.711 p < 0.05), those who received the ‘dementia’ vignette (β = −0.817, p < 0.05) and those whose family or close circle of friends ever had problems similar to the person described in the vignette (β = −1.003, p < 0.05) were significantly associated with lower social distance scores. Interestingly, participants who were presented with either the ‘depression’ (β = −1.072, p < 0.05; β = −1.019, p < 0.05) or ‘OCD’ vignette (β = −1.879, p < 0.05; β = −1.495, p < 0.05) were associated with lower ‘dangerous/unpredictable scores’ and ‘social distance’ scores, participants who had attended clinical placements (β = 0.822, p < 0.05; β = 0.730, p < 0.05) were associated with significantly higher dangerous/unpredictable and social distance scores.
Table 4Multivariate linear regression analyses for variables predicting stigma dimensions.
| Weak not sick | Dangerous/unpredictable | Social distance | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| β | 95% confidence interval | p value | β | 95% confidence interval | p value | β | 95% confidence interval | p value | ||||
| Gender | ||||||||||||
| Male | −0.206 | −0.698 | 0.286 | 0.412 | 0.092 | −0.510 | 0.694 | 0.764 | −0.711 | −1.307 | −0.115 | 0.020 |
| Female | Ref | Ref | Ref | |||||||||
| Ethnicity | ||||||||||||
| Malay | 0.578 | 0.131 | 1.025 | 0.011 | 0.221 | −0.326 | 0.769 | 0.428 | −0.525 | −1.067 | 0.017 | 0.058 |
| Indian | 0.305 | −0.289 | 0.899 | 0.313 | −0.560 | −1.287 | 0.167 | 0.131 | −0.356 | −1.076 | 0.363 | 0.331 |
| Others | −0.636 | −1.596 | 0.323 | 0.193 | 0.338 | −0.837 | 1.513 | 0.572 | 1.158 | −0.005 | 2.321 | 0.051 |
| Chinese | Ref | Ref | Ref | |||||||||
| Average monthly household income per capita over the past 1 year | ||||||||||||
| Below SGD2000 | 0.166 | −0.380 | 0.711 | 0.551 | 0.086 | −0.582 | 0.754 | 0.801 | −0.367 | −1.028 | 0.294 | 0.276 |
| SGD2000–5999 | 0.167 | −0.335 | 0.669 | 0.513 | 0.345 | −0.270 | 0.960 | 0.271 | 0.287 | −0.322 | 0.895 | 0.355 |
| SGD6000 and above | Ref | Ref | Ref | |||||||||
| Current education | ||||||||||||
| Degree | −1.175 | −1.676 | −0.674 | 0.000 | −0.639 | −1.253 | −0.026 | 0.041 | −0.452 | −1.058 | 0.155 | 0.144 |
| Diploma and others | Ref | Ref | Ref | |||||||||
| Clinical placement experience | ||||||||||||
| Yes | 0.404 | −0.036 | 0.845 | 0.072 | 0.822 | 0.283 | 1.361 | 0.003 | 0.730 | 0.197 | 1.264 | 0.007 |
| No | Ref | Ref | Ref | |||||||||
| Attended psychiatry lecture | ||||||||||||
| Yes | −0.159 | −0.756 | 0.437 | 0.600 | −0.916 | −1.646 | −0.186 | 0.014 | −0.719 | −1.442 | 0.004 | 0.051 |
| No | Ref | Ref | Ref | |||||||||
| Vignette type | ||||||||||||
| Depression | 0.597 | 0.010 | 1.184 | 0.046 | −1.072 | −1.790 | −0.354 | 0.004 | −1.019 | −1.730 | −0.308 | 0.005 |
| OCD | 0.107 | −0.465 | 0.678 | 0.714 | −1.879 | −2.579 | −1.180 | 0.000 | −1.495 | −2.187 | −0.803 | 0.000 |
| Alcohol abuse | 0.759 | 0.186 | 1.331 | 0.010 | 0.308 | −0.394 | 1.009 | 0.389 | −0.272 | −0.966 | 0.422 | 0.442 |
| Dementia | −0.027 | −0.610 | 0.555 | 0.927 | −0.032 | −0.745 | 0.681 | 0.930 | −0.817 | −1.523 | −0.112 | 0.023 |
| Schizophrenia | Ref | Ref | Ref | |||||||||
| Family or close circle of friends ever had problems similar to person described in the vignette | ||||||||||||
| Yes | −0.457 | −0.889 | −0.025 | 0.038 | −0.521 | −1.050 | 0.008 | 0.054 | −1.003 | −1.526 | −0.479 | 0.000 |
| No | Ref | Ref | Ref | |||||||||
Discussion
The main purpose of this study was to examine the extent of overall stigma towards people with mental disorders (depression, OCD, schizophrenia, dementia and alcohol abuse) and factors that were significantly correlated with the stigma dimensions amongst the nursing student population in Singapore. In general, results from this study are encouraging as it showed evidence of a relatively low endorsement of stigmatizing attitudes towards people with mental disorders within the nursing student population. In fact, when compared against the larger Singapore population (
Subramaniam et al., 2016
) as shown in supplementary table 1, the nursing student population in Singapore (PS1–77.2%; PS2–23.0%; PS3–17.2%) were less likely to endorse stigmatizing attitudes for every item in the ‘weak not sick’ dimension as compared to Singapore's general population (PS1–89.4%; PS2–50.8%; PS3–38.5%), based on percentage of those who ‘agree’ to each item in the scale. In the ‘dangerous/unpredictable’ dimension, the nursing student population (PS4–18.6%; PS5–5.0%; PS6–47.0%; PS7–21.4%; PS8–18.4%) were less likely to endorse stigmatizing attitudes on all items except ‘PS7 (If I had a problem like X's I would not tell anyone) as compared to Singapore's general population (PS4–35.7%; PS5–10.6%; PS6–62.5%; PS7–21.4%; PS8–45.3%). In the ‘social distance’ dimension (Supplementary Table 2), the nursing student population (SD1–25.2%; SD2–27.4%; SD3–11.8%; SD4–30.2%; SD5–66.0%) were more willing to have social contact with people who have a mental disorder as compared to Singapore's general population (SD1–32.4%; SD2–22.4%; SD3–18.2%; SD4–42.8%; SD5–70.2%), with the exception of item ‘SD2 (How willing would you be to spend an evening with X?)’.While previous studies have shown that nursing students hold diverse views and attitudes about mental disorders, they were found to be generally positive in various studies such as those conducted in New Zealand (
Surgenor, Dunn and Horn, 2005
), Hong Kong (- Surgenor L.
- Dunn J.
- Horn J.
Nursing student attitudes to psychiatric nursing and psychiatric disorders in New Zealand.
International Journal of Mental Health Nursing. 2005; 14: 103-108https://doi.org/10.1111/j.1440-0979.2005.00366.x
Callaghan, Shan, Yu, Ching and Kwan, 1997
) and across several countries in Europe (Chambers et al., 2010
). However, results of some studies are contrary to current results. For example, a study in Sweden found that nursing students did not demonstrate a positive attitude towards persons with mental disorders as compared to their general population (- Chambers M.
- Guise V.
- Välimäki M.
- Botelho M.
- Scott A.
- Staniuliené V.
- Zanotti R.
Nurses' attitudes to mental illness: A comparison of a sample of nurses from five European countries.
International Journal of Nursing Studies. 2010; 47: 350-362https://doi.org/10.1016/j.ijnurstu.2009.08.008
Ewalds-Kvist, Högberg and Lützén, 2012
).Taking into consideration participants' age range of 16 to 35 years in this study, it could perhaps reflect a growing knowledge and understanding about mental disorders amongst the younger age group. Similarly, previous research studies showed that people from the younger age group tend to be less stigmatizing when compared to the ones from the older age groups (
Chong et al., 2007
; - Chong S.
- Verma S.
- Vaingankar J.
- Chan Y.
- Wong L.
- Heng B.
Perception of the public towards the mentally ill in developed Asian country.
Social Psychiatry and Psychiatric Epidemiology. 2007; 42: 734-739https://doi.org/10.1007/s00127-007-0213
Hayward and Bright, 1997
; Subramaniam et al., 2016
). Furthermore, as nursing students, they are probably more familiar and knowledgeable about treatment, causes and outcomes of mental disorders, which may have led to less stigmatizing attitudes towards people with mental disorders. In fact, previous research studies reported that familiarity with mental disorders and people suffering from them was associated with positive attitudes (Hayward and Bright, 1997
; Angermeyer and Dietrich, 2006
). This would have contributed to the development of more informed perspectives of people with mental disorders which may have decreased the stigma surrounding mental disorders. Nevertheless, looking at the level of knowledge alone would be insufficient to form an understanding of nursing students' attitudes towards people with mental disorders. It is likely that knowledge has an intricate relationship with other sociodemographic characteristics of individuals. In fact, a study by Griffiths, Christensen and Jorm, 2008
found that that depression literacy was inversely related to stigma after controlling for other sociodemographic variables including age and education level. Further research exploring the relationship of sociodemographic characteristics with knowledge and subsequently attitudes, would be beneficial in enriching the literature.- Griffiths K.
- Christensen H.
- Jorm A.
Predictors of depression stigma.
BMC Psychiatry. 2008; 8https://doi.org/10.1186/1471-244x-8-25
We found that those who had clinical placement experience (professional contact) had significantly more stigmatizing attitudes towards people with mental disorders on two stigma dimensions: ‘dangerous/unpredictable’ and ‘social distance’. This showed that these nursing students were more likely to perceive people with mental disorders as dangerous and unpredictable, and wanting greater social distance from them. Prior studies have shown mixed evidence of how contact experience, including having attended clinical placement affects attitudes towards people with mental disorders. According to contact hypothesis, interaction with people from a different group can lead to changes in attitudes, beliefs and stigma towards them. A literature review done by
Couture and Penn, 2003
found both personal and professional contact to be associated with positive attitudes to mental disorders. In a similar vein, research studies comparing the level of stigma amongst nursing students before and after psychiatric clinical placements found that clinical placements helped to foster positive attitudes towards mental health nursing (Happell and Gaskin, 2012
) and that this platform facilitated the demystification of preconceived ideas and stereotypes that students have towards mental disorders (Schafer, Wood and Williams, 2011
). Other studies however found no support for the contact hypothesis. A study amongst nursing students in Hong Kong showed that previous contact with people with mental disorders had no significant effect on students' attitudes towards people with mental disorders (Callaghan, Shan, Yu, Ching and Kwan, 1997
). Another study done by Gras et al., 2014
which investigated stigmatizing attitudes amongst mental healthcare professionals also found that personal and work experience in mental health did not influence stigmatizing attitudes towards people with mental disorders. However, results from our study may perhaps indicate that negative attitudes towards people with mental disorders were developed during the clinical placement experience or that negative preconceptions held towards people with mental disorders prior to clinical placements were hardened during contact with them. A possible explanation for either interpretation could be due to exposure to situations that nursing students were not fully prepared to face or deal with such as in witnessing psychotic or violent behaviours from patients, which - Gras L.
- Swart M.
- Slooff C.
- van Weeghel J.
- Knegtering H.
- Castelein S.
Differential stigmatizing attitudes of healthcare professionals towards psychiatry and patients with mental health problems: Something to worry about? A pilot study.
Social Psychiatry and Psychiatric Epidemiology. 2014; 50: 299-306https://doi.org/10.1007/s00127-014-0931-z
Fisher, 2002
study found to contribute to negative experiences reported by healthcare students.- Fisher J.
Fear and learning in mental health settings.
International Journal of Mental Health Nursing. 2002; 11: 128-134https://doi.org/10.1046/j.1440-0979.2002.t01-1-00205.x
Having a family member or a close friend (close contact) who had similar problems as the one in the vignette, was significantly associated with lower stigmatizing attitudes on two stigma dimensions: ‘weak not sick’ and ‘social distance’. Having a family member or close friend with a mental disorder may result in increased feelings of empathy and greater knowledge of the mental disorder itself. Furthermore, associations with persons with mental disorders by family ties or friendships may have resulted in similar experience of the negative consequences of mental disorders stigma (
Corrigan, Morris, Michaels, Rafacz and Rϋsch, 2012
) which could have led to greater empathy and hence less stigmatizing attitudes.Participants who were presented with the ‘depression’ and ‘alcohol abuse’ vignette were significantly more likely to perceive the person in the vignette as ‘weak not sick’ in comparison to those presented with the ‘schizophrenia’ vignette.
Angermeyer, Matschinger and Schomerus, 2013
found that public attitudes towards people will mental disorders are disorder specific and there is an increasing difference between attitudes towards schizophrenia and other mental disorders including their perceived causal attributions. Schizophrenia was more likely to be attributed to brain disease while depression to stress and alcohol dependence was less likely to be attributed to both brain disease and negative life events as causes. In another review, Schomerus et al., 2010
found that the public viewed alcohol-dependent patients as having more responsibility for their condition and a reflection of “weakness of character” in contrast to those who are suffering from schizophrenia and depression. Additionally, those presented with the ‘depression’ vignette were more likely to perceive the person as ‘weak not sick’ as compared to those presented with ‘schizophrenia’, as they may have associated depression with psychosocial causes instead of biological causes, thereby assuming that one could be resilient against it. By extension, some people believe depression to be associated with a fluctuation of mood that is within the individual's control as opposed to it being a disorder (Schomerus, Matschinger and Angermeyer, 2006
), seeing them as weak and responsible for their own condition (Aromaa, Tolvanen, Tuulari and Wahlbeck, 2010
).Participants who were presented with the ‘depression’ or ‘OCD’ vignette reported significantly lower scores on the ‘dangerous/unpredictable’ dimension as compared to those presented with schizophrenia. It was also found that those presented with the ‘depression’, OCD’ or ‘dementia’ vignette reported significantly lower scores on the ‘social distance’ dimension as compared to those presented with the ‘schizophrenia’ vignette. Previously,
Schomerus et al., 2010
found that participants perceived persons with schizophrenia to be more dangerous and desired greater social distance from them as compared to those with depression or anxiety disorders. Angermeyer and Dietrich, 2006
found that labels elicited the belief that those who are affected with schizophrenia are dangerous and unpredictable, and in turn triggers negative emotional reactions such as fear and aggression. This consequently results in increasing desire for social distance. Notably, the vignette that participants were presented with did not confirm the type of diagnosis, only examples of its symptomology. Thus, participants who endorsed stigmatizing attitudes may have done so on the basis of perceiving the symptoms and behaviours of those with schizophrenia as out of the ordinary, alarming or bizarre.Male participants were significantly associated with lower social distance scores as compared to female participants, suggesting that they are more likely to be willing to make social contact with persons with mental disorders than the latter participants. Results were not consistent with the few prior studies that explored associations between gender and stigmatizing attitudes. Some found women to be less stigmatizing than men (
Angermeyer, Matschinger and Holzinger, 1998
; - Angermeyer M.
- Matschinger H.
- Holzinger A.
Gender and attitudes towards people with schizophrenia. Results of a representative survey in the Federal Republic of Germany.
International Journal of Social Psychiatry. 1998; 44: 107-116https://doi.org/10.1177/002076409804400203
Farina, 1981
), while other studies found no significant gender difference (Chou and Mak, 1998
). Even though this study showed that male participants were less likely to desire social distance from people with mental disorders, the underrepresentation of male participants in this population is a concern as it makes it difficult to draw conclusions on gender based differences.- Chou K.
- Mak K.
Attitudes to mental patients among Hong Kong Chinese: A trend study over two years.
International Journal of Social Psychiatry. 1998; 44: 215-224https://doi.org/10.1177/002076409804400307
Nursing education implications
Considering the negative correlation between close contact of people with mental disorders and stigma in this study, psychiatric nursing curriculum could focus on creating a closer contact experience between nursing students and people with mental disorders prior to clinical placements. Additionally, nursing schools could also review their preparation methods for students attending clinical placements, and include managing students' expectations of the institution they would be attending at for their clinical placements and types of patients they would be interacting with. This study also showed that stigma towards mental disorders varies based on its type. Possibly, nursing schools could effectively reduce stigma towards people with mental disorders by addressing identified misconceptions of people with each mental disorder i.e. people with depression or people with schizophrenia in depth rather than addressing it as a single concept i.e. people with mental disorders.
Strengths and limitations
This study has various strengths including a relatively large sample size and the use of standardized questionnaires to assess for responses across multiple disorders, thus aiding to expand the dearth of research which have analysed differences in nursing students' perception across various mental disorders. However, the present study has a few limitations. The study is limited to analyses done based on the two scales in the study – DSS and SDS. There may be other aspects of stigma that persist amongst nursing students such as behavioural discrimination that was not measured in this study. Lastly, a vignette-based approach may not reflect respondents' actual behaviour in real life. Future research should look into conducting qualitative studies that examine students' experience during clinical placements to explore their influence on attitudes towards mental disorders and gain a more insightful understanding of their experiences.
Conclusion
While there is relatively low endorsement of stigmatizing attitudes amongst nursing students in Singapore towards people with mental disorders, efforts are still needed to address existing stigma towards certain types of mental disorders. Further exploration into the correlation between nursing education and clinical placements are crucial to form a better understanding of how these platforms influence the level of stigma amongst students. Perhaps the psychiatric nursing education could deal with stigma in a more effective way by addressing misconceptions of individual mental disorders during teaching and clinical placements as well. Essentially, enriching students' clinical placements experience would be vital in helping to ameliorate stigmatizing attitudes amongst nursing students.
Conflict of interest
None.
Acknowledgment
The authors would like to thank the schools for allowing us to conduct the study amongst their students. We also want to thank the participants for their time and efforts in the study. This research was supported by the Singapore Ministry of Health's National Medical Research Council under the Centre Grant Programme (Grant No.: NMRC/CG/004/2013).
Appendix A. Supplementary data
Supplementary tables
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Article info
Publication history
Published online: June 04, 2018
Accepted:
June 2,
2018
Received in revised form:
March 19,
2018
Received:
June 5,
2017
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© 2018 The Authors. Published by Elsevier Inc.
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