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COMMUNITY PSYCHIATRY: RESULTS OF A PUBLIC OPINION
SURVEY
CHRISTOPH LAUBER, CARLOS NORDT, HELENE HAKER, LUIS FALCATO &
WULF RO
¨
SSLER
ABSTRACT
Background: Mental health authorities must know the public’s attitude to com-
munity psychiatry when planning community mental health services. However,
previous studies have only investigated the impact of demographic variables on
the attitude to community psychiatry.
Aim: To assess the influence of psychological and sociological parameters on the
public opinion of community psychiatry in Switzerland.
Method: Linear regression analyses of the results of a public opinion survey on a
representative population sample in Switzerland (
n
¼ 1737).
Results: Most respondents have positive attitudes to community psychiatry. In
the regression analysis (
R
2
adjusted ¼ 21.2%), negative emotions towards men-
tally ill people as depicted in the vignette, great social distance, a positive attitude
to restrictions, negative stereotypes, high rigidity and no participation in commu-
nity activities significantly influenced negative attitudes to community psychiatry.
Additionally, other parameters, e.g. contact with mentally ill people and the nation-
ality of the interviewee, have a significant influence.
Conclusions: In planning psychiatric community services, general individual
traits and emotive issues should be considered because they influence the
response towards community psychiatry facilities in the host community.
INTRODUCTION
A major objective of modern psychiatry is to treat people with mental illness in the commu-
nity. Whereas the USA and the UK began the implementation of community psychiatry in
the early 1950s, and some parts of Western Europe, e.g. Italy and Germany, followed in
the 1970s and 1980s, other countries are only just starting to build up psychiatry services out-
side hospitals (Cohen et al., 2003; D’Avanzo et al., 2003; Dernovsek et al., 2003; Dubois et al.,
2004; Frost-Gaskin et al., 2003; Hutchinson et al., 2004; Kohn et al., 2004; Lambert et al.,
2000; Malhi et al., 2003; Marusic, 2004; Mastrogianni & Bhugra, 2003; Norton, 2004; Ro
¨
ssler
& Salize, 1995a, 1995b; Ro
¨
ssler et al., 1996; Tausig et al., 2003; Ungvari & Chiu, 2004;
Verdoux, 2003). However, the move towards community-based mental health care has
caused extensive opposition, mostly by the directly involved neighbourhood (Taylor &
Dear, 1981). Thus, for mental health authorities, knowledge of the public’s attitude to
International Journal of Social Psychiatry. Copyright & 2006 Sage Publications (London, Thousand Oaks and
New Delhi) www.sagepublications.com Vol 52(3): 234–242. DOI: 10.1177/0020764006067200
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community psychiatry is important when planning community mental health services.
Various parameters were found to influence the public’s attitude to psychiatry (Aghanwa,
2004; Al Krenawi et al., 2004; Aydin et al., 2003; Corrigan et al., 2003; Furnham & Buck,
2003; Kocmur & Dernovsek, 2003; Loewenthal et al., 2003; Magliano et al., 2004; Mallett
et al., 2004). Previous studies have identified demographic factors as having an influence
on the public’s attitude to community psychiatry (Brockington et al., 1993; Wolff et al.,
1996). This analysis of a representative public opinion survey in Switzerland also includes
sociological and psychological variables.
METHOD
The sample
We drew a representative sample of the Swiss residential population, aged 16–76 years, living
in a private household with telephone mainlines (n ¼ 1737) (Lauber et al., 2000a). People
aged over 76 years were excluded from participation because they often have problems under-
standing the interview (Jorm et al., 1997). Out of all Swiss phone numbers (hit rate ¼ 89.7%),
a random sample of households was drawn. A target person in each household was selected
using the Kish method (1949), which allows the researcher to randomly select the household
member to be interviewed according to eight tables based on age, sex and number of residents
in the household. The response rate was 63%. Throughout the sampling, a total of 1037
persons refused the interview. The main reasons for refusal were ‘no interest’ (39%), ‘dis-
approve of opinion polls’ (20%) and ‘no time’ (15%). Of the refusals, 76% occurred
before the contacted person received any information about the subject of the interview.
To test for both sampling and non-response bias we took into account the distribution of
the demographic characteristics of sex, age, nationality, the socioeconomic status in terms
of profession groups, and spatial differentiation in terms of urbanity. We compared the
sample with the available census data of Switzerland (Swiss Federal Statistical Office,
2001). There is a small overrepresentation of Swiss women over 36 years and an underrepre-
sentation of non-Swiss men. Unskilled workers are underrepresented in the sample whereas
people with scientific and technical professions and non-employees are overrepresented. This
finding remains valid when the influence of sex and citizenship is controlled for. With regard
to the place of residence, participation of people in urban centres is relatively low in pro-
portion to the population, whereas relatively too many participants live in periurban
communities. In comparison, demographic characteristics show only small differences
(maximum 2%). More divergence was found in spatial distribution (7%) and socio-
economic status (9%). These findings indicate a certain middle-class bias in the sample.
However, considering that the overall differences are small, we regard our sample as largely
representative (Lauber et al., 2001; Lauber et al., 2002a; Lauber et al., 2004).
The interview
Public attitudes were assessed using computer-assisted telephone interviewing (CATI) in
cooperation with an institute for survey research. CATI should particularly reduce potential
measurement errors associated with questionnaire item wording and ordering, interviewers’
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verbal behaviour and data processing (Lavrakas, 1993). All interviewers were thoroughly
trained and supervised during the survey. If the target person in a contacted household
agreed to participate, an interview date was arranged. Contact and date of interview were
spaced at least one week apart so that written material containing visual aids could be deliv-
ered in the meantime in order to facilitate the interview and increase data quality.
Instruments that have been proved in international research were included in the question-
naire. First, general attitudes towards mental illnesses and psychiatric institutions were
assessed, e.g. attitudes towards community psychiatry (Brockington et al., 1993; Taylor &
Dear, 1981; Wolff et al., 1996; Cronbach’s coefficient of reliability: 0.75) and restrictions
towards mentally ill people (Lauber et al., 2000a; Lauber et al., 2000b; Cronbach’s :
0.48). Second, a vignette depicting a person with either major depression or schizophrenia
fulfilling the respective DSM-III-R criteria was presented. Third, different variables including
demographic factors (such as age, gender, education, profession) were assessed: negative
emotions (Lauber et al., 2000a; Cronbach’s : 0.73) and social distance towards the case pre-
sented (Lauber et al., 2004; Cronbach’s : 0.85), participation in community activities
(Lauber et al., 2002a; Cronbach’s : 0.74), rigidity of interviewees (Lauber et al., 2002b;
Cronbach’s : 0.62) and stereotypes (Lauber et al., 2000a; Cronbach’s : 0.50) held by the
interviewees, and, finally, contact with mentally ill people (Lauber et al., 2003; Cronbach’s
: 0.49). Stereotypes are the mentally ill’s assumed characteristics compared with the
normal population. Rigidity means the individual’s preference for clarity and stability in
life, and also a low ability to adapt to changes.
Attitude to community psychiatry was assessed using six items from Taylor and Dear’s
(1981) study. Because of limited resources we chose those items that loaded highest in the
analyses by Taylor and Dear (1981), Brockington et al. (1993) and Wolff et al. (1996). The
interviewees were asked to rate each statement on a five-point Likert scale ranging from
‘I strongly disagree (1)’ to ‘I strongly agree (5)’:
Locating mental health facilities endangers the residential neighbourhood.
It is frightening to think of people with mental problems living in the residential neighbour-
hood.
Residents should accept the location of mental health facilities in their neighbourhood to
serve the needs of the local community.
Local residents have good reason to resist the location of mental health services in their
neighbourhood.
Mental health facilities should be kept out of residential neighbourhoods.
Locating mental health facilities in a residential area downgrades the neighbourhood.
Statistical analyses
Linear regression analysis was used to determine the relationship between co-varying pre-
dictor variables and ‘attitude to community psychiatry’ as the independent variable. In a
first step, we analysed the socio-demographic variables. We then included sociological and
psychological variables. To construct the scale ‘positive attitude to community psychiatry’
we recoded all items except for item 3.
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RESULTS
Percentages of acceptance and rejection of the different statements regarding community psy-
chiatry are presented in Table 1. In general, the Swiss population has a highly positive atti-
tude to community psychiatry (mean scale value: 4:12 0:73; all items recoded with the
exception of item 3). Only a few missing data occurred.
The linear regression analysis with demographic variables (Table 2) showed that people
with higher education and people with social professions – defined as a profession either in
social welfare or in health services (Swiss Federal Statistical Office, 2001) – have a signi-
ficantly more positive attitude to community psychiatry. Non-Swiss compared with Swiss
citizens have a significantly more negative attitude to community psychiatry. However, the
model explained only 3.7% of the variance ( R
2
adjusted). The model including psychological
and sociological parameters (Table 3) explains 21.2% of the variance (R
2
adjusted). Apart
from nationality and having children under the age of 18 years, demographic factors have
no significant influence. In their place, attitude to community psychiatry is influenced by emo-
tions towards the mentally ill person, as depicted in the vignette ( ¼0:163; p < 0:001),
social distance ( ¼0:162; p < 0:001), attitudes to restrictions ( ¼0:143; p < 0:001),
stereotypes ( ¼0:129; p < 0:001), rigidity ( ¼0:122; p < 0:001) and participation in
community ( ¼ 0:099; p < 0:001). Previous contact with mentally ill people is a weak but
significant predictor as well.
Table 1
Acceptance and rejection of various aspects regarding community psychiatry ( n ¼ 1737)
‘I strongly
disagree’
‘I disagree’ ‘I neither
agree nor
disagree’
‘I agree’ ‘I strongly
agree’
Missing
Danger to
neighbourhood
62.2%
(n ¼ 1080)
22.9%
(n ¼ 397)
9.7%
(n ¼ 168)
3.8%
(n ¼ 66)
1.2%
(n ¼ 21)
0.3%
(n ¼ 5)
Mentally ill in the
neighbourhood are
frightening
56.0%
(n ¼ 973)
22.2%
(n ¼ 385)
14.2%
(n ¼ 247)
5.5%
(n ¼ 95)
1.9%
(n ¼ 33)
0.2%
(n ¼ 4)
Acceptance of
psychiatric facilities in
community
2.2%
(n ¼ 38)
3.0%
(n ¼ 52)
12.7%
(n ¼ 220)
35.2%
(n ¼ 611)
46.6%
(n ¼ 809)
0.3%
(n ¼ 5)
Opposition against
facilities in the
neighbourhood
50.0%
(n ¼ 869)
23.5%
(n ¼ 408)
13.6%
(n ¼ 237)
9.2%
(n ¼ 160)
3.1%
(n ¼ 54)
0.5%
(n ¼ 9)
Facilities out of
residential areas
55.4%
(n ¼ 963)
17.0%
(n ¼ 296)
12.8%
(n ¼ 223)
10.3%
(n ¼ 180)
4.0%
(n ¼ 70)
0.3%
(n ¼ 5)
Downgrading of
residential areas
37.9%
(n ¼ 658)
18.4%
(n ¼ 319)
18.2%
(n ¼ 316)
19.7%
(n ¼ 342)
5.3%
(n ¼ 92)
0.6%
(n ¼ 10)
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DISCUSSION
In this representative population survey in Switzerland, the majority of the respondents have
a positive attitude to community psychiatry. However, the degree of positivity depends on the
context. In the linear regression analysis, negative emotions to the person depicted in the
vignette, social distance, a positive attitude to restrictions, negative stereotypes, rigidity
and no participation in community activities predict negative attitudes to community psy-
chiatry. Additionally, other parameters (the nationality of the interviewee, contact with men-
tally ill people, and having children under the age of 18 years) are weak but significant
predictors.
Table 2
Results of the linear regression analysis for demographic factors associated
with a positive attitude to community psychiatry in Switzerland
(n ¼ 1733; R
2
(adjusted) ¼ 0.037)
B b p value
Demographic variables
Nationality (non-Swiss) 0.237 0.117 < 0.001
Education (high) 0.157 0.106 < 0.001
Social profession* (yes) 0.197 0.103 < 0.001
Children (under 18 years) 0.070 0.044 ns
Sex (female) 0.013 0.009 ns
Age (high) 0.009 0.006 ns
* Defined as a profession either in social welfare or in health services (Swiss
Federal Statistical Office, 2001).
Table 3
Results of the linear regression analysis for demographic, psychological, and sociological factors associated
with a positive attitude to community psychiatry in Switzerland (n ¼ 1336; R
2
(adjusted) ¼ 0.212)
B b p value
Demographic variables
Nationality (non-Swiss) 0.154 0.076 < 0.01
Children (under 18 years) 0.083 0.052 < 0.05
Education (high) 0.065 0.044 ns
Social profession* (yes) 0.048 0.024 ns
Age (high) 0.022 0.015 ns
Sex (female) 0.011 0.007 ns
Psychological and sociological variables
Emotional reaction (negative) 0.240 0.163 < 0.001
Social distance (high) 0.238 0.162 < 0.001
Positive attitude to restrictions (high) 0.214 0.143 < 0.001
Stereotypes (negatives) 0.190 0.129 < 0.001
Rigidity (high) 0.179 0.122 < 0.001
Participation in community activities (high) 0.145 0.099 < 0.001
Contact with mentally ill people (high) 0.085 0.055 < 0.05
* Defined as a profession either in social welfare or in health services (Swiss Federal Statistical Office, 2001).
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Weaknesses and strengths of this survey
Before interpreting these results, some methodological limitations of this survey should be
acknowledged: First, this study highlights the problems with research on public attitudes,
e.g. the tendency to include communicative and cooperative respondents who are responding
because of social desirability (Wolff et al., 1996). Thus, we chose telephone interviews that are
considered superior to face-to-face interviews in terms of confidentiality and social desir-
ability (Frey & Oishi, 1995). Second, attitude to community psychiatry should not be mis-
taken for actual interpersonal behaviour, but can be considered as a ‘proxy’ measure of
planned behaviour (Pinfold et al., 2003). Third, one could wonder why the response rate is
not higher than 63%. Although the response rate may be reduced relative to the face-to-
face interview, it is higher than using the mailed interview technique (Platt, 1985). Moreover,
our response rate is in line with other public opinion surveys (Jorm et al., 1997) and it should
also be noted that no incentives for participants were given. Fourth, complete data are
required to be included in the linear regression analysis. Thus, we lost a part of the sample
because of missing data. Finally, owing to the sample size we found associations that
might be of little practical relevance. Thus, we only consider associations above the 1%
level (i.e. <0:10).
Nonetheless, some strengths of this analysis can be mentioned: this representative sample
allows us to draw a valid picture of the public attitudes towards mental illness in Switzerland.
To the best of our knowledge, this is the first study to include this diversity of psychological
and sociological variables to explain the attitude to community psychiatry. Moreover, these
results can be compared with those of Taylor and Dear (1981), Brockington et al. (1993) and
Wolff et al. (1996) as these authors used a vignette and the same items to assess the attitude
towards community psychiatry. However, different methodological and contextual aspects
have to be acknowledged: our sample is representative for the general population of Switzer-
land. Other studies are of more limited representativity: Wolff et al. (1996) studied a sample
in a defined South London area and Brockington et al. (1993) investigated a sample in the
Midlands. Finally, Taylor and Dear’s factor 2, Brockington et al.’s factor 1 and Wolff et
al.’s ‘fear and exclusion’ are comparable to our scale ‘attitude to community psychiatry’.
These studies found the total number of children, social class, age, education, occupation
and gender to be predictive of the attitude to community psychiatry. We cannot confirm
most of these findings, as the effects of demographic variables become weaker when psycho-
logical and sociological variables are included in the analysis.
Ambiguous attitudes towards people with mental illness in the community
The good news is that the majority of the population in Switzerland has positive attitudes to
community psychiatry. However, the degree of positivity depends on the context. The item
asking whether the presence of mentally ill people would downgrade a residential area had
both the most negative and the most indecisive answers. The lukewarm attitude may be
explained by the perceived self-relevance of the issue (Petty et al., 1997). The regression
analysis revealed that emotional factors play an important role regarding attitudes to com-
munity psychiatry. Negative emotions to the person depicted in the vignette and social dis-
tance, ‘people’s behaviour of keeping away unpredictable, frightening, and threatening
persons as far as possible’ (Link et al., 1999), are the most powerful predictors of a negative
LAUBER ET AL.: COMMUNITY PSYCHIATRY 239
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attitude to community psychiatry. Together with other negative predictors such as restric-
tions and stereotypes, more social distance is predictive of a generally negative attitude to
mentally ill people (Lauber et al., 2002b; Lauber et al., 2003; Nechamkin et al., 2003).
Implications for mental health policy
Public attitude does not adhere to simple patterns of explanation (Bhugra, 1989). Link (2001)
emphasised that, on a community level, only a multi-faceted and multi-level approach
addressed deeply held beliefs and thus led to effective and sustained changes of attitudes.
Consequently, two implications for mental health policy can be drawn from these results:
Emotional arguments must be focused, e.g. the fear that mental health services are down-
grading a given residential area. Especially for intervention campaigns, one way is to
enable direct contact with people with mental illness. Several authors (Pinfold et al.,
2003) showed that these contacts are reducing fear and negative attitudes.
The finding of negative emotional reactions towards people with mental illness calls for small
and inconspicuous mental health services that do not threaten the public. These small
services provoke fewer emotions and, thus, are better accepted among the general popula-
tion (Aderibigbe et al., 2003; Commander et al., 2003).
ACKNOWLEDGEMENT
The study was funded by the Swiss National Research Foundation (grant no. 32–52571.97).
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Christoph Laube r, MD, Psychiatric University Hospital, Zurich, Switzerland.
Carlos Nordt, PhD, Psychiatric University Hospital, Zurich, Switzerland.
Helene Haker, MD, Psychiatric University Hospital, Zurich, Switzerland.
Luis Falcato, MA Psychiatric University Hospital, Zurich, Switzerland.
Wulf Ro
¨
ssler, MD, MA, Psychiatric University Hospital, Zurich, Switzerland.
Correspondence to Christoph Lauber, Psychiatric University Hospital, Milita
¨
rstrasse 8, PO Box 1930, CH-8021
Zurich, Switzerland.
Email: christoph.lauber@puk.zh.ch
242 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 52(3)
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