Mental health workers' attitudes toward mental illness in Fiji

Abstract

Objective To survey mental health workers' attitudes toward mental illness in Fiji as a means of understanding the attitudes of these staff. Design A questionnaire survey using a previously validated scale: Attitudes Toward Acute Mental Health Scale (ATAMHS�33),�wasmodifiedanddistributedto � registered nurses and mental health workers at a major mental health care setting in Fiji. The ATAMH (33) is a 33 item measure of attitudes developed specificallyforusewithininpatientmentalhealth� settings. Setting A major in‑patient mental health care setting in Fiji providing primary, secondary and tertiary care.

Full text

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72
Mental health workers’ attitudes toward mental
illness in Fiji
AUTHORS
Kim Foster
PhD, MA, BN, DipAppSc (Nursing), RN, RPN
Senior Lecturer, School of Nursing, Midwifery and
Nutrition, James Cook University, Cairns, Queensland,
Australia.
kim.foster@jcu.edu.au
Kim Usher
PhD, MNursSt, BA, DNE, DHS, RN (Endorsed
Psychiatric)
Professor, School of Nursing, Midwifery and Nutrition,
James Cook University, Townsville, Queensland,
Australia.
John A Baker
PhD, MPhil, MSc, BNurs(Hons), RN, CPN
Lecturer, School of Nursing, Midwifery and Social Work,
The University of Manchester, United Kingdom.
Sainimere Gadai
RN, DipN, BNSc, MNSt,
Nursing Tutor, Fiji School of Nursing, Suva, Fiji.
Samsun Ali
RN, DipN,
Senior Nurse, St Giles Hospital, Suva, Fiji.
KEY WORDS
attitudes, mental health, mental illness, mental health
workers, Fiji
ABSTRACT
Objective
To survey mental health workers’ attitudes toward
mental illness in Fiji as a means of understanding the
attitudes of these staff.
Design
A questionnaire survey using a previously validated
scale: Attitudes Toward Acute Mental Health Scale
(ATAMHS33),wasmodiedanddistributedto
registered nurses and mental health workers at a
major mental health care setting in Fiji. The ATAMH
(33) is a 33 item measure of attitudes developed
specicallyforusewithininpatientmentalhealth
settings.
Setting
A major in‑patient mental health care setting in Fiji
providing primary, secondary and tertiary care.
Subjects
71 registered nurses and medical orderlies in a mental
health setting in Fiji completed the measure.
Main outcome measure
Theidenticationofmentalhealthworkers’attitudes
toward mental illness in Fiji.
Results
The participants expressed both positive and
negative attitudes toward individuals in mental
healthcare.Positiveattitudescanbeidentiedina
range of answers to questions including psychosocial
causational beliefs and when comparisons were made
with physical health issues. Negative attitudes were
expressed with respect to alcohol abuse and lack of
self control, individuals with mental illness lacking
control over their emotions, psychotropic medications
being used to control disruptive behaviour, and that
mental illness is caused by genetic factors. A number
of questions provided mixed responses.
Conclusions
This paper provides a baseline of attitudinal measure
of mental health workers in Fiji toward mental illness.
It will enable future educational interventions to be
evaluated and comparison to be made with other
culturesandcountriesintheSouthPacicregion.
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INTRODUCTION
Attitudesinuencebothprofessionalandpersonal
behaviour. In particular, stigma and discrimination
associated with mental illness and expressed by
mental health professionals as well as the general
public, results in the under‑use of mental health
services (Esters et al 1998 in Emrich et al 2003).
Contact with individuals who have mental illnesses,
and education that replaces myth with fact, can
decrease stigmatisation and positively affect
attitudes (Halter 2004; Tay et al 2004; Emrich et al
2003; Read and Harre 2001).
For the past fifty years, programs aiming to
de‑stigmatise mental illness have advocated for
medical rather than psychological explanations of
mental illness. Biological and genetic factors have
been promoted as underlying causes and people
with mental disorders were considered ‘ill’ in the
same sense as those with medical conditions.
Current evidence however disputes the assumption
that this information will result in more positive
attitudestowardmentalillness.Inasurveyofrst
year psychology undergraduates in New Zealand
for instance, Read and Harre (2001) found that,
contrary to the assumption of de‑stigmatisation
programs, genetic and biological causal beliefs were
related to more negative attitudes toward those with
mental illness.
Previous studies also demonstrate that health
professionals have negative attitudes toward some
aspects of mental illness. Hugo (2001) found that
mental health professionals were less optimistic
about prognosis and less positive about likely
long‑term outcomes when compared with the general
public. In this study however mental health nurses
were generally more optimistic than other health
professionals. Jorm et al (1999) also found that
compared to members of the Australian public, health
professionals (ie general practitioners, psychiatrists
and clinical psychologists) rated long‑term outcomes
more negatively and believed discrimination to be
more likely. This may be because health professionals
have greater contact with mental illness and
individuals who have chronic or recurrent problems
than the public and therefore may be more realistic in
their assessment of long‑term outcomes. If this is so,
according to Jorm et al (1999), health professionals
need to be aware of their attitudes and be careful
about what expectations they convey to patients and
their families. Certainly, negative attitudes toward
mental illness appear to worsen the overall quality
of life of individuals with mental disorders.
Further, providing culturally specic care involves
ensuring that clinical staff are properly educated
on underlying issues (Morrison and Thornton 1999).
Cultural diversity in knowledge about and attitudes
toward mental illness requires that this issue be
explored in a wide range of cultures, especially in
developing countries such as those in the South
Pacicregion.
Anecdotal evidence has suggested there may be
stigmatizing attitudes toward mental illness in
Fiji (Aghanwa 2004), although there have been
nostudiesidentiedwhichsurveytheattitudesof
mental health workers within Fiji. Aghanwa (2004)
conducted 980 structured interviews with residents
of Greater Suva, 25.3% (n = 248) of whom were
health workers, to explore the extent of knowledge
about mental illness and attitudes toward people with
mental illness in Fiji. Health workers were recruited
mainly from the general hospital and included all
categories of health professionals and ancillary
staff. Aghanwa’s (2004) results showed that a far
greater proportion of health workers than each of
the other categories considered the hospital was
a source of help for people with mental illnesses;
expressed the greatest dislike for ‘labelling’; and
considered that persons with mental illness were
signicantlydifferentfromotherpeople,“believ[ing]
that the way the patients would be perceived would
depend on the type of the mental illness” (p.370).
This latter nding supports that from an earlier
Australian survey (Hugo 2001) of the attitudes of
mental health nurses, medical staff, and allied health
staff toward depression and schizophrenia where
these professional groups believed that people with
schizophrenia would be more likely to experience
discrimination.
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To date, much of the research into attitudes has
focused on a broad range of health professionals
including medical practitioners and psychologists
(eg Feifel et al 1999; Singh et al 1998), and
comparisons of their attitudes to those of the general
public (Kurihara et al 2000). More recently though,
investigatorshaveincludedorspecicallyassessed
nurses’ attitudes towards mental illness (eg Baker
et al 2005; Halter 2004; Tay et al 2004; Emrich
et al 2003; Hugo 2001; Morrison and Thornton
1999; Munro and Baker 2007). Baker et al (2005)
developed, piloted and validated a new measure
of attitudes in acute mental health care staff:
the Attitudes Toward Acute Mental Health Scale
(ATAMHS‑33). The original 64‑question measure was
distributedtoasampleofqualiedandunqualied
nurses working in mental health care units in the
NorthofEngland.Factoranalysisresultedinanal
scale consisting of 33 questions. The authors of
the ATAMHS‑33 claim that the tool has the potential
to inform development of strategies to reduce the
impact of these attitudes on service user care and
evaluate the effects of educational interventions
addressing attitudinal issues in mental health
care. Their ndings identied ve components of
attitudes to consumers within acute mental health
care settings: care or control, semantic differentials,
therapeutic perspective, hard to help, and positive
attitudes.
Using the ATAMHS‑33 (modied ‑ see ‘Methods’
section below) in the present study with a sample
of Fijian nurses and medical orderlies may provide
initial evidence that will inform future mental health
educational programs in Fiji. In addition, it adopts
therecommendationstoreneandfurthervalidate
the tool with more diverse cultural samples, as
the Baker et al (2005) sample was drawn from
densely populated, inner city units with high levels
of deprivation which they noted could inuence
attitudes (Munro and Baker 2007; Baker et al
2005).
AIMS
The present study aimed to survey mental health
workers’ attitudes toward mental illness in Fiji
as a means of understanding the attitudes of
staff. Modication, piloting and validation of the
ATAMHS‑33 questionnaire (Baker et al 2005) to the
Fijian nursing context also aimed to assist future
development of an appropriate measurement tool
for use in pre‑and post‑test assessments with future
groups enrolled in a proposed mental health nursing
postgraduate program commencing in Fiji in 2006.
METHOD
The project design was a questionnaire survey that
aimed to provide a snapshot assessment of mental
health workers’ attitudes toward mental illness in
Fiji. The measurement scale for this survey was
an existing tool, the Attitudes Toward Acute Mental
Health Scale (ATAMHS 33) which combines Likert
scales (n=25) and Semantic Differentials (n=8).
Six of the thirty‑three questions were modied
slightlytoreectdifferencesinterminology,English
expression, and health care context relevant for Fiji.
For example, ‘Patients who abuse substances should
not be admitted to acute wards’ was changed to
‘Patients who abuse drugs and alcohol should not be
admitted to hospital’. The investigators of this project
andaFijiannurseworkingintheeld,reviewedand
modiedthequestionnaireforcontentvalidity.The
instrument was not translated into local languages,
as the target population was drawn from several
ethnic groups and a vast majority of the people in
Fiji understand and speak the English language
(Aghanwa 2004). The Likert questions were coded:
1‑7, with 4 representing the neutral mid point. Seventy
percent agreement in a single direction (either 1 to
3 or 5 to 7) was determined as group consensus for
a question. The semantic differentials were scored
on a 0‑10 scale with a score of 5 indicating the mid
point.Ascoregreaterthanverepresentedamore
positive attitude.
Data were also collected on the socio‑demographic
characteristics of participants, such as: age, gender,
education, and occupation. Prior to administration of
the survey, ethics approval was sought and gained
from the relevant university Human Research Ethics
Committee and the Fiji Ministry of Health Ethics
Committee.
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Recruitment of the sample
Participants were recruited from a group of registered
nursing staff and medical orderlies attending a
one‑day workshop (repeated for four consecutive
days) on mental health for staff at the only psychiatric
hospital in Fiji which provides primary, secondary and
tertiary care to clients throughout Fiji. The hospital has
four wards and 190 beds and caters for clients with
acute and chronic mental illnesses, as well as clients
with intellectual disability and those on forensic
orders. Medical orderlies comprise approximately
twothirdsofthestafngatthehospitalandprovide
much of the day to day care of clients. Registered
nurses form the remaining one third. The workshop
aimed to provide professional development for the
majority of the staff working at the hospital.
Inclusion criteria were: adults (18 years of age or
more) who were able to comprehend and write the
English language and were working as either a nurse
or orderly in mental health care in Fiji.
Data Collection
The questionnaire was administered on one occasion
only to a group of registered nurses and medical
orderlies attending a workshop at St Giles Hospital
in Fiji. An information sheet detailing the purpose
of the survey and its requirements. Other relevant
information was available to all potential participants
as they entered the workshop venue. At the beginning
of the workshop the rst author explained the
details of the project to all potential participants and
administered the questionnaire to those who wished
to take part. To avoid perceived or actual coercion of
participants, local hospital staff were not involved in
this process. To assist those participants with literacy
difculties,itemsonthequestionnairewerereadto
the group when necessary and a Fijian nursing tutor
and nurse (SG and SA) were available to assist the
co‑investigator orparticipants with claricationof
specicliteracyaspects.Thequestionnairehowever
was self‑administered to the extent that participants’
literary competence in English language permitted.
Data Analysis
Data were managed and analysed using the
Statistical Package for the Social Sciences (SPSS
Version 13). A number of statistical tests were
performed on the data including initial descriptive
statisticsandattributionofthedatatovepreviously
identiedcomponents(Bakeretal2005).Attitudes
of the registered nurses and medical orderlies were
compared using chi‑square test, and nonparametric
correlation examined the significance of the
association between some socio‑demographic and
knowledge/attitudevariables.Thep<0.05levelwas
usedforstatisticalsignicance.
Table 1: Participants who completed the ATAMHS
(33) (modied)
Variable Number
Gender
Male 27 (38%)
Female 44 (62%)
Position
Nurse 23 (32.4%)
Orderly 48 (67.6%)
Level of education
Tertiary 21 (29.6%)
Post‑secondarycerticate 12 (16.9%)
Secondarycerticate 23 (32.4%)
Post‑secondarycerticateand
Secondarycerticate
12 (16.9%)
Missing 3 (4.2%)
Mental health course/certicate
Yes 24 (33.8%)
Not stated 47 (66.2%)
Age range
20‑24 6
25‑29 10
30‑34 13
35‑39 5
40‑44 13
45‑49 13
50‑54 7
55‑59 4
RESULTS
Of a potential 72 participants, 71 chose to take part
in the survey, giving a response rate of 98.6%. This
group constituted the vast majority of mental health
workers at the hospital. The demographics of the
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population can be found in table 1. Participants had
worked in psychiatry from between 2 and 477 months
(mean 170.3, SD 133.0 or median 132.0).
Ten questions received greater than 70%
endorsement in one direction by the mental health
Table 2: Questions which received greater than 70% endorsement in a single direction
Question
Number
Question
% agreement
Implication
for attitude
Nurses n=23
(32.4%)
Orderly n=48
(67.6%)
Combined
Cumulative %
Question 4
‘Mentally ill patients have no control
over their emotions’
16
(69.5%)
37
(77%)
75.7%
disagree
Positive
Question 11
‘Mental illness is the result of negative
social circumstances’
15
(65.2%)
38
(79.2%)
75.7%
agree
Positive
Question 12
‘Many normal people would become
mentally ill if they had to live in a very
stressful situation’
16
(69.5%)
42
(87.5%)
81.7%
agree
Positive
Question 13
‘Those with a psychiatric history should
never be given a job with responsibility’
21
(91.3%)
32
(66.6%)
74.6%
disagree
Positive
Question 14
‘Those who attempt suicide leaving
them with serious liver damage should
not be given treatment’
22
(95.6%)
42
(87.5%)
80.1%
disagree
Positive
Question 23
‘Psychiatric illness deserves as much
attention as physical illness’
20
(86.9%)
38
(79.2%)
74.3%
agree
Positive
Question 24
‘The manner in which you talk to
patients affects their mental state’
21
(91.3%)
43
(89.6%)
91.4%
agree
Positive
Question 1
‘People who abuse alcohol have no self
control’
18
(78.2%)
41
(85.4%)
83.1%
agree
Negative
Question 21
‘Psychiatric drugs are used to control
disruptive behaviour’
21
(91.3%)
42
(87.5%)
91.3%
agree
Negative
Question 22
‘Mental illnesses are caused by genetic
factors’
15
(65.2%)
38
(79.1%)
76.8%
agree
Negative
Table 3: Semantic differentials (scoring 0‑10)
Semantic differential Mean SD
Implication
for attitude
Safe‑dangerous 4.1 2.7 Negative
Adult‑child 7.2 2.6 Positive
Mature‑immature 6.3 2.6 Positive
Optimistic‑pessimistic 3.9 2.6 Negative
Cold hearted‑caring 5.7 2.9 Positive
Polite‑rude 4.1 2.7 Negative
Harmful‑benecial 3.9 2.9 Negative
Clean‑dirty 4.6 2.9 Negative
workers (table 2). Responses to all semantic
differential questions are described in table 3.
Those semantic differentials with a mean score less
thanveareindicativeofapoorerattitudetoward
service users.
There was no statistical difference between
attitudinal scores and gender and those who
had undertaken further mental health training
or certicates. There were statistical differences
between registered nurses and medical orderlies for
two of the domains ‘Care or control’ (p=0.021), and
‘Therapeutic perspectives’ (p=0.036). Secondary
certificates compared to tertiary also had a
signicantdifferenceinonedomain‘careorcontrol’
(p=0.006).
For overall comparison with the original study, data
wereclusteredintothevedomainsidentied(table
4).
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DISCUSSION
Overall, there was evidence of both positive and
negative attitudes toward people with mental
illness by mental health workers in this study, with
some differences in attitudes evident between
registered nurses and orderlies. Only one of the
questions (Question 13 in the domain ‘Therapeutic
Perspectives’), however is the same as the questions
identied in Munro and Baker’s (2007) nding
of attitudinal differences between qualied and
unqualiedstaff.
In the current study, unqualied staff held more
positive as well as more negative attitudes than
qualiedstaff.ThisisgenerallyconsistentwithMunro
andBaker’s(2007)ndingandoverallconclusion
thatitcannotbeassumedqualiedstaffwillhold
morepositiveattitudesthanunqualiedstaff.Itis
possible that other variables such as professional
development training or other support may have
inuenced their attitudes. Evidence of positive
attitudes from all the mental health workers in this
study(tables2and3)canbeidentiedinresponses
to seven of the Likert questions (Questions 4, 11,
12, 13, 14, 23, 24) and three of the semantic
differentials (Adult:child; Mature:immature; Cold
hearted:caring). The mean scores for these three
semanticdifferentialsweregreaterthanve,which
provides further evidence of positive attitudes
toward people with mental illness. There is however
potentiallyamethodologicalawwiththesemantic
differential Adult‑child and Mature‑immature, as all
Table 4: Domain scores for the ve components (ATAMHS (33) modied)
Subscale
Number
of items
Theoretical
minimum
Theoretical
maximum
Observed
minimum
Observed
maximum
Mean SD Skewness Kurtosis
Care or control 12 12 84 32 66 47.8 7.64 0.357 0.002
Semantic
differentials
7 0 70 13 61 32.7 9.8 0.518 0.588
Therapeutic
perspective
6 6 42 9 39 28.3 6.3 ‑0.603 0.770
Hard to help 4 4 28 5 23 12.3 4.1 0.686 ‑0.013
Positive
attitudes
4 4 31 7.4 29 23.6 4.3 ‑1.254 2.415
ATAMH (33)
modied
33 26 255 104.3 201.4 114.6 18.1 0.572 0.882
staff worked within adult mental health services (over
16 years of age). These questions could have been
misinterpreted as to working with children. Altering
the wording to Childlike:adultlike may have elicited
a different attitudinal response.
Thecurrentstudy’sndingofpositiveattitudesby
these mental health workers is generally consistent
with Munro and Baker’s (2007) although direct
comparison was not made due to differences in
the sample and context of care. The ndings are
also, while not directly comparable with Aghanwa’s
(2004) previous study in Fiji, broadly consistent
with his conclusion that education about, and
experience working with, mental illness may assist
the development of more positive attitudes toward
mental illness. In accordance with previous studies
with nurses in particular, (Tay et al 2004; Emrich
et al 2003; Hugo 2001), it is also possible that
further education and training on mental illness
and therapeutic strategies could result in the
development of more positive attitudes for these
mental health workers, including the medical
orderlies who have had limited education in mental
illness. As Baker et al (2005) identify however,
evidence of positive attitudes alone does not
indicate whether there is corresponding therapeutic
behaviour and quality of care for clients. Research into
clients’ perceptions of these mental health workers’
attitudes could provide greater understanding as
to the effect, if any, of their positive attitudes on
client care.
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Three questions (table 2) provide evidence of these
mental health workers’ negative attitudes toward
people with mental illness (Questions 1, 21, 22).
Thisisinkeepingwiththendingsofseveralother
studies, although there are particular differences.
In the Singh et al (1998) study which aimed to
evaluate the impact of a psychiatric placement on
4th year medical students post placement, 92.7%
of the sample of medical students disagreed that
psychiatric drugs were used to control behaviour.
However, 91.3% of mental health workers in the
current study agreed with this statement. This
conictinagreementcouldprovideevidenceofthe
reliance on medication within mental health settings
tomanagedifcultandchallengingbehaviour.This
could be the experience of staff; given that these
mental health workers work within inpatient settings,
a notion of ‘ill health’ pertaining to clients admitted
is probably common. However this appraisal does
contribute directly to a poorer attitude toward
service users. It is clear that a biological or genetic
perspective of illness (Question 22) contributes
toward a negative attitude and that a vulnerability
perspective of mental illness is preferable to a
biological one (Read and Harre 2001; Read and
Law 1999; Cho and Mak 1998). Interestingly, more
orderlies (79.1%) agreed with this statement than
the nurses (65.2%). Two other questions (Q12
and Q13) in table 2 showed major differences in
opinions between nurses and orderlies. Fifteen
Likert questions appeared to show evidence of
divided opinion.
This study presents new research into the attitudes of
healthcare staff within Fijian mental health services.
The data provides a baseline for future educational
interventions which aim to improve both knowledge
and attitudes of registered nurses and medical
orderlies in Fiji. It will also enable comparisons to be
made with other cultures and countries in the South
Pacicregion.Withtheintroductionofaspecialist
postgraduate course for mental health nurses in Fiji,
there is also opportunity for education on additional
theoretical perspectives to that of the traditional
biological explanation for mental illness. This brings
a concomitant opportunity to explore therapeutic
nursing strategies to address disruptive behaviours
and symptoms of mental illness which complement
and/or extend those of medication administration.
Limitations of the study
The limitations of the study include a relatively
small sample of health workers working within one
mental health inpatient setting in Fiji. The design of
thequestionnairewasoriginallyinuencedbythe
need to survey the attitudes of acute mental health
nurses who worked with service users encountered
within the UK. The scale as such may not have been
transferable to a different country/culture. The
amendment of some questions was required in order
tomoreappropriatelyreectFijianmentalhealthcare
contextsanduseoflanguage.Thereisalsodifculty
incomparingtheattitudesofqualiedandunqualied
workers within this setting due to their differing roles
and professional responsibilities.
Notwithstanding these limitations, this paper does
present new data on the attitudes of mental health
workers in Fiji. There is now a need to undertake
a larger survey of attitudes toward mental illness
by mental health workers. Further analysis of the
formation of attitudes contained within the measure
used in this study could use qualitative methodologies
to explore in greater detail the development of
attitudes.
CONCLUSION
Whilst this study has taken a cursory look at the issue
of attitudes of mental health workers within Fiji, it has
provided some important indications of registered
nurses’ and medical orderlies’ perceptions of mental
illness and people who have mental illness in Fiji.
The attitudes of mental health workers in Fiji have
not been sought previously. This important area of
work is currently under‑researched and further work
could improve our understanding of the attitudes
that mental health workers maintain and how these
inuencethequalityofcareconsumersreceive.
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