KNOWLEDGE AND ATTITUDE ABOUT MENTAL ILLNESS AMONG NURSING STAFF

The magnitude of mental health problem is cosiderable. However the attitude of the general public towards mental illness and mentally ill people is largely negative. Perception and knowledge of the nursing staff on this topic is important as they directly deal with patients and their relatives, and they are also involved in disseminating health information. A negative attitude is known hindrance to providing quality service to mentally or physically ill persons. This study, therefore, carried out among nursing staff at B. P. Koirala Institute of Health Sciences (BPKIHS) a tertiary care center in Nepal, aims to find out nurses’ knowledge and attitude about mental illness. It is a cross-sectional, descriptive study with 110 respondents, who were predominantly females (97.27%) and young (mean age=25.7year). The study revealed some interesting findings as many of the participants thought mentally ill people are ‘ insane’ (37.5%). The majority had showed their knowledge about causes of mental illness as genetic or inherited (65.4%) and biochemical disturbances (90.0%). About three fourth were ready to work together (71.8%) and chat with them (91.8%). Respondents expressed their faith in psychiatrists (93.5%) but less in faith healers (3.0%). The vast majority had obtained information about mental illness from ‘seeing mentally ill persons’ (94.0%) followed by communication with medical personnel (84.5%). This study revealed that there was overall adequate knowledge and by and large a positive attitude. ORIGINAL ARTICLE Journal of Nepal Medical Association 2003; 42: 27-31 Shyangwa P M * , Singh S * , Khandelwal S K * * B.P. Koirala Institute of Health Sciences, Dharan, Nepal. Address for correspondence : Dr. Pramod M. Shyangwa, M.D. Asst. Professor, Dept. of Psychiatry B.P. Koirala Institute of Health Sciences, Dharan, Nepal. Email: pshyangwa@yahoo.com psychiatric problem in the community as well as in hospitals.2 Knowledge and attitude is a complex and interrelated construct. While the knowledge refers to the fact that a person knows about a subject through personal experiences, cultural practices or from others, the attitude encompasses knowledge, experiences, personal variables and emotions related to particular topics.3 As early psychiatric intervention is known to reduce morbidity and mortality in the patients with physical illness, the need for an early referral to psychiatric services is not overemphasized. The nurses’ role in this regard is being increasingly recognized.4 In addition to that, the knowledge, attitude and beliefs of nursing staff regarding mental illness will be key, as they are directly involved in providing mental health care along with

general care to needy physically and psychologically ill patients.Similarly a trained nurse should be actively involved in mental health disseminating activities.Although there is body of foreign studies in this topic, indigenous study, to our knowledge, is lacking.Considering all these facts the current study is carried out with following objectives: 1.To assess the level of knowledge of nurses regarding mental illness.2. To find out attitude towards mental illness and mentally ill people.

METHOD AND MATERIAL
The sample consisted of 110 nursing staff (out of 170), were working in BPKIHS, a tertiary level general hospital.A structured, standard questionnaire was supplied to the respondents for their response after obtaining informed consent.Most of them had responded immediately, but those who could not, had taken questionnaire with them and returned some time later the questionnaire consisted of 35 items which aimed to find out etiology, general conception, diagnostic methods, treatment modalities and their efficacy as well as their source of information.The attitude related questionnaire was directed to elicit information about their attitude towards mental illness and the mentally ill people.The questionnaire was covered by a self-designed sheet to record following socio-demographic information: age, sex, religion, and education; district of domicile.Name was omitted to maintain anonymity.

RESULTS
A total of 110 nursing staff completed the questionnaire with mean age of 25.7 years.The majority of subjects were from the young age group (15-24yr).Of them 107 (97.27%) were females and 3 (2.27%) were males.One hundred two (92.72%) had completed certificate course of nursing whereas the rest 8 (7.27%) had bachelor level.In response to the source information regarding mental illness (Table VI), the majority of the respondents reported to have received it from seeing mentally ill people (94.0%), doctors and health workers (84.5%), friends and relatives (79.0%), print media (80.0%), electronic media (radio 59.1%, TV 78.1 %) and other sources (75.0%).Family members (25.4%) and faith-halers (23.6%) contributed very little to their information.Sixty-five percent respondents expressed their satisfaction with current knowledge.

DISCUSSION
Many studies have consistently shown the high rates of psychological problems among patients with physical illness at inpatient and outpatient levels.A literature review revealed that 25-30% of inpatient and 50-60% of outpatient suffer from one or another kind of psychological distress or disorder requiring attention. 2Nurses working in general hospitals have an important role in dealing with patients having psychiatric problems.They help in referring patients to psychiatrists as they closely associate with patients and easily notice behavioral changes in them, if adequately sensitized.Attitude, knowledge and practice are closely related concepts and have an immense influence on a person's practice.John and Martean 5 noted that behavior and beliefs of health professionals including nurses influence the heath outcome of patients.
Our study has shown some interesting findings, which must be seen in light of the prevalent concepts of mental illness and their treatment among the general population and recent spurt in the health and educational awareness among the public.
Responses to questions on mental illness and mentally ill patients have been mixed.A sizeable number had felt that mentally ill were 'insane' 'violent' and 'dangerous' indicating their negative view.Similar view was found in a study conducted in US, where majority (82.4%) respondents believed that symptoms of mental illness are associated with potential violence. 6It can have implication in patient care and overall A large majority (93.6%) felt that physical symptoms could also be the manifestations of mental illness.The majority (65.5%) did not believe that marriage could cure mentally ill people; however, a small minority (5.5%) felt that marriage could have curative effect.The majority (69.0%) believed mentally ill people could be treated at home and the majority (54.5%) was ready to choose a marriage partner even who had family history of mental illness.Almost half of the respondents (46.3%) considered newer investigative modalities like MRI or CT scan are being necessary for diagnosis of mental illness.outlook to the discipline.Yet the majority felt that marriage could not cure a mental illness and patients could be treated at home.They felt that physical symptoms could be part of a mental disorder.This is a significant finding as they endorse the view that in the eastern culture or Hindu philosophy there is no dichotomy between mind and body and psychological and physical symptoms can be present in both psychiatric disorders as well as physical discords.
These responses may not correspond fairly to the general beliefs held in the Nepalese society.The majority of subjects in this study expressed the idea that marriage is not a solution for mental illness, which is contrary to the general public's belief.Most of the respondents felt that God's curse, witchcraft or evil spirits does not cause mental illness, which again may be contrary to the general public's prevailing view but are comparable to the views of nurses in a study from India. 4 Both the views can be explained to some extent by respondents' educational background as all had basic medical knowledge.
Respondents were divided equally on the issue whether modern sophisticated investigative modalities are required to establish psychiatric diagnosis.More than half of the subjects expressed their willingness to marry the family member whose family member has mental illness.It shows their high positive attitude towards mentally ill people.An Indian study conducted among nurses showed that 91.2% were against the marriage of their relatives even to a recovered psychiatric patient 4 .Regarding etiology of mental illness, the vast majority held fairly good knowledge about it, which is in keeping with current knowledge in this field.Such information might have been acquired from training.Unscientific but generally attributing factors for mental illness like sin, curse, disregard of religion, witchcrafts did not hold water as a cause of mental illness in the study.In developing countries more than western cultures, supernatural phenomena like witchcraft and possession by evil spirits are seen as important causes of mental illnesses 7 .Along with biological causes for mental illness, respondents also correctly underscored the importance of psychosocial causes including financial constraint as cause of mental illness.This view goes parallel with the opinion held by western population 8 .Subjects' belief in genetic heretability and biochemical disturbances in the brain indicated their better knowledge of the etiology of mental illness, which is contrary to the general public's perception.It is encouraging to document the knowledge of etiological factors among the nurses, as it will be helpful in information disseminating activities.
Certain questions were asked in order to know their perception about the capability of mentally ill person to shoulder certain responsibility.The majority had a pessimistic outlook.A great proportion of respondents felt that mentally ill persons can not take care themselves and a large number believed that they may not be able to maintain good and long-lasting relationship with others.Such view might have emerged from their understanding that only visibly (severely) disturbed persons are mentally ill.Nevertheless, overwhelming majority had expressed positive and helping attitude towards these unfortunate people.Many respondents showed their willingness to work together, chat together and live in the same house.This kind of mentally ill-friendly behavior will not only be beneficial for the patients but also will be a good example for others.
Regarding the treatment of mental illness, the majority of respondents concurred with the presumed etiological factors.For example, vast majority viewed that treatments provided by psychiatrists are most effective followed by general practitioner.In one western study psychiatrists and psychologists are rated less highly than general practitioners for minor psychiatric problems, but are more likely seen as helpful for schizophrenia. 9Alternative treatment modalities like herbals, yoga, visiting holy shrines was considered as ineffective.Particular belief and faith about the treatment help to generate help-seeking behavior.From the responses, we assume that our respondents seek help from psychiatrist as a first priority.In Malaysia, belief in supernatural powers by mentally ill persons was seemed to be related with greater use of faith healers. 7e information about the mental illness and mentally ill people by majority study subjects was obtained from 'seeing mentally ill persons' (94.0%), followed by communication with doctors and health workers (84.5%), and by reading news papers (80.0%).But only 25.4% acquired knowledge about mental illness by suffering themselves or seeing mental illness in relatives.It can be explained by the fact that cohort of subjects had training in medical branch where they had had an opportunity to interact with medical personnel.Similar result was found in a UK study, where 33% of respondents cited personal experience of someone with mental disorders as their main source of information, while a further 10% cited friends and relatives. 9

CONCLUSION
The majority had fairly good knowledge about the causes of mental illness and accordingly they preferred possible effective modalities of treatment.Almost half of them were not satisfied with their current knowledge reflecting their willingness to acquire more information.It calls for further information imparting activities to nursing staff of BPKIHS.

Table II
that mentally ill people could not take care of self (43.0%), family (67.2%) and relationships (72.7%) and majority felt that they can not work with full responsibility (77.0%).Table IV pertains to respondents' attitude on working with mentally ill people.A large majority of respondents expressed