A Comparative Sample Study of Sweden contra India
Sandra Frykman Julia Angbrant
Psychology, bachelor's level 2018
Luleå University of Technology
Department of Business Administration, Technology and Social Sciences
Attitudes Towards Mental Illness
A Comparative Sample Study of Sweden contra India
Julia Angbrant & Sandra Frykman
Bachelor in Philosophy Psychology
Luleå University of Technology
Department of Business Administration, Technology and Social Sciences Engineering Psychology
with India. To measure attitudes towards people with mental illness the questionnaire Community Attitudes Towards Mental Illness (CAMI) was used containing positive and negative statements regarding mental illness. These statements are divided into the four attitude categories of Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology. The questionnaire study consisted of a total of 410 students; 272 from Sweden and 138 from India. Sweden and India were chosen because of their differences based on factors that recent studies have shown affect a community’s attitudes towards mental illness;
socio-economic, religion and culture. The results show that there is a difference in attitudes between the two countries in three out of the four attitude categories, where India showed a more positive attitude than Sweden towards mental illness meaning they have a greater sense of authoritative approach, goodwill, and social inclusion. This result was expected in the sense that there was a significant difference between the countries but not in the sense that India was to be the country to have a more positive attitude than Sweden since it goes against what previous research indicated.
Keywords: mental illness, attitudes, CAMI, high-income country, lower-middle- income country, culture, religion
med Indien. För att mäta attityderna gentemot personer med psykisk ohälsa användes
frågeformuläret Community Attitudes Towards Mental Illness (CAMI) innehållandes positiva samt negativa påståenden inom ämnet mental ohälsa. Dessa uttalanden är uppdelade i de fyra attityd-kategorierna: Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology. Studien bestod av totalt 410 studenter; 272 från Sverige och 138 från Indien. Sverige och Indien blev valda som länder genom deras skillnader baserade på faktorer som tidigare studier har visat ha effekt på ett samhälles attityder gentemot psykisk ohälsa;
socioekonomi, religion samt kultur. Resultaten visar att det finns en skillnad i attityd mellan de två länderna i tre utav de fyra attityd-kategorierna där Indien visade på en mer positiv attityd gentemot psykisk ohälsa än vad Sverige gjorde vilket innebär att Indien har ett mer auktoritärt förhållningssätt, social inkludering samt känsla för välvilja. Detta resultat var delvis förväntat då vi förutspådde en skillnad mellan länderna men då tidigare forskning indikerat, genom
faktorerna nämnda tidigare, att Sverige borde ha en mer positiv attityd än Indien var den delen av resultaten inte förväntad.
Nyckelord: mental ohälsa, attityder, CAMI, höginkomstland, lägre medelinkomstland, kultur, religion
Introduction
In 2001, the World Health Organisation (WHO) estimated that one in four people would experience a mental health condition during their lifetime and that approximately 450 million people worldwide are disabled as a consequence (Janet, 2001). In recent years, mental illness is becoming increasingly acknowledged as a global issue (Eaton, Kakuma, Wright, & Minas, 2014). At the same time, depending on which part of the world a person is living at the
situation for the ones suffering from mental illness can vary a lot. For example, access to proper health care may vary considerably, depending on where you are located, which in turn often depends on the country's economic growth. Even factors like culture and belief systems can affect the situation of the people that are suffering from mental illness.
Definition of important concepts
In order to create understanding for the reader and reduce the risk of open interpretation, we have chosen to begin by explaining some key concepts in the study. By defining these, we clarify what we mean when we use the different terms.
High income countries and lower-income countries
The concepts are created by the World Bank and are based on their estimates of GNP per capita. By 2017, lower-income countries refer to countries with gross domestic product (GNP) per capita lower than 1,006 US dollars. High-income countries refer to countries with gross domestic product (GNP) per capita over 12,235 US dollars (The World Bank, 2017). This classification is based strictly on income and does not take other factors into account that could affect the level of development in a country (The World Bank, 2017).
Mental disorder / mental illness
WHO has defined mental disorders the following way:
Mental disorders comprise a broad range of problems, with different symptoms.
However, they are generally characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others. Examples are schizophrenia,
depression, intellectual disabilities and disorders due to drug abuse. Most of these disorders can be successfully treated. (www.who.int/mental_health/management)
Culture
In this report, we will refer to culture in the terms of individualism and collectivism.
Attitudes
The term attitudes refer to a person’s underlying psychosocial processes only being revealed when aggravated by specific factors (Antonak & Livneh, 2000).
Stigma
The term stigma refers to a social devaluation of a person due to an “attribute that is deeply discrediting” and can be conceptualised as consisting of “problems of ignorance, prejudice and
discrimination” (Semrau, Evans-Lacko, Koschorke, Ashenafi, & Thornicroft, 2015).
Selected countries
In the following study, we intend to investigate two contradictions based on the factors that recent studies have shown affect a community’s attitudes towards mental illness; socio- economic, religion and culture. These factors are further explained in the next section. The two selected countries are India and Sweden. The countries are chosen based on factors that may affect the situation of the ones suffering of mental illness and the factors are opposites in the two countries, meaning that Sweden is on one side of the scale while India is on the other.
By doing this comparing study about attitudes towards mental illness in each country, we intend to investigate if the previous research about what factors that may affect stigma and people's attitudes in this area are correct or not. We intend to investigate the two countries’
attitudes towards mental illness in terms of their openness meaning how accepting the population are towards mental illness as a whole, towards people being mentally ill and how willing people are to be exposed to mental illness and talk about it.
Swedes, being generally non-religious (Global Index of Religiosity and Atheism, 2012), of a horizontal individualistic culture (Shavitt, Torelli & Riemer, 2011) and a high income country (The World Bank, 2017), should according to previous research be more open to mental illness in the sense of being more accepting towards it, susceptible to talk and learn about it (Ghanean, Jacobsson & Törnkvist, 2013; Stuart, 2016).
India, being religious (Global Index of Religiosity and Atheism, 2012), of a vertical
collectivistic culture (Triandis & Bhawuk, 1997), and a lower-middle income country (The World Bank, 2017), should according to previous research be less open, god willing and accepting to mental illness and through that have a more negative attitude towards it (McDaid, Knapp & Raja, 2008).
Factors leading to a difference in attitudes towards mental illness
In the article “Mental Health Service Provision in Low- and Middle-Income Countries”, which was published in the journal “Health Services Insights” the provision of mental health services in low- and middle-income countries is discussed (Rathod et al., 2017). Comparisons between high- and low-income countries show a significant difference in the presence of a mental health workforce including psychiatrists, nurses, psychologists, and social workers.
Apart from the fact that the supply of help for those who suffer from mental illness is
significantly higher in high-income countries than in lower-income ones, the culture and view of mental health can be experienced differently. In fact, cultural and religious attributes of illness and belief systems that influence help-seeking behavior further complicate access to services and outcomes for mental health (Rathod et al., 2017).
Socio-economic factors
Socio-economic factors, e.g. poverty and access to healthcare, have been found to be
associated with outcomes of mental illness (Lund et al., 2011) and are determining the context in which stigma is enacted and experienced. In low- and middle-income countries, including India, where the main part of the population do not have access to benefits of the social
welfare, the negative economic consequences of stigma can express itself by discrimination in work. This may threaten the economic survival of an entire family (Koschorke et al., 2014).
In high-income countries, access to mental health care is more developed and thereby people are more exposed to it (WHO, 2014). By it being more available to the population, the stigma lowers and will therefore not affect the individual and its family as negatively as it might in lower-income countries. A functioning, well-known, existing social welfare system, e.g. a suicide prevention one, might lower the stigma in the country since people are more exposed and aware to the psychological welfare in their society (WHO, 2014).
Religious factors
Being the birthplace of Hinduism and Buddhism, religion has always been an important part of India’s everyday life and culture (Jyoti & Kour, 2017). The three biggest religions in India are Christianity, Islam and Hinduism (Heitzman & Worden, 1996) while the two biggest ones in Sweden are Christianity and Islam (www.myndighetensst.se). People will have different attitudes and views of illness, their symptoms and its meaning depending on their religious beliefs.
According to the Islamic belief and the Qur’an, God is omega and alpha meaning that everything begins and ends with the all-knowing Allah. Therefore, if someone were to be mentally ill, it is part of God’s plan and is either a punishment deserved or a trial well needed in order to absolve the individual in question (Koenig, 2016). By believing that it is part of a plan, one might try to endure the symptoms instead of seeking professional help or even acknowledge it as a mental illness.
In Hinduism, the common Hindu belief is that everything is karma, meaning that all you do has consequence and at the same time many Hindus stigmatize mental illnesses
(www.health.qld.gov.au). By believing that mental illness is caused by karma, it is easy to assume that Hindus generally will have the attitude that individuals suffering from mental illness are deserving of doing so because of a misdeed in a previous life.
In regards for Christianity, studies have shown that a large number of Christians suffering from mental illness, believe their symptoms are caused by demons (Koenig, 2016). By believing this, people will tend to see practitioners of exorcisms to a greater degree than a professional
psychologist leading to not acknowledging the symptoms as mental ones (Mercer, 2013). By not thinking of one’s symptoms as a psychological illness but of a demon taking over one’s body, e.g., one might not understands one’s need in seeking psychological help and thereby not forming a sound understanding nor attitude towards mental illness.
According to reports from Win-Gallup International Association (2012), 81% of the Indian population call themselves religious while only 19% of the Swedish population gave the same answer.
Quack (2013) describes what affects people’s help-seeking behavior in the north of India and how this in turn affects their attitude. He found that even though the patients’ symptoms were
identified by their relatives and family as psychological ones, they were taken to see a religious healer (Quack, 2013).
Religion, tradition and different ideological beliefs might cause a certain behavior not being as inviting to different approaches such as professional psychological or psychiatric help. When being asked, people in India answered that both medicine and prayer are important but when being asked to explain and assess their problems, they were not able to but relied fully on the healers and doctors they had visited earlier. If a society has a tradition of only going to healers, it is natural that that’s where they will keep going and they will keep on believing that it is ghosts or demons causing their illness, and not understand that it is a psychological issue (Quack, 2013). This shows that tradition, and religion along with it, has strong impact on the societies and its people. By not accepting mental illnesses for what it is but seeing the
symptoms as demons, ghosts or a sign of God, it is hard to expect people to have a positive attitude towards it.
Culture
Individualism and collectivism are attitudes and beliefs linked the society’s culture reflecting social norms and values (Hampton, 2017). Collectivism is a perception that sets the common interests over the individual interests (www.merriam-webster.com). Individualism on the other hand is a perception that sees the individual's freedom and independence as the highest value (www.merriam-webster.com). There are four types of individualism-collectivism; horizontal collectivism, horizontal individualism, vertical collectivism and vertical individualism
(Hampton, 2017) where the horizontal orientation focuses on equality among people and the vertical orientation focuses on a hierarchy within society and among all individuals (Singelis, Triandis, Bhawuk, & Gelfand, 1995).
Horizontal collectivism as well as horizontal individualism is not correlated with stigmatizing attitudes towards mental illness (Hampton, 2017). Vertical collectivism focuses on how much individuals value their interdependence as well as their group’s competition with other groups (Singelis et al., 1995). Vertical individualism sees the individual as either better or worse than the surrounding people (Hampton, 2017). By viewing every individual as its own, and seeing everything in the perspective of competitiveness, stigmatizing mental illness and viewing people being mentally ill as less valuable (Hampton, 2017).
Sweden, being a horizontal individualistic society (Shavitt, Torelli, & Riemer, 2011) indicates that its population should have a less stigmatizing and more positive attitude towards
individuals with mental illness. India, being a vertical collectivistic society (Triandis & Bhawuk, 1997) indicates that its population should have a more stigmatizing and negative attitude towards individuals with mental illness.
According to Lee et al. (2005) a collectivist culture does not protect psychiatric patients against familial stigma. An entire family will take up the shame and burden of having a mentally ill member throughout the course of the illness (Lam, Tsang, Chan, & Corrigan, 2006).
However, the interfamilial and social connections of moral favor and relationship can break down in the face of the powerful forces of stigma. Ultimately, families might abandon a
member with a mental disorder. Such abandonment is especially distressing because unmarried adults are generally expected to live with their parents and siblings (Lee et al., 2005).
Earlier research has found that it is common around the world to have negative attitudes towards mental illness and that it is even more so when a person has not been in contact with it through a relative, friend or by being sick oneself (Siqueira, Abelha, Lovisi, Sarução, &
Yang, 2017). Studies show that the stigma surrounding mental illness affects people in a way causing them to not seek help, this increasing the stigma even more (Siqueira, Abelha, Lovisi, Sarução, & Yang, 2017).
Community Attitudes towards Mental Illness- CAMI scale
When the psychiatric care changed from former institutions to becoming more free forms of care in society, Taylor and Dear (1981) developed a questionnaire aimed to investigate the public's attitudes towards the mentally ill. They called this questionnaire Community Attitudes towards Mental Illness (CAMI). To develop this new questionnaire, they used the two easily understood and well validated scales OMI (Opinions about Mental Disease) and CMHI (Community Mental Health Ideology). Since the 80s, the CAMI scale has been in continuous use and applied in many settings worldwide (CAMI Scale, 2017a). CAMI is divided in four attitude categories where each category contains of 10 statements. The four attitude categories are Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology.
Authoritarianism was measured by statements such as "the mentally ill must be
institutionalized" and "the mentally ill are not to blame for their problems". This category measures the participants’ way of looking at mental illness as a disease, looking at the people suffering from it, knowledge of how it develops and how the people being ill should be handled. A high mean value here indicates an understanding of how people become mentally ill and a humane sense of how people being ill best should be taken care of.
Benevolence investigated claims like "more tax money should be used for care of mentally ill"
and "mentally ill have long been victims of mockery". A high mean value in this category would indicate a good will towards people with mental illnesses.
Social Restrictiveness investigates if the mentally ill are perceived as dangerous, e.g. through the allegation: "Mentally ill are a danger to themselves and to others". A high mean value in this category indicates a social openness towards people with mental illness.
The last category of Community Mental Health Ideology investigates claims such as: "It is scary to think that mentally ill people live in common neighbourhoods". A high mean value in this category indicates community inclusiveness (Taylor & Dear, 1981) and thereby a more positive attitude towards people with mental illness.
Aim and research questions
The aim of this study is to compare the attitudes towards mental illness, based on the factors religion, socio-economics and culture, in a high-income country to a lower-income country.
We intend to investigate this by taking a sample and have therefore selected two countries that fall into each income-category; Sweden and India. In order to correspond to the time- and amplitude frame of our bachelor thesis, we have decided to limit the comparison to the attitudes of students in the two chosen countries.
Research questions:
- Does the attitude towards mental illness differ between students in India and Sweden?
- How does this result live up to what previous suggestions/theories in research indicate?
Hypothesis
Our hypothesis is that there will be a difference in the attitudes towards mental illness, both among the students but more distinctly between the two countries of Sweden and India. We believe that the students in Sweden will have a more positive attitude while the students in India will have a more negative one. This hypothesis is based on the previous research that indicates that factors such as socio-economic belonging, religion and culture have been found to have impact on the life situation with mental illness and in determining the context in which stigma is enacted and experienced.
Method Design
The study had a between-group design with two groups; participants living in Sweden (Group 1) and participants living in India (Group 2). The dependent variable is in this case the attitude of the participants towards mental health.
Participants
We got in contact with our participants in India at several different universities throughout the country through professors in different departments giving us access to their students and by the schools official Facebook pages. In Sweden, the contact has been made through the contact registry available at Luleå University of Technology.
Since we were not primarily interested in examining differences between gender and age, selection of participants was not stratified with respect to these variables. The only selections made were that the participants were born in either Sweden or India, currently being university students and that they had not studied any form of psychology at university level.
Group 1, with Swedish students, consisted of 272 participants and group 2 with Indian student consisted of 138 participants, which makes a total of 410 participants in the questionnaire study. This number of participants allowed for valid conclusions and did fit the project’s timeframe.
Questionnaire
In order to collect information about the attitudes the participants have towards mental health, we used “The Community Attitudes towards Mental Illness scale (CAMI)”. CAMI is designed
by Taylor and Dear (1981). CAMI contains 40 claims about mental illness that are rated on a five-degree Likert-scale (CAMI Scale, 2017b ). The questionnaire is in English and the same questionnaire was used in Sweden and India. A test version of the questionnaire in digital form was sent to five people in a pilot study to see if there were any errors or problems with the questionnaire. The questionnaire was sent to the participants digitally by email and via Facebook communities. The emails and Facebook posts contained a link to the survey and information about the study. Appendix 2 and Appendix 3 contain the information that was sent along with the link to the survey. Appendix 4 and Appendix 5 contain the questions sent to the participants via the link to the online survey. The emails to the Swedish participants were sent by us personally in February 2018. We were given access to the Swedish students' email addresses via Luleå University of Technology. In India, the email was sent through the students' teachers, which we had contact with both in person and by email. The emails to Indian students and the posts in the universities’ Facebook communities were sent out in March and April 2018. Due to the fast responses and high number of participants in Sweden, we did not need to send a reminding email to the Swedish participants. In India we had to remind the teachers to send out the questionnaire and to encourage their students to participate.
Data analysis
When compiling the data from the questionnaire and comparing the two sample groups, several independent t-tests have been conducted to investigate if there were any differences between the two groups. We investigated the test's properties with Cronbach’s Alpha for the attitude categories in the test. The statistical software SPSS was used for analysis.
The answers were converted based on the instructions in the original study on CAMI (Taylor
& Dear, 1981). Five of the 10 statements in each category expressed a positive sentiment with reference to the underlying concept, and the other five were negatively worded. For example, for the authoritarianism category, five statements expressed a pro-authoritarian sentiment, and five were anti-authoritarian. The response format for each statement was the standard Likert five-point labelled scale: Strongly Agree/Agree/Neutral/Disagree/Strongly Disagree. All responses were converted from words to numbers. Pro-questions were converted as follows:
Strongly Agree = 5 and Strongly Disagree = 1. Negative Anti-questions were converted the opposite way: Strongly Agree = 1 and Strongly Disagree = 5. Thus, high value indicates a more positive attitude towards mental illness for all questions.
Ethical considerations
As the study was based on people's attitudes and opinions about mental illness, which in some contexts can be perceived as a private and sensitive subject, it was of high importance that we related to the research ethical principles developed by the Swedish Research Council and the Indian Research Council as well as the National Association of Psychological Science in India, this in order to respect the participants.
We used anonymous questionnaires. The participants received information about the purpose of the study and were able to give their consent as they completed the questionnaire. In terms of use, content and empirical data were used exclusively for this study.
Results
To investigate whether there are any differences in attitudes between Sweden and India, a comparison was made with the two countries’ responses to the questions from the
questionnaire CAMI. Several independent samples t-tests were performed, and the result show a statistically significant difference in three out of a total of four attitude categories (Table 1).
Table 1
Swedish and Indian students’ mean scores (M) and mean differences (diff) in the four attitude categories with t-tests.
Category Nationality N M diff t
Authoritarianism Sweden 272 21.9632 -2.25416 -3.985*
India 138 24.2174
Benevolence Sweden 272 38.2316 -2.58722 -4.069*
India 138 40.8188
Social Restrictiveness Sweden 272 23.2206 -2.32001 -.208
India 138 23.3188
Community Mental Health Ideology
Sweden 272 35.4191 -.09825 -3.726*
India 138 37.7391
*p < 0.05
Figure 1. Mean scores for Swedish and Indian students in each attitude category.
Authoritarianism
The Swedish participants’ (M=21.9632) responses to the questions in this category differed from the Indian participants’ (M=24.2174) responses, t(408) = -3.985, p < .001. This means the Indian participants have a more authoritative approach towards people with mental illness.
Benevolence
The Swedish participants’ (M=38.2316) responses to the questions in this category differed from the Indian participants’ (M=40.8288) responses, t(408) = -4.069, p < .001. This means the Indian participants have a higher sense of goodwill towards people with mental illnesses.
Social restrictiveness
As can be seen in Table 1, the countries did not differ in the category of Social restrictiveness.
Community Mental Health Ideology
The Swedish participants’ (M=35.4191) responses to the questions in this attitude category differed from the Indian participants’ (M=37.7391) responses, t(408) = -3.726, p < .001. This means the Indian participants are more including in their community towards people with mental illness.
Table 2
Swedish and Indian students’ mean scores (M) and mean differences (diff), in questions differing the least and most, with t-tests.
Question Nationality N M diff t p
6. The mentally ill are a burden on society. (B)
Sweden 272 3.50 -.967 -8.408 .000*
India 138 4.47
10. The mentally ill have for too long been the subject of ridicule.
(B)
Sweden India
272 138
3.72 3.82
-.102 -1.008 .934
11. A woman would be foolish to marry a man who has suffered from mental illness, even though he seems fully recovered. (SR)
Sweden 272 3.72 -.102 -1.008 .934
India 138 3.82
20. Residents should accept the location of mental health facilities in their neighbourhood to serve the needs of the local community. (CI)
Sweden 272 3.56 -.546 -6.196 .000*
India 138 4.11
29. Mental hospitals are an outdated means of treating the mentally ill.
(A)
Sweden 272 2.95 .304 3.296 .000*
India 138 2.64
30. The mentally ill do not deserve our sympathy. (B)
Sweden India
272 138
4.28 4.09
.189 1.895 .936
(A) = Authoritarianism (B) = Benevolence
(SR) =Social Restrictiveness
(CI) = Community Mental Health Ideology
Questions that differed the most
As can be seen in Table 2, question 6, 20 and 29 are the questions where the participants from each country show the biggest differences in their answers.
In question 6: “The mentally ill are a burden on society”, the Swedish participants had a lower mean (M=3.50) than the Indian participants (M=4.47). This result indicates that Indian
participants show a higher sense of goodwill.
In question 20: “Residents should accept the location of mental health facilities in their neighbourhood to serve the needs of the local community” the Indian participants had a higher mean (M=4.11) than the Swedish participants (M=3.56). This indicates that the Indian participants are more including, in their community, towards people with mental illness.
In question 29: “Mental hospitals are an outdated means of treating the mentally ill”, an Anti- Authoritarianism question, the Indian participants had a lower mean (M=2.64) than Swedish participants (M=2.95) indicating that the Swedish participants have a more authoritative approach.
Questions that differed the least
As can be seen in Table 2, questions 10, 11 and 30 are the ones where the responses from the participants from each country have the most united answers. In these questions, the difference between the countries' participants is the smallest.
In question 10: “The mentally ill have for too long been the subject of ridicule”, Swedish students (M=3.72) and Indian students (M=3.82) have similar means. Both countries show a neutral attitude with a tendency of agreeing with the statement in question 10.
In question 11: “A woman would be foolish to marry a man who has suffered from mental illness, even though he seems fully recovered”, Swedish participants (M=3.72) and Indian participants (M=3.82) have similar means. Both countries show a neutral position with a tendency of agreeing with the statement in question 11.
In question 30: “The mentally ill do not deserve our sympathy”, Swedish participants (M=4.28) and Indian participants (M=4.09) have similar means. Both countries have a tendency to disagree with the statement in question 30.
Psychometric properties of CAMI
Table 3
Correlations between attitude categories.
Authoritarianism Benevolence
Social Restrictiveness
Authoritarianism ⎯
Benevolence -.713 ⎯
Social Restrictiveness .650 -.588 ⎯
Community Mental
Health Ideology -.645 .722 -.723
(N=410)
The correlations in Table 3 suggest that the attitude factors are not independent of each other.
The correlations in our study are similar to the correlations in the Taylor and Dear (1981) study. The highest inter-dimension-correlation (r =.723) being between the two categories of Social Restrictiveness and Community Mental Health Ideology (Table 3).
Table 4
Scale reliabilities (Cronbach’s Alpha) in this study and in the Taylor and Dear (1981) study.
Taylor & Dear (1981)
Our Study (2018)
Authoritarianism .68 .73
Benevolence .76 .85
Social Restrictiveness .80 .76
Community Mental Health Ideology .88 .85
(N=410)
To investigate the CAMI test’s properties, internal consistency was assessed with Cronbach’s Alpha for each of the four attitude categories. The alpha coefficients in our study were
compared with the alpha coefficients in Taylor and Dear (1981) study. As can be seen in Table 4, the reliabilities in our study are similar to those reported by Taylor and Dear (1981). In our study, reliability is higher in the attitude categories of Authoritarianism as well as in
Benevolence but slightly lower in the attitude categories of Social Restrictiveness and
Community Mental Health Ideology (Table 4). Overall, these alpha analyses indicate that our test had about the same reliability as the original test in 1981.
Discussion Results discussion
The purpose of this study was to investigate whether there are any differences in attitudes towards mental health in the countries of Sweden and India and how this result lives up to what previous suggestions/theories indicates. The results show differences in attitudes towards mental illness between the countries. However, these differences do not correspond with our hypothesis or with what previous research suggests. Based on previous research, the hypothesis was that the Swedish population would have a more positive attitude towards mental illness in comparison with the Indian population due to the general differences in religion,
socioeconomic status and culture. The results show the opposite. The Indian participants had a more positive and accepting attitude in the attitude categories of Authoritarianism,
Benevolence, and Community Mental Health Ideology. This means that India has a greater sense of authoritative approach, goodwill and social inclusion towards people with mental illness.
Lund et al. (2011) claim that low- and lower middle-income countries should have a higher level of stigma due to a lower exposure to mental health care which, according to our results, proved to be wrong. The Swedish participants all live in a small city while the Indian
participants live in one of the world's biggest cities. A big city is more developed than a small one leading to more exposure to several things, possibly including mental illness and mental health care. So, perhaps residents in the big cities of India have a higher exposure to mental health care and thereby a greater awareness of mental illness than residents in the small cities of Sweden have? Lund et al. (2011) found that low exposure to mental health care leads to high levels of stigma, which therefore might explain our results. According to Shavitt et al. (2011), a country with a horizontal individualistic culture like Sweden should have a less stigmatizing and more positive attitude towards individuals with mental illness than a country with a vertical collectivistic culture like India. This theory is, according to our results, not supported based on the assumption that the cultural belongings of the sample groups represent a
horizontal individualistic and a vertical collectivistic culture.
Previous research and theories suggest that the outside world and context affect a person's view on mental health and we believe this can be related to our result. We believe that one
explanation to our result is related to the selection of Indian participants; students. They might not represent the typical resident in a low- or lower-middle-income country with collectivistic culture and strong religious beliefs. Young academics from bigger cities of India might not have a strong religious belief or act according to a collectivistic culture and definitely do not come from a low income background. The Indian students might be more individualistic than we believed, come from a high income background and lack strong religious belief. With the Internet making the world a smaller place, cultures are being mixed and information is more accessible than ever before, and culture is not as divided as it once was. Therefore, the Indian students may have been affected by the western, more individualistic culture and the Swedish students may have been affected by the eastern, more collectivistic culture.
The results could also be an effect of deteriorated validity of the CAMI test. The test might have been valid a decade or two ago, but with the world changing, developing and in a sense
becoming smaller, it may have lost some of its capability to discriminate between different cultures attitudes towards mental illness in a proper way. The fact that the greatest difference between the two countries was in the attitude category of Benevolence might make it necessary to reappraise the belief that a collectivistic society would induce negative attitudes towards mental illness. It is, according to the results, more probable that the people of a collectivistic culture are more caring towards the people around them leading to a higher willingness of showing goodwill towards people with mental illness, a higher eagerness to be kind and help out.
The results from the questions that differed the most and least should be interpreted with care.
Many questions and comparisons may produce a few big differences by chance. For example question 29 indicates a more authoritative approach among the Swedish participants, but this is contrary to the global result for the category Authoritarianism where the Indian participants show a more authoritative approach.
Method discussion
This study only contains data on university students’ attitudes. Young adults with high education, in India where education at universities cost money, must have good financial background. This may have affected the outcome. Older people or people from lower social classes, in both countries, might have generated other results. We were aware of the risks with delimiting the study to university students. The rationale for this was the availability of
comparable groups.
Since the samples were not representative for the populations in Sweden and India it is inadequate to generalize the results to the populations in the countries. Any generalization must be delimited to university students. For valid generalization to the populations large and representative samples must be used. This study used rather large, but far from population representative samples.
The benefits of using an electronic questionnaire are low cost and freedom for the participants to fill it out whenever they want to. A downside is loss of control of who actually fills it out.
In a study of a subject of sensitive nature, like this study, the result can become systematically partial to the participants' perceptions of what are correct and socially accepted response options. This phenomenon is called social desirability and occurs in the vast majority of self- reports and significantly increases the risk of misleading results (King & Bruner, 2000). This may have had an effect on our results. The fact that the questionnaire was in English, and we assume that English was not the native language for the majority of the participants, may have influenced the results. The statements we consider containing more difficult, formal or
uncommon English words had more neutral answers. Possibly, if the participant did not understand the assertion completely influenced how the person responded to the question.
Translating the original CAMI into Swedish and Hindi might have been preferable, but our lack of translation resources forced us to use an English questionnaire for all participants, both Swedish and Indian.
Because of our preconception that studying psychology was rare among students in India, only students, Swedish as well as Indian, who never had taken any psychology courses were allowed to participate. This was a precaution to make the samples as similar as possible. However, this proved to be a mistake since a third (33.2%) of the contacted students in India indeed had studied psychology at university level. Since a big number of students in India, as well as in Sweden, seem to have studied psychology, they should have been included to make the samples larger and more representative.
In the results we found a few outliers who had responded in extreme ways on all or most of the questions, but they did not affect the results as a whole and were therefore not excluded in the analyses.
Reliability and Validity
By using an already established and proven useful tool as the CAMI-scale, the internal validity and reliability of the statements and the scale was high. To reach high validity, the statements and information shown to the participants should be the same for everyone (Bryman, 2011).
By sending out the questionnaire in English to both the Indian and Swedish students, the validity is high but would have been even higher if we had sent it in respective country’s mother tongue; Hindi and Swedish.
Does the study measure what it intends to measure, in this case people's attitudes? Since we chose to use a well-developed and well-known attitude questionnaire where focus is on attitudes towards mental illness, the concept validity of the study becomes high. By choosing a questionnaire that experienced researchers have designed and the fact that the questionnaire has been tested in several previous studies, the concept validity of the study was confirmed. That level of validity would have been impossible to achieve with a questionnaire developed by us.
All attitude categories had an internal consistency well above α = .70. This, in combination with the fact that the values were similar, and in two attitude categories somewhat higher, in our study compared to the Taylor and Dear (1981) study, indicates high reliability (Table 4).
Conclusions
The results show differences in attitudes towards mental illness between the countries of Sweden and India in the attitude categories Authoritarianism, Benevolence, and Community Mental Health Ideology. In these categories, the Indian students have greater sense of
goodwill, social openness and social inclusion towards people with mental illness. These conclusions are contrary to our hypotheses.
Suggestions for further research
In future studies, it would be of value to confirm the test’s validity by comparing different sampling groups with different attitudes that have been assessed with independent tools. It would also be interesting to study attitudes towards mental illness in different age- and gender groups. Maybe there's a gender or age aspect, and this could also give suggestions that
surroundings and upbringing may have an effect on people's attitudes towards mental illness.
Since our hypothesis was made on the case that the three factors of religion, socio-economics and culture should affect the attitude towards mental illness, it would also be interesting to conduct a bigger study where one aims to find out which, if any, of the factors of religion, socio-economics and culture that actually do affect the attitude towards mental illness and in what way.
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Appendices
Appendix 1 - Information about the questionnaire
Thank you for taking your time to answer this questionnaire aiming to find what the attitudes are among students towards mental illness.
The following statements express various opinions about mental illness and the mentally ill.
The mentally ill refers to people needing treatment for mental disorders but who are capable of independent living outside a hospital. Please pick the response which most accurately describes your reaction to each statement. It's your first reaction which is important. Don't be concerned if some statements seem similar to ones you have previously answered. Please be sure to answer all statements.
The answers will be given by one of the following responses:
- Strongly Agree - Agree
- Neutral - Disagree
- Strongly Disagree
The responses will be anonymous and it should take you no more than 10 minutes.
Thank you for your participation!
Appendix 2 - Message sent out to students in Sweden (group 1).
Hej!
Vi är två svenska psykologstudenter som gör en studie om attityder gentemot psykisk ohälsa i Sverige och Indien och skulle uppskatta din medverkan. Enkäten är på engelska och kommer ta er ungefär 5-10 minuter att fylla i.
https://goo.gl/forms/PzeLNynfuAAZnHl73
Tack på förhand!
Vi frågor gällande enkäten kontakta gärna j---@mail.com
s---@mail.com Vänliga hälsningar, Sandra & Julia
Appendix 3 - Message sent out to students in India (group 2).
Hello!
We are two Swedish psychology students, who are are studying attitudes towards mental illness in Sweden and India and would appreciate your participation. The survey is in English and will take you about 5-10 minutes to fill in.
https://goo.gl/forms/Sc8NAWnj4CeAq25A3 Sincerely,
Julia Angbrant & Sandra Frykman
Appendix 4 - The opening question in the Questionnaire for Swedish students (Group 1)
• Are you from Sweden? *
Yes No
• Are you currently a university student? * Yes No
• Are you or have you ever studied psychology at university? *
Yes No
Appendix 5 - The opening questions in the Questionnaire for Indian students (Group 2)
• Are you from India? *
Yes No
• Are you currently a university student? * Yes No
• Are you or have you ever studied psychology at university? *
Yes No
Appendix 6 – The CAMI Questionnaire
1. As soon as a person shows signs of mental disturbance, he should be hospitalized.
SA A N D SD
2. More tax money should be spent on the care and treatment of the mentally ill.
SA A N D SD
3. The mentally ill should be isolated from the rest of the community SA A N D SD
4. The best therapy for many mental patients is to be part of a normal community.
SA A N D SD
5. Mental illness is an illness like any other.
SA A N D SD
6. The mentally ill are a burden on society.
SA A N D SD
7. The mentally ill are far less of a danger than most people suppose.
SA A N D SD
8. Locating mental health facilities in a residential area downgrades the neighbourhood.
SA A N D SD
9. There is something about the mentally ill that makes it easy to tell them from normal people.
SA A N D SD
10. The mentally ill have for too long been the subject of ridicule.
SA A N D SD
11. A woman would be foolish to marry a man who has suffered from mental illness, even though he seems fully recovered.
SA A N D SD
12. As far as possible mental health services should be provided through community based facilities.
SA A N D SD
13. Less emphasis should be placed on protecting the public from the mentally ill.
SA A N D SD
14. Increased spending on mental health services is a waste of tax dollars.
SA A N D SD
15. No one has the right to exclude the mentally ill from their neighbourhood.
SA A N D SD
16. Having mental patients living within residential neighbourhoods might be good therapy, but the risks to residents are too great.
SA A N D SD
17. Mental patients need the same kind of control and discipline as a young child.
SA A N D SD
18. We need to adopt a far more tolerant attitude toward the mentally ill in our society.
SA A N D SD
19. I would not want to live next door to someone who has been mentally ill.
SA A N D SD
20. Residents should accept the location of mental health facilities in their neighbourhood to serve the needs of the local community.
SA A N D SD
21. The mentally ill should not be treated as outcasts of society.
SA A N D SD
22. There are sufficient existing services for the mentally ill.
SA A N D SD
23. Mental patients should be encouraged to assume the responsibilities of normal life.
SA A N D SD
24. Local residents have good reason to resist the location of mental health services in their neighbourhood.
SA A N D SD
25. The best way to handle the mentally ill is to keep them behind locked doors.
SA A N D SD
26. Our mental hospitals seem more like prisons than like places where the mentally ill can be cared for.
SA A N D SD
27. Anyone with a history of mental problems should be excluded from taking public office.
SA A N D SD
28. Locating mental health services in residential neighbourhoods does not endanger local residents.
SA A N D SD
29. Mental hospitals are an outdated means of treating the mentally ill.
SA A N D SD
30. The mentally ill do not deserve our sympathy.
SA A N D SD
31. The mentally ill should not be denied their individual rights.
SA A N D SD
32. Mental health facilities should be kept out of residential neighbourhoods.
SA A N D SD
33. One of the main causes of mental illness is a lack of self-discipline and willpower SA A N D SD
34. We have the responsibility to provide the best possible care for the mentally ill.
SA A N D SD
35. The mentally ill should not be given any responsibility.
SA A N D SD
36. Residents have nothing to fear from people coming into their neighbourhood to obtain mental health services.
SA A N D SD
37. Virtually anyone can become mentally ill.
SA A N D SD
38. It is best to avoid anyone who has mental problems.
SA A N D SD
39. Most women who were once patients in a mental hospital can be trusted as babysitters.
SA A N D SD
40. It is frightening to think of people with mental problems living in residential neighbourhoods.
SA A N D SD
Appendix 7 - Table 5
Swedish and Indian students’ mean scores (M) and mean differences (diff) in all questions with t-tests.
Question Nationality N M diff t p
1. As soon as a person shows signs of mental disturbance, he should be hospitalized. (A)
Sweden 272 2.01 -.297 -2.900 .001*
India 138 2.31
2. More tax money should be spent on the care and treatment of the mentally ill. (B)
Sweden 272 3.94 .231 2.280 .307
India 138 3.71
3. The mentally ill should be isolated from the rest of the community. (SR)
Sweden 272 1.64 -.031 -.353 .469
India 138 1.67
4. The best therapy for many mental patients is to be part of a normal community. (CI)
Sweden 272 3.65 -.280 -2.965 .037*
India 138 3.93
5. Mental illness is an illness like any other. (A)
Sweden 272 2.32 -.079 -.588 -.278
India 138 2.40
6. The mentally ill are a burden on society. (B)
Sweden 272 3.50 -.967 -8.408 .000*
India 138 4.47
7. The mentally ill are far less of a danger than most people suppose.
(SR)
Sweden 272 2.54 -.014 -.134 .074
India 138 2.56
8. Locating mental health facilities in a residential area downgrades the neighbourhood. (CI)
Sweden 272 3.37 -.687 -6.221 .001*
India 138 4.06
9. There is something about the mentally ill that makes it easy to tell them from normal people. (A)
Sweden 272 2.09 -.770 -7.273 .246
India 138 2.86
10. The mentally ill have for too long been the subject of ridicule. (B)
Sweden India
272 138
3.72 3.82
-.102 -1.008 .934
11. A woman would be foolish to marry a man who has suffered from mental illness, even though he seems fully recovered. (SR)
Sweden 272 3.72 -.102 -1.008 .934
India 138 3.82
12. As far as possible mental health services should be provided through community-based facilities. (CI)
Sweden 272 3.70 -.229 -2.434 .013*
India 138 3.93
13. Less emphasis should be placed on protecting the public from the mentally ill. (A)
Sweden India
272 138
2.80 2.90
-.101 -.961 .141
14. Increased spending on mental health services is a waste of tax dollars. (B)
Sweden 272 4.17 -.175 -1.891 .042*
India 138 4.35
15. No one has the right to exclude the mentally ill from their
neighbourhood. (SR)
Sweden 272 2.10 .411 4.257 .019*
India 138 1.69
16. Having mental patients living within residential neighbourhoods might be good therapy, but the risks to residents are too great. (CI)
Sweden 272 3.55 .349 3.573 .888
India 138 3.20
17. Mental patients need the same kind of control and discipline as a young child. (A)
Sweden 272 2.64 -.607 -5.639 .033*
India 138 3.25
18. We need to adopt a far more tolerant attitude toward the mentally ill in our society. (B)
Sweden 272 3.94 -.385 -4.176 .051
India 138 4.33
19. I would not want to live next door to someone who has been mentally ill. (SR)
Sweden 272 2.23 .054 .521 .042*
India 138 2.17
20. Residents should accept the location of mental health facilities in
Sweden 272 3.56 -.546 -6.196 .000*
India 138 4.11
