Attitudes of Health Workers towards People with Mental Health Problems in Mosul City – Iraq

: Objective: The main objectives of this research were to identify the attitudes of Iraqi Health workers towards mentally ill people in Mosul city in Iraq and to investigate possible factors, which impacton Iraqi health workers’ attitudes to people with mental health problems. Method: A survey quantitative method wasused to address the research questions. The survey involved a pilot study to test the feasibility of the survey. Alpha-coefficient reliability tests output was (0.82) and indicated strong reliability on each attitudinal scale. To eliminate the ethical issue, the survey sample utilized a systematic random sample, with a target number for the sample of 300 of health workers. The present research conducted in Mosul medical area in Iraq from July to October 2011. Statistical Package for the Social Science program (SPSS, version 19) was used to analyze the data. Results: Only 273 of 300 surveys were in actuality completed and used for analysis. (52.7%) of the respondents were females. There was a heavier distribution of respondents in the (18-24) age group, representing (51.6%) of the total survey sample. The results of the one-sample test demonstrate a finding of no significance for the relationship between gender and attitudes (Sig= 0.16). The differences of the means among the age groups were tested using one way ANOVA. Analysis of variance for the differences between total respondents’ scores and their age indicated non -significance of observing the comparison of group means (Sig = 0.167). Conclusion :The research questions and hypotheses pertained directly to the variables of age, gender, and any other notable finding as housed within the first research question. Although the data analysis shows there are biases in responding, there are in general negative attitudes of health workers in Iraq towards people with mental health problems.


INTRODUCTION:
The life of an individual depends on, physical, mental, and social health. Mental health is as vital as physical health to the general well-being of individuals, societies and countries (WHO, 2001)¹. Mental disorders are universal and they affect people of all countries regardless of age, gender and income. Hence, mental health problems have been recognized as an important cause of morbidity (WHO, 2001)¹. Although mental illnesses affect many people around the world, there are many misunderstandings accompanied people with mental problems and the mental illness itself. In Arabic countries for instance, the word madness is often associated with mentally ill and all people with mental problems are alike (Okasha, 1999)². Al-Adawiet al. (2002)³ tried to find out the social factors that influence on person's attitude towards people with mental illness (PWMI). Following three wars and political conflict in Iraq, there is a clear increase in the mental health problems in particular post-traumatic stress disorder (Raed and Law, 1999) 4 .According to the World Health Organization (2001) ¹, mental illness is considered as the fourth reason leading to morbidity of elderly in Iraq. Ritter and Lampkinillustrated in (2010) 5 that ''Sigma is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance. Stigma leads others to avoid living, socializing or working with, renting to, or employing people with mental disorders, especially severe disorders such as Schizophrenia''. The stigma attached to the mental disorders has resulted in negative attitudes of people suffering from them. These inappropriate and poor views about mental illness and negative attitudes add to the barriers in the management of the mental health problems (Alwan, 2004) 6 . Therefore, this study aimed to survey the attitudes of Iraqi Health workers towards mentally ill people in Mosul city in Iraq and to investigate possible factors that might have affected people to formulate these attitudes.

METHODOLOGY:
The present study proposal was based on a quantitative research design, using a survey questionnaire as a tool of inquiry. The tool was adapted from a study by Sadiket al.
(2010), when the researcher conducted the first systematic survey of attitudes toward mentally illness and people with mental illness in Iraqi society (Sadiket al., 2010) 7 .Several statements of this questionnaire were modified and developed to increase the validity of this instrument and to be more appropriate for achieving the aims of the present research. The survey in this study involved pilot study to test the feasibility of the survey, though no pre-treatment or experimental treatment was used for this data design. The pilot study conducted in July 2011 helped to strengthen the internal validity of the survey. It involved 12 experts from different health departments and professionals' level in Iraq and the UK. Alpha-coefficient reliability tests output was (0.82) and indicated strong reliability on each attitudinal scale.The questionnaire was divided into two parts. Part one included questions of demographics, such as age, income, gender, location, marital status, and other defining social variables that may inform the topic. Part two contained the section on attitudes and perceptions on mental illness. A Likert-style rating scale was used to score the answers for the attitudes/perceptions portion of the survey. Likert scale is a summated rating scale that provides a simple and economic means of obtaining data on a person's attitudes, beliefs, and behavioral intentions (Frankfort-Nachmias and Nachmias, 2008) 8 . The scale used to extract numerical data for statistical analysis rates from (1-5), with 1 representing strongly disagree, and 5 representing strongly agree. Statistical Package for the Social Science program (SPSS, version 19) was used to analyze the data. The present research conducted in Mosul medical area in Iraq.To eliminate the ethical issue, the survey sample utilized a systematic random sample. The sample was 273 participants, were in actuality completed the questionnaires.The participants of this research recruited from health workers in Mosul city hospitals in Iraq. The sample was based on inclusion criteria, which entailed that the participant must be a health care professional of Iraqi nationality; over the age of 18; and consented to participate in the survey.There were already periodic seminars for health workers that hold weekly in the target hospitals. The agreement and permission were gained from the seminar's coordinator to take last part of these seminars' time to distribute the questionnaires with envelops.The questionnaire included a brief explanation about how to fill it and state how long it may take to complete. The participants would able to complete the questionnaire and hand in directly to the researcher who was available for a half an hour after the seminar; otherwise, they could fill it, put it in an envelopeand hand in to the seminar's coordinator within two weeks. To encourage the participants to respond to this survey, each questionnaire included a written statement concerning to the purpose, aims and benefits of this research.   Table (3) the data analysis for 36 statements of the attitudes that included in the survey.

RESULTS:
Although the data analysis shows there are bias in responding, there are in general negative attitudes of health workers in Iraq towards people with mental health problems. For instance, (64.1%) of the participants respond 'strongly disagree' on the following statement 'The best way to help those with a mental illness to recover is to let them stay in the community and live a normal life'. While (63.0%) of them responded 'strongly disagree' on the following statement 'Should not laugh at the mentally ill even though they act strangely'.

DISCUSSION:
In general, the survey sample revealed a stigma based on individualized bias as demonstrated in the participants' responses, where people with mental illness should live a normal life as long as the survey sample population did not have to actually be involved in a personal way with such persons (Nordt et al., 2006) 9 . For example, Question 36 asked respondents to rate their response to if they would be ashamed if someone in their family were diagnosed with a mental illness. Around 58% of responses fell within the disagreement categories, while 24% fell within the agreement categories, and 18% remained neutral. The results of this question reflect a change in internal perceptions when the issue becomes personal. It is fairly uncomplicated for someone who does not have to deal with a family member with a mental illness to be more emotionally removed from the issue than a person who is closely related to someone with a mental illness. Thus, when the issue was theoretically personalized, the responses reflected an internal shift in perspective from impersonal, to personal (Al-Adawi, (2002) ³; Green, (2000) 10 ).The problems these types of misperceptions engender is supported by research by the World Health Organization, which notes some common problems that people with mental illness face in society today, including social stigma, social discrimination, violence and abuse by others, restricted political and civil rights, being excluded from participating in society, reduced access to health, social, emergency, and relief services, reduced opportunities for education, employment, and income generation, and increased prevalence of disability and premature death (World Health Organization, 2010) 11 .The findings concluded there was not a significant relationship between gender and attitudes of the health care workers. In addition, there is no significant relationship between age and the health care workers. The research question refers to a potential influential relationship of the cultural perceptions of Iraqi survey sample participants, and how they view the character of mental illness. These factors were not tested in the statistical data set, though the analysis of the attitudinal type questions does reveal some qualitative-style informational findings (Green, 2000) 10 . The findings from the survey on general attitudinal results were not tested for significance; rather, they do offer a highly qualitative element that provides a rich fabric of information to tie into the statistical findings, and to help guide future research endeavors.

CONCLUSION:
The results of the survey questionnaire reflect a social bias that may be influenced by the cultural base of Iraq toward mental illness and those dealing with mental illness, although gender and age may not be significant factors in these findings.While it is known that people in Iraq may have biases toward their fellow citizens living with mental illness, what it is less well-known are the cultural determinants that continue to feed that bias. As such, developing effective interventions is at present, a haphazard approach, with some interventions working in some situations, and not in others.

RECOMMENDATIONS:
1.The present research recommends that the future study should be examined the relationship between cultural elements (such as sex and gender) and societal attitudes toward mental illness and those with mental illness and what types of approaches for raising social awareness to truly address the biases in the people's attitudes, and hence the quality of life for people with mental illness. 2. Initiate educational programmes regarding mental illnesses knowledge through governmental or non-governmental organizations focused in particular on the health workers and on Iraqi community in general in order to change the negative attitudes towards people with mental health problems.