Attitudes of Healthcare Professionals towards Mental Illness: A Survey Study in Ras Al Khaimah

Background: Negative and stigmatizing attitudes and behaviours towards people with mental health problems have the potential to lead to a lack of access to care, under-treatment, social marginalization, and can undermine the relationship between the patient and provider. The study aimed to measure attitude of healthcare professionals towards mental illness. Methods: Across sectional descriptive study was conducted over one month from April to May 2019 at Ras Al khaimah medical and health Science University and affiliated health care facilities. Mental Illness Clinicians’ Attitudes Scale version 4 Questionnaire was used to collect data from participants after obtaining their informed consent with assured confidentiality. Results: The study included 113 health care professionals. The mean score of attitude of health care professionals towards mental illness was 57.8 ± 10.8 out of 96. Negative attitudes were reported about the dangerousness, respect and suspicion over recovery of people with mental health problems, interactions with them in clinical practice, and fear of disclosure to colleagues or friends about mental health problems and confidence in capabilities of assessing mental health problems in primary care. The significant positive attitude was found among participants who were university faculty than those who worked in hospitals and Primary care centres (P = 0.04). Health care professionals who were university faculty and responses towards mental illness. Conclusion: Educational programs might be useful to raise awareness towards the stigmatizing attitudes towards mental health and mental illnesses.


Introduction
Mental Health is a subject that has frequently surfaced in the past few years with numerous public programs and campaigns to educate the public. Although the knowledge of Mental Illness (MI) has been improved [1], studies showed that people usually perceive individuals with MI as dangerous with unpredictable behaviours and loss of control [2] [3]. Consequently, many persons suffering from common mental disorders are often subjected to discriminative and stigmatizing behaviours in the community, inside their families and among friends [4].
People with MI come into regular contact with a wide range of doctors in varying specialities. Indeed, an increase in the number of individuals seeking psychological support has been registered worldwide [5] [6]. International efforts currently encourage and reinforce the use of non-specialists in mental health care because it is common for them to already be involved in mental health detection, treatment, and management, especially in limited resource settings where mental health providers are limited and/or unevenly distributed within these countries [7] [8]. However, the attitudes of these Healthcare Professionals (HCPs) are not always positive and encouraging [9]. Scientific literature showed that the healthcare system, even if non-institutional, is an environment where people living with mental health problems experience stigma. These negative experiences within the healthcare system are attributable in part to healthcare professionals' stigma against mental illness [10]. Stigma toward individuals with Mental Illness is a severe social problem as well as a heavy burden for affected people [4] [5] [11]. This constant exposure to stigmatizing attitudes has the potential to lead to a lack of access to care, to under-treatment, to social marginalization, and can undermine the relationship between the patient and provider [12] [13] [14].
Therefore, identifying gaps in the attitudes of HCPs towards mental illness have important clinical implications. These gaps may be used to tailor the content of training programs in order to raise awareness of the importance of mental health as an essential component of wellbeing and make them more clinically useful. The current study aimed to measure the attitude of healthcare professionals including physicians, nurses and university faculty towards mental health and mental illness in the Emirate of Ras Al khaimah, UAE.

Design and Settings
A cross sectional, descriptive study was conducted over one month at college of medicine, Ras Al Khaimah Medical and Health Science University, UAE and the affiliated teaching health care facilities namely: Saqr and Ibrahim Obaidullah Hospitals and Ras Al khaimah, Mamourah Primary Health care centres).

Participants
Healthcare professionals from college of medicine, RAKMHSU and affiliated health care facilities including faculty, physicians and nurses.

Sampling Method
Recruitment was facilitated by the directors of the office of human resource in the assigned facilities. A compiled list included all HCPs (174), composed of consultants and general practitioners was prepared. A sample of 120 participants was decided based on the margin of error (5%), confidence level (95%), total population (174) and response distribution (50%) [15]. Participants were purposively sampled from the intercom directory list to include as many different specialties, surgical, medical and primary care from hospital, primary health care centres and Ras Al Khaimah, College of Medicine, UAE. A Google form that included the participant information sheet and consent form were sent via their electronic mails.

Data Collection Tool
An anonymous self-administrate questionnaire (Appendix) was used to collect the data from the respondents. It included the demographic characteristics and the sixteen items Mental Illness Clinicians' Attitudes (MICA) Scale (version 4.0). This scale was used to measure the health care professional attitudes towards mental illness with answers ranging on a six-point Likert scale. Items number 3, 9, 10, 11, 12, and 16, items were scored as follows: "strongly agree" = 1; "agree" = 2; "somewhat agree" = 3; "somewhat disagree" = 4; "disagree" = 5; and "strongly disagree" = 6. All other items were reverse-scored. Scores on individual items were summed to obtain the overall score for each participant within a range of 16 -96 points. A higher global score indicates a more negative perception of mental illness and the field of mental health. Furthermore, the MICA-v4 was found to have good internal consistency (α = 0.72) and item-total correlations. The scale had low rates of missing data, good readability and took less than 4 minutes to complete. The MICA-v4 scale was found to be reliable, valid and acceptable tool [9].

Ethical Considerations
The required administrative regulations were fulfilled. The Local Institutional Ethics Committee's approval was obtained before commencement of the study.
The objectives of the study were adequately explained to participants and their informal written consent was obtained with assured confidentiality.

Data Analysis
SSPS version 21 was used for data analysis. Descriptive analysis was done by percentage, mean and standard deviation. Participants' answers to the MICA-4 items were presented as a single category of "favourable answers." This category included suggested answers tend toward the positive (i.e., "strongly agree" and "agree") and suggested answers tend toward the negative (i.e., "strongly disagree" and "disagree") for reverse-scored items. ANOVA and Student t-test were used to compare the mean score of attitude as regard to socio-demographic/ practice characteristics. The level of significance was at 0.05.

Results
The study included 113 health care professionals that represented 94.2% responses after exclusion of the incomplete ones. The mean age of the studied respondents was 38.77 ± 10.12 years. More than half of them were female (57.5%), 69.1% were married and 71.7% were non-Arab. Nearly half of the respondents were physicians (46%), followed by nurses (38.1%) and university faculty (15.9%). More than half of the respondents had more than 10 years of experience in the healthcare field ( Table 1).
The mean score of the attitude of health care professionals towards mental illness was 47.8 ± 10.8 out of 96. Figure 1 showed  The mean scores of attitude was significantly associated with profession and workplace (P = 0.04, P = 0.02S respectively. Positive attitude was found among respondents who were professor (41.3 ± 8.3) and working in university (39.8 ± 8.02) compared with physicians and nurses (47.4 ± 11.30, 51.1 ± 9.91 respectively) who are working in Primary health care centres and hospitals (43.2 ± 9.41, 53.6 ± 8.81 respectively). Health, care professionals who had a working experience of more than 10 years had significant positive attitude than those who had less than 10 years (45.37 ± 10.26 Vs 47.64 ± 11.38, P = 0.005). No significant difference was found between attitudes and age, gender or nationality ( Table 2).

Discussion
The current study did not intend to sample the views of a representative sample of health care professionals but rather to highlight the ever-present stigma sur-  [25]. Participants' gap in attitude towards mental illness was made apparent by several questions that were answered negatively (Figure 1). Fear from people with mental health illness as showed by most HCPs in the current study (q5.12) is an effect of stigmatization common in many countries [26] [27].
The perceived lower levels of confidence in capabilities for mental disorders in the current study (Q 8 &14) may be anticipating. As non-specialists often, continue to favour referral consultations for depression and/or anxiety, despite some apparent knowledge [24] [28]. Indeed, stigmatization may lead to disinterest, especially among primary care staff, under-diagnoses and/or under-reporting [29]. Thus, referral of patients presenting with mental illness is still very common [20], limiting non-specialists contact and involvement with these conditions in clinical practice, as shown in current study. In addition, there is a significant number of HCP's downplaying the seriousness of mental illness despite the number of mental illnesses being on the rise [30]. This might have serious implications for the ability of medical professionals to be empathic towards patients with mental illness, which may contribute to poor doctor-patient relationships and reduced quality of care.
When the mental health field is considered, stereotypes of the profession and professional continue to persist. These stereotypes produce a negative image of psychiatry and the psychiatrist and indicates that the profession is seen as unscientific and ineffectual and a low prestige profession [31]. Therefore, near-ly30% of HCPs in the current study admitted that being a healthcare professional in the field of mental health is not considered as or equal to a real health/social care professional (Q3). These stereotypes within the healthcare community feed psychiatric state of the patient's well-being, or that psychiatrists do not need to know or will not be able to deal with physical issues [32]. Interestingly, participants in the current study showed that they are compassionate towards people with mental illness, but not towards their own selves. this discrepancy in attitudes was noticed in question 16, 87.6% of HCP's seem to be positive about working with someone who reveals that they're suffering from a mental illness, nevertheless, in question 4, nearly 50% of them are not willing to disclose any mental illness that they may be suffering from. This finding suggests that while there may be an understanding of mental illness, there still is a notable amount of stigma within the HCPs particularly doctors [33]. Davidson and Shatner found that 71% of doctors described themselves as embarrassed when seeing another doctor. Embarrassment was reported to be more prominent for mental health problems [34]. Doctors were also more reluctant to seek help for "less-defined" illnesses, such as stress, sexual difficultly, and alcohol dependence [35] [36]. Although all HCPs agreed in question 11, that a mentally ill patient under the care of an HCP should also undergo an assessment of physical health.
However, this is challenged in question 13, where only 7.1% responded positively -which means 92.9% of HCPs, according to this question, are more likely to attribute a complaint of a physical illness symptom (such as chest pain) from a mentally ill patient to their mental illness. Indeed, the underlying stigma is important to point out as it precipitates "diagnostic overshadowing". As a result, this can lead to a substantial number of misdiagnoses and delays in treatment, with severe and dangerous outcomes to the patient's health [37].
Research has shown that providing the opportunity for positive social contact, interaction, and involvement with people living with mental health issues is effective in decreasing negative beliefs about mental illness. The current study results showed that healthcare professionals who have worked more than 10 years showed more significant positive attitude than those who have worked less than 10 years. This finding most likely due to their presence in the medical field for a considerable period of time exposing them to have more opportunities to contact and interact with people with mental health issues. Furthermore; they have observed how the attitudes towards mental illness have changed over time [38]. In conclusion, the identified gaps in HCPs mental health literacy in current study and the myriad of findings pointed out by the scientific research, call attention to the need to raise awareness of the importance of mental health as an essential component of wellbeing.