TITLE PAGE

TOPIC: A SYSTEMATIC REVIEW ON PERCEPTION OF SOCIETY

REGARDING MENTALLY ILL PATIENTS IN THE COMMUNITY
AND ITS EFFECT ON ADHERENCE TO PRESCRIBED MEDICATION
BY THE PATIENTS

A Thesis submitted as partial requirement for the degree of

Bachelor of Pharmacy

DDT COLLEGE OF MEDICINE

By

_______________ _________________

October, 2019

Supervisor: Tinaye Seosenyeng

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Declaration of authorship

I _________________ ___________________

Declare that:

(a) All the work described in this report has been carried out by me – and all the
results (including any survey findings, etc.) given herein were first obtained by me –
except where I may have given due acknowledgement to others;

(b) all the prose in this report have been written by me in my own words, except
where I may have given due acknowledgement to others and used quotation marks,
and except also for the occasional brief phrases of no special significance which may
be taken from other people’s work without such acknowledgement and use of
quotation marks;

(c) all the figures and diagrams in this report have been devised and produced by
me, except where I may have given due acknowledgement to others.

I understand that if I have not complied with the above statements, I may be
deemed to have failed the project assessment, and/or I may have some other
penalty imposed upon me by the Board of Examiners.

Signed by Student …………………………. Date….../………….../……….

Thesis Approved for Submission by the Undersigned Supervisor

Supervisor: Tinaye Seosenyeng……………………. Date….../………….../……….

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ABSTRACT
Poor awareness of mental health issues can be regarded as one of the main
causes of discrimination against patients leading to delayed progress and
ineffectiveness of treatment and management. Adequate education and
raising awareness on mental health issues can help society understand how
to better assist and support mental health patients which will in turn help
patient feel appreciated thus resulting in good response to treatment.

There is a lot of stigma attached to mental health in Africa. This makes most
patients not want to seek any treatment and end up living with mental illness,
causing more psychological damage in most cases. Because of the fear of
being stigmatized most patient are reluctant to seek medical help while the
illness is at the initial stages. Their families also do not encourage such
patients to seek help as they do not want to be associated with someone
suffering from mental illness. This branding or denouncing of mentally ill
patients can also result in poor response, adherence and subsequent relapse
to treatment.

There seems to be inadequate research information on the full extent of how

society in general view mentally ill patients and how the society’s behaviour
towards mentally ill patient affect the patient’s progress in terms of
medication/treatment adherence.

The research question of the present systematic review therefore is:

 What are society’s perceptions that influence a mentally ill patient health
seeking behaviour and subsequent adherence to prescribed
medication?

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Table of Contents
Declaration of authorship...............................................................................................................2
1. INTRODUCTION.............................................................................................................................6
1.0. RATIONALE OF THE STUDY.....................................................................................................9
1.1. Research question:................................................................................................................9
1.2. General Aims.........................................................................................................................9
1.3. Specific Objectives.................................................................................................................9
2. LITERATURE REVIEW....................................................................................................................10
2.1. Global Perspective View of Society on Mentally Ill Patients in the Community and Its Effect
on Medication Adherence – USA.....................................................................................................10
2.2. Global Perspective View of Society on Mentally Ill Patients in the Community and Its Effect
on Medication Adherence -Asia......................................................................................................11
2.3. Global Perspective View of Society on Mentally Ill Patients in the Community and Its Effect
on Medication Adherence - Africa...................................................................................................12
2.4. Global Perspective View of Society on Mentally Ill Patients in the Community and Its Effect
on Medication Adherence-Europe...................................................................................................13
2.5. Global Perspective View of Society on Mentally Ill Patients in the Community and Its Effect
on Medication Adherence-SADC.....................................................................................................15
2.6. Global Perspective View of Society on Mentally Ill Patients in the Community and Its Effect
on Medication Adherence – BOTSWANA........................................................................................16
3. METHODOLOGY...........................................................................................................................17
3.1. Research Philosophy............................................................................................................17
3.2. Research Approach..............................................................................................................17
3.3. Research Design...................................................................................................................18
3.4. Inclusion Criteria..................................................................................................................18
3.5. Exclusion Criteria.................................................................................................................19
3.6. Data Collection.....................................................................................................................19
3.7. Data Analysis........................................................................................................................20
3.8. Ethical Consideration...........................................................................................................20
4. Results.........................................................................................................................................20
4.1. Study Selection....................................................................................................................20
5. DISCUSSIONS...............................................................................................................................23
5.1. SUMMARY OF EVIDENCE..........................................................................................................23
5.1.1. PUBLIC STIGMATIZATION.......................................................................................................23
5.1.2. SELF STIGMATIZATION...........................................................................................................24
5.1.3. KNOWLEDGE AND BELIEFS....................................................................................................26
5.1.4. DELAYED TREATMENT...........................................................................................................27

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 5.1.5. NEGATIVE ATTITUDES BY HEALTH WORKERS........................................................................27
5.2. LIMITATIONS.............................................................................................................................28
5.3. CONCLUSIONS...........................................................................................................................28
6. REFERENCES................................................................................................................................30

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1. INTRODUCTION
In African communities mental health patients are often seen as victims of
witchcraft by those envious of them or are being punished supernaturally.
Often patients were excluded from the community, ending up living their lives
as homeless people in terrible conditions. As such, most people facing mental
health issues end up suffering in silence because of stigmatization as insane
without proper diagnosis and do not seek proper help in time. Caregivers are
also in fear of being shamed by society and thus either hide the patient or
abandon the patient completely. Some divorce their spouse in order to avoid
the commitment that comes with taking care of a patient (Venkatesh et al,
2016). Society not only have little knowledge on how to help patients but also
what causes mental illness. Over 53% of Malay mental health patients
attributed their illness to supernatural causes (Khan et al, 1996.).

The second leading cause is being attributed to substance abuse by Nigerian

patients as stated by Adewuya and Makanjuola (Adewuya et al, 2008).
Trauma was also noted to be a well-known cause of mental illness, 11% of
patients acknowledged it. Views of accusation are linked to stigma by society.
Association with supernatural causes result in negative views intolerance and
stigma when compared to bio psychosocial causes like environment and
genetics (Gureje et al 2006). Adewuya and Makanjoua also noted that
societies in more rural areas attributed causation to supernatural influences
than suburban communities who saw bio psychosocial factors as the leading
cause of mental illness (Adewuya et al, 2008). Due to associating mental
illness with bad things in rural areas patients tend to be more stigmatized than
in urban areas. Studies have indicated that older adults living in isolated rural
counties demonstrated higher levels of public and self-stigma and lower levels
of psychological openness than older adults in urban areas even after
accounting for education, employment, and income. However, no differences
emerged in reported willingness to use specialized mental health care in the

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event of significant distress (Stewart et al 2015).

One study showed that rural residents with a history of depressive symptoms
labelled people who sought professional help for the disorder somewhat more
negatively than their urban counterparts. Logistic models controlling for
sociodemographic characteristics demonstrated that the more negative the
labelling, the less likely depressed rural residents were to sought for
professional help (Rost, et al 1993). This is most likely due to lack of
information about the disease and associating it with disability and weakness.

Another study (Vodel et al 2007) showed that being prompted to seek help
and knowing someone who had sought help were both related to positive
expectations about mental health services. The same study proved that being
prompted to seek help and knowing someone who had sought help were
related to more positive attitudes toward help seeking. Also, knowing
someone who had sought help was related to the intention to seek help. Of
those who sought psychological help, approximately 75% had someone
recommend that they seek help and about 94% knew someone who had
sought help. This further proves that having information on illness and seeing
positive progress in other patients helps improve perception of mental illness.
According to Mackenzie et al women exhibited more favourable intentions to
seek help from mental health professionals than men. This is likely due to their
positive attitudes concerning psychological openness (Mackenzie et al 2006).
Results from this study suggest that negative attitudes related to psychological
openness might contribute to men's underutilization of mental health services.
Help-seeking attitudes do not appear to be a barrier to seeking professional
help among older adults, although their intentions to visit primary care
physicians might be (Manderscheidetal 2010).

It has been proven to be a difficult task to properly classify mental disorders

due to lack of agreement on what the classification criteria should be based on

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(Stengel, 1959). The establishment of dimensional models has helped create
a better understanding of mental illness (Hankin, Benjamin L et.al 2016).
Initially it was thought to have two dimensional models, namely internalizing
spectrum of disorders like depression ,anxiety and externalized disorder
spectrum like substance use disorders (Krueger,et al ,2003).Some studies
also identified two subgroups within the internalising spectrum; a distress
clustered PTSD, general anxiety and a fear clustered OCD ,phobic disorder
(Slade et al,2006).

The onset of psychiatric disorders usually occurs from childhood to early

adulthood (Raevuori A et al 2014). Paus et al stated that anxiety disorders and
impulse control disorders occur in childhood with mood disorders and
substance disorders occurring in the midteens (Paus et al 2008). Mental
disorders are associated with higher negative functional effects than physical
disorders (Buist‐Bouwman et al, 2006). Which might be a gateway to more
aggressive stigma for mental illness patients. Mental illness symptoms vary
according to the conditions, but the more common ones include changes in
sleep or appetite, rapid mood changes, drop in functioning, problems with
concentration, memory or logical though, increased sensitivity and avoidance
of over stimulating situations, apathy, illogical thinking, feeling disconnected,
nervousness and unusual behaviour (Parekh 2020). A proper diagnosis on
mental illness can only be done after a physical exam is carried out to ensure
the symptoms the patient is feeling aren’t due to a physical problem, followed
by a lab test e.g. test for thyroid function. A psychological evaluation is the last
step in diagnosis (Mayo Clinic.2020). A lot of psychiatric disorders are linked
to family history including depression, narcissistic personality disorder and
anxiety (Shorter, 2009). Some studies have also revealed high heritability for
many mental disorders especially autism and schizophrenia (Insel, 2009).
Other risk factors for mental illness include having a chronic illness,
environment, traumatic experiences, brain damage, substance use, and
history of abuse in children, few healthy relationships and previously having

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had mental illness (Abuse, 2013). Protective factors are conditions that
improve resistance to risk factors. These include exercise, pro-social
behaviour as well as social support of family and friends (Saxena et al, 2006).

HISTORY OF MENTAL ILLNESS

During the primitive era, mental illness was directly tied to religion. (Hinshaw
and Cicchetti,2000) mentioned that dating back 500,000 years people put
circular holes in the skulls of individuals thought to have a mental illness in
order to let the evil spirits out. Views changed dramatically in the Greco-
Roman era. In the early Greek times the supernatural beliefs regarded as
causes for mental illness continued (Rosen E and Gregory I, 1965). In ancient
Greece “Hippocrates believed that abnormal behaviour originated from
internal bodily causes, particularly imbalances of the four basic fluids (yellow
bile, black bile, phlegm, and blood) (Hinshaw and Cicchetti, 2000)”.
Hippocrates also believed that the brain was responsible for mental and
emotional purposes. The middle Ages witnessed a shift back to belief in the
supernatural model. Society used exorcisms, torture, and death by fire, and
starvation to rid the person of evil. Hospitals for the insane began to develop
in the 16th century. The treatment in these asylums was cruel and inhumane
(Hinshaw and Cicchetti, 2000). The fear of individuals with mental illnesses in
other places made the number of asylums increase. During the time of the
French Revolution Philippe Pinel (1745-1826) advocated for a humanitarian
approach to the treatment of people with mental illnesses. Pinel demanded
the removal of chains on inmates in asylums. He believed that doctors should
treat people with mental illnesses (Sarason IG and Sarason BG, 1998). The
early 20th century included an increase in beliefs of a biological basis for
mental illness, which (Hinshaw and Cicchetti, 2000) explained. The Mental
Hygiene movement, which encouraged the humane treatment of people
diagnosed with mental illnesses, was founded in 1908 (Strickland Br, 1998).
Psychotropic medications were invented in the 1950’s according to (Hinshaw
and Cicchetti, 2000) and (Rosen and Gregory, 1965). The second half of the

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20th century focused improving psychotropic medications and fighting
stigmas. These treatments all stem from the biological model that was
predominant Gureje O et.al, 2005) during this period of history

1.0. RATIONALE OF THE STUDY

Most African countries including Botswana still see mental illness as a taboo
(Quinn, 2007). This leads to non-willingness to learn about mental health and
how better accommodate in the day to day lives (Segal et al, 2005). This
stigma also tends to affect how patients see themselves (Watson et al 2007).
This is known as self-stigma (Corrigan et al 2006). The members of society
act as such due to not understanding the true causative agents of mental
illness as stated by Angermeyer 1999 especially in not poorly developed
countries (Patel 2007). Sayce has suggested that a positive and inclusive
attitude towards patients results in them progressing better health wise (Sayce
2001). The motivation and key rational of this study are that there is limited
research information about how society perceives mental illness patients. This
also entails how society perceptions about mental illness affects medication
adherence, especially for Botswana. Stigmatizing attitudes towards mental
illness, largely held in the general population in many countries, ultimately
lead to various forms of social rejection and segregation of the people
suffering from mental problems. Even in societies where an important amount
of public and private funds are allocated for high quality psychiatric care
services, the social expression of stigma and the lack of social support for the
mentally ill patients can dramatically impede these efforts. The public opinions
about mentally ill patients significantly affect their self-concept, their
willingness to seek professional help, the evolution of the illness, and their
opportunities for social integration (Perlick, 2001; Freidl, Lang, & Scherer,
2003; Sartorius & Schulze, 2005). These negative consequences of mental
illness stigma are sufficient reasons to justify the necessity to develop and
implement efficient attitude change programs.

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1.1. Research question:
What is the effect of society perception about mental illness on mental illness
patient’s adherence to treatment?

1.2. General Aims

To investigate the perceptions of society on mentally ill patients in the
community and its effect on medication adherence.

1.3. Specific Objectives

 Identify perceptions of society towards mental illness
 Establish the impact of society perceptions about mental illness on
mental patients’ adherence to treatment

2. LITERATURE REVIEW
Literature review, it demonstrates a broader and extensive review of
secondary data from past studies in order to gain in-depth understanding of
the research topic. Chapter two of this research work deals with literature
review.

2.1. Global Perspective View of Society on Mentally Ill Patients in

the Community and Its Effect on Medication Adherence – USA

In the U.S., prevalence of serious psychiatric disorders (SPD) is exceptionally

high among correctional populations. Large group of individuals with SPD are
found in jails and prisons house at a rate more than triple that of hospitals and
alcohol or other drug misuses ranges between 10% and 60%, rates which is 5
times that of the general population with SPD (D. Farabee et al 2019). This
has been attributed to many things including inadequate mental health

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treatment resources for the community (Yohanna D, 2013),
deinstitutionalization of mentally ill individuals (Torrey et al, 2010) and
criminalization of mental illness (Teplin A, 1984). Inmates are screened for
mental illness upon admission. Mentally ill inmates are provided care but have
a higher chance of ending up in solitary confinement where they are also at
risk of self-harm, suicide and other psychiatric injuries as they won't have
constant monitoring as stated by Hafemeister and George,2012. High rates of
incarcerated mentally ill individuals might influence negative views of mental
illness patients with people associating them with criminal activity.

2.2. Global Perspective View of Society on Mentally Ill Patients in

the Community and Its Effect on Medication Adherence -Asia

Asia is a continent with cultural and economic diversity which affects the care
and rehabilitation for psychiatric patients. Asia ranked second in terms of the
prevalence of common psychiatric disorders and these was contributed by
patients not receiving adequate psychiatric treatment. Asians with mental
illness were considered to be dangerous and aggressive due to lack of
personal and financial resources to handle stigma and mental health
professionals mainly worked in urban areas (Z, Zhang. et al 2019).( Baba, Y.
et al 2017) Japan in line with the efforts to diminish the stigma surrounding
mental illness, including schizophrenia, goals of treatment have expanded
beyond alleviating psychiatric symptoms to the successful assimilation into a
community where one can achieve social well-being. There are about 130
million Chinese suffering from mild to severe psychiatric disorders (Huang, Y
2018). Around 7.8 million Chinese suffer from schizophrenia, accounting for
9.2 percent of the total number of Chinese with disabilities, there are 100,000
new cases of schizophrenia per year. Society discriminates against Chinese
with psychiatric illnesses more seriously than other disabled people (Duan,
X.J. 2018). Only 31.40% of the residents held a positive attitude towards
psychiatric illnesses, rural residents are more discriminating than urban
residents, which may be related to factors such as understanding of mental
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illnesses. Recent research suggests that a trend towards individualism in
China might increase social distance from people with mental illness (Corrigan
et al., 2010). On the other hand, due to the traditional collectivistic nature of
Chinese culture, individuals with mental illness are more likely to agree with
and internalize public stigma (Lam et al., 2010). Stigma's impact may
therefore be especially severe among Chinese individuals with mental illness.
Chinese people with mental illness commonly experienced and anticipated
stigma in interpersonal contacts, employment settings and mental health
services (Chien et al., 2014). Almost half of individuals with mental illness in
China internalize negative stereotypes and experience self-stigma (Lien et al.,
2015). Stigma is associated with negative emotions, poor quality of life limited
social networks and poor functioning among Chinese people with mental
illness (Chien et al., 2014). About 40% of individuals with mental illness in
Hong Kong avoided social contact and wanted to end their lives as a result of
stigmatization (Lee et al., 2005).
Individuals with mental illness often feel a sense of low self-esteem/well-being
as they are rejected and discriminated against by others due to stigma.( Link
BG, Struening EL, Neese-Todd S, et al 2001)Accordingly, they are reluctant to
be identified as having a mental illness, resulting in high rates of treatment
avoidance.(. Kessler RC, Berglund PA, Bruce ML, et al, 2001).

2.3. Global Perspective View of Society on Mentally Ill Patients in

the Community and Its Effect on Medication Adherence -
Africa

In Africa the experience of stigma by people with mental illness is common.

Mental health is also becoming a major public health problem in Ethiopia due
to poverty, war, famine, displacement and homelessness. However, little is
known about the perception of the public regarding mental health problems
which leads to increase in people suffering from mental illness. Stigma and
discrimination towards mental illness and those affected are ubiquitous and

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insidious across Zambian society. In Nigeria, people with mental illness were
believed to be mentally retarded, to be a public nuisance and to be
dangerous.
(Tibebe and Tesfay, 2015)In the past few years, one of the notable
reinforcing factors of the belief in magical concepts of mental illness and death
in West Africa is the unfortunate upsurge in the broadcast of these beliefs over
the electronic media. Historically, psychiatry began to appear in the mass
media of the Western world in the 1940s; and specifically television started to
provide information (although largely negative) about mental health to the
public in the 1950s.7 8 A few films, notably The Snake Pit, showed the
psychiatrically ill to be violent and malicious, often being treated as other than
human (Freeman H et.al,1994)But, despite this stigmatising influence, the
mass media continue to be an important source of public information on
mental health issues, shaping people’s attitudes towards mental illness.
Furthermore, in the course of clinical practice, many encountered patients and
their relatives attributing mental illness to supernatural forces and quoting the
films they watched as one of the sources of their information. This erroneous
belief usually makes it difficult for the patients to gain the required insight, with
subsequent poor compliance with treatment.

2.4. Global Perspective View of Society on Mentally Ill Patients in

the Community and Its Effect on Medication Adherence-
Europe

Poor mental health can have a substantial adverse impact on the life of
European citizens. One in four of us can expect to experience a mental health
problem during our lifetimes. Around 9% of the European population
experience depressive disorders in any one year, while the most severe
psychotic disorders are much less common with a 12 month prevalence rate
of 2.6% (Wittchen, H.U. and F. Jacob, 2005)

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The economic costs of poor mental health are enormous, having been
estimated at €386 billion (2004 prices) in the EU 25 plus Norway, Iceland and
Switzerland [2]. The majority of these costs are incurred outside the health
care system; the costs of lost productivity from employment can account for as
much as 80% of all cost of poor mental health (Knapp M 2003). Other impacts
include the deterioration of personal relationships and great strain on families
(Thornicroft G et.al, 2004), a higher-than-average risk of homelessness
(Anderson, R., R. Wynne, and D. McDaid 2007) and increased contact with
the criminal justice system. Moreover, almost uniquely, individuals with mental
health problems may be involuntarily detained in hospital and/or treated
without their consent, during times when they may lack insight into their
condition and be a danger to themselves or others (Dressing, H. and H.J.
Salize, 2004) They struggle with the symptoms and disabilities that result from
the disease and also are challenged by stereotypes and prejudice that result
from misconceptions about mental illness (Corrigan & Watson, 2002). People
with mental illness often internalize negative stereotypes, resulting in self-
stigma and low self-esteem. They may think: “people with mental illness are
bad and therefore I am bad, too” (Rüsch et al., 2009). Self-stigma occurs
when people internalize these public attitudes and suffer numerous negative
consequences as a result. In this aspect, the individual becomes aware of the
negative stereotypes that other people attribute and necessarily agrees with
these stereotypes and applies them to himself (Corrigan, Watson, & Barr,
2006).According to Watson, Corrigan, Larson, et al. (2007), two self-stigma
implications deserve attention: self-devaluation, resulting from the perception
of inclusion in a devalued category and self-isolation, as a consequence of the
concern about how other people will respond to their condition. When people
perceive devaluation, they may avoid situations where public disrespect is
anticipated. The implications therefore occur in a vicious cycle, in which
aspects of recovery are blocked in treatment, as well as other spheres of the
individual's life, as attempts to avoid stigmatization, causing a decrease in
social support. With the implications of self-stigmatization, there is a decrease

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in self-esteem and self-efficacy, contributing to a lack of hope in achieving life
goals and worsening of the course of the mental illness (Link, Phelan,
Bresnahan, et al., 1999). Other consequence related to self-stigmatization is
what has been called the “why try” effect, in which self-stigma functions as a
barrier to achieving life goals.

The realization that stigma might be the most important obstacle to the
provision of mental health care and to the development of mental health
programs has been increasing in parallel with the improvement in treatment of
mental disorders. In the past, stigma was perceived as an understandable
accompaniment of diseases for which there was no effective treatment, and
which often resulted in behaviours contrary to social norms, as well as in a
lasting disability. Stigma of a disease often indicates that the persons who
suffer from that disease are dangerous, likely to infect or otherwise harm
others, that they are incurable, and that they are of little or no value to society.
The discovery of a treatment that cures the disease changes such perceptions
and signals that it is worth investing in treatment because it will return the sick
individuals to useful roles in society. It also signals that persons affected by
the disease have not become valueless because they have the illness. Many
felt that the lack of effective treatments was the main cause of stigmatization
related to mental illness and that the discovery of effective treatment will
decrease stigma—as it was the case with tuberculosis and other diseases
which lost their stigma (and the power to stigmatize individuals who suffered
from them) once effective treatments were available.

2.5. Global Perspective View of Society on Mentally Ill Patients in

the Community and Its Effect on Medication Adherence-SADC

The attitude of health care providers is key to ensuring this (Lawrie SM, 1999).
Individual beliefs, situational circumstances and personality characteristics
have been identified as significant determinants of people’s attitudes towards

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people with mental illness (Lawrie SM, 1999) with society’s conceptualisation
of mental disorders having a strong influence on practical professional
responses even in the face of information to the contrary (Littlewoods R, 1999)
Health care providers are therefore often guilty of treatment stigma (Lawrie
SM, 1999) of PWMI. With the decentralization of mental health care and its
integration into primary health care services in South Africa (Hugo M.2001),
many general health care providers who have not been exposed to patients
with mental disorders, now have to provide health services to users with
mental disorders. Previous studies outside of Africa suggest a high level of
stigma and discrimination amongst general health care providers as well as
mental health care providers (Carr V and Halpin S, 2002). Among health
professionals, mental health professionals have been found to be less
optimistic about prognosis and the long term outcomes for people with mental
illness than other health professionals (kukuma R et.al, 2010). This therefore
calls for interventions targeted at mental health professionals as well as other
health care service providers whose services are vital to the recovery of
people with mental illness. Stigma and discrimination towards mental illness
have been said to be less severe in African countries. (Fabrega H, 1999) It is
unclear however whether this finding indicates that Africa represents a
geographical region that does not experience stigma, or whether there is a
dearth of research in these societies. (Gureje O et.al, 2005) Indeed, studies
elucidating mental illness stigma and discrimination derive mainly from
Western countries, with a paucity of comprehensive studies having been
conducted in Africa, particularly in Sub-Saharan Africa. (. Lauber C and
Rossler W, 2007) the few studies conducted in Africa have suggested that the
experience of stigma by people with mental illness may in fact be common.
(Shibre T, Negash A, Kullgren G, et al, 2001)

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2.6. Global Perspective View of Society on Mentally Ill Patients in
the Community and Its Effect on Medication Adherence –
BOTSWANA

There has been insufficient epidemiological research. This explains the lack of
reliable information that would be expected of current evidence-based mental
health approaches. Funding for medical research through the National Council
for Scientific and Technical Investigations is almost nonexistent. Under these
conditions, research in the biomedical areas is restricted to the
pharmaceutical industry (P.sidandi et.al,2011)

3. METHODOLOGY

3.1. Research Philosophy

The term research philosophy means the way in which data about any
particular phenomenon should be collected. It helps the researcher in
determining the right framework of the entire study (Collins, 2017). There are
a number of different types of research philosophies that are usually followed
in the research work. Those philosophies are axiology, interpretivism, realism,
positivism, epistemology, and ontology. More definitely, these research
philosophies are the summary of personal experience and knowledge (Howell,
2012).

Since the study intends to assess KAP among health practitioners and factors
leading to under-reporting, positivism philosophy is the suitable one as
compared to other types. This is due to the fact that positivism is focused on a
single and objective reality, and draws causal effects and relationships

3.2. Research Approach

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The research approach is thought to be a procedure of the study, which
consist of different steps that will followed in the study. It explains the steps
like data collection method, analysis and interpretation techniques. It has
been indicated that the there are three different types of research approaches
that are usually adopted in research studies (Creswell, 2017). Those types are
a qualitative research approach, quantitative research approach, and mixed
method approach. More precisely, a qualitative research approach is centred
on non-numerical data. Qualitative studies are mainly focused on the
description of the facts, symbols, metaphors, theories, and characteristics.
The mixed method approach brings up the method in which both qualitative
and quantitative approaches are simultaneously used (Leavy, 2017). This
research is a quantitative study since it deals with numerical data. Five articles
that assess factors causing under-reporting are screened and analysed.

3.3. Research Design

Studies design holds undeniable crucial inside the research work because it
permits the researcher in achieving the goal in a systematic manner. A
research may be number one or secondary study, have a look at more
importantly this have a look at has adopted secondary information systematic
evaluate. The layout of the study basically mentioned the way wherein
statistics has to be composed based totally at the studies method, because
the technique is qualitative, the design of the study can be from the
subsequent four sorts of the case study, grounded concept, ethnography, and
phenomenology. It has been established that research design performs a
central role in a study. This is due to the fact that it enables the researcher in
setting the complete approach of the study with the help of relevant data
series methods and evaluation strategies (Lewis, 2015).

This is a qualitative study which made use of secondary data to gather

information. The qualitative approach focuses on qualities of human behaviour
(Ferreira, Mouton, Puth, Schurink & Schurink, 1988). The aim of such method

18
is not to generalise but to understand and interpret the meanings and
intentions that underlie everyday human actions (Bailey, 1987; Bogdan &
Taylor, 1975; De Vos, 1998; Ferreira et al., 1988). More specifically this study
was a systematic review guided PRISMA approach.

3.4. Inclusion Criteria

In general, inclusion criteria refer to the aspects that need to be covered by
the selected content. Those aspects make the material most appropriate to be
included in the study. Considering the selection criteria for the systematic
review methodology adopted for data collection of articles, inclusion was
based on a number of factors, such as year of publication in this research
from 2010 to present validity of data and adherence to PRISMA research
approach.

3.5. Exclusion Criteria

Defined as features of the potential study participants who meet the inclusion
criteria but present with additional characteristics that could interfere with the
success of the study or increase their risk for an unfavourable outcome.
Common exclusion criteria include characteristics of eligible individuals that
make them highly likely to be lost to follow-up, miss scheduled appointments
to collect data, provide inaccurate data, have comorbidities that could bias the
results of the study, or increase their risk for adverse events (most relevant in
studies testing interventions).

For the purpose of this study, year publications that do not fall within 2010 to
2020 period will meet the exclusion criteria. Furthermore, publications that do
not address the specific research topic or containing abstracts only will be
excluded in this study.

19
3.6. Data Collection

Records series is a crucial step within the research observe as it gives a

perception into the statistics and figures associated with a phenomenon on the
idea of which the researchers acquire the intention of the study. Records
collection techniques vary with respect to the look at method and layout.
Moreover, data can be collected through different types including primary
method and secondary method (Adams, 2014). Extra mainly the number one
technique of records collection is primarily based on direct data collection via
the researcher. Mainly, the number one technique of statistics gives first-hand
fats at the unique subject place. In assessment to it, the secondary supply of
facts collection is an indirect manner of collecting information, specifically on
this way of accumulation facts, the researcher considers previous studies to
develop an information of the involved phenomenon. It is to be mentioned that
the data gathered with the aid of this method is not current but gives all the
vital information had to present acquire the purpose of the study (Schutt,
2011)

For the purpose of this study, data will be collected using secondary data
from published research work. A PRISMA will be used and is defined as an
evidence-based minimum set for reporting in systematic review and meta-
analyses.

3.7. Data Analysis

Data analysis is the last step of the research work. In this step, the
researcher interprets and examine the collected data. The present study
is a quantitative research. Quantitative research depends on collecting
and analysing of numerical data to clarify, predict or control variables
and phenomena of interest. Five articles were selected and analysed

20
from research paper that discuss how patients were seen by society in
this study. This method is used because of time-constrained and ethical
reasons.

3.8. Ethical Consideration

Ethics are an important part of human life in all personal and

professional dimensions. It helps people in following the standards of
living and working in case of the corporate entity. It has been established
that following ethics in research work improves its credibility and
reliability. Moreover, there are some ethical standards of research work
which are to be followed by the researcher strictly. It is highly not ethical
to label others efforts with one’s own name. By so doing can even make
a researcher liable to legal action. (Miller et al, 2012).

4. Results

4.1. Study Selection

The research work of this study adopted a secondary data systematic review
of the research topic. Data was collected from academically reputable data
bases and studies were selected using the PRISMA tool approach for
inclusion and exclusion. Five out of 58 articles were selected in the final
analysis of the findings.

21
 The PRISMA diagram below presents a summary of how data has been
collected.
IDENTIFICATION

Records identified through

Additional records
database searching (n=52)
identified through
others sources (n=6)

Records after duplicates removed (n=50)

SCREENING

Records screened (n=45) Full-text articles excluded

(n=30) due to specific
focus
ELIGILIBILTY

Full-text articles assessed Full-text articles excluded

for eligibility (n=7) (n=15) Due to year of
publication

Studies included in Final synthesis

INCLUDED

(meta-analysis) (n=5)

N=

Fig 3.1 PRISMA flow diagram showing data collection process

22
 Table1: Perception of the society on mental illness patients in the community

No Main Author Tittle Year Findings/Reasons

Stigma and mental health-  delayed treatment

1 Bhumika T Vankatesh caregivers perspective a qualitative 2015  shunned by the society
analysis  stigmatization

 attitudes by health
workers
2 Alemayehu Tibebe Public Knowledge and Beliefs 2015
 stigmatization
about Mental Disorders in
 knowledge and beliefs
Developing Countries: A Review attitude

3 Andrew B. Borinstein Public Attitudes Toward Persons
With Mental Illness
 stigmatization
 lacks of knowledge
2019
about mental illness
 negative attitudes
towards mental illness

 Anticipated stigma
 internalized stigma
4 Annie B. Fox How and when does mental illness 2018
 reluctant to help-
stigma impact treatment seeking?
seeking
Longitudinal examination of
relationships between anticipated
and internalized stigma, symptom
severity, and mental health service

23
 use

 self-stigma
 public stigma
5 Haide Chen Association among number of 2014
 unwillingness to seek
mental health problems, stigma
help
and seeking help from
 negative attitudes
psychological services; a path
towards professional
analysis among adolescents
help

perception of the society on mental illness patient on the

community

shunned by society

reluctant to help-seeking
Axis Title

self-stigma

lacks of knowledge and beliefs

Negative attitudes by health workers

stigmatization

0 1 2 3 4 5 6

no of articles

5. DISCUSSIONS

5.1. SUMMARY OF EVIDENCE

5.1.1. PUBLIC STIGMATIZATION

This study was to review perceptions held by the society on mental ill patients
and their effects on medication adherence associated. 100% of the journals

24
which were reviewed indicated that stigmatization is one the most perception
held by the society on mental ill patients.

Stigma may be defined as a process involving labelling, separation,

stereotype awareness, stereotype endorsement, prejudice and discrimination
in a context in which social, economic or political power is exercised to the
detriment of members of a social group (Link & Phelan, 2001)

Corrigan (2004) classified stigma into two types: public stigma and self-
stigma. Public stigma refers to the perception of the public that the stigmatized
group is socially unacceptable People are threatened by the stigma of being
labelled as having mental health problems in several ways which include
stereotypes, prejudice, and discrimination (Corrigan, 2004). Previous studies
have consistently found that the public holds negative attitudes toward
individuals who have been identified as having a mental illness and often
describes these individuals in negative terms ( Angermeyer and Dietrich,
2006). On one hand, stigma is associated with a higher level of psychiatric
symptom severity.

Stigmatization is one of the main factors inhibiting the use of health services
and the adherence to treatment (Corrigan, Lurie, Goldman, et.al. 2005;
Zartaloud and Madianos, 2010). People with mental illnesses who internalize
stigma, accept negative images associated with mental illnesses, agree with
the stereotypes and endorse the idea of stigmatization (Link and Phelan,
2001) Due to this negative attitude towards mental illness in South Asian
communities, mental health help is often not considered by the majority of
South Asians (Suhail, 2005). This negative perception of mental illness has a
detrimental effect not only on people in need of mental health treatment but
also extends to people already seeking treatment. As argued by (Corrigan and
Kosyluk, 2014) in order “to avoid labelling, some people refrain from seeking
services that would be helpful, or they do not continue to use services once
initiated. This cessation of treatment does not bode well for the individual

25
themselves or family members who are also affected by the illness of their
relative.

5.1.2. SELF STIGMATIZATION

People with mental illness are challenged doubly. They struggle with the
symptoms and disabilities that result from the disease and also are challenged
by stereotypes and prejudice that result from misconceptions about mental
illness (Corrigan and Watson, 2002). People with mental illness often
internalize negative stereotypes, resulting in self-stigma and low self-esteem.
They may think: “people with mental illness are bad and therefore I am bad,
too” (Rüsch et al., 2009). Self-stigma occurs when people internalize these
public attitudes and suffer numerous negative consequences as a result. In
this aspect, the individual becomes aware of the negative stereotypes that
other people attribute and necessarily agrees with these stereotypes and
applies them to himself (Corrigan, Watson and Barr, 2006). When people
perceive devaluation, they may avoid situations where public disrespect is
anticipated. The implications therefore occur in a vicious cycle, in which
aspects of recovery are blocked in treatment, as well as other spheres of the
individual's life, as attempts to avoid stigmatization, causing a decrease in
social support. With the implications of self-stigmatization, there is a decrease
in self-esteem and self-efficacy, contributing to a lack of hope in achieving life
goals and worsening of the course of the mental illness (Link, Phelan,
Bresnahan, et al., 1999) The studies identified that higher levels of self-stigma
result in lower levels of adherence to treatment and that lower levels of self-
stigma result in greater adherence to treatment. Therefore, there is a direct
relationship between self-stigma and low adherence to treatment (medicated
or psychosocial). In an integrative review, studies in which scales with the
objective of measuring the level of self-stigma were used (Assefa, Shibre,
Asher, et al., 2012; Fung, Tsang and Corrigan, 2008; Rüsch, Corrigan,
Wassel, et al., 2009; Tsang, 2013; Tsang, Fung and Chung, 2010; Vrbová,

26
Kamarádová, Látalová, et al., 2014), revealed high levels of self-stigma in
people with mental illnesses and low levels of adherence to treatment.
According to these authors, a possible reason for the relationship between
high levels of self-stigma and low levels of adherence to treatment is that
people with mental illnesses want to hide their diagnosis to avoid
discrimination. . On the other hand, Assefa et al. (2012) and Fung et al. (2010)
indicated that the more serious are the symptoms, the greater the self-stigma
and the lower the adherence to treatment, data which is in line with the results
of studies by Thornicroft et al. (2008) and Yen et al. (2005).

5.1.3. KNOWLEDGE AND BELIEFS

Jorm et al. introduced the term ‘mental health literacy’ and have defined it as
“knowledge and beliefs about mental disorders which aid their recognition,
management or prevention” (Jorm AF, 2000). The need for the public to have
greater mental health literacy is highlighted by the high lifetime prevalence
of mental disorders (up to 50%), which means that virtually everyone will
either develop a mental disorder or have close contact with someone who
does (Jorm AF, 2000). In some developing countries where more than half of
the population may be illiterate the dimensions of mental health literacy are
totally different from those in Western countries (Mubbashar MH and Farooq
S, 2001). Supernatural causes of mental disorders are more widely held and
traditional sources of help, such as spiritual healers, are preferred over
medical advice for a range of mental health problems in these countries
(Mubbashar MH and Farooq S, 2001).

In one study conducted in Agaro, Ethiopia to assess how mental health

problems perceived by a community, a significant number of people implicated
supernatural powers as causing mental health problems which is in

27
agreement with other studies conducted in Ethiopia. Such traditional notions
whereby supernatural powers are attributed to controlling the wellbeing of an
individual’s mind are widespread in all ethnic or religious groups in Ethiopia.
Similar results were also observed in other African studies (Deribew A, 2005).
In developing countries like India and Morocco a vast majority of people
attributed the schizophrenic symptoms to supernatural phenomena, drug use,
stressful life events, and heredity or personality deficiencies (Zafar SN et.al,
2008). As shown in another study conducted in Iraq, the population did have a
fairly reasonable understanding of the aetiology of mental illness, citing
genetic factors, negative life events, brain disease and substance abuse as
key causes although God’s punishment and personal weakness were also
viewed as major factors (Sadik S et.al, 2010). Evidences from rural Cameroon
shows that Christians had a greater tendency to associate epilepsy to
witchcraft with respect to Muslims. However the difference was not statistically
significant (Luchuo EB et.al, 2010). Regarding gender differences in
knowledge and belief about the etiology of mental illness, findings indicates
that more women than men believed that mental illness is due to possession
by evil spirits (Benea A and Ghuloum S, 2010).

5.1.4. DELAYED TREATMENT

More often than realized, the treatment of the mentally ill patients is delayed
because of the fear of the stigma attached to mental illness in the society. The
caregivers are habitually in denial of having a partner/family member who is
mentally ill. They fear being isolated from the society and destroying their
family name and status in the community. This results in the patient not
receiving the required treatment at the right time and thus results in further
deterioration of his/her mental health. This unfortunately worsens the physical,
emotional and even financial condition of the caregiver.

5.1.5. NEGATIVE ATTITUDES BY HEALTH WORKERS

28
Primary care of mental disorders is crucial in all parts of the world because of
the sheer scale of psychiatric morbidity, and especially in sub Saharan Africa
where specialist expertise is very scarce (Ignacio LL et.al, 2010). Literacy
survey results from developing countries indicate a lack of basic mental health
training associated with a failure to recognize mental health problems,
restricted knowledge concerning psychotropic drug therapy, and an inability to
visualize practical forms of mental health care which could be introduced at
primary care level (Ignacio LL et.al, 2010).

Recently attention has turned towards mental health professionals.

Stigmatising attitudes towards people with mental health problems are also
seen even within the mental health professions. Several surveys have
indicated little difference between the attitudes of the general public and
psychiatrists (Lauber C et al, 2008). A survey of the attitudes of staff at all
psychiatric inpatient and outpatient facilities in the German speaking area of
Switzerland was conducted and results compared with that for the general
public (Nordt C,2006). Psychiatrists were found to have more negative
stereotype views of people with mental health problems than the general
public or other mental health professionals. There was also no distance in the
degree of social distance towards people with schizophrenia between mental
health professionals and the general public.

5.2. LIMITATIONS

There seems to be inadequate research information on the full extent of how

society in general view mentally ill patients and how the society’s behaviour
towards mentally ill patient affect the patient’s progress in terms of
medication/treatment adherence. This as a result present limited information
to be reviewed in order to come up with a complete research without risking
biasness on the findings.

5.3. CONCLUSIONS

29
From the studies reviewed, it is concluded that there is a low level of mental
health literacy in developing countries. Concerning the aetiology of mental
disorders Supernatural causes of mental disorders are more widely attributed
in developing countries. Spiritual sources of help found to be preferred over
medical sources for mental health problems in these countries. Contrary to
findings indicating that stigma and discrimination towards mental illness is
high in developing countries, this review showed that stigma and
discrimination towards mental illness is in fact common in these
countries .Generally, there is low awareness of mental health illness among
the society, and that is very discouraging as this will facilitate later report of
mental health cases to the health centres for early treatment. There is also a
very lack of awareness of the causes of mental illness, and this results in lack
of support of community level efforts to tackle the causes of mental health
illness since the people are already unaware of the causes of mental illness.
Most people in the society appear to have negative attitudes toward the
mentally ill, and this could entrench stigmatization and discrimination against
mental illness This is an indication that stigma and discrimination against the
mentally ill is widespread and with that it will bring low self-esteem and
unworthy on mental ill patients resulting in low medication adherence and
failure to treatment. The widespread belief in supernatural causes is likely to
act as a barrier to designing effective therapy for mental ill .however this call
for increased awareness and education impartation about mental illness
amongst the society

30
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