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Public Knowledge and Beliefs about Mental Disorders in Developing Countries: A Review | OMICS International
ISSN: 2167-1044
Journal of Depression and Anxiety
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Public Knowledge and Beliefs about Mental Disorders in Developing Countries: A Review

Alemayehu Tibebe1* and Kenfe Tesfay2
1Public Health Programs Expert, Tigrai Private Health Facilities Association, Mekelle, Tigrai, Ethiopia
2Department of Public Health, Mekelle, Ethiopia
Corresponding Author : Alemayehu Tibebe
Public Health Programs Expert
Tigrai Private Health Facilities Association
Mekelle, Tigrai, Ethiopia
Tel: 251939099495
E-mail: [email protected]
Received: August 11, 2015 Accepted: October 07, 2015 Published: October 10, 2015
Citation: Tibebe A, Tesfay K (2015) Public Knowledge and Beliefs about Mental Disorders in Developing Countries: A Review. J Depress Anxiety S3:004. doi:10.4172/2167-1044.S3-004
Copyright: © 2015 Tibebe A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Keywords
Mental health literacy; Mental health; Public; Knowledge; Beliefs and developing countries
Background
Today, mental health problem is recognized as a public health problem in developed as well as developing countries [1]. The public health significance of mental and behavioral disorders is demonstrated by the fact that they are among the most important causes of morbidity in primary care settings and produce considerable disability [2].
One of the perceived causes of its high incidence is the low level of mental health literacya [3] According to 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”. Mental health literacy consists of several components, including: (a) the ability to recognize specific disorders or different types of psychological distress; (b) knowledge and beliefs about risk factors and causes; (c) knowledge and beliefs about self-help interventions; (d) knowledge and beliefs about professional help available; (e) attitudes which facilitate recognition and appropriate help-seeking; and (f) knowledge of how to seek mental health information [4].
Several studies have shown that knowledge of public attitude to mental illness and its treatment is a vitally important prerequisite to the realization of successful community-based programs. The recognition of mental disorder also depends on a careful evaluation of the norms, beliefs and customs within the individual’s cultural environment [5].
Some studies conducted in Africa have suggested that the experience of stigma by people with mental illness may be common, but there is no information on how widespread negative attitudes to mental illness may be in the community [6].
In Ethiopia where poverty, war, famine, displacement and homelessness are common, mental health is also becoming a major public health problem. However, little is known about the perception of the public regarding mental health problems [1].
This paper is therefore designed to review public knowledge and belief about mental disorders (mental health literacy) in developing countries with particular emphasis on the public knowledge and beliefs about causes and symptoms of mental disorders, public attitude and perception towards people with mental illness and help seeking behaviors. The review will provide important evidences from developing countries which are relevant to introduce the concept of mental health literacy in Ethiopia as there has been no systemic review of evidences on mental health literacy and to guide the development and implementation of a mental health policy in Ethiopia where mental health policy is absent.
Objectives
The main objective of this paper is to review studies on public knowledge and belief about mental disorders (mental health literacy) in developing countries with particular emphasis on the public knowledge and beliefs about causes and symptoms of mental disorders, public attitude and perception towards people with mental illness and help seeking behaviors, the review has the following specific objectives.
• To review and critically appraise literatures on the knowledge and beliefs about mental disorders in developing countries.
• To fit different experiences and findings together to provide scientific and empirical evidence on the issue of mental health literacy in developing countries.
• Describe the wide range of beliefs and perceptions about mental disorders.
• Identify gaps in knowledge and beliefs about mental disorders.
• Provide possible recommendations that could serve as a guide to public health policies, further researches and applications on the area of mental health literacy.
Methods
A search for peer reviewed journal articles and reports published after 2005 have been made using MEDLINE data base (pub med), Google scholar and DOAJ online internet sources. The search used mental health literacy, mental health, public, knowledge, beliefs and developing countries separately or in combination as a key word. Some studies published before 2005 included in the review as they provide relevant and basic information regarding mental health literacy in developing countries.
Publications regarding public knowledge and beliefs about mental disorders (mental health literacy) in developing countries are selected in the review. However, it is found that only few articles are comprehensively addressed the issue of mental health literacy in developing countries.
Therefore, 21 (63 publications were found) studies that addresses the issue from developing sub Saharan African, south East Asia, and Middle East countries has been extensively reviewed.
In addition, the review gives particular emphasis on publications that focused on public knowledge and beliefs about causes and symptoms of mental disorders, public attitude and perception towards people with mental illness and help seeking behaviors.
Results
Mental disorders
Mental disorders are diseases that affect cognition, emotion, and behavioral control and substantially interfere both with the ability of children to learn and with the ability of adults to function in their families, at work, and in the broader society [7].
Common mental disorders are depressive and anxiety disorders that are classified in ICD-10 as: “neurotic, stress-related and somatoform disorders” and “mood disorders”. The public health significance of mental and behavioral disorders is demonstrated by the fact that they are among the most important causes of morbidity in primary care settings and produce considerable disability [2].
Mental illness affects one in four people at some stage during their lives. It is estimated that 450 million people are experiencing mental illness at any one time, most of whom live in developing countries [8].
In any event, it is more likely that poverty and common mental disorders interact with one another in setting up, in vulnerable individuals, a vicious cycle of poverty and mental illness. Rather than actual income, factors such as insecurity, hopelessness, poor physical health, rapid social change and limited opportunities as a result of less education may mediate the risk of suffering from mental disorders [2].
Mental health literacy in developing countries
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” [4].
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 [4].
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 [9]. 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 [9].
One study on gender differences in KAP1 towards mental illness reveals that men had better knowledge, beliefs and attitudes towards mental illness than women. Most of the women were afraid and not willing to keep friendships with the mentally ill [10].
Knowledge and beliefs about the etiology of mental illness
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 agreement with other studies conducted in Ethiopia. Such traditional notions whereby supernatural powers are attributed to controlling the well being of an individual’s mind are widespread in all ethnic or religious groups in Ethiopia. Similar results were also observed in other African studies [1].
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 [11].
As shown in another study conducted in Iraq, the population did have a fairly reasonable understanding of the etiology 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 [12]. Evidences from rural Cameroon shows that Christians (22.7%) had a greater tendency to associate epilepsy to witchcraft with respect to Muslims (13%). However the difference was not statistically significant [13].
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 [10].
Public recognition of mental disorders
Studies from two African [Ethiopia and Nigeria] countries concerning public recognition of mental disorders have been consulted. Respondents in study from Ethiopia recognized only overt psychotic symptoms such as talking to oneself excessive talkativeness and aggression as signs of mental health problem [1].
Similarly, the most common symptoms proffered by respondents in the Nigerian study as manifestations of mental illness included aggression/destructiveness [22.0%], talkativeness [21.2%], eccentric behavior [16.1%], and wandering [13.3%] [5].
In one study designed to look into the experience of internalized stigma in mentally ill persons in Tehran, many expressed a concern about being recognized as having a mental illness causing problems in their family. Many told that they tried to conceal the fact that they were mentally ill from their family and from those close to them in order to avoid problems for themselves, their relatives, and those near to them. Another issue was the feeling that mentally ill people are considered violent and dangerous— a recurring theme in studies of perceptions of the mentally ill worldwide. Their willingness to talk about their situation strongly suggests that further qualitative studies would be of great interest to enable us to find out more about how people view mental illness and the mentally ill, and the consequences for those with a mental illness [14].
Public attitude and perception of people with mental illness
Few studies conducted in Africa have suggested that the experience of stigma by people with mental illness may in fact be common [15].
Results from the study in Zambia revealed that stigma and discrimination towards mental illness and those affected are ubiquitous and insidious across Zambian society [15]. In Nigeria, People with mental illness were believed to be mentally retarded, to be a public nuisance and to be dangerous [6]. Similar Nigerian study in ‘Karfi’ village ascertained that the majority of the respondents harbored negative feelings towards the mentally ill, mainly in the form of fear and avoidance. Literate respondents were seven times more likely to exhibit positive feelings towards the mentally ill as compared to non-literate subjects [OR=7.6, 95% confidence interval = 3.8–15.1] [5].
One study conducted in Uganda showed that a strong interrelationship exists between poverty and mental illness, with stigma playing a crucial mediating role [16].
In another study conducted in Iraq to assess public perception of mental health, around half of respondents thought people with mental illness should not get married, and that people with mental disorders should not have children while just under half thought one should avoid all contact with people with mental illness. Just over half thought they could maintain a friendship with someone who had a mental illness, but less than one fifth thought they could marry someone with mental illness [12]. Similar results were reported from Tehran, Iraq, all respondents (n=123) reported that they have experienced feelings of alienation, discrimination, and social withdrawal [17].
Knowledge and attitude of health workers concerning mental disorders
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 [18]. 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 [19].
In study to assess KAP of primary health care workers, the majority of the sample did however hold some stigmatizing attitudes about depression, [believing that becoming depressed is a way that people with poor stamina deal with life difficulties] which may contribute to the difficulty which some experience in differentiation between unhappiness and clinically significant depressive illness [18]. Several respondents of one Ugandan qualitative study indicated that the psychiatric hospital itself is a major source of stigma [20].
Help seeking behavior
Beliefs about professional help may be very different in developing countries. For example, in Ethiopia traditional sources of help, such as witchcraft, holy water and herbalists were preferred over medical help for a range of mental health problems. By contrast, medical help was overwhelmingly preferred for physical health problems [9]. There was a statistically significant difference between the more educated and the less educated respondents on their preferred place of help for mental health problems [p=0.001] [1].
Psychotherapy is a widely used psychiatric treatment modality in large cities of Pakistan. A significantly greater preference for psychotherapy was noticed among younger, females, more educated and financially independent participants. Similar was the case for respondents who were better aware of this modality and who supported its use as an adjuvant to pharmacotherapy [p<0.05] [12].
People more likely to seek a religious remedy were very religious [OR = 2.32 CI = 1.28–4.237], less educated [illiterate OR = 3.84, CI = 1.033–14.258; primary OR = 2.69, CI = 1.026–7.035; higher secondary OR = 1.86, CI = 1.017–3.40], living in a joint family system [OR = 2.281, CI = 1.121–4.642] and those who had given a religious cause for schizophrenia [OR = 6.56, CI = 3.156–13.630] [21]. One study in India revealed that only few (18%) of the study participants reported that they would visit a psychiatrist if they had an emotional problem but 35 % of the participants agreed to visit a traditional healer for their problem [14].
Limitaions of the Review
Only 18 studies meet the inclusion criteria for the review and it is difficult and at the same time limited to extrapolate the findings to the whole developing world as these studies are subjected to methodological variation and limited scope. Small sample size is another common methodological problem in some of the reviewed studies.
Cultural variability is also another limitation that can affect the implication of the review. Therefore, the findings of this review could give some insights to policy makers and other concerned bodies whose work is related to mental health literacy in Ethiopia, however, the review has limitation to guide policy development and implementation.
Conclusions and Recommendations
From the studies reviewed, it is concluded that there is a low level of mental health literacy in developing countries. Concerning the etiology 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 low in developing countries [6], this review showed that stigma and discrimination towards mental illness is in fact common in these countries. It is also possible to conclude that there is a significant gender difference in knowledge, attitude and beliefs towards mental disorders.
Evidences suggested that Information, education and communication [IEC] should be at the heart of mental health promotion activities which aimed to raise the low level of mental health literacy in developing countries like Ethiopia. These IEC activities need to be incorporated in to countries mental health policy and integrated with primary health care settings.
Future Research
This review highlighted that there have been only few studies that have specifically examined mental health literacy in developing countries and further comprehensive studies need to be conducted to understand the level of mental health literacy in developing countries like Ethiopia. It is also found that it is important to give due attention to improve the quality of studies on the area of mental health literacy in developing countries setting with particular emphasis on methodological problems.
Acknowledgement
The authors would like to acknowledge Addis Continental Institute of Public Health and Mekelle University, school of public health for giving this chance and successfully facilitate the whole process of the review.
1KAP: knowledge, attitude and practice.
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