|Year : 2016 | Volume
| Issue : 1 | Page : 56-62
Knowledge and attitudes of secondary and higher secondary school teachers toward mental illness in Ahmedabad
Nimesh Parikh1, Minakshi Parikh2, Ganpat Vankar2, Chintan Solanki2, Girish Banwari1, Prateek Sharma1
1 Department of Psychiatry, Seth V. S. Hospital, Ahmedabad, Gujarat, India
2 Department of Psychiatry, Civil Hospital, Ahmedabad, Gujarat, India
|Date of Web Publication||17-Feb-2016|
Dr. Nimesh Parikh
Department of Psychiatry, Seth V. S. Hospital, Ahmedabad - 380 006, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Teachers can be trained in early identification of possible mental illness and referral which is well-established in the west and lacking in India. Hence, we attempt to study the knowledge and attitudes of secondary school teachers toward mental illness and probable gender differences in these measures. Materials and Methods: Five hundred and twenty teachers from English medium schools of Ahmedabad city were assessed by a self-reported, predesigned and pretested 25 item questionnaire, the first 15 of which assessed their knowledge about mental illnesses and the remaining 10 pertained to negative attitudes. Results: 79.4% of teachers were 45 years or less, 77.5% were female teachers and 86.9% were married. 76% of teachers scored <7 out of 15 which points toward majority of them having inadequate knowledge. 63.6% scored 5 or more on the negative attitudes questionnaire, which points toward high prevalence of negative attitudes. Females had comparatively more knowledge than males about symptoms and management of mental illness, although there was no significant gender difference in the attitude toward mental illnesses. Conclusion: The knowledge of teachers about mental illness is insufficient, and they hold a lot of stigma against mentally ill as demonstrated by their low score in attitude.
Keywords: Attitude, knowledge, mental illness, school teachers
|How to cite this article:|
Parikh N, Parikh M, Vankar G, Solanki C, Banwari G, Sharma P. Knowledge and attitudes of secondary and higher secondary school teachers toward mental illness in Ahmedabad. Indian J Soc Psychiatry 2016;32:56-62
|How to cite this URL:|
Parikh N, Parikh M, Vankar G, Solanki C, Banwari G, Sharma P. Knowledge and attitudes of secondary and higher secondary school teachers toward mental illness in Ahmedabad. Indian J Soc Psychiatry [serial online] 2016 [cited 2019 May 19];32:56-62. Available from: http://www.indjsp.org/text.asp?2016/32/1/56/176770
| Introduction|| |
World Health Organization's (WHO) definition of health includes complete physical, mental, and social well-being and not merely an absence of disease or infirmity.  When it comes to mental illnesses, unless the symptoms are too dramatic or rather extremely distressing, they are often neglected by the relatives and are considered to be due to some kind of weakness on the patient's part.  On top of it, owing to the stigma associated with being labeled as a psychiatric patient,  consulting a mental health specialist is deferred until the limits of tolerance can be stretched no further.  This results in late diagnosis, delayed treatment institution, overall poor prognosis, or adverse outcomes such as self-harm, risky behavior, and untimely deaths by suicide which could have been prevented only if timely treatments were initiated. 
According to WHO reports, one out of five children suffers from a disabling mental illness and suicide is the third leading cause of death among adolescents.  Studies show that a majority of mental illnesses start by mid-teens  and most of these teens are students who spend almost half of their waking time under guidance/observation of their teachers in school who are well-educated professionals working in close contact with these teenagers as a part of their routine duties. They are the neutral observers (in contrast to the parents who's observation may be occasionally biased) who are in a position to spot the subtle changes in behavior of their students before they develop full-blown (apparent) symptoms. Hence, teachers can be a major resource as well as an important link in the chain of referral systems which if tapped well, can prove to be of immense importance in the service of early identification, timely referral, reducing stigma, and promoting awareness about mental illnesses.
Western countries have identified and efficiently established a "tier system" as far as referencing is concerned regarding children with probable mental illness; school teachers constituting the basic tier 1 and have proven to be effective.  Several other studies have also evaluated the need  and feasibility  of incorporating school teachers in the mental health system. The scenario in India (in this regard) is highly disappointing. Lack of a planned, structured, and validated awareness/teaching module for teachers make them susceptible to the prevailing levels of mental health awareness in the general population, which is dismally low. Apart from a few studies done on Indian teachers regarding the identification of hyperactivity  and assessing awareness,  conclusive data is lacking. This raises a question on the ability of teachers to recognize the personality changes heralding mental illness. In India, knowledge of and attitude toward mental illness have been studied in general public,  mental health professionals,  community health workers,  relatives of and patients themselves,  and found to be subnormal. A similar study assessing knowledge about mental illnesses was done in the Nigerian community and akin to India population, their also the results were dismal.  Knowledge of mental illnesses and attitude toward people with mental illness share the same fate in Western countries also, contrary to the expected. 
Hence, in this study we have attempted to assess the knowledge and attitudes of secondary and higher secondary school teachers toward mental illness. If the extent of knowledge or lack thereof can be examined, training programs for teachers in child and adolescent mental health can be developed; these would better equip the teachers to notice the earliest symptoms of mental disturbance in their students, they would feel more confident of addressing these issues directly, they would become more effective confidantes and would know what problems they could handle at their own level and which problems require a referral to a professional mental health specialist. This could go a long way toward making our teenagers more healthy mentally, growing into psychologically more sturdy adults and ultimately, a more sound society. With this context, we planned the study keeping the following objectives in mind:
- To study the knowledge of secondary and higher secondary school teachers about mental illness and also to study the gender differences in it
- To study the attitudes of secondary and higher secondary school teachers toward mental illness and also to assess the gender difference, if any.
| Materials and Methods|| |
Sample and methodology
The study sample comprised school teachers (secondary and higher secondary) of 14 reputed English medium schools of Ahmedabad city, Gujarat state. These schools were selected based on their proximity to the author's parent institute. After taking requisite approvals of the review boards of the parent institutes, these schools were approached seeking permission for data collection. Eleven schools consented, three refused, two on account of a tight schedule, and one saw no fruitful purpose in the study. Data collection from a school was scheduled as per the time slot allotted to the authors by the school principle. All the teachers teaching secondary and higher secondary classes were approached in the staff rooms; purpose and methodology were explained. It was clearly stated that their signing of the consent form will indicate their agreement to be a part of this study. Consenting teachers were given a set of response sheets comprising a consent form, demographic detail sheet, and the questionnaire to be filled completely in about 20 min. They were instructed to deposit their filled forms in a sealed box which was placed outside their respective staff rooms and the filled boxes were then taken by the authors to the parent institute for evaluation, to preserve anonymity.
Owing to the lack of specific tool to measure the knowledge and attitude of school teachers in India toward mental illness, a structured questionnaire with 25 questions was prepared comprising two parts (Part A assessing the knowledge and Part B measuring the attitude of teachers toward mental illness).
Part A comprise 15 multiple choice questions subcategorized into three parts (1, 2, and 3; five questions for each subparts) measuring the knowledge about symptoms, etiology and epidemiology and management of mental illness, respectively. From the four choices provided (as a probable response to a statement), one option is the most appropriate, and if that's chosen, the answer is marked as correct otherwise it is scored as an incorrect response. Correct and incorrect responses are scored as one and zero, respectively, thus the total knowledge score ranging from 15 to 0, a higher score indicative of more knowledge. Part B incorporates 10 derogatory statements with a yes or no response, yes indicates negative attitude, and no is indicative of positive attitude scored as one and zero, respectively. The total score ranges from 0 to 10, with the higher score indicative of a more negative attitude.
The questionnaire was constructed with the consensus of five subject experts (NCP, MNP, GKV, CS, and GHB) and was found to have good face validity and construct validity. This was assured by giving the questionnaire to other consultant psychiatrists who were not a part of this study and incorporating their inputs in the final version of the scale. Reliability analysis was done by test-retest method in a pilot study on thirty teachers from a school not included in the study sample after a period of 3 weeks (high level of positive correlation between the responses to the statements, both the first time and the "retest" time after 3 weeks). Internal consistency, evident by Cronbach's α, for the current study sample, was 0.55.
After complete data collection, a master chart was prepared. Descriptive statistics, that is, frequencies and percentage were used to categorize the data while Chi-square and Students' t-test were used to measure the significance of differences in mean scores of the response to the statements asked, by male and female teachers. Data were analyzed by SPSS version 20 (IBM) and significance was set at P < 0.05.
| Results|| |
In all, 579 teachers were approached out of which 564 teachers participated in this study (response rate being 97.3%) but 44 forms were discarded during analysis on account of not being completely filled. Therefore, the study sample consisted of 520 subjects [Figure 1].
|Figure 1: Frequency distribution of cumulative knowledge scores obtained by school teachers toward mental illness (higher score indicative of better knowledge)|
Click here to view
Out of the 520 teachers, 413 (79.4%) teachers were aged 45 years or less whereas 107 (20.6%) teachers were more than 45-year-old. Four hundred and three (77.5%) were female teachers while the number of male teachers was 117 (22.5%). The majority (452, i.e., 86.9%) were married, and 68 (13.1%) teachers were single. A clear majority of 89% (n = 463) opined that at the end of their official training as teachers they were ill-equipped to recognize, let alone handle, mental illness in their students. Almost, an equal number (n = 465, 89.4%) expressed readiness to take 2 days' training in child and adolescent mental health.
Knowledge about mental illnesses
When the sum total of score assessing teachers' knowledge regarding mental illness was calculated, five teachers (nearly 1%) had 0 score, majority, 63.3% scored 3-6 out of 15 and not a single teacher scored more than 12 points [Figure 1].
When the score obtained on the five statements assessing knowledge about symptoms of common mental illnesses were totaled, only 10 teachers (1.9%) could answer all five correctly whereas 58 teachers (11.2%) did not gave a single correct reply. Twenty-six percentage of teachers could correctly state that hallucinations are experiencing things that are not there. More female teachers agreed to the fact that symptoms of depression do not include poor judgment and inability to control one's impulse as evident by 56% females having correct response as compared to 44% males (P < 0.05). Similarly majority (90%) of teachers could not understand that phobia is an intense and extreme fear, about which more male teachers were ignorant (97%) as compared to females (88%) (P < 0.05) [Table 1]. In addition, statistically female teachers had better mean knowledge score (1.68 ± 1.077) as compared to males (1.36 ± 1.004, P < 0.05) [Table 2].
|Table 1: Response to statements and mean scores obtained in Part A (subpart 1) of questionnaire (depicting knowledge of school teachers toward symptoms of mental illness) |
Click here to view
|Table 2: Response to statements and mean score obtained in Part A (subpart 2) of questionnaire (depicting knowledge of school teachers toward etiology and epidemiology of mental illness) |
Click here to view
A total of 31.7% of teachers (n = 165) marked all the responses to this subpart incorrectly. Only 29% of teachers could choose the correct option that 1 in 5 people from the general population would suffer from mental illness at some time during their lives. Again, female teachers' outscored male teachers significantly in understanding or predicting the prevalence of mental illnesses better in two items:
- 31.5% female teachers correctly marked the true prevalence of mental illness as compared to male teachers (20.5% and P < 0.05)
- In addition, 49% of female teachers understood that it is not true that mentally ill patients' children always end up with mental illness as compared to 32% of male teachers (P < 0.05) [Table 3].
|Table 3: Response to statements and mean score obtained in Part A (subpart 3) of questionnaire (depicting knowledge of school teachers toward management of mental illness) |
Click here to view
Out of the five questions assessing teachers' knowledge regarding common aspects of treatment of psychiatric disorders, a sizeable number of teachers (n = 46, 8.8%) scored zero while 21 teachers (4%) gave all five correct responses and majority (n = 309, 59.5%) gave one or two correct responses. For example, only 28.2% of teachers knew that there was usually a delay of 2-4 weeks before the antidepressants medicines start their effect. Again here, female teachers had statistically significant better knowledge about delay in antidepressant action (31.7% as compared to 16% in latter), understanding that psychiatric medications are nonhabit forming drugs (47% as compared to 32% in later, P < 0.05) and the safe use of electroconvulsive therapy in patients (81% and 66% in females and males, respectively) (P < 0.05). Overall female teachers significantly have better knowledge scores regarding the management of mental illness (mean in females = 2 ± 1.360, males 1.4 ± 1.115) (P < 0.000).
Attitude toward mental illnesses
When we calculated the total negative attitude score among the teachers [Table 4], 26 teachers (5%) had a positive attitude (zero score on Part B), majority (n = 370, 71.1%) fell into the 4-7 score bracket whereas 37 teachers (15.7%) scored in range of 8-10, that is, high negative attitudes toward mental illnesses. The difference in scores of males and females in Part B were not found to be statistically different.
|Table 4: Response to statements and mean score obtained in Part B of questionnaire (depicting attitude of school teachers toward mental illness) |
Click here to view
| Discussion|| |
Adolescent and child, mental health in respect to the identification of signs by the teachers, can be considered as the most critical and neglected area of psychiatry. , Management of mental illnesses in adolescents start from recognizing the needy adolescent (student), supporting them, guiding them into the right direction, ensuring that they take regular treatment, and continue regular follow-up as well as rehabilitating them back into the society. Teachers are a major professional resource of the community and it is surprising that this resource has not been fully tapped. A study conducted on Indian community health workers  prior to their training, observed that as few as 22% could recognize depression, and even fewer (9.1%) could recognize psychosis.
Lack of knowledge about psychiatric illnesses is widely prevalent outside India, too. A study done in Nigerian community  revealed an equal lack of scientific knowledge regarding mental illness. Middle school students from developed countries like the United States  also exhibit a lack of knowledge about psychiatric disorders. Our study, in a similar vein, reveals teachers' lack of knowledge regarding symptoms, prevalence, causation, and treatment of mental disorders. If 7 out of 15 were considered the qualifying score, only 24% of all teachers would pass. In such a situation, teachers might not be able to suspect early symptoms of mental illness in their students. They may notice that a previously bright student is suddenly lagging behind academically, but will mostly attribute it to wrong reasons. Earlier treatment institution and consecutively better prognosis will be missed.
Talking about negative attitudes and stigma attached to mental illnesses, many studies have been conducted in India and elsewhere but not with teachers as the study population. All have uniformly observed substantial negativity toward mentally ill patients. The general public of Southern India  responded adversely toward statements regarding the requirement of humane treatment in mentally ill. Another study conducted in Eastern India  suggests that rural Indians showed a higher stigma score than urban Indians. Yet another study in community health workers of Bangalore  compared pre and posttraining attitudes and obtained dismal results. A significant minority of UK public possess negative attitude toward people with mental health problems.  Schizophrenic patients report the feeling of being stigmatized against by friends, relatives, and colleagues in interpersonal relationships as well as sociooccupational roles in India  and Germany.  Teachers, unless trained specifically in the area of mental health, are a part of the general population, and it is hardly surprising that our study revealed the widespread existence of negative attitudes toward mental illness. When nearly half the teachers believe that mental illnesses are a result of nonbiological causes, it is followed by a simple logic that they would not consult a mental health professional straight away. Most people consult a psychiatrist as a last resort and if they take psychiatric treatment than they feel ashamed in mentioning it. When mental illness would be so stigmatized in self and close family members, it would be much less acceptable to fellow citizens. No wonder, about half the teachers stated that they would try to avoid friends and neighbors with mental illness, would not employ people with past history of mental illness in responsible jobs, would be afraid of approaching a person with odd behavior and considered mentally ill patients to be a burden to the society. A categorical majority of 89% refused to consider a marital alliance with people with a past history of mental illness for themselves or family members.
To our knowledge, no studies have found or specifically discussed gender differences in knowledge of and attitudes of school teachers toward mental illnesses. The new generation shows us a glimmer of hope though fluctuating. Study by Wahl et al. reports that 90% of students agreed that people with mental illness deserved respect. A very high majority (89%) of the teachers from our sample felt that they were not equipped to recognize psychological difficulties in students after their qualifying training as teachers and so they do not feel confident about addressing the issue of mental illness in the class. It is heartening that teachers expressed a keen interest in learning more about mental illnesses and how to recognize them as is evident from the fact that most (89.6%) of the teachers also expressed readiness to take 2 days' training in child and adolescent mental health.
Limitations of the study
This is a first of its kind study in urban school teachers, but the findings need to be replicated in wider samples of teachers and in multiple settings (rural teachers and from Gujarati and Hindi medium). A follow-up study of the same sample might show the consistencies of this result while a survey post an educational program will help us in judging the impact of training and may simultaneously correct the prevailing misbeliefs.
| Conclusion|| |
In incorrect knowledge lies the dissipation of ignorance, misbelief, and negative attitudes. Teachers are in a unique position of transmitting their knowledge and perpetuating it. In our study, we find that secondary school teachers have major lacunae in their knowledge of and attitude toward mental illness. However, as compared to male teachers, female teachers have a slightly better understanding of mental illnesses. With thorough training of teachers in mental health, in general and child, and adolescent mental health in particular, they can make an attitudinal shift from being negative to being positive toward the psychologically disturbed. Very importantly, identifying abnormal behavior and sign and symptoms of mental illness would help the children in receiving timely apt interventions. This positive attitude and better knowledge would automatically permeate into the minds of the ready recipients called their students who are the future of our society. It would be a major leap toward envisioning a culture where mentally ill would not be stigmatized and labeled but would rather be expected to smoothly mingle back into the society as soon as they became asymptomatic. There is an urgent need for a training module for teachers, and later, the knowledge and attitude of teachers can be reassessed to study the impact of the training.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
WHO. The World Health Report 2001. Mental Health: New Understanding; New Hope. Geneva: WHO; 2001. Available from: http://www.who.int/whr2001/2001/
. [Last accessed on 2013 Oct 25].
Socall DW, Holtgraves T. Attitudes toward the mentally ill: The effects of label and beliefs. Soc Quart 1992;33:435-45.
Weiner B, Perry RP, Magnusson J. An attributional analysis of reactions to stigmas. J Pers Soc Psychol 1988;55:738-48.
Corrigan PW, Rowan D, Green A, Lundin R, River P, Uphoff-Wasowski K, et al.
Challenging two mental illness stigmas: Personal responsibility and dangerousness. Schizophr Bull 2002;28:293-309.
McLaughlin CG. Delays in treatment for mental disorders and health insurance coverage. Health Serv Res 2004;39:221-4.
WHO. Preventing Suicide: A Guide for Teachers and Other School Staff, Mental and Behavior Disorders, Department of Mental Health 2000. Geneva: WHO; 2000.
Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustün TB. Age of onset of mental disorders: A review of recent literature. Curr Opin Psychiatry 2007;20:359-64.
Gowers S, Thomas S, Deeley S. Can primary schools contribute effectively to tier I childmental health services? Clin Child Psychol Psychiatry 2004;9:419-25.
Koller JR, Bertel JM. Responding to today′s mental health needs of children, families and schools: Revisiting the preservice training and preparation of school-based personnel. Educ Treat Child 2006;29:197-217.
Lauria-Horner BA, Kutcher S, Brooks SJ. The feasibility of a mental health curriculum in elementary school. Can J Psychiatry 2004;49:208-11.
Daniel LT, Gupta S, Sagar R. Effect of educational module on knowledge of primary school teachers regarding early symptoms of childhood psychiatric disorders. Indian J Psychol Med 2013;35:368-72.
Mendossa DR, Shihabuddeen I. Mental health literacy among elementary school teachers in rural South India. Delhi Psychiatry J 2003;16:362-6.
Ganesh K. Knowledge and attitude of mental illness amongst general public of Southern India. Natl J Community Med 2011;2:175-8.
Kishore J, Radhika M, Mamta P, Jiloha RC, Ingle GK. Beliefs and attitudes towards mental health among medical professionals in Delhi. Indian J Community Med 2007;32:198-200.
Gregory A, Mitchell K, Shoba R, Sujatha SC, Anthony FJ. A mental health training program for community health workers in India: Impact on knowledge and attitudes. Int J Ment Health Syst 2011;5:1-6.
Loganathan S, Murthy RS. Living with schizophrenia in India: Gender perspectives. Transcult Psychiatry 2011;48:569-84.
Oye G, Benjamin OO, Lola C. Community study of knowledge of and attitude to mental illness in Nigeria. Br J Psychiatry 2005;186:436-41.
Wahl O, Susin J, Lax A, Kaplan L, Zatina D. Knowledge and attitudes about mental illness: A survey of middle school students. Psychiatr Serv 2012;63:649-54.
Ben H. An analysis of contemporary public attitudes towards, and public representations of mental illness. Ment Health Care Community 1999;8:431-40.
Schulze B, Angermeyer MC. Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives and mental health professionals. Soc Sci Med 2003;56:299-312
Jadhav S, Littlewood R, Ryder AG, Chakraborty A, Jain S, Barua M. Stigmatization of severe mental illness in India: Against the simple industrialization hypothesis. Indian J Psychiatry 2007;49:189-94.
[Table 1], [Table 2], [Table 3], [Table 4]