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      Stigma toward mental and physical illness: attitudes of healthcare professionals, healthcare students and the general public in Pakistan

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          Abstract

          Background

          The evidence base for stigma in mental health largely originates from high-income countries.

          Aims

          This study from Pakistan aimed to address the gap in literature on stigma from low- and middle-income countries.

          Method

          This cross-sectional study surveyed 1470 adults from Karachi, Pakistan. Participants from three groups (healthcare professionals, healthcare students and the general public) completed the adapted Bogardus Social Distance Scale (SDS) as a measure of stigma.

          Results

          All three groups reported higher scores of stigma toward mental disorders compared with physical disorders. SDS scores for mental illness in the general public were significantly higher than in healthcare students (mean difference (MD) 6.93, 95% CI 5.45–8.45, P < 0.001) and healthcare professionals (MD 6.93, 95% CI 5.48–8.38, P < 0.001). However, SDS scores between healthcare students and healthcare professionals were not significantly different (MD 0.003, 95% CI −1.14–1.14, P > 0.99). Being female was associated with lower stigma scores and being over the age of 30 years was associated with higher stigma scores.

          Conclusions

          Stigma campaigns in Pakistan need to target the general population. However, evidence of negative attitudes toward mental illness in healthcare students and healthcare professionals supports the need for stronger emphasis on psychiatric education within undergraduate and postgraduate training in Pakistan.

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          Most cited references31

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          Implicit bias in healthcare professionals: a systematic review

          Background Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients. Methods PubMed, PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. Two reviewers assessed the eligibility of the identified papers based on precise content and quality criteria. The references of eligible papers were examined to identify further eligible studies. Results Forty two articles were identified as eligible. Seventeen used an implicit measure (Implicit Association Test in fifteen and subliminal priming in two), to test the biases of healthcare professionals. Twenty five articles employed a between-subjects design, using vignettes to examine the influence of patient characteristics on healthcare professionals’ attitudes, diagnoses, and treatment decisions. The second method was included although it does not isolate implicit attitudes because it is recognised by psychologists who specialise in implicit cognition as a way of detecting the possible presence of implicit bias. Twenty seven studies examined racial/ethnic biases; ten other biases were investigated, including gender, age and weight. Thirty five articles found evidence of implicit bias in healthcare professionals; all the studies that investigated correlations found a significant positive relationship between level of implicit bias and lower quality of care. Discussion The evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population. The interactions between multiple patient characteristics and between healthcare professional and patient characteristics reveal the complexity of the phenomenon of implicit bias and its influence on clinician-patient interaction. The most convincing studies from our review are those that combine the IAT and a method measuring the quality of treatment in the actual world. Correlational evidence indicates that biases are likely to influence diagnosis and treatment decisions and levels of care in some circumstances and need to be further investigated. Our review also indicates that there may sometimes be a gap between the norm of impartiality and the extent to which it is embraced by healthcare professionals for some of the tested characteristics. Conclusions Our findings highlight the need for the healthcare profession to address the role of implicit biases in disparities in healthcare. More research in actual care settings and a greater homogeneity in methods employed to test implicit biases in healthcare is needed.
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            Development and psychometric properties of the reported and intended behaviour scale (RIBS): a stigma-related behaviour measure.

            Although stigma in relation to mental health has been defined as including components of knowledge, attitudes and behaviour, no psychometrically tested instrument to assess behavioural discrimination at the population level has been developed. This paper presents details of the development and psychometric properties of the Reported and Intended Behaviour Scale (RIBS), an instrument based on the Star Social Distance Scale, to assess reported (past and current) and intended (future) behavioural discrimination among the general public against people with mental health problems. Three studies were carried out to evaluate psychometric properties of the RIBS (Study 1, n = 92; Study 2, n = 37; Study 3, n = 403). Adults aged 25-45 in socio-economic groups: B, C1 and C2 (middle-income groups) took part in development and testing of the RIBS. Internal consistency and test-retest reliability is moderate/substantial. Strong consensus validity was found, as rated by service users/consumers and international experts in stigma research. Use of a behavioural outcome may be important to evaluate the effectiveness of interventions intended to reduce stigma and/or discrimination related to mental illness. The RIBS was found to be a brief, feasible and psychometrically robust measure for assessing mental health-related reported and intended behavioural discrimination.
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              Attitudes of mental health professionals toward people with schizophrenia and major depression.

              Several studies reveal poor knowledge about mental illness in the general population and stigmatizing attitudes toward people with mental illness. However, it is unknown whether mental health professionals hold fewer stigmatizing attitudes than the general population. A survey was conducted of the attitudes of mental health professionals (n = 1073) and members of the public (n = 1737) toward mental illness and their specific reaction toward a person with and without psychiatric symptoms ("non-case" as a reference category). Psychiatrists had more negative stereotypes than the general population. Mental health professionals accepted restrictions toward people with mental illness 3 times less often than the public. Most professionals were able to recognize cases of schizophrenia and depression, but 1 in 4 psychiatrists and psychologists also considered the non-case as mentally ill. The social distance toward both major depression and the non-case was lower than toward schizophrenia. However, in this regard, there was no difference between professionals and the public. The study concludes that the better knowledge of mental health professionals and their support of individual rights neither entail fewer stereotypes nor enhance the willingness to closely interact with mentally ill people.
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                Author and article information

                Journal
                BJPsych Open
                BJPsych Open
                BJO
                BJPsych Open
                Cambridge University Press (Cambridge, UK )
                2056-4724
                September 2020
                03 August 2020
                : 6
                : 5
                : e81
                Affiliations
                [1]Division of General Psychiatry, Centre for Addiction and Mental Health; and University of Toronto , Canada
                [2]Pakistan Institute of Living and Learning , Pakistan
                [3]Pakistan Institute of Living and Learning , Pakistan
                [4]Pakistan Institute of Living and Learning , Pakistan
                [5]General Adult Psychiatry, South London and Maudsley NHS Foundation Trust , UK
                [6]General Psychiatry, Solent NHS Trust , UK
                [7]Later Life Psychiatry, Greater Manchester Mental Health NHS Foundation Trust; and University of. Manchester , UK
                [8]Department of Applied Psychology, Bahauddin Zakariya University , Pakistan
                [9]Department of Psychiatry, Ziauddin Hospital , Pakistan
                [10]Department of Psychiatry, University of Toronto ; and Centre for Addiction and Mental Health , Canada
                [11]Pakistan Institute of Living and Learning , Pakistan
                [12]Division of Psychology & Mental Health, University of Manchester , UK.
                Author notes
                Correspondence: Tayyaba Kiran. Email: tayyaba.kiran@ 123456pill.org.pk
                Author information
                https://orcid.org/0000-0002-8575-3364
                https://orcid.org/0000-0003-2046-6193
                https://orcid.org/0000-0003-4142-868X
                Article
                S2056472420000666
                10.1192/bjo.2020.66
                7453804
                32741419
                61259f0d-cbc9-40ef-ae74-2863542c5775
                © The Author(s) 2020

                This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 08 November 2019
                : 30 June 2020
                : 02 July 2020
                Page count
                Figures: 1, Tables: 4, References: 41, Pages: 6
                Categories
                Papers

                healthcare professionals,mental illness,physical illness,stigma and discrimination,social distance scale

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