Keywords

Knowledge; Attitude; Mental illnesses; Nigeria

Introduction

Understanding mental illness in Nigeria is something that has to be taken contextually and historically. There is a large misconception and misinformation on the context of the subject amongst Nigerians. The general belief is that preternatural or supernatural forces, witches, evil spirits and even God cause mental illness [1-7]. These beliefs have influenced the attitude of Nigerians towards the mentally ill. Historically, people with mental illnesses were burned, hanged, mutilated, abandoned and restrained with chains, all in the bid to save their souls, or bring redemption to their families and curb the iniquities causing mental illness within the families [1,7]. These beliefs on the etiology of mental illness shape attitudes and have been shown to have a huge impact on the acceptance of the mentally ill amongst Nigerians [8].

Research has linked negative societal attitude with the behaviour of the mentally ill, rather than the cause of these mental illnesses [1,8,9]. Thus, mentally ill persons are frequently referred to as dangerous, suspicious, unstable, unreliable, irresponsible, and homicidal [1]. These labels on the mental behaviour of the mentally ill have aggravated stereotypes and provoked further prejudices on people with mental illnesses [9].

The impact of the stigmatizing attitude and poor knowledge of mental illness among Nigerians have shown to be a major hurdle to improving mental health in Nigeria. Current evidence points to the paucity of basic knowledge about mental illness, its causes and characteristics. This in turn affects the needed priorities on what services or facilities are required to manage them. Conversely, there is a growing evidence that changing the perception of Nigerians to mental illness will result in a better and more improved mental health care within the country [1]. This scoping review was designed in a bid to evaluate the level of peer-reviewed literature and information on the knowledge of, perceptions and attitude of Nigerians towards mental illness. The results summarize the views of Nigerians on mental health issues, challenges, existing gaps in literature and possible interventions that could help unravel this issue. It is hoped that this review will instigate feasible and practical interventions, raise policies and health education programs that will improve mental health literacy among Nigerians.

Methods

Scoping reviews are exploratory studies that systematically map literature on select topics with the goal of determining the feasibility of conducting a systematic review, summarizing and disseminating research findings to knowledge users and identifying gaps where further research may be required. As a form of synthesis, or systematic reviewing, scoping reviews are nascent and methodological frameworks being refined [10]. This scoping review employed the methodological framework and advancements put forward by several authors [11-13]. They involve six stages, which include:

1. Identifying the research question

2. Identifying relevant studies

3. Selecting the studies

4. Charting the data

5. Collating, summarizing and reporting of the results, and

6. Conducting consultation exercises (optional)

The review methodology helped provide flexibility for synthesis of a variety of study designs and article types [11,12]. Although presented in steps, the process was not linear as some steps were repeated to ensure a comprehensive assessment of the study.

Stage 1: Identification of the research question

Research questions used in scoping studies are initially broad as the focus is to summarize the breadth of evidence by linking a clear purpose to a well-defined set of literature [11]. The primary question that guided this scoping review was: What are the knowledge of and attitude towards mental disease among residents in Nigeria?

Stage 2: Identification of studies relevant to the research question

This stage involved identifying relevant studies by developing a search strategy, keywords, search sources, time span and language filters [11,12]. With the involvement of the Saskatchewan College of Medicine librarian, a broad search strategy was designed using the following keyword combinations and their synonyms: ‘Knowledge’, ‘Attitude’, ‘Mental illness’ and ‘Nigeria’ (Table 1). Six electronic bibliographic databases (Web of Knowledge, PUBMED/ MEDLINE, EMBASE, Scopus, PsycINFO, and PsychARTICLES) were searched using a syntax composed of all identified keywords and their synonyms. Table 1 also provides the search strings and queries used in identifying relevant articles for the review. The initial article search was commenced on April 17, 2016 and completed on May 28, 2016. A second search was carried out from June 09 to June 10, 2016 using all identified electronic bibliographic. Thirty (30) articles were retrieved randomly based on title and abstract screening, and their references searched to avoid missing relevant articles. Hand searching of articles cited in full text articles retrieved, were completed (the snowball phenomenon). To ensure completeness, a third search was carried out from July 18 to July 20 2016 using same syntax and bibliographic databases. No grey literature was used or retrieved in this study.

Table 1: Keywords (with synonyms) and search strings used for literature search.

Citation management: All citations were imported or manually entered using the reference managers Endnote X7 and Mendeley Desktop 13.8. Associated full text articles were thereafter added to citations for further reviewing. Duplicates were removed manually after assembling citations.

Stage 3: Study selection

At this stage, the search strategy was refined based on title and/or abstracts retrieved for the initial search results. This was achieved by applying a pre-developed eligibility criteria and selection process.

Eligibility criteria: Owing to the large number of anticipated articles for this topic, this study was limited to the following;

1. Peer-reviewed journal articles,

2. Review articles written in English or English/French, and

3. Review articles that assessed a combination of any of the keywords; knowledge (or its synonyms), attitude (or synonyms), Mental illness (or its synonyms) and Nigeria.

No timeline restrictions were placed. All articles that failed to fall within these criteria were excluded.

Selection process: A two-stage selection process was used to assess the relevance of articles identified from the search. After deduplication and application of the inclusion criteria, all identified articles were manually screened for relevance by checking their titles and abstracts for identified keywords. Full text articles (FTAs) were retrieved at this stage, if they had at least one or more identified keyword combinations. The second level screening process involved reading the full text articles retrieved from the first stage to ensure selected articles reflect an answer to the research question [11]. Thus, several iterations of stages 1 to 3 occurred. The selection process was carried out by two reviewers and a reviewer agreement score calculated. The overall kappa was 0.91, which represents a high level of agreement.

Stage 4: Charting the data within included studies

This step involved reading and re-reading the full text articles from those selected to identify and chart key themes that may support or contradict ideas identified from other included scoping review articles on a standard data extraction sheet [11]. For this scoping study, a tabular spreadsheet was created using Microsoft Excel 2013 for data entry and coding. The following title fields were entered for selected scoping articles:

• Author(s): Names of leading author and co-authors

• Year: Year of publication in identified journal

• Title: Title of publication article or research

• Study design: Research design (cross-sectional, case-control, cohort, case studies, etc.)

• Study type: Quantitative, qualitative or mixed study type

• Setting: Location of study

• Summary/Abstract

• Knowledge of mental illness among residents in Nigerian community

• Attitude towards mental illness among residents in Nigerian community

• Comparisons noted

• Study strengths

• Limitations to study (Table 2).

Table 2: Summary of articles included in scoping review (n=25).

Stage 5: Collating, summarizing and reporting results of the review synthesis

This stage is aimed to provide a coherent structure from the scoping review results, so the chart, using descriptive numerical summaries and thematic analysis [11]. In this study, the data gathered was subsequently analysed thematically and quantitatively, using QSR International's NVivo 10 qualitative data analysis Software and IBM SPSS Statistics for Macintosh, Version 21.0. Results of analysis and frequency tables are displayed in Tables 2-5.

Results

Study selection

A total of 2079 peer-reviewed articles were retrieved from the overall search; with 2063 collected from the six bibliographical databases selected, and 16 from hand-searching of references and snowball phenomenon. Following deduplication and relevance screening, 111 articles were found to meet the eligibility criteria (based on their titles and/or abstracts). All 111 Full Text Articles (FTAs) were thereafter reviewed for inclusion based on their relevance to the research question. Of the 111 FTAs read, 86 articles failed to meet these eligibility criteria, leaving a total of 25 peer-reviewed articles for inclusion into the final scoping review (Figure 1).

Descriptive numerical summary

The overall characteristics for the scoping articles are shown in Table 3. The peer-reviewed articles included fourteen (56%) published between the years 2000 and 2010, seven (28%) published before the year 2000, and four (16%) published after the year 2010.

Table 3: General attributes of publications included in the scoping review (n=25).

Word terminologies used to describe the keywords for the search strategy in this scoping review were consistent across selected articles. Of the 25 articles, 11 (44%) articles used beliefs to describe the knowledge of mental illnesses, six (24%) used the word perception alternatively for knowledge and 8 (32%) used ‘knowledge’ as keyword terminology. Similarly, 17 of the 25 (68%) articles used attitude as keyword terminology describing attitude to mental illness, and 15 (60%) used the key word terminology ‘mental illness’ (Table 3). Only one article however, defined beliefs in the context of mental health. Definition of terms used was rare except where belief was described as an acceptable knowledge and a cognitive information an individual accepts about an object. In other words, a subset of knowledge [7]. The term attitudes were not defined in any selected publication.

Reported methods from scoping articles

The methodological characteristics of reviewed articles are summarized in Table 4. Twenty-four (96%) studies used crosssectional research design with one applying a community-based participatory (CBP) approach. With regards to study type, 22 (92%) were quantitative studies and two (8%) mixed studies. All data provided in these studies were primary data (Tables 2 and 4). The largest data set contained information on 2342 respondents from three different communities participating in the study [8,14].

Table 4: Methodological characteristics of publications included in the scoping review (n=25).

Questionnaires and survey instruments were used as primary source of data collection for all identified articles including the CBP research. Focus group discussion was used in collecting qualitative data from participants in one study which also utilized standardized questionnaires [15].

Methodological strengths and limitations of the scoping articles

The methodological strengths and limitations of identified scoping studies are summarized in Table 2. Fourteen (56%) articles acknowledged possible strengths, limitations and bias with their respective studies and research designs. Notable limitations reported were poor sample size (A, B, K, M, Y), social desirability bias (D, E, L, O) and cultural differences which may influences beliefs and choices (H, I, J, O, V,). For example, in a cross-sectional quantitative study set out to determine the attitude of high school teachers to mental illness. The lack of a comparison group was dully recognised as a major limitation to the study as well as poor validity and a possible social desirability bias given that the respondents were educated and well enlightened [16].

Authors of selected scoping studies generally attributed their study strengths to the large sample sizes they got (G, H, I) and an intervention arm of the study (B). The attitudinal change ascribed to an educational program was noted to be significant in a community based intervention [17].

Although not all scoping articles reported limitations in their respective studies, we inferred further researcher limitations from the results and nature of data of these respective studies as, language biases, selection biases, reporting biases and possibly confounding especially with the mixed method studies (D, F).

Thematic analysis and study findings

We grouped the findings of the scoping review into two groups; 1) Knowledge of mental illnesses among Nigerians and 2) Attitude towards mental illness among Nigerians. Results for each are summarized in Table 5.

Table 5: Overview summary of major primary outcomes in Knowledge and Attitude towards the mentally ill described in publications included in the scoping review (N=25).

Knowledge of mental illnesses among Nigerians: Knowledge, perceptions and beliefs of Nigerians about mental health and illness was assessed quantitatively in all of the scoping articles (92% (23/25) assessed purely quantitatively and 2/25(8%) assessed both qualitatively and quantitatively). Standardized structured questionnaires like the Familiarity with mental illness questionnaire (B), the Opinion on Mental Illness (OMI) scale(T,U), the Taylor and Dear Inventory of Community Attitude to Mental Illness(CAMI) (A,W), the modified version of Bogardus Social Distance Scale(B,G), the Discrimination and Stigma Scale (DISC 12) (F) and the Community Screening Interview for Dementia and Blessed Dementia Scale(Y) among other tested survey instruments were used to assess the knowledge of and attitude towards mental illness.

After analysing results of individual articles across all 25 scoping articles, we categorized the knowledge of causal attribution of mental illness based on common responses to;

a) Medical-which included hereditary, brain dysfunction, and other biological factors,

b) Supernatural- witchcraft, ‘juju’ (sorcery), evil spirits, divine punishment, etc. and

c) Psychosocial-poverty, stress, drugs and alcohol abuse, traumatic event, shock, etc.

The most common causal attribution to mental illness noted was ascribed to supernatural causes. This was reported as a primary outcome for knowledge of causes of mental illness in 36% (9/25) (A,C,E,H,K,N,Q,R,X). Six articles (24%) recorded psychosocial causes (I,J,K,O,P,W) as a major cause of mental illness while only two articles (8%) reported medical causes (D,Y).

Several studies also assessed the knowledge and preference of treatment options for people with mental illness, in addition to knowledge and attitude. Of the 25 articles scoped, six (24%) expressed a preference for unorthodox (traditional) treatment options (C,N,O,Q,R,X) while 20% (5/25) expressed a preference for orthodox (western) treatment options (D,L,P,W,Y). Mental illness was generally viewed in a bad light Nigerians, in articles reviewed. Three scoping articles (12%) reported a bad prognosis of mental illness as one of the primary outcomes assessing the knowledge of prognosis of mental health (H,J,V) (Table 5).

Attitude towards mental illness among Nigerians: The scoping review also scoped the attitude of Nigerians towards people with mental illness. After analysing data charts from all 25 scoping articles, we thematically categorized attitude(s) of Nigerians towards mental illness into seven categories (Table 5);

a) Social distance and avoidance: This is the degree to which someone is willing to accept or associate with people having different social characteristics-in this case mental illnesses [14,18].

b) Marriage stigma: This included the willingness to marry, to stay in marriage or be given in marriage to someone with mental illness.

c) Job entrustment stigma: This included the freedom for a mentally ill person to work among or be employed among healthy or non-mentally ill persons.

d) Perceived dangerousness: This is the perception that an individual with a mental illness is extremely dangerous [18,19].

e) Social acceptance: This included acceptance at work, home and society where they lived in)

f) Sympathy: The awareness of someone’s distress and expressed compassion for them [1]

g) Indifference: A condition in which the person is unconcerned with symptoms of others [20]

The most prevalent attitude expressed as a primary outcome from all 25 articles scoped was social distance and avoidance (B,C,F,G,H,I,J,K,L,M,Q,S,W). Social distance was expressed in 52% (13/25) of scoping articles. Following that was perceived dangerousness due to fear, anger or mistrust towards mentally ill persons (A,B,F,H,J,L,O,P,T,U,V,W). Perceived dangerousness was expressed in twelve (48%) of scoping articles. Marriage stigma was recorded in 16% (4/25) of scoping articles (C,L,O,S). Job entrustment stigma (C,L), Social acceptance(O,L) and sympathy (O,D) were noted as primary outcomes of attitude towards mental illness in 8% (2/25) of scoping articles respectively. Only one article recorded and indifference to mental illness (L) (Table 5).

Discussion

This scoping review applied a systematic approach to assess the knowledge and attitude toward mental illness by Nigerians. The findings show some cross-cultural variations, however, still similar in outcomes. Evaluating attitude towards mental illness through the knowledge of the causes of mental illness was critical and important for future service organization. Such findings have linked causal attribution and stigmatising attitude to mental illness [8,21,22]. Results from the scoping review showed a poor knowledge and widespread belief that mental illnesses were caused by supernatural forces including sorcery, witchcraft and punishment from God for sins. Culturally, Nigerians regardless of education seem to adhere in varying degrees to a belief in supernatural causation for any illness or outcome [20]. Results from the scoping review even showed that this belief was not limited to the public alone, but also popular among the workers in health care sectors (A,J,K,M,S,T,U,W,X). A belief in supernatural causation project people with mental illness as dangerous and distasteful [8].

Psychological causes such as alcohol, drugs and substance abuse, stress, and trauma were also implicated as common causes of mental illness. Again, this is a common belief among Nigerians who tend to attribute mental illness causation to psychological or social influences.

The downside to this view is that it tends to instigate more stigmatization rather than sympathy as the society views the mental illnesses as being self-inflicted or self-deserving [1,4,20,22]. All these objectionable views and beliefs on causes of mental illness by Nigerians, further complicates the preference for type of care. A supernatural view of the cause of mental illness will imply that unorthodox (traditional) means of treatment supersedes the orthodox means. Hence, spiritualists and traditional healers are then patronized. Although results from our scoping review showed that a few studies reported preference for a combination of both treatment options (J,Q,R), it is likely that the element of cultural misconception, which has been shown in the Nigerian society to affect their health seeking behaviour, may still make them choose the traditional means of treatment over the western approach. This behaviour doesn’t only relate in reference to mental illness but in other illness types. The issue is that a lot of Nigerians who have lost hope in the health-care system, will resort to spiritual answers by going to prayer houses, traditional healers and spiritualists. No articles were found comparing the treatment approaches. Findings of such studies potentially will reduce stigma and impact attitudinal beliefs about mental illness.

Although studies have claimed that there is less stigmatizing attitude towards mental illness in Nigeria [23], this scoping study showed otherwise. Several studies have shown that stigmatizing attitude to mental illness is significantly associated with stereotypes and discrimination [1,21]. It was concerning the report that the Nigerians seem to despise people with mental disorders more than their illnesses (D,F,G,H,I). Overall, negative views were expressed in all scoping articles reviewed in this study (A-Y). In some studies, negative attitude expressed were indicative of age, gender, educational or economic status (A,B,C,F,G,H,I,J,K,L,M,Q,S,W). A notable article was a study carried out in Lagos, Nigeria’s most populous state, supposedly laden with the educated and elite (F). Results from this study revealed a widespread negative attitude towards mental illness even after previous studies may have said otherwise [3]. The most common views about the mentally ill reported from the scoping review, was perceived dangerousness (A,B,F,H,J,L,O,P,T,U,V,W) and social distance (B,C,F,G,H,I,J,K,L,M,Q,S,W). Studies have shown that these two negative views stimulate social resentment [21] and foster social distance [14,15]. Regrettably, there were also no changes in knowledge and attitude views over time, comparing older articles (below the year 2000) and newer articles (abover the year 2000).

There were a few research gaps observed from this scoping review. One striking observation was a rarity of studies carried out in the eastern part of Nigeria. Nigeria is a culturally assorted country with dissimilarities in access to mental health services which could affect knowledge and attitude to mental illness [24]. Nevertheless, several studies among other ethnic groups in this scoping review have suggested a widespread poor knowledge of and attitude towards mental illness which have been shown to have a strong validity and reliability (A,B,C,E,J,K,L,M,N,O,P, Q,R,T,U,X,Y). Secondly, the focus on mental illness as a general term rather than on specific mental disorder may have created a bias to respondents in individual studies, who have little or no knowledge about the term mental illness or may possess a narrow view of what the term means.

However, the findings of this scoping review support observations from other studies done outside Nigeria even though methodological differences may preclude comparability [25-30]. This corroborates the notion that stigma is a universal phenomenon, but experiences are local [27]. Thus, the need for mental health literacy is a global subject. The impact of education on the knowledge and attitude of Nigerians to mental illness was studied in a few of the scoping reviews (B,I,K,M,P,S,U,W,X,Y) and showed that mental health literacy was significantly associated with positive attitude towards mental illness. It has been said that an increase in literacy and education regarding the mental health and illnesses, will result in an improvement in attitude toward people with mental illness [8] as mental health illiteracy is a renowned source of stigmatizing attitude towards the mentally ill [22]. A potential direction this finding leads is the need to demonstrate effective interventions so as to curb the attitudinal excesses [40].

Conclusion and Recommendations

The outcome of this scoping review is a validation of a chronic widespread public stigmatization of the mentally ill. This demonstrates the need for mental health literacy in all levels of education. A better understanding of mental illness would significantly improve knowledge and attitude towards mentally ill persons. There is an urgent necessity, to improve the health care system in Nigeria, by developing strategies that would improve mental health literacy, and change stigmatizing attitude at both institutional and community levels. This will in the long run improve the quality of the societal attitude towards mental illness and the socio-economy of the mentally ill.

One practical yet feasible way to improve literacy in mental health, is by instituting age-appropriate school-based educational programmes. Although complexities may arise in creating these educational programs, reason being that stigmatizing attitude and beliefs in supernatural causation have been shown to still exist among educated health workers, however, it’s a good place to start from. Another practical recommendation is to increase psychiatry clerkship rotations for medical students, beyond 4 weeks. This will help familiarize students more with mental health diseases outside their pre-conceived misconceptions. In addition, it is necessary to encourage health workers (nurses, psychologists, psychiatrists and other health care professionals) to show positive attitude towards mentally ill persons as this play an important role in influencing their response to treatment. Missing in the scoping review was the role of the media in propagating attitudinal observation or changes. Future studies to examine how the media can play a role in education or reducing stigma.

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