Contents

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Atabong Emmanuel Njingu^1,2 and Lawrence Kanjo Ndumu³

Metadata

DOI: https://doi.org/10.61915/pnd.501588

Abstract

Introduction

Mental health is essential to an individual’s well-being; it is also essential for interactions between a person and his or her family and between a person and the environment. Mental health is critical to the development of communities and nations [1,2]. Mental disorders impose a significant global economic burden, with an estimated total cost of 2.5 trillion US dollars, which is expected to more than double by 2030 [3].

Many people with mental illnesses either do not receive appropriate treatment or do not receive treatment at all, resulting in a treatment gap for mental disorders that is larger than for any other somatic disease [1,3]. People suffering from mental illness face not only the burden of the illness but also the stigma associated with mental disorders.

The stigma associated with mental disorders includes negative thoughts, feelings, and attitudes toward these people [4], and these negative thoughts and feelings toward people with mental illnesses have resulted in profound social exclusion and social discrimination of people with mental illnesses [5,6].

According to studies, knowledge and causal belief about mental health disorders are factors that influence stigma toward people with mental illnesses [7,8]. Many countries have launched campaigns to raise mental health awareness in order to reduce the stigma associated with mental illness and increase the willingness of people with mental illnesses to seek help; the “Time to Change” campaign in England, launched in 2009, aimed at changing the way people think and act about mental disorders [9].

Similar campaigns have been launched in Western countries such as New Zealand (Like minds like mine) [10], Denmark launched a national mental disorder anti-stigma campaign in 2015 [11], and Canada launched a ten-year anti-stigma campaign in 2013 [12]. These anti-stigma initiatives aimed to increase public awareness and change attitudes and behaviors toward mental disorders.

Globally, the prevalence of mental disorders is high; approximately 10 to 20% of children and adolescents worldwide suffer from psychological problems [13–15]. In Sub-Saharan Africa, approximately 14% of children and adolescents have a mental health problem, with 9.5 percent meeting the diagnostic criteria for a mental illness [16]. Mental health disorders account for approximately 12.2 percent of the total disease burden in Cameroon [17].

A study conducted in 2013 among Primary Health Care Providers (PHCPs) in Cameroon’s Fako Division found that less than half of PHCPs had prior formal training in mental health, that roughly two-thirds of PHCPs in this study were uncomfortable working with patients suffering from depression, and that only about 2% of study participants were familiar with standard diagnostic tools for depression [18].

Another study conducted among Cameroonian medical students revealed that approximately 31% of Cameroonian medical students suffer from major depressive disorder [19]. To the best of our knowledge, no study in Cameroon has been conducted among the general population to assess knowledge, attitudes, and behaviors toward people with mental illnesses.

Objective:

To close this gap, we set a goal of assessing public knowledge, attitudes, and behaviors toward people with mental illnesses in Cameroon’s Southwest Region.

Materials and Methods

Study design, period, and setting

From August 2nd to August 31st, 2021, an observational cross-sectional study was conducted among residents of Cameroon’s South West Region. Data were collected using a pretested online questionnaire in order to limit contact with people in the context of Covid-19. Google forms were used to create English and French versions of the study questionnaire. Survey links were distributed to potential study participants via WhatsApp and Facebook groups of authors and collaborators.

Study population and sampling

We sought males and females aged 18 and up who live in Cameroon’s South West Region. Everyone who agreed to participate in this study was able to complete the questionnaire online. A sample size calculator was used to estimate a target sample size of 385 [20]. Based on the population of Cameroon’s Southwest Region, a margin of error of 5%, a confidence level of 95%, a 50% response distribution, and a population of 1,534,232 people were used [21]. There were 400 participants in this study.

Study procedures and Variables

The link to the online questionnaire was distributed via social media platforms (“WhatsApp,” Facebook, and groups) as an open invitation for people aged 18 and up to click on the link, consent to the study, and then complete the rest of the online questionnaire. The questionnaire was available in both English and French, with each version containing 68 questions. The questionnaire was divided into two sections.

The first section collected sociodemographic information such as age, gender, place of residence (rural or urban), level of education (primary/no formal education, secondary and tertiary), employment type (healthcare worker, non-healthcare worker, unemployed), and religious affiliation (Christian, Muslim, not religious, other).

The second section of the questionnaire consisted of three scales: the Mental Health Knowledge Schedule (MAKS), the Community Attitudes Toward Mental Illness (CAMI), and the Reported and Intended Behavior Scale (RIBS). The three scales have all been validated in both English and French [22].

Mental Health Knowledge Schedule 

This is a twelve-item scale that was used to measure mental health-related knowledge, it is made up of two parts, the first part consists of six items that cover stigma related to mental health; help-seeking, acknowledgment, support, employment, treatment, and recovery.

The second part is made up of six items that assess the classification of various conditions as mental illness [23]. Each item was scored on a 5-point Likert scale from, strongly agree = 5 to strongly disagree = 1. The total score was calculated by adding the points scored for each of the twelve questions, a higher score indicated better knowledge. The reliability of MAKS was found to be 0.71 using Lin’s concordance statistics, overall internal consistency of items 1 to 5 was 0.65 [23].

Community Attitudes towards Mental Illness 

This scale consists of 40 items divided into four subscales each with 10 items; Authoritarianism (AU) refers to a view of mentally ill people as someone who is inferior and requires supervision and coercion. Benevolence (BE) corresponds to a humanistic and sympathetic view of mentally ill persons. Social Restrictiveness (SR) expresses the belief that mentally ill persons are a threat to society and should be avoided and Community Mental Health Ideology (CMHI) means acceptance of mental health services and the integration of mentally ill persons into the community [24].

All answers were scored from 1 (strongly disagree) to 5 (strongly agree) on a Likert scale. Negatively stated items were reversely recoded before analysis. The total level of stigma against mentally ill persons was calculated by summing the result from each subscale. Higher scores indicated less stigma towards persons with mental illness  A Cronbach’s α score of 0.87 was obtained for the CAMI scale [25].

Reported and Intended Behavior Scale 

[26–28]; consists of eight items divided into two groups of four. The first group focuses on behavior reported in past or present experiences regarding the following areas: live with, work with, live nearby, or have a relationship with a person with a mental health problem.

The second group focuses on future intentions to establish contact with people with mental health problems in the same areas as described above. Each answer was scored from 1 (strongly disagree) to 5 (strongly agree) on a Likert scale, “I don’t know” was coded as neutral (3). The total score is a sum of all the scores of the 10 items, higher scores correspond to more favorable expected behaviors. The overall internal consistency of RIBS was 0.85 based on Cronbach’s α score [26–28].

Data management and data analysis

Data collected were entered into Microsoft excel 2016, were cleaned, exported, and was analyzed using Statistical Package for Social Sciences (SPSS v20). Continuous variables were summarized using mean and standard deviation. Categorical variables were summarized using counts and percentages. Independent-sample t-test was used to compare two means, ANOVA test was used to compare 3 or more means.

Hierarchical stepwise linear regressions were carried out; in the first step, the MAKS score was used as the dependent variable and sociodemographic variables were used as independent variables. In the second step, the CAMI score was used as a dependent variable, and the sociodemographic variables and the knowledge score were used as independent variables.

In the third step, the RIBS score was used as the dependent variable and the sociodemographic variables, knowledge, and attitude scores as independent variables. All items with p < 0.1 in bivariate analysis were used as independent variables in the linear regression model to take out potential confounding factors. Statistical significance was set at p<0.05.

Results

Four hundred (400) participants completed the study questionnaire out of the over 1500 people who received it through various social media groups making a 26.7% response rate. 223 (55.75 percent) were females, the majority (48.25 percent) were between the ages of 20 and 39, 289 (72.25 percent) lived in cities, and 111 (27.75 percent) lived in rural areas. Table I details the remaining sociodemographic characteristics.

The CAMI, MAKS, and RIBS [26–28] 25th, 50th, and 75th percentiles were used as cut-off points for low, medium, and high scores, respectively (Table 2a). 72.1 percent of study participants had a high level of public stigma toward people suffering from mental illness. In terms of knowledge, 32.1 percent had little knowledge of mental health, while 62.3 percent had favorable attitudes toward people with mental illnesses.

The MAKS scale had a mean score of 44.21. (SD, 7.34). The mean RIBS score was 18.28 (standard deviation: 5.61), and the mean CAMI score was 118.12. (SD, 8.32). In the bivariate analysis of factors associated with total CAMI score, urban dwellers had a significantly higher mean total CAMI score (less stigma) than people who live in rural areas (139.01 (9.21) vs. 125.93 (20.22), p0.001). People with a tertiary level of education scored higher in the CAMI scale than people with primary/no formal education (138.01 (12.03) vs. 126.77 (12.32) p<0.001).

Healthcare workers (138.94 (8.23) vs. 135.43 (7.39), p0.001), people with close relatives/friends with mental illness (137.98 (14.17) vs. 135.01 (17.51), p0.001), and people suffering from/having recovered from mental illness (137.08 (12.16) vs. 131.06 (7.12), p0.001) all had significantly higher CAMI scores (less stigma). In terms of the CAMI score, there was no statistically significant difference between genders or religious affiliations.

People living in cities had significantly higher MAKS scores (better knowledge of mental health) than those living in rural areas (38.80 (16.35) vs. 31.85 (11.75), p0.001). People with tertiary education had higher MAKS scores than those with primary/no formal education (39.10 (8.01) vs. 34.13 (7.30), p=0.004).

Healthcare workers (39.89 (16.09) vs. 34.10 (13.10), p = 0.001), people with close relatives/friends with mental illness (39.91 (12.05) vs. 37.32 (9.01), p = 0.043), and people suffering from/having recovered from mental illness (36.01 (9.31) vs. 36.01 (9.31), p0.001) had significantly higher mean MAKS scores (Table 2b).

Similarly, on the RIBS scale, people living in cities (16.20 (6.16) vs. 14.11 (14.01), p = 0.012), people with close relatives/friends suffering from mental illness (16.08 (16.69) vs. 14.37 (17.29), p=0.006), and people suffering from/having recovered from mental illness (16.18 (4.63) vs. 15.01 (3.76), p=0.040) had significantly higher RIBS scores (Table 1). Table 3 shows the results of multiple linear regression analysis with MAKS, CAMI, and RIBS scale as independent variables.

The MAKS scale was used as the dependent variable in the first multivariate linear regression model. The findings revealed that living in a rural area (β = -0.514, p 0.001) and being a non-healthcare worker (β = -0.245, p 0.05) significantly predicted lower mental health knowledge, whereas tertiary education (β = 0.018, p 0.05), having a close relation/friend with mental illness (β = 0.029, p 0.05), and having a current or past history of mental illness (β = 0.079, p 0.05) significantly

The CAMI scale was used as the dependent variable in the second multivariate regression model. Higher MAKS scores (β = 0.142, p 0.001), living in an urban area (β = 0.372, p 0.001), tertiary level of education (β = 0.812, p 0.001), having a close relative/friend with mental illness (β = 0.376, p 0.001), and having a current or past history of mental illness (β = 1.032, p 0.001) were all associated with a lower likelihood of stigmatizing people with mental illness (higher CAMI scores).

The RIBS scale was used as an independent variable in the third multivariate regression model. Higher MAKS scores (β = 2.120, p 0.001), higher CAMI scores (β = 1.043, p 0.001), having a close relative/friend with mental illness (β = 0.610, p 0.001), and having a current or past history of mental illness (β = 2.381, p 0.001) all significantly influenced positive behavior (higher RIBS scores) towards people with mental illnesses (Table 3).

Discussion

The goal of this study was to see how mental health knowledge affected community attitudes and behaviors toward people with mental illnesses in Cameroon’s Southwest Region. Our findings revealed that up to one-third of the study population lacked basic mental health knowledge, as well as a high prevalence of negative attitudes and stigma toward people with mental illnesses. These findings are consistent with previous research in middle and low-income countries [18,24,26,29,30].

The most common reasons for discriminatory attitudes and stigmatization of people with mental illnesses were misperceptions about the causes of mental illnesses. In two separate studies conducted in Cameroon and the Middle East [18,24], sin, misfortune, and God’s punishment were listed as perceived thoughts of mental disorders in the study population; in this study, mystical retribution was stated as a cause of mental illness by more than 75% of study participants, in addition to the above reasons.

Living in urban areas, having a tertiary level of education, working in healthcare, having close relatives/friends with mental illness, and people who are suffering from/have recovered from a mental disorder were all associated with higher mental health knowledge in this study.

These findings are consistent with other studies, whereas others found the opposite. Our study found that people in cities had significantly better mental health knowledge than people in rural areas, which is similar to the findings of Carla et al, who discovered that people in North Lebanon had better mental health knowledge than people in Bekaa [24].

Mental health awareness campaigns should target rural populations to help close this gap. Carla et al. discovered that having a relative with a mental illness increases knowledge of mental health, as does regular contact with mentally ill people [31]. In this study, unlike previous studies [9,24,32], age and gender had no effect on mental health knowledge.

Our study discovered that people with high MAKS scores exhibited positive behavior and attitudes toward people with mental disorders in terms of attitudes and behaviors toward mentally ill people. This suggests that greater mental health knowledge promotes positive behaviors and attitudes, which is consistent with Carla et al’s findings and other studies in developing countries [24,33,34].

Individuals with a higher level of knowledge may have had the opportunity to be educated on mental health, as a result of which they became more understanding and had better attitudes. Other studies, however, suggest that having a higher level of knowledge of mental disorders causes people to be more distant from mentally ill people because they are aware of their actual symptoms and behaviors; thus, higher mental health knowledge did not affect attitudes and behaviors toward mentally ill people in these studies [24,35–37].

In this study, people living in cities had higher CAMI and RIBS scores than those living in rural areas, which is consistent with other studies [18,24,38]. This disparity could be attributed to higher levels of education and increased access to mental health awareness campaigns and mental health facilities among urban residents [18,24,38].

Having a close relative or friend with mental illness, as well as a current or previous history of mental illness, was associated with a lower likelihood of stigmatizing people with mental illness (higher CAMI scores) and had a significant impact on the positive behavior (higher RIBS scores).

This is consistent with other studies’ findings [24,39]. The strongest predictor of positive attitudes and behaviors toward the mentally ill, according to González-Sanguino et al [39], was having or having had contact with someone with mental illness or suffering from it oneself. Carla et al. discovered a similar result, claiming that having people with mental illnesses in the family increased benevolence and raised the CAMI score [24].

The relationship between age and gender and MAKS, CAMI, and RIBS scores has produced contradictory findings [24,32,36,39]. In our study, there was no correlation between these demographic variables and MAKS, CAMI, or RIBS scores. More investigation is required to establish a clear relationship between these variables.

Limitation:

Because of its applicability and a good representation of the study population, we used a cross-sectional design. There may be bias in the data because the participants in this study provided us with information via a self-reported questionnaire. We used a large sample size and items specifically designed for stigma assessment to overcome some limitations. This is the first time a Cameroonian community’s level of stigma has been described.

The relationship between age and gender and MAKS, CAMI, and RIBS scores has produced contradictory findings [24,32,36,39]. In our study, there was no correlation between these demographic variables and MAKS, CAMI, or RIBS scores. More investigation is required to establish a clear relationship between these variables.

Conclusions

This study’s findings provide preliminary evidence of a relatively high level of stigma and negative behaviors toward the mentally ill in Cameroon’s Southwest Region. In this country, where there is no clear framework for treating mental health conditions, assessing other factors affecting people with mental health conditions, such as public stigma and behaviors toward them, was critical.

The main finding of our study was that greater mental health knowledge was associated with less stigmatization of the mentally ill. In Western countries, mental health awareness campaigns have been shown to increase mental knowledge and, as a result, reduce stigma. The same strategy, involving both rural and urban residents, should be used in Cameroon to reduce the high level of negative attitudes and behaviors toward people with mental illnesses.

Ethical considerations

Ethics approval was obtained from the institutional review board of the Cameroon Baptist Convention Health Services. Participants also gave consent to willingly participate in the survey by clicking the ‘Accept’ button and were then directed to complete the questionnaire.

Author’s contributions

AEN: conception and design of the study, data collection, data interpretation, data analysis, drafting, and review of the manuscript. LKN: conception and design of the study, data collection, review of the manuscript. AEN data analysis, data interpretation, drafting, and review of the manuscript. LKN data interpretation, AEN, and LKN drafting and review of the manuscript. All authors revised and approved the final version of the manuscript.

Acknowledgments

We are grateful to Nkuma Innocentia, Taku Clara, and Fombo Enjeh Jabbossung and all those who helped us in sharing the online questionnaire for this study. We are equally thankful to all those who took part in this study.

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