Non-mental health workers’ attitudes and social distance towards people with mental illness in a Nigerian teaching hospital.

Author(s): Olatunji F. Aina[a], O. Yewande Oshodi[a], Adebayo R. Erinfolami[a], Joseph D. Adeyemi[a], and Tajudeen. F Suleiman[b]

aDepartment of Psychiatry, College of Medicine, University of Lagos, PMB 12003, Lagos, Nigeria. bDepartment of Psychiatry, Lagos University Teaching Hospital, Lagos.

Correspondence to Dr. O.F. Aina. [email protected]


Background: Studies on attitudes towards mental health in Nigeria have been mainly community-based surveys.

Objective: To determine the knowledge and attitudes towards mental illness (MI) of health workers in a Nigerian Teaching Hospital.

Methods: A stratified sample of 256 health workers completed an Attitude to Mental Illness Questionnaire (AMIQ) designed for this study.

Results: Most participants (62.1% to 80.9%) identified scientific factors such as genetic inheritance as causes of MI; 24.8% identified spiritual factors as potential causes. Effective methods of treatment identified by respondents include orthodox methods (84.6%) and a combination of traditional and orthodox management (37.8%). There were varying shades of negative attitudes towards mentally ill persons (MIPs).

Conclusion: The health workers showed some degree of social distance to MIPs, and there is need for psycho-education to improve their knowledge in mental health.


Studies on attitudes towards mentally ill persons (MIPs) have reported divergent views; but with a number showing psychiatrically ill people are stigmatized [1,2]. According to Erving Goffman (1963), stigma refers to any attribute, trait or disorder that marks an individual as being unacceptably different from the “normal” people with whom he or she routinely interacts and that elicits some form of community sanctioning [3]. The World Health Organization (WHO) also described stigma as a mark of shame, disgrace or disapproval that results in an individual being shunned or rejected by others [4]. Consequently, MIPs and even their relatives have been found to suffer from an insidious form of discrimination particularly in Africa [5,6,7].

Among health care workers, including mental health professionals, studies in Europe and America have also documented their negative attitudes towards MI [8,9].

In Nigeria, a number of community-based studies have shown negative attitudes towards MIPs [5,7]. However, despite the dearth of psychiatrists in Nigeria and the involvement of non-mental health workers in the care of medically ill patients with co-morbid psychiatric complications, there has been no previous study among such workers; hence this study.

Materials and methods

The study setting

The study was carried out in Lagos University Teaching Hospital (LUTH); Lagos is the commercial capital of Nigeria. LUTH is a tertiary hospital with 761 beds and a staff of about 2620.


A questionnaire was used to elicit socio-demographic variables of participants.

The 'Attitudes to Mental Illness Questionnaire' ("AMIQ") constructed for this study was designed to explore respondents’ knowledge about mental illness (MI) such as causes, effective treatment modalities, any relative or friend with MI, how to relate with MIPs, their willingness to befriend, marry or work with a MIP, how to prevent MI, and if MI is infective or not. The "AMIQ" was developed in two stages. First, questions were constructed to cover the identified areas of beliefs and attitudes to mental illness and piloted on 30 health workers of different cadres (who were omitted from the main study). These responses were then used to develop the final 10-item instrument. Some items have dichotomous ‘Yes’ or ‘No’ response options while others contain lists of responses that are not necessarily mutually exclusive.

Subjects and procedure

The study was carried out after approval by the institutional review board. The sample of subjects was obtained through stratified random sampling. Overall, the research questionnaire was administered to 322 subjects who gave their consent to the study, but only 246 (76.4%) completed and returned the questionnaires.

Data analyses

Data were analyzed with SPSS-PC version l3. Descriptive statistics and bivariate comparisons with Chi-squares were obtained, with the level of significance set at 5%.


A total of 246 health workers were studied, with slightly more men (53.7%) than women in the sample.  The mean age was 31.7 (±7.7) years. The largest numbers of respondents were house officers, 82 (33.3%) followed by nurses (28%) – see Table 1.


Table 1. Socio-demographic characteristics of respondents



Percentage (%)




























Marital Status


















Educational Qualification



University graduate















Job Description


Resident Doctors

House Officers


Others (Pharmacists, Admin. Staff, Lab Tech.)



















Perceived causes, effective treatment and prevention of mental illnesses.

Most respondents, 170 (69.1%), believed there were multiple causes of MI, with substance abuse being mentioned most often. The respondents who attributed MI to scientific causes such as substance abuse and genetic inheritance were mostly doctors. Some respondents, especially nurses, laboratory technologists and administrative staff identified spiritual factors of “demonic attacks” (24.8%) and “curses” (15.9%) as possible aetiologies of MI. Only seven (2.8%) respondents indicated MI could be infectious through physical contact with  MIPs.

Social distance and stigma

Almost half of the respondents, 122 (49.6%) admitted to have relatives or friends with MI. Slightly over half (51.6%) were unsure of how they could relate with a MIP. Eighty four (34.2%) claimed they would relate normally or cordially, while 23 (9.3%) admitted they would relate with caution or preferably keep a social distance due to perceived dangerousness of  MIPs.

Close to two-thirds (64.6%) of the respondents admitted they could not live with or get married to a MIP. Reasons given were:

  • "it is difficult to cope with a MIP",
  • "they are dangerous", and
  • "they are emotionally unstable and unpredictable".

Only 68 (27.6%) of respondents claimed they could live with or marry a MIP. The remaining 19 (7.8%) were not sure if they could live with or marry a MIP.

The majority of the respondents, 176 (71.6%) stated they could be friends and work with a MIP. However, close to one-fifth (19.5%) claimed they could neither befriend nor work with such patients. Twenty two (8.9%) were not sure if they could work with or be a friend to a MIP.

Relationship between socio-demographic factors and beliefs/ attitudes to mental Illness variables

Significant relationships were found between some socio-demographic factors and attitudinal variables. Occupation, that is the type of health profession, had significant relationship with perceived causes of MI (X2 =48.62, df=30), effective treatment option for MI (X2 =59.01, df=25), prevention of MI (X2 =81.48, df=45) and relating with a MIP (X2 =56.91, df=45) all at p<0.05. Significant relationship was also found between sex and effective treatment option for MI (X2 =11.99, df=5) and relating with MIPs (X2 =17.49, df=9) at p<0.05. Educational qualification had significant relationship with only relating with MIPs (X2 =56.30, df=36), p<0.05.


Unlike most previous studies in Nigeria that were community-based, our study attempted to evaluate the attitudes of non-psychiatric health workers to MI in a teaching hospital. Close to two-thirds of the respondents, especially doctors attributed causes of MI to scientific factors such as genetic inheritance. This is not surprising given the clinical background of such respondents. However, most non-clinicians attributed causes of MI to supernatural/ psychosocial factors, and this is in keeping with findings from most previous community-based studies in Nigeria [5,7].

Most respondents (84.6%) believed in the effectiveness of orthodox medical care; and 26.0% attributed effective treatment of MI to fasting and prayer. This finding supports the fact that Nigerians irrespective of their educational qualification and occupation are known to be religious. When confronted with serious illnesses, such as psychotic disorders, most resort to spiritual intervention for their healing; orthodox psychiatric management becomes the last resort when spiritual interventions fail [10,11].

Varying shades of social distance and stigmatizing relationship with  MIPs were given by our subjects; and this is similar to findings from previous community-based studies in Nigeria [5,7,12]. Similar stigmatizing attitudes towards  MIPs have also been reported among non-psychiatric doctors and even among mental health professionals in Europe, but psychiatrists were found to exhibit greater advocacy for mental health care than their non-psychiatric counterparts [8,9]. In our study, the observed stigmatizing attitudes of the non-psychiatric health workers may lead to unwillingness to look after patients with concurrent physical and psychiatric disorders, as found in previous studies [13].


In this study, our subjects showed varying shades of negative attitudes towards the MIP. It is thus concluded that to reduce stigma against MI in Nigeria, health workers need to undergo a psycho-educational programme in Continuing Medical Education.



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