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Swedish attitudes towards persons with mental illness Article in Nordic journal of psychiatry · September 2011 DOI: 10.3109/08039488.2011.596947 · Source: PubMed
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Swedish attitudes towards persons with mental illness TORBJÖRN HÖGBERG, ANNABELLA MAGNUSSON, KIM LÜTZÉN, BÉATRICE EWALDS-KVIST
Högberg T, Magnusson A, Lützén K, Ewalds-Kvist B. Swedish attitudes towards persons with mental illness. Nord J Psychiatry 2012;66:86–96. Background: Negative and stigmatizing attitudes towards persons with mental illness must be dealt with to facilitate the sufferers’ social acceptance. Aim: The present study aimed at survey Swedish attitudes towards persons with mental illness related to factors impacting these attitudes. Material and Methods: New CAMI-S based on the questionnaire “Community Attitudes to Mental Illness in Sweden” ([CAMI] Taylor & Dear, 1981) was developed with nine behavioral–intention items and thus comprised a total of 29 items. Of 5000 Swedish people, 2391 agreed to complete the questionnaire. Principal component analysis rendered four factors reflecting attitudes towards the mentally ill: Intention to Interact, Fearful and Avoidant, Open-minded and Pro-Integration, as well as Community Mental Health Ideology. The factors were analyzed for trends in attitudes. By MANOVA, the experience of mental illness effects on mind-set towards the sufferers was assessed. By means of logistic regression, demographic factors contributing to positive attitudes towards persons with mental illness residing in the neighborhood were assessed. Results: By New CAMI-S, the Swedish attitudes towards the mentally ill were surveyed and trends in agreement with living next to a person with mental illness were revealed in three out of four factors derived by principal component analysis. Aspects impacting the Swedish attitudes towards persons with mental illness and willingness to have him/her residing in the neighborhood comprised experience of mental illness, female gender, age (31–50 years), born in Scandinavia or outside Europe, only 9 years of compulsory school and accommodation in flat. Conclusion: The New CAMI-S came out as a useful tool to screen Swedish attitudes towards persons with mental illness. Most Swedes were prepared to live next to the mentally ill. • Mental illness, New CAMI-S, Swedish attitudes towards persons with mental illness. Torbjörn Högberg, Karolinska Institutet, Institution of Clinical Neuroscience, Stockholm Centre for Psychiatric Research and Education, Stockholm, Sweden. E-mail:
[email protected]; Accepted 27 May 2011.
A
ll people are of equal value and have equal rights. Yet, a substantial part of the Swedish population perceives persons with mental illness as unpredictable and dangerous (1–3). Namely, a person with a mental illness is portrayed as 10 times more likely to be a violent criminal than a mentally healthy person in prime-time television. As a result, viewers considered locating mental health services in residential neighborhoods as endangering the residents and were less likely to support living next to persons with mental illness (4). In contrast, metaanalysis indicated that most violent persons were not psychotic and most people with a psychotic illness were not violent (5). Also culture shapes public attitudes towards mental illness (6) as well as lack of knowledge about mental disorders (7–9). Therefore, through information campaigns, the Agency for Disability Policy Coordination has sought to influence the public’s
© 2012 Informa Healthcare
attitudes positively towards persons with mental illness and increase the general awareness about mental disorders (10). Consequently, negative and stigmatizing attitudes towards persons with mental illness must be dealt with to facilitate the sufferers’ social acceptance to hinder their marginalization and stigmatizing (11–13). Stigma—“a stick” or a “mark” (gr.) originally denoting an unusual or defamatory sign in a person’s moral character—is nowadays referred to as a social construct comprising four interrelated components: 1) people distinguish and label human differences; 2) labeled persons are caused damage by cultural beliefs and negative stereotypes; 3) labeled persons are placed in distinct categories to separate “us” from “them” and 4) labeled persons experience status loss and discrimination (14, 15). Stigmatization comprises both acknowledgement of individual differences based on specific characteristics
DOI: 10.3109/08039488.2011.596947
SWEDISH ATTITUDES TOWARDS PERSONS WITH MENTAL ILLNESS
and a steadily continuing belittling of a person (16). A stigmatized socially rejected person with mental illness enlarges his own feelings of alienation. In other words, negative stereotypes are transposed to “own self ” causing internalization of stigma leading to degradation of the self and feelings of shame combined with lower selfesteem and poorer self-confidence as well as with an inferior self-image (17). Educated people are presumed to display more positive attitudes towards persons with mental illness, although the “not in my backyard” (NIMBY)-phenomenon might be at hand, i.e. knowledgeable persons do not necessarily want to live next to them (18, 19). Furthermore, personal experience of mental illness is presumed to affect intolerance towards mental disorders (20–22). In addition, negative attitudes towards persons with mental illness links to older age, lower standard of living and lower education (19, 23). Moreover, the concept “attitude”, is tripartite: cognitive, affective and behavioral, i.e. the cognitive part includes beliefs, the affective part comprises emotions, and the behavioral part covers actions or intention to act or interact. Presently, a special focus is placed on the behavioral part, i.e. on the intention to interact with the mentally ill, more correctly, on the willingness to live next to persons with mental illness (24–26). Presently the definition of persons with mental illness includes mental dysfunctions requiring long-term treatment (27).
Aim The present study aims at screening Swedish people’s attitudes and to cluster recurrent themes in these mindsets towards persons with mental illness related to personal experience of mental illness and to demographic factors.
respondents had finished a 9-year compulsory school, 36.6% (n ⫽ 833) completed upper secondary school, 27.5% (n ⫽ 625) had a university degree but 14.9% (n ⫽ 339) were subjected to other schooling. With reference to respondents’ (n ⫽ 2391) experience of mental illness in general, 57.7% (n ⫽ 1331) had no such experience. However, 3% (n ⫽ 72) had experience of their own mental illness, 28.6% (683) had experienced relative’s, friend’s or other’s mental illness, 8% (n ⫽ 192) had occupational experience of such illness and 4.7 (n ⫽ 113) had experiences of mental disorders in varying ways.
Internal reliability of the New CAMI-S instument The “New CAMI-S” instrument was an improvement of “CAMI-S” (Community Attitudes to Mental Illness in Sweden; 22) and Cronbach’s alpha of the “New CAMI-S questionnaire” was computed (α ⫽ 0.954). Items numbered 19, 21, 23, 27, 29, 31, 34, 36, 41, 42 and 45 were negatively worded and their scoring was therefore reversed. The behavioral–intention items were numbered: 19, 22, 25, 28, 31, 34, 37, 40 and 43 (Table 2). In view of the fact that all loadings exceeded 0.44, no item was excluded. A principal component analysis was carried out on the 29 items with the Varimax rotation method, applying the Kaiser rule to drop all components with eigenvalues under 1.0. After a varimax rotation, each factor was presumed to have either large or small loadings of any particular variable and thus yielded results to make it easy to identify each variable with a single factor. The eigenvalues for the four factors were: 12.90, 1.62, 1.35 and 1.20. Inspection of the factors’ underlying themes brought about the following names: 1) Intention to Interact, 2) Fearful and Avoidant, 3) Open-minded and ProIntegration and finally 4) Community Mental Health Ideology. These factors are largely consistent with those found by Högberg et al. (20) and Rudder-Baker (22). The principal component analysis for the 29 items and Cronbach’s alpha for each factors are shown in Table 2.
Material and Methods Demographics
Statistical analysis
A drop-out analysis is given in Table 1. Furthermore, Table 1 presents demographic factors: it elucidates that the respondents’ age and income approximated the normal distribution fairly well. Just over a quarter (25.9%) of the respondents had an annual income between 160,000 to 235,000 SEK, and slightly more than 28.6% resided in major cities. Most of the respondents were married or cohabiting but a third of the cohabiting couples lived at separate places. A total of 13% of the respondents’ were born in other countries and 4% did not possess a Swedish citizenship. Regarding respondents’ accommodation, 57.7% (n ⫽ 1336) lived in own house as compared with 39.9 (n ⫽ 923) who resided in a flat or lived under other conditions (2.4% [n ⫽ 56]). Altogether 21% (n ⫽ 477) of the
The results were computed by SPSS, versions 15 and 17, as follows: Principal Component Analysis was carried out with the Varimax rotation method applying the Kaiser rule to drop all components with Eigenvalues under 1.0. Also Cronbach’s Alpha, Logistic regression with analysis of Maximum Likelihood estimates and Odds Ratio estimates were computed. MANOVA, partial Eta squared (η2), χ2 as well as Wallis kruskal-Wallis one-way analysis of variance by ranks analysis of variances were carried out. Also Jonckheere trend tests were calculated where the alternative hypothesis is tested against a null hypothesis of no systematic trend across treatments. The test can be applied for data for k independent samples, when measurement is at least ordinal, and when it is possible to specify a priori the ordering of the groups (36).
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T. HÖGBERG ET AL.
Table 1. Drop-out analysis: Respondents’, non-respondents’ as well as sample’s characteristics. Respondents n Gender Men Women Age classes (10 years.) ⬍ 19 years 20–29 30–39 40–49 50–59 60–69 70–79 80– Country of birth Sweden Other Citizenship Swedish Other Marital status Married Unmarried Lives at separate place Other Income None (0) 1–84,999 85,000–159,999 160,000–234,999 235,000–309,999 310,000– All Municipality 1. large cities 2. Suburban 3. Major cities 4. Commuter municipalities 5. Rural municipalities 6. Productive municipalities 7. Municipalities (other) ⬎ 25,000 inhab. 8. Municipalities 12,500–25,000 inhab. 9. Municipalities ⬍ 12,500 inhabitants All
Non-respondents %
n
%
n
%
1037 1354
43.4 56.6
1337 1257
51.5 48.5
2374 2611
47.6 52.4
73 290 380 402 451 440 268 87
3.1 12.1 15.9 16.8 18.9 18.4 11.2 3.6
100 498 497 452 386 334 208 119
3.9 19.2 19.2 17.4 14.9 12.9 8 4.6
173 788 877 854 837 774 476 206
3.5 15.8 17.6 17.1 16.8 15.5 9.5 4.1
2108 283
88.2 11.8
2081 513
80.2 19.8
4189 796
84 16
2293 98
95.9 4.1
2374 220
91.5 8.5
4667 318
93.6 6.4
1177 796 306 112
49.2 33.3 12.8 4.7
1037 1111 312 134
40 42.8 12 5.2
2214 1907 618 246
44.4 38.3 12.4 4.9
94 294 402 619 510 472 2391
3.9 12.3 16.8 25.9 21.3 19.7 100
213 402 486 647 428 418 2594
8.2 15.5 18.7 24.9 16.5 16.1 100
307 696 888 1266 938 890 4985
6.2 14 17.8 25.4 18.8 17.9 100
358 365 683 167 82 177 323 172 64 2391
15 15.3 28.6 7 3.4 7.4 13.5 7.2 2.7 100
527 421 689 139 77 161 328 167 85 2594
20.3 16.2 26.6 5.4 3 6.2 12.6 6.4 3.3 100
885 786 1372 306 159 338 651 339 149 4985
17.8 15.8 27.5 6.1 3.2 6.8 13.1 6.8 3 100
Results Trends favors the mentally ill From Tables 3–6 it can be seen whether the Swedish people agreed, were neutral or disagreed to the statements in each of the four factors derived from the principal component analysis. By means of χ2, it was indicated that there was a difference between the three response groups “totally disagree”, “neutral” and “totally agree” towards the statement included in factor 1: Intention to Interact and based on the mean numbers of n in each response group (means ⫽ 346, 673 and 1294) it seemed plausible to assume that there was a response trend. By means of Jonkheere’s trend test, a significant (P ⬍ 0.01) tendency to
88
Sample
answer in a more positive way was the case in Factor 1. In other words, a preparedness to interact with a person with a mental illness seemed to be at hand. Regarding factor 2: Fearful and Avoidant, it was shown by means of χ2 that there was a difference (P ⬍ 0.01) between the response groups towards the negative claims incorporated in this factor. Based on the means of responses: “totally agree” (mean ⫽ 201), “neutral” (mean ⫽ 492) and “totally disagree” (mean ⫽ 1607), a trend seemed likely to be at hand. By means of Jonkheere’s trend test, a significant (P ⬍ 0.01) tendency in the answers was found. Most people (mean ⫽ 1607) did not agree with a statement like “It is best to avoid NORD J PSYCHIATRY·VOL 66 NO 2·2012
NORD J PSYCHIATRY·VOL 66 NO 2·2012
*The numbering of the items refers to their placement in the New CAMI-S questionnaire.
Factor 1 (F1): Intention to interact (II) 22.* I can consider working together with someone who has a mental illness. 25. I would invite someone to my home even if I know they had a mental illness. 28. I can consider being friends with someone who had been a patient in the psychiatric care. 30. Most persons who were once patients in a mental hospital can be trusted as babysitters 35. The mentally ill should not be treated as outcasts of society 37. If someone had been a patient in the psychiatric care became one of my neighbors, I would welcome them into my home sometimes. 40. I would speak in a natural manner with neighbors who have had a mental illness. 43. If someone who had a mental illness in the past became my neighbor, I would visit him/her. Factor 2 (F2): Fear and Avoidance (FA) 19. I am against that someone with mental illness lives in my neighborhood. 21. It is frightening to think of people with mental problems living in residential neighborhoods 23. I would not want to live next door to someone who has been mentally ill 27. It is best to avoid anyone who has mental problems 29. The best way to handle the mentally ill is to keep them behind locked doors 31. I would avoid talking with neighbors who have had a mental illness in the past. 34. I would be worried if I visited someone with a mental illness. 36. The mentally ill should be isolated from the rest of the community Factor 3 (F3): Open-minded and Pro-integration (OP) 32. Residents should accept the location of mental health facilities in their neighborhood to serve the needs of the local community 33. The mentally ill are far less of a danger than most people suppose 38. Locating mental health services in residential neighborhoods does not endanger local residents 39. Mental illness is an illness like any other 41. Mental health facilities should be kept out of residential neighborhoods 42. Local residents have good reason to resist the location of mental health services in their neighborhood 44. Less emphasis should be placed on protecting the public from the mentally ill 45. Having mental patients living within residential neighborhoods might be good therapy but the risks to residents is too great Factor 4 (F4): Community Mental Health Ideology (ID) 17. The best therapy for many mental patients is to be part of a normal community 18. As far as possible, mental health services should be provided through community based facilities 20. We need to adopt a far more tolerant attitude toward the mentally ill in our society 24. Residents have nothing to fear from people coming into their neighborhood to obtain mental health services 26. No one has the right to exclude the mentally ill from their neighborhood
Table 2. Principal component analysis for 29 items with Cronbach’s alpha for each factors.
0.874
0.909
0.901
0.907
Cronbach’s α
227 234 142 136 213
192 178 063 355 410 119 484
465 370 385 088 112 349 149
143 159 254 345 422
135
350
632 625 615 676 612 603 531 612
271 245
671 724 112 192 233 257 168 427 380 228
272 295 245 156 211 229
F2 FA
546 630 666 441 482 736
F1 II
732 722 637 494 518
346 348 230 178 146 270 100
472 640 481 745 720 422 627
160 223 257 390 292
405
192 184 124 192 432 145 009 351
220 073
349 297 336 103 435 140
F4 ID
606
356 420 274 161 142 044 262 111
154 270
186 258 111 440 019 286
F3 OP
SWEDISH ATTITUDES TOWARDS PERSONS WITH MENTAL ILLNESS
89
90 1.63 1.56 1.42 1.54 1.40 1.54 1.27 1.50
5.06 4.30
s
4.20 4.37 4.96 2.99 5.08 4.28
Mean
5.5 13.2
18.0 14.6 7.9 41.0 7.2 14.6
%
126 300 346.4
410 333 181 922 166 333
n
Totally disagree
19.2 35.0
31.3 30.8 20.3 39.8 16.4 34.8
%
440 798 672.8
713 896 467 895 378 795
n
Neutral
75.3 51.8
50.7 54.6 71.8 19.2 76.4 50.6
%
1727 1179 1294.4
1156 1250 1652 434 1756 1156
n
Totally agree
χ2(14) ⫽ 2808.8 ⬎ 36.12, P ⬍ 0.01; S ⫽ 160 ⬎ 90, P ⬍ 0.01
χ2 and Jonkheere’s trend S1 χ2; S
4.58 4.60 4.74 4.84 5.17 5.26 4.67 5.23
Mean
1.51 1.50 1.48 1.44 1.21 1.19 1.38 1.17
s
12. 7 12.0 11.1 10.2 4.5 4.9 9.8 4.8
%
292 277 254 234 104 112 226 109 201
n
Totally agree
26. 3 26. 4 23.6 20.7 17.9 15.2 26.2 14.4
%
n 606 609 543 475 419 350 603 331 492
Neutral
61.0 61.6 65.3 69.1 77.6 79.9 64.0 80.8
%
1406 1418 1502 1583 1783 1838 1471 1851 1606.5
n
Totally disagree
χ2(14) ⫽ 565.9 ⬎ 36.12, P ⬍ 0.01; S ⫽ 194 ⬎ 90, P ⬍ 0.01
χ2 and Jonkheere’s trend S1 χ2 ; S
s, standard deviation 1Jonckheere trend test. The alternative hypothesis is tested against a null hypothesis of no systematic trend across treatments. The test can be applied when you have data for k independent samples, when measurement is at least ordinal, and when it is possible to specify a priori the ordering of the groups, the test is onetailed (Field, 2004).
19. I am against that someone with mental illness lives in my neighborhood. 21. It is frightening to think of people with mental problems living in residential neighborhoods 23. I would not want to live next door to someone who has been mentally ill 27. It is best to avoid anyone who has mental problems 29. The best way to handle the mentally ill is to keep them behind locked doors 31. I would avoid talking with neighbors who have had a mental illness in the past. 34. I would be worried if I visited someone with a mental illness. 36. The mentally ill should be isolated from the rest of the community Mean
Factor 2: Fear and Avoidance Item
Table 4. Factor 2: Fear and avoidance comprising eight statements respondents had to agree to.
1Jonckheere
s, standard deviation. trend test. The alternative hypothesis is tested against a null hypothesis of no systematic trend across treatments. The test can be applied when you have data for k independent samples, when measurement is at least ordinal, and when it is possible to specify a priori the ordering of the groups, the test is onetailed (Field, 2004).
22. I can consider working together with someone who has a mental illness. 25. I would invite someone to my home even if I know they had a mental illness. 28. I can consider being friends with someone who had been a patient in the psychiatric care. 30. Most persons who were once patients in a mental hospital can be trusted as babysitters 35. The mentally ill should not be treated as outcasts of society 37. If someone who had been a patient in the psychiatric care became one of my neighbors, I would welcome them into my home sometimes. 40. I would speak in a natural manner with neighbors who have had a mental illness. 43. If someone who had a mental illness in the past became my neighbor, I would visit him/her. Mean
Factor 1: Intention to interact Item
Table 3. Factor 1: Intention to interact comprising eight statements respondents had to agree to.
T. HÖGBERG ET AL.
NORD J PSYCHIATRY·VOL 66 NO 2·2012
NORD J PSYCHIATRY·VOL 66 NO 2·2012
812.3
392
808.1
17.8 917
661.8
32.4 1077 1.51 4.13
49.8
918 40.7 911 40.4 427 1.53 3.91
18.9
1203 527 404 52.4 23.1 17.8 581 754 736 25.0 33.0 32.4 519 1001 1134 1.77 1.65 1.57 4.19 3.95 4.20
22.6 43.9 49.8
1.47 1.53 4.23 3.94
13.2 20.1
302 461
37.4 37.0
854 846
49.4 42.9
1025 981
H ⫽ 1.12, n.s.; S ⫽ 42 ⬍ 64, n.s. 1048 45.8 866 37.9 373 16.3 1.55
% n % s
4.09
n % n
Totally agree Neutral Totally disagree
s, standard deviation. trend test. The alternative hypothesis is tested against a null hypothesis of no systematic trend across treatments. The test can be applied when you have data for k independent samples, when measurement is at least ordinal, and when it is possible to specify a priori the ordering of the groups, the test is onetailed (Field, 2004). 1Jonckheere
Table 9 provides an overview on effects of demographics on the principal component analysis as a whole. It can be seen that female gender impacts the factors: Fearful and Avoidant and Open-minded and Pro-Integration. Belonging to the age group 18–30 years affects Intention to Interact and Open-minded and Pro-Integration, and age group 31–50 years affects all factors. Living in a flat as well as being born in Scandinavia influence Intention to Interact with a person with mental illness. Only nine years of compulsory school affect three of the four factors: Intention to Interact, Fearful and Avoidant and Open-minded and Pro-Integration, and finally to be employed has an effect on all four factors.
32. Residents should accept the location of mental health facilities in their neighborhood to serve the needs of the local community 33. The mentally ill are far less of a danger than most people suppose 38. Locating mental health services in residential neighborhoods does not endanger local residents 39. Mental illness is an illness like any other 41. Mental health facilities should be kept out of residential neighborhoods 42. Local residents have good reason to resist the location of mental health services in their neighborhood 44. Less emphasis should be placed on protecting the public from the mentally ill. 45. Having mental patients living within residential neighborhoods might be good therapy but the risks to residents are too great Mean
Logistic regression results on factors
Mean
To find out if the experience of mental illness was significantly related to the factors: 1) Intention to Interact, 2) Fearful and Avoidant, 3) Open-minded and ProIntegration, as well as to 4) Community Mental Health Ideology, a multivariate analysis of variance (MANOVA) was computed with the factors as dependent variables by the source: six levels of experience of mental illness. The four factors by source yielded significant results (P ⬍ 0.001) and the partial eta-squared (η2) ranged from 0.22 to 0.45. No significant difference was found between factors 1 and 2 (Tables 7 and 8).
Factor 3: Open-minded and Pro-integration Items
Impact of experience of mental illness on attitudes
Table 5. Factor 3: Open-minded and Pro-integration combining eight statements respondents had to agree to.
anyone who has mental problems”, that is to say, most people did not seem to be fearful and avoidant towards mentally ill individuals. With reference to factor 3: Open-minded and ProIntegration, the respondents were not consistent in their response to the claims because a difference between the groups “totally disagree”, “neutral” and “totally agree” was not found (n.s.) and no significant trend was revealed (n.s.) either. Consequently, no pattern was detected when analyzing responses to this factor. When analyzing factor 4: Community Mental Health Ideology by means of χ2, a difference between groups “totally disagree”, “neutral” and “totally agree” towards the statement included in the factor was found (P ⬍ 0.01). Furthermore, based on the inspection of the means for each group (means ⫽ 253, 733 and 1269), a significant (P ⬍ 0.01) trend was calculated. The trend was positive (i.e. in agreement) towards statements like: “No one has the right to exclude the mentally ill from their neighborhood” or “We need to adopt a far more tolerant attitude toward the mentally ill in our society”. Accordingly, the present results based on responses to three out of four factors yielded that the respondents displayed trends towards positive attitudes towards mental illness and mentally ill persons.
Kruskal–Wallis H and Jonkheere’s S H; S1
SWEDISH ATTITUDES TOWARDS PERSONS WITH MENTAL ILLNESS
91
92
s, standard deviation. trend test. The alternative hypothesis is tested against a null hypothesis of no systematic trend across treatments. The test can be applied when you have data for k independent samples, when measurement is at least ordinal, and when it is possible to specify a priori the ordering of the groups, the test is onetailed (Field, 2004). 1Jonckheere
1573 1269.4 64.2 602 732.6 26.2 220 253.4 9.6 1.45 4.69
246 302 1.47 1.48 4.46 4.28
10.7 13.3
34.2 35.1
786 799
55.1 51.6
1367 1173
χ2(8) ⫽ 268.3 ⬎ 26.12, P ⬍ 0.01; S ⫽ 75 ⬎ 45, P ⬍ 0.01 1097 1137 47.8 49.3 980 496 219 280 1.38 1.43
17. The best therapy for many mental patients is to be part of a normal community 18. As far as possible, mental health services should be provided through community based facilities 20. We need to adopt a far more tolerant attitude toward the mentally ill in our society 24. Residents have nothing to fear from people coming into their neighborhood to obtain mental health services 26. No one has the right to exclude the mentally ill from their neighborhood Means
4.32 4.30
9.5 12.2
42.7 38.5
n % n % Mean
s
Totally disagree
Factor 4: Community Mental Health Ideology Item
Table 6. Factor 4: Community Mental Health Ideology including five statements respondents had to agree to.
%
Neutral
n
Totally agree
χ2 and Jonkheere’s trend S1 χ2; S
T. HÖGBERG ET AL.
Aspects contributing to the willingness to live in the neighborhood of persons with mental illness were subjected to a deeper analysis by means of direct logistic regression (Tables 10 and 11). The analysis was performed to assess the impact of a number of demographic factors on the likelihood that the respondents would or would not like to have a person with mental illness in their neighborhood (item 19). The binary dependent variable was coded as positive [coded on response alternatives 1–3] or negative [coded on response alternatives 4–6]) towards persons with mental illness in their neighborhood. The full model containing all predictors was statistically significant, χ2 (df ⫽ 17, n ⫽ 2066: positive ⫽ 449: negative ⫽ 1617) ⫽ 85.61, P ⬍ 0.0001, indicating that the model was able to distinguish between respondents who were or were not positive towards mentally ill individuals in their neighborhood. Concordant association of predicted probabilities and observed responses was 63.4%. Based on odds ratio or effect sizes, women were twice more likely compared with men to react positively towards having a person with mental illness in their neighborhood. Besides female gender, factors linked to a favorable attitude towards persons with mental illness in the neighborhood are shown in Table 11.
Discussion The aim of the present study was to survey Swedish attitudes towards persons with mental illness related to factors impacting these attitudes by means of New CAMI-S comprising a behavioral–intention element reflecting the intent to interact with persons with mental illness. This was done by clustering the respondents’ recurrent themes about mental illness by means of principal component analysis yielding four factors called: Intention to Interact, Open-minded and Pro-Integration, Fearful and Avoidant, Community Mental Health Ideology. These factors were subjected to trend analyses to reveal in which direction, in agreement or disagreement, the respondents’ answers to the statements in each factor, went. The trend analysis in Factor 1 revealed a preparedness to interact with a mentally ill person. Most respondents were in agreement with statements like: “I can consider working together with someone who has a mental illness” or “I would speak in a natural manner with neighbors who have had a mental illness.” Most people did disagree with statements like “I would not want to live next door to someone who has been mentally ill or otherwise”; “The best way to handle the mentally ill is to keep them behind locked doors”. To be precise, most people did not seem to be fearful and avoidant towards persons with mental illness. The present results are based on responses to three out of four factors yielding trends in agreement with positive attitudes towards mental illness and mentally ill NORD J PSYCHIATRY·VOL 66 NO 2·2012
SWEDISH ATTITUDES TOWARDS PERSONS WITH MENTAL ILLNESS
Table 7. Impact of experience of mental illness on factors: Intention to interact, Fear and Avoidance, Open-minded and Pro-integration and Community Mental Health Ideology. Four factors retrieved from principal component analysis as dependent variables in MANOVA by experiences of mental illness Factor 1 (F1): Intention to interact by number of conditions: Respondent’s own, other’s or professionally experienced mental illness
Factor 2 (F2): Fear and Avoidance by number of conditions: Respondent’s own, other’s or professionally experienced mental illness
Factor 3 (F3): Open-minded and Pro-integration by number of conditions: Respondent’s own, other’s or professionally experienced mental illness
Factor 4 (F4): Community Mental Health Ideology by number of conditions: Respondent’s own, other’s or professionally experienced mental illness
n ⫽ 2024
Number of experiences of mental illness (five conditions)
Mean
s
0.00 1.00 2.00 3.00 4.00 5.00 0.00 1.00 2.00 3.00 4.00 5.00 0.00 1.00 2.00 3.00 4.00 5.00 0.00 1.00 2.00 3.00 4.00 5.00
40.55 38.38 43.04 46.18 47.00 51.00 40.07 38.42 41.35 43.39 43.89 45.00 33.82 31.90 35.46 36.84 35.33 45.33 22.48 21.59 23.27 25.03 23.78 27.33
9.36 9.95 7.96 7.31 4.50 2.65 7.72 7.98 6.83 6.30 4.70 3.00 8.84 8.89 8.88 8.82 7.75 2.52 5.64 5.58 4.87 4.30 3.39 2.31
132 1604 205 62 18 3 132 1604 205 62 18 3 132 1604 205 62 18 3 132 1604 205 62 18 3
t-test (two-tailed) between factor means F1 ⫽ F2, F1 ⬎ F3 ⫽ t(10) ⫽ 2.954, P ⫽ 0.014, F1 ⬎ F4 ⫽ t(10) ⫽ 9.929, P ⫽ 0.0001 F2 ⬎ F3 ⫽ t(10) ⫽ 2.577, P ⫽ 0.0276; F2 ⬎ F4 ⫽ t(10) ⫽ 13.717, P ⫽ 0.0001 F3 ⬎ F4 ⫽ t(10) ⫽ 6.029, P ⫽ 0.0001
s, standard deviation.
persons. Even in the middle of the 1960s, Phillips (28) stated that laymen’s increased ability to recognize different types of mental illnesses made it possible to estimate their willingness to have as neighbor a paranoid schizophrenic (70%), simple schizophrenic or depressed neurotic (96.7%) and phobic–compulsive or normal (100%). Then with added knowledge that these persons had been in mental hospital, the willingness to have as a neighbor a paranoid schizophrenic (43.3%), simple schizophrenic (78.3%), a depressed neurotic (83.3%) and a phobiccompulsive (93.3%) or a normal (96.7%) had changed for the worse. Presently, most of the respondents (71.8%) agreed with the statement “I can consider being friends with someone who had been a patient in the psychiatric care”. Currently, the concept of being mentally ill comprised all kinds of disorders but 61% did not refuse a
mentally ill person living in his neighborhood while 12.7% rejected a mentally ill as neighbor. This means that the NIMBY phenomenon time and again is at hand, implying that people with serious mental illnesses may be dangerous and unpredictable, which a part of the Swedish population may perceive as a fact (1, 2, 3, 29, 30). It was presently observed that previous experience of mental illness significantly affected all four factors, of which three comprised trends of positive attitudes towards mental disorder, in agreement with findings stating that different kinds of personal experience correlate with positive attitudes towards persons with mental illness (1, 20). On the other hand, the experience of mental disorders may be intensely negative, and therefore leads more often than not to a wish to keep a safe
Table 8. Multivariate analysis of variance: Tests of between-subjects effects with Factors 1–4 as dependent variables by experience of mental illness. Source Experience of mental illness
NORD J PSYCHIATRY·VOL 66 NO 2·2012
Dependent variable
Type III sum of squares
df
Mean square
F
Sig.
η2
Factor 1 Factor 2 Factor 3 Factor 4
8836.73 3538.92 4385.40 1344.18
5 5 5 5
1767.35 707.78 877.08 268.83
19.089 11.688 11.144 9.007
0.000 0.000 0.000 0.000
0.045 0.028 0.027 0.022
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T. HÖGBERG ET AL.
Table 9. Overall results of logistic regression: Impact of demographics on principal components. Factor/item F1. Intention to Interact 22. 25. 28. 30. 35. 37. 40. 43. F2. Fear and Avoidance 19. 21. 23. 27. 29. 31. 34. 36. F3. Open-minded and Pro-Integration 32. 33. 38. 39. 41. 42. 44. 45. F4. Community Mental Health Ideology 17. 18. 20. 24. 26.
Gender female
Age group 18–30
***
Age group 31–50
Accommodation: flat
***
Birth country: Scandinavia
Education: 9-year compulsory school
Employment
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
***
*** *** ***
*** *** ***
***
*** ***
*** ***
***
*** *** ***
*** ***
*** *** *** ***
***
***
***
*** *** ***
***P ⬍ 0.0001.
distance from persons with mental illness (7, 18). The stigmatized socially rejected person with mental illness internalizes then his/hers stigma leading to an inferior self-image (17). However it is also known that a relative’s experience of mental illness may diffuse his/her mental health and may constitute such a heavy burden that some relatives believed that a relative with a mental illness would be better off dead, and/or wished that the relative with a mental illness and the relative had never met, and that the relative with a mental illness had never been born (31). Demographic factors impacting a person’s willingness or reluctance to live in the same neighborhood as a person with a mental illness was analyzed. Currently, persons of the female gender, aged 31–50 years, born in Scandinavia or outside Europe, educated 9 years of compulsory schooling and living in a flat were found to be more sympathetic towards persons with a mental illness as opposed to previous research (1, 7), claiming that
94
high education correlates with a positive attitude towards persons with a serious mental illness. It is known that negative attitudes towards persons with mental illness link to lower standard of living (19, 23). This was not confirmed in the present study, where 28.6% of the
Table 10. Logistic regression: Type 3 analysis of effects of demographics on “not in my neighborhood” (item 19). Effect
df
Wald χ2
Pr ⬎ χ2
Gender Age group Marital status Children (n) Children (age group) Country of birth Education Housing condition Inhabitants (n)
1 3 1 1 1 2 3 2 3
41.70 9.90 1.60 0.03 1.18 11.50 6.61 0.17 2.90
⬍0.0001 0.019 0.206 0.868 0.278 0.003 0.086 0.921 0.41
NORD J PSYCHIATRY·VOL 66 NO 2·2012
SWEDISH ATTITUDES TOWARDS PERSONS WITH MENTAL ILLNESS
Table 11. Analysis of maximum likelihood and odds ratio estimates for demographic data predicting a “not in my neighborhood attitude” (item 19). Maximum likelihood estimates Wald χ2
Odds ratio estimates Pr ⬎ χ2
Parameter
df
Estimate
s
Gender: woman Age group 18–30 31–50 51–65 Marital status (single) Children (n) Children (age group) Country of birth other than Europe Scandinavia Education other
1
0.36
0.19
41.70
⬍0.0001
1 1 1 1 1 1 1
0.11 ⫺ 0.034 0.00 0.09 0.03 ⫺ 0.18 ⫺ 0.46
0.06 0.14 0.10 0.07 0.18 0.17 0.20
0.56 9.48 0.00 1.60 0.03 1.18 5.49
1 1
0.41 ⫺ 0.09
0.13 0.12
9 years compulsory school Upper secondary school Housing other
1
⫺ 0.21
1
Flat Inhabitants 50–100,000 ⬍50,000 ⬎100,000
Parameter
Point estimates
Wald 95% CI limits
vs. man
2.04
1.66
2.54
0.453 0.002 0.994 0.206 0.868 0.278 0.019
vs. age 66– vs. age 66– vs. age 66– vs. cohabiting
0.89 0.57 0.78 1.19 1.03 0.83 0.60
0.55 0.38 0.56 0.91 0.73 0.60 0.30
1.43 0.86 0.38 1.55 1.46 1.16 1.31
10.38 0.56
0.001 0.453
1.43 0.75
0.89 0.52
2.31 1.07
0.11
3.81
0.051
0.66
0.47
0.93
0.10
0.09
1.19
0.275
0.90
0.68
1.19
1
0.07
0.26
0.08
0773
1.10
0.51
2.38
1
⫺ 0.06
0.15
0.15
0.699
vs. rest of Europe vs. college/ university vs. college/ university vs. college/ university vs. house/row house vs. house
0.96
0.68
1.19
1 1 1
⫺ 0.16 ⫺ 0.04 0.13
0.13 0.10 0.13
1.56 0.13 1.07
0.212 0.717 0.300
vs. rural area vs. rural area vs. rural area
0.80 0.90 1.07
0.42 0.50 0.56
1.51 1.62 2.01
vs. rest of Europe
s, standard deviation.
respondents resided in major cities. The connection between families, friends and neighbors was surveyed by Hilber (32), who consulted 30,000 people and found that on average homeowners interact 30% more than renters with their immediate neighbors in developed neighborhoods. The flats are more likely than homes to be rented and the interaction between neighbors living in flats may be minimal, and the inhabitants do not necessary know each other not to mention each other’s mental history. Regarding methods, 2391 (47.9%) agreed to participate in the present study after two reminders. The drop-outs comprised object-loss and partial-loss but the partial loss was less than 5%, which was approved by the CSA and the response rate was considered satisfactory. The population consisted of Swedish people aged 18–85 years. Altogether 56.6% females and 43.4% males completed the questionnaires, the numbers can be compared with 1.03 men and women (aged 15–64 years) and 0.73 men and women aged ⬎ 65 years (33). The gender balance was considered reasonable in the present study. The concept of “mental illness” included a variety of psychiatric disorders such as e.g. depression, anxiety, alcoholism and schizophrenia (18, 34). In order to counteract ambiguity about the concept in question, the cover letter explained that the Swedish reform of psychiatric care (1995) NORD J PSYCHIATRY·VOL 66 NO 2·2012
implied that “persons with a serious mental illness” are nowadays integrated in the community, thus helping the respondent to recognize a “person with a serious mental illness” as a person with long-term mental disturbance resulting in daily dysfunctions requiring long-term treatment (13, 35).
Conclusion To sum up, the present study aimed at surveying Swedish attitudes towards persons with mental illness related to factors impacting these attitudes. By New CAMI-S, the Swedish attitudes towards persons with mental illness were surveyed and trends showed in three out of four factors derived by principal component analysis that the Swedes were rather in agreement with living next to a person with mental illness. Aspects impacting the Swedish attitudes towards persons with mental illness and their willingness to have him/her residing in their neighborhood comprised experience of mental illness, female gender, age (31–50 years), born in Scandinavia or outside Europe, only 9 years of compulsory education and accommodation in a flat. The New CAMI-S came out as a useful tool for screening Swedish attitudes towards persons with a mental illness.
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T. HÖGBERG ET AL. Acknowledgment This study was partially funded by research grants from The Swedish National Board of Health and Welfare.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Author contributions TH was responsible for the study conception and design, performed the data collection and drafted the manuscript. KL and AM made critical revisions to the paper and supervised the study. BE-K carried out the statistical analysis and was advisory in the drafting of the manuscript.
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