Asian Journal of Psychiatry 31 (2018) 58–62

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Mental health literacy in family caregivers: A comparative analysis T

⁎ 1
Kanika Mehrotra , Snigdha Nautiyal , Ahalya Raguram
Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India

A R T I C L E I N F O A B S T R A C T

Keywords: The present study was undertaken to examine the current level of mental health literacy in family caregivers and
Mental health literacy to compare the changes over a 23-year period between 1993 and 2016.
Stigma The current sample consisted of 60 family caregivers of patients with major mental illness from the in-patient
Attitudes toward mental illness and out-patient departments of NIMHANS assessed on the Orientation towards Mental Illness Scale (OMI). This
was compared with data of 80 family caregivers from previous study done in 1993.
Family caregivers in the current study showed a significant positive trend on comparison with the previous
study. However, area of abnormal behaviour shows a worsening of negative attitudes. Hopelessness and hypo-
functioning, relating to the factor of after-effects of mental illness show no significant difference.
While knowledge about mental illnesses can be improved by providing information, this does not auto-
matically translate to integration of the mentally ill in society. Current initiatives need to be matched with
specific and sustained efforts to reduce stigma associated with mental illness which have persisted unchanged.

1. Introduction deprived opportunities. (National Mental Health Survey, 2016).

Mental health literacy is a prerequisite for early recognition and
intervention in mental disorders. Beliefs and attitudes toward mental
illness underscores interactions with the mentally ill, the opportunities
and support offered to them, personal experiences with psychological
distress and corresponding help-seeking behaviour.
Jorm et al. (1997) introduced the term ‘mental health literacy’
which is defined as “knowledge and beliefs about mental disorders
which aid their recognition, management or prevention”. Mental health
literacy consists of several components, including: (a) the ability to
recognise specific disorders or different types of psychological distress;
(b) knowledge and beliefs about risk factors and causes; (c) knowledge
and beliefs about self-help interventions; (d) knowledge and beliefs
about professional help available; (e) attitudes which facilitate re-
cognition and appropriate help-seeking; and (f) knowledge of how to
seek mental health information. (Jorm et al., 1997).
A key barrier to mental health services in India and other low and
middle-income countries is misconceptions and poor awareness and
knowledge about mental illness (Ignacio et al., 1983; Kermode et al.,
2009, 2010; Prabhu et al., 1984; Thara et al., 1998; Thara and
Srinivasan, 2000). From a cultural perspective, mental disorders are
associated with a considerable amount of stigma in Indian society. Such
individuals and their families face numerous challenges due to pre-
vailing attitudes, media portrayals, societal discrimination and
The key stakeholders to mental health care include mental health
professionals, family caregivers and public health officials. Shallow
level of understanding of mental illness creates a cascade of effects
including help seeking and treatment delays and barriers in carrying
out accurate demographic studies. Addressing this knowledge gap can
enhance increased awareness and timely treatment. (Loganathan et al.,
2017)
Passage of time is a factor that can indicate a change in mental
health literacy levels owing to the variable, non-static nature of atti-
tudes. There have been very few studies that map changes in mental
health literacy over time – especially in the Indian context. Time trend
analyses and national surveys from Australia and Germany indicate that
mental health literacy has increased significantly since the past few
decades. These changes are largely attributed to government, profes-
sional, charitable and industry wide efforts to enhance public knowl-
edge about the ubiquity of mental disorders and the treatments avail-
able. (Goldney et al., 2004; Angermeyer et al., 2009).
At the same time, results also suggest despite an increase in mental
health literacy of the public, the desire for social distance from people
with mental illness has remained unchanged or even increased. The
authors suggest that the assumption of anti-stigma campaigns and
psychoeducation is enough to change attitude towards mental illness,
needs to be re-thought (Angermeyer et al., 2009, Schomerus et al.,
2012). Reconfiguring stigma reduction strategies may require providers

⁎
Corresponding author.
E-mail address: kanika@vknnimhans.in (K. Mehrotra).
1
Present Address: Shanthi Hospital and Research Centre, Bangalore, Karnataka, India.

https://doi.org/10.1016/j.ajp.2018.01.021
Received 26 September 2017; Received in revised form 31 January 2018; Accepted 31 January 2018
1876-2018/ © 2018 Elsevier B.V. All rights reserved.
K. Mehrotra et al.
and advocators to shift emphasis from knowledge dissemination to
competence and inclusion (Pescosolido et al., 2010).
Indian families have been typically described as having magico-re-
ligious explanatory models for mental illness (Srinivasan and Thara,
2001) however with greater awareness this seems to be changing to
medical and biological models of illness (Srinivasan and Thara, 2001).
Studies also indicate significant gender differences in mental health
literacy, especially with regard to help-seeking. It has been observed
that males were significantly less likely to endorse seeing a doctor or
psychologist the treatment of psychosis and other major mental dis-
orders (Cotton et al., 2006; Leong and Zachar, 1999)
Previous personal experience with mental health services and par-
ticipation in awareness programmes or any form of psychoeducation is
an important factor implicated both in mental health literacy and help-
seeking behaviour. Such persons are more positive to medical inter-
ventions such as pharmacotherapy, psychotherapy and inpatient psy-
chiatric treatment (Dahlberg et al., 2008). Psychoeducation-based in-
terventions aimed at family caregivers show significant improvement in
knowledge and self-stigma. (Amaresha et al., 2018)
Other determinants including education, age and socio-economic
status also play a role in the levels of mental health literacy and atti-
tudes towards mental illness. Higher socio-economic status, education
levels and ages are generally associated with higher levels of mental
health literacy (Lauber et al., 2005; Mackenzie et al., 2006)
The past few decades have seen a tremendous change in the land-
scape of mental health services in the country. From a predominantly
mental hospital based service, provision has now moved to general
hospitals and primary health centres (Isaac, 1996). India has also wit-
nessed the implementation of the national mental health program
(NMHP) and more recently the Mental Health Bill (2016) that aim to
provide better access to services and to destigmatize mental illness in
the population. Several advocacy groups, including media, have high-
lighted need for scaling up services and providing comprehensive
mental health care. (National Mental Health Survey of India, 2016). At
the same time, there remains a significant treatment gap in the care of
the mentally ill in India attributed to poor awareness, presence of
stigma and limited resources (National Mental Health Survey of India,
2016).
A time-trend analysis in this shifting Indian context can be instru-
mental in shedding light on important issues including changes in
mental health literacy levels, areas of disparity, current attitudes and
levels of stigma with regard to mental illness.
2. Method
The present study aims to examine the current level of caregivers’
mental health literacy and compare changes in levels over the period of
1993 to 2016 with two cross-sectional samples from the two time-
periods.
2.1. Operational definitions
2.1.1. Mental health literacy
Jorm et al. (1997) defines mental health literacy as “knowledge and
beliefs about mental disorders which aid their recognition, manage-
ment or prevention.” In the present study, this was measured utilizing
the Orientation to mental illness scale (OMI).
2.1.2. Caregiver
In this study, caregiver is defined as a family member, living in the
same household as the patient and actively involved in the day-to-day
care of the patient. If there are multiple family caregivers in the family
then the relative who spends the maximum time with the patient and is
involved in the direct care (e.g. supervising medication, ensuring per-
sonal hygiene etc.) were included.
59
Asian Journal of Psychiatry 31 (2018) 58–62
2.2. Tools
2.2.1. Patient data sheet
This included information about socio-demographic and clinical
details including patients’ age, sex, education, occupational status,
marital status, diagnosis, age of onset of illness, duration of illness.
2.2.2. Caregiver data sheet
This included information regarding the caregivers’ demographic
data such as age, sex, education, occupational status, income, marital
status, background (rural/urban) duration of contact with patient and
relationship with the patient. This sheet also had questions related to
whether the caregiver has been provided with information regarding
the nature of the patients’ illness.
2.2.3. Orientation towards mental illness scale (OMI, Prabhu, 1983)
It is a 67-item clinical administered scale measuring the individual’s
degree of unfavourable orientation to mental illness. It provides scores
on 13 factors, grouped into 4 areas including causation (folk belief,
psychosocial stress, organic causation), perception of abnormality (non-
restrained behaviour, weak cognitive control, fidgety behaviour bizarre
behaviour), treatment (folk therapy, psychosocial manipulation, phy-
sical methods of treatment) and after effects (hopelessness, hypo
functioning, rejection of the mentally ill) that have been obtained
through factor analysis. The respondents are required to indicate the
degree of agreement or disagreement on five-point likert scale, ranging
from completely disagree (1) to completely agree (5). Scores for each
factor are obtained by summating the scale values for each item which
comprise a particular factor. The higher the score, the more un-
favourable orientation it indicates. The score range falls between 67
and 335 for the total score and it requires about 30–40 min for com-
pleting the scale. This tool was used to study mental health literacy. The
tool is available in English and also has a Hindi translation provided.
2.3. Procedure
The total sample size including both the studies done in 1993 as
well as 2017 was 140 (n = 80 + 60) collected through purposive
sampling. Both the study samples comprised of the family members of
adult patients with a diagnosis of a psychotic or affective disorder (F20-
29 and F30-39) established through clinical assessment based on ICD-
10 and were collected from the in-patient and out-patient departments
of NIMHANS. Both the samples had the same inclusion and exclusion
criteria, operational definitions of caregivers and utilized the same tools
and procedures.
2.3.1. Inclusion criteria
Family caregivers of age 18 or above
at least 7 years of formal education
proficient in either Hindi or English
living with and directly involved with care of patient for a minimum
of six months prior to participation in the study
family caregivers of patients with illness duration of at least two
years
2.3.2. Exclusion criteria
Family caregivers with history of alcohol or other substance de-
pendence or neurological or neurosurgical conditions.
An attempt was made to include a proportional number of male and
female family caregivers in the study. Family caregivers of patients in
the outpatient and in-patient setting at the National Institute of Mental
Health and Behavioural Sciences (NIMHANS) fulfilling inclusion cri-
teria were taken with informed consent. The study was approved by the
institutional ethical committee.
K. Mehrotra et al. Asian Journal of Psychiatry 31 (2018) 58–62

Table 1 causation than in the earlier study. These findings are in keeping with
Sociodemographic data of the patients in current study (N = 60) and previous study recent Indian studies where only a small number of respondents felt
(N = 80).
supernatural causes were responsible for mental illness (Srinivasan and
Patient data N = 60 Percentage (%) N = 80 Percentage (%) Chi square Thara, 2001; Salve et al., 2013). These findings have been attributed to
value the recent psychoeducation and community based mental health lit-
eracy programmes which tend to emphasize the bio-medical models of
Age in years
mental illness (Kermode et al., 2009)
18–29 36 60 31 38.75 7.003*
30–39 16 26.70 27 33.75 There appears to be a significant negative trend in the present study
40–49 8 13.40 22 26.82 about the perception of abnormal behaviour among mentally ill. This
Gender indicates that the family caregivers in the present study perceive these
Male 38 63.30 43 53.75 1.291 behaviours as manifestations of mental illness to a greater degree than
Female 22 36.70 37 46.25
in the 1993 study. Further, compared to family caregivers in 1993, they
*Significant at the 0.05 level. also believe that mentally ill persons have cognitive impairments pre-
venting effective functionality. Similar findings have been reported in
2.4. Analysis other studies. For instance, Poreddi et al. (2015) found that 45.9% of
the respondents in their study felt that mentally ill persons are unable to
The variables measured included sociodemographic and clinical maintain friendships, are dangerous (54%) and incapable of gainful
data of the patients and caregiver orientation towards mental illness. employment (59.1%).
Chi-square was utilized to compare the data from 2017 and 1993 on In beliefs about treatment, there is a significant difference between
demographic details of caregivers, the level of significance was fixed at the two on the factors of psychosocial manipulation and physical
0.5 level. Unpaired t-test of significance for unequal sample size was methods of treatment. Since the items of these two factors focus on
used to compare the values of factors on OMI of the two studies. The aspects such as environmental change, use of electroconvulsive therapy
level of significance was fixed at the 0.05 level. Descriptive statistics and brain surgery as treatment methods for mental illness, it is un-
including mean, percentage and standard deviation were used to depict surprising that the family caregivers of the present study did not en-
the sociodemographic profile of the patients and caregiver. dorse these treatment methods to the same extent as in 1993. These
findings are in line with other studies that indicate a greater number of
individuals recognizing the need for medical intervention efficacy of
3. Results and Discussion
psychotropic drugs on symptoms of mental illness. (Schoonover et al.,
2014; Loureiro et al., 2015, Angermeyer et al., 2013). However, it is
3.1. Patient sociodemographic data
noteworthy that there was no significant difference with regard to be-
lief in folk therapies for the treatment of mental illness by participants
Table 1 indicates that patients in the 2017 study were significantly
of both studies. Religious practises are an integral part of the cultural
younger than those studied in 1993. This can be speculated to be in-
fabric of India. Since faith healers offer hope, emotional support, and a
dicative of higher mental health literacy and timely help-seeking be-
means of enlisting social support, it may seem as a viable option to
haviour. It also should be kept in mind that most of the major mental
caregivers. Another reason for their popularity could be the paucity of
illnesses like schizophrenia occurs in early adulthood (Häfner et al.,
mental health professionals in India and the demands on their time and
1994; Castle et al., 1993; Perälä et al., 2007). In both studies, male
expertise that are already placed (Veltman et al., 2002).
patients outnumber females, possibly owing to greater prevalence rates
Another reason for the beliefs regarding folk therapies remaining
among men (Grohol, 2013). It could also be attributed to cultural fac-
unchanged can be attributed to the items that comprise this factor.
tors due to which men may have better access to mental health services
Several items allude to the use of yoga and ayurvedic remedies as ef-
than women. (Okojie, 1994; Ojanuga and Gilbert, 1992).
fective treatments for mental illness. In the period between 1993 and
2016, the application of yoga therapy and ayurvedic methods for
3.2. Caregiver sociodemographic data treatment for mental illness have greatly expanded and gained greater
acceptance. This has been particularly true with regard to the use of
Caregivers in the study done in 2017 are significantly older with yogic practises. (Barton, 2011).
higher education levels than those studied in 1993. In comparison to In the perception of after effects of mental illness, there is no sig-
the data from 1993, significantly more of the caregivers are parents and nificant difference in factors of hopelessness and rejection of the men-
fewer are spouses. There is no significant difference in the gender dis- tally ill. Despite positive trends in other areas, there continues to be a
tribution of caregivers in the two studies. These changes appear to be pervasive sense of hopelessness about the outcome of mental illness
reflective of the socio-economic and family composition and structural Therefore, this may indicate that discriminatory attitudes towards the
changes in the country relating to urbanization, higher education levels mentally ill continue to persist despite positive trends in other areas of
and later marriage and child-bearing ages. (Sharma and Kaur, 2017) the OMI.
(Table 2). This finding underscores the fact that attempts to improve mental
health literacy in the community must first consider the prevailing
3.3. Caregivers’ orientation to mental illness beliefs and develop intervention modules that can be integrated with
the community’s belief system of mental illness.
Table 3 illustrates the differences on the orientation towards mental
illness of the participants in present study from those in the Nautiyal 3.4. Limitation of study
study (1993). With regard to beliefs about the causation of mental ill-
ness, respondents in the present study have significantly lower mean The limitation of our study was the purposive nature of the sample
scores on all factors viz. folk belief, psychosocial stress and organic thereby restricting its generalization to other samples with similar
causation. characteristics.
This indicates that compared to the family caregivers in 1993, fewer Since there are some significant differences in the age-range and the
family caregivers currently attribute the cause of mental illness to education levels of the caregivers studied, the results of this time-trend
magico-religious Similarly, currently among family caregivers there is analysis should be interpreted with caution, as factors such as age,
lesser attribution of mental illness to psychosocial stress or organic education and socio-economic status can also impact on the mental

60
K. Mehrotra et al. Asian Journal of Psychiatry 31 (2018) 58–62

Table 2
Demographic details of family caregivers on current study and previous study in 1993.

Caregiver data N = 60 (Current study) Percentage (%) N = 80 (Previous study) Percentage (%) Chi-square value

Age in years
18–29 4 6.70 22 27.00 34.205**
30–39 4 6.70 28 35.00
40 above 52 21.70 30 37.00
Gender
Male 20 33.30 35 45.00 1.559
Female 40 66.70 45 55.00
Education in years
7–10 10 16.70 31 38.75 13.664**
11–12 17 28.30 22 37.50
13–15 20 33.30 30 37
16–17 13 21.70 5 6.75
Relation to patient
Parent 45 75.00 35 43.75 17.609**
Spouse 5 8.00 30 37.50
Sibling 10 16.70 15 18.75

*Significant at 0.05 level; **significant at 0.01 levels.

Table 3 There is a plurality of beliefs among respondents regarding causa-

Comparison of groups on OMI of current study and previous study in 1993. tion of mental illness – folk beliefs, organic causation, and psychosocial
stress exist side by side. This has significant bearing for the mental
OMI Factors Current study Previous Study Max. t value
N = 60 N = 80 score
health practitioner who must navigate a bio-psycho-social model of
mental illness with other existing magico-religious beliefs in the com-
Mean S.D Mean S.D munity. A strategy that involves religious institutions in raising
awareness about mental health issues while considering public's socio-
Folk Belief 27.60 10.06 36.79 12.11 60 4.771**
Psychosocial Stress 39.81 8.93 42.76 12.17 65 2.121*
cultural attitudes may pave the way for greater potentialities of ade-
Organic Causation 9.66 2.77 14.05 6.92 20 4.639** quate psychiatric care, destigmatize the mental health system, and care
Non–restrained 23.88 5.97 19.38 7.95 30 3.675** provider (Ta et al., 2018).
Behaviour Another significant aspect involves the measure used to capture
Weak cognitive 14.5 3.28 9.81 2.08 15 10.324**
changing attitudes. If the items in the measure do not capture the ad-
control
Fidgety behaviour 7.68 1.85 6.53 6.96 10 1.243 vances made in the treatment of mental attitudes over time then this
Bizarre behaviour 8.86 2.66 10.71 2.58 15 4.143** will impact the results. This was also seen in the measure used in the
Folk therapy 13.85 4.24 13.91 4.87 25 0 0.076 current study which does not reflect the acceptance of yoga and other
Psychosocial 10.55 2.49 12.44 2.06 15 4.91** Indian therapies in the treatment of mental illness. Therefore, the items
manipulation
Physical methods of 3.85 1.95 5.80 1.23 10 7.233**
of the measures studying attitudes should also be revised from time to
treatment time.
Hopelessness 17.46 6.32 19.55 6.53 30 1.900
Hypo-functioning 12.81 3.58 14.04 5.28 20 1.555 Conflict of interest
Rejection of mentally 13.16 2.82 15.93 6.33 20 3.160**
ill
None.
*Significant at the 0.05 level; **significant at the 0.01 level.
Sources of support
health literacy levels.
Since the samples of both studies were taken from the out-patient This research did not receive any specific grant from funding
and in-patient departments of a tertiary psychiatric facility, the care- agencies in the public, commercial, or not-for-profit sectors.
givers all had the opportunity of gaining some amount of psychoedu-
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