Primary care physicians’ attitudes towards patients with mental health problems in Hong Kong

TP Lam 林大邦, YS Ku 辜彥璇

HK Pract 2009;31:186-189

Summary

Stigma attached to mental illness discourages people in need from seeking professional help for their health problems. Its adverse implications on public health render it an important healthcare issue. Albeit much research work was carried out with respect to opinions held by various professions towards a variety of illnesses within different contexts as well as their relationship with factors like education and clinical experiences, most of them were Western studies and the situation in Hong Kong, especially in the primary care setting, is far from clear. An understanding of the local situation can provide useful information for the fur therance of quality medical care and also an opportunity for professionals in the field to reflect on their own attitudes towards mental illness.

摘要

精神問題往往被標籤醜化，人們因而諱疾忌醫，放棄尋 求專業協助。這種情況對公共健康有損無益，實在值得醫護 界關注和重視。西方針對不同專業人員在不同環境下對各類 疾病的看法，以及它們與不同因素如教育及臨床經驗的關 係，雖然已有不少研究，但有關香港現況的描述，特別是基 層醫療的情況，卻付之闕如。本地在這方面的研究，不僅可 以提供寶貴的參考資料，提高醫療服務的水平，醫護人員更 可籍此反思自身對精神病的觀感和態度。

Introduction

Society is known to exhibit negative opinions towards mental disorders, and stigma is a major obstacle to the improvement of quality of life for people suffering from mental health problems.¹ Stigmatizing attitudes towards people with mental illness are not just confined to the lay person but also shared by personnel in the healthcare sector including psychiatrists, family physicians, nurses, and psychologists.^2-5 Physical complaints of persons with psychiatric illness may be invalidated as imaginary or considered to be related to their psychiatric condition and rejected by non-psychiatric medical specialties.⁶ Those with mental illness may be put at risk of receiving fewer or lower quality medical and preventive healthcare services due to stigma originating from healthcare providers.⁷ Stigmatizing opinion may impede the help seeking of patients with mental problems and lead to underdiagnosis and mistreatment of mental or physical conditions. Stigma thus has substantial public health implications.

Factors related to stigma

Stigma is a multi-faceted area best understood by examining from different levels and perspectives.⁸ It is a common approach to describe or compare attitudes of various target populations, towards different types of illnesses, within different contexts. A qualitative study of stigma from the subjective perspective of patients with schizophrenia revealed that discriminating behaviours such as a lack of interest and personal attention, conveyance of negative prognosis expectation, disrespect, and ridicule were found in their contacts with mental health professionals.⁹ Other studies also suggested that health professionals may have even more negative attitudes to mental disorders than the general public;^10,11 whereas conflicting results were found in some other studies.^12,13 The more negative responses of family physicians to questions tapping their attitudes in social setting than that within the clinical context may reflect a buffering effect of professional rol e.¹⁴

There are differences in the extent of stigma across various medical categories such as anxiety, obesity, and cancer. Within the stigmatized condition of mental illness, perceptions vary across disorders.¹⁵ Stigmatization of schizophrenia was found to be significantly higher than that of depressio n.¹⁶ Consistently, family physicians’ views were more negative about a patient with schizophrenia than an otherwise identical patient with depression or diabetes.³ Not only patients’ diagnosis but also the level of acuity may affect the attitudes of treatment staff.¹⁷

The findings regarding the relationship between knowledge and attitudes were more diverse. Stigmatizing opinions may not be closely related to knowledg e.¹⁵ Indeed, medical education can both aggravate and reduce stigma.¹⁸ The results of a study in Turkey indicated that anti-stigma education can improve attitudes of family physicians towards schizophreni a.¹⁹ Yet another one showed that the attitudes of physicians towards mentally ill patients were worse than that of the staff with least education in a teaching hospital, suggesting possible negative effects of medical education syste m.²⁰

Health professionals’ negative expectation of the treatment outcomes may reflect a more realistic view, given their better medical knowledge of mental disorders, or a biased one due to their experience in managing people with chronic or recurrent problem s.² In a survey done in Australia, more than 80% of mental health professionals reported that the most important reason for holding their attitudes was based on their experiences of working with people who have mental problems;¹⁰ whilst another study showed that exposure to clinical experience did not significantly affect nursing students’ attitudes towards people with mental illnes s.²¹

Findings of another Australian survey indicated that psychiatrists and family physicians of younger age held more negative attitudes, and the age group effect may be explained by the greater time accorded to psychiatry and behavioural sciences in the medical undergraduate curriculum.² There are reforms in medical education across different generations, and clinical experience accumulates as one becomes more senior in terms of years of practice. In this connection, age may be one of the variables that are related to an individual’s opinion about mental illness.

Attitudinal change, as a continuous process, cannot be achieved rapidly but involves a change in one’s belief model as well as alterations within the social environment.¹⁸ Thus apart from education and clinical experiences that presumably influence the views of health professionals,²² the impact of other factors like the nature of interaction and quality of contact with people having mental disorders, history of psychiatric illness in families and friends are also attracting interest in the literature.

Situation in the local primary care setting

The attitudes of health professionals’ are not only a product of clinical training, accumulative clinical experience and social environment but also the cultural norms as healthcare providers cannot divorce themselves from the culture in which they liv e.^23,24 Most of the studies on stigmatization of people with mental illness in the literature derive from Western countries.8 In Hong Kong, studies on stigma were mainly focused on the general population and mental health service users but rarely on health professions. There is one local study that explored the existence of stigmatizing opinions held by healthcare personnel towards psychiatric patients in a hospita l.²⁵ Since attitudes are not just individual characteristics but may also reflect the culture of work setting within the healthcare system,² the investigation of attitudes of primary care providers working in the community about mental illness may provide useful information on this subject.

Indeed, primary care doctors are the major providers of healthcare to citizens in the community. 25-40% of primary care consultations are reported to have a significant psychological component,²⁶ and there is an increasing expectation of primary care doctors to carry a bigger share of care to patients with common psychological problems.²⁷ Therefore, it is of vital importance to investigate the attitudes held by primary care physicians towards patients presenting with mental problems, which will inevitably affect the quality of care in terms of doctor-patient interaction, diagnosis, management and outcomes, for both mental and physical complaints.

Stigmatization may direct at families of people with mental illness. The stigma "spills over" onto well family members by virtue of their association with the stigmatized individual e.g. being labeled as "carrier" or "at ris k".²⁸ Given the genetic basis of some mental illnesses e.g. schizophrenia, it is interesting to explore the attitudes and beliefs of family physicians towards mentally ill patients’ family members, who may be looked after by them as well.

The effect of education on healthcare professionals’ attitudes about mental illness in Hong Kong has not been explored. It has been reported that healthcare personnel, particularly family physicians, express their willingness to participate in training programmes and activities concerning schizophrenia, regardless of their attitude s.¹⁷ Indeed, it is beneficial to develop culturally appropriate packages tailored to the educational needs of family physicians.²² It would therefore be fruitful to know if some formal and systematic training in mental healthcare aiming to improve local primary care physicians’ knowledge, skills and confidence in the care of patients with psychological problems could help bring about more positive views towards psychiatric illness.

The inconsistency in findings of previous overseas studies regarding the factors related to the health professionals’ opinions on mental illness, as well as the scarcity of research work carried out in Hong Kong about the attitudes of healthcare providers, suggested that the situation in the local context, particularly in the primary care setting, is far from clear. Given the existing gap in the knowledge of Hong Kong doctors’ beliefs and opinions about mental illness and those suffering from it, the factors contributing to the formation of their views, and the future educational needs of primary care doctors in this respect, more research is warranted in order to have a better understanding of this important healthcare issue. Healthcare professionals and policy makers will then be provided with the appropriate local data to take necessary action to enhance the quality of healthcare in the community for the well-being of the general public. In addition, such mental health attitudinal research studies may help raise the self-awareness of any stereotyping or stigmatizing opinion that may be held amongst the healthcare providers.

Conclusion

There is evidence to suggest that the role of healer does not necessarily assume a more positive attitude towards people with mental health problems or fewer negative stereotypes. Contrarily, healthcare providers may be contributing to the phenomenon of stigmatization, whether actively or passively, consciously or unconsciously.²⁹ Medical professionals have a clear duty to reflect on their own attitudes and be aware of their behaviours at individual level before they can educate and convince the general public to fight against the stigma associated with mental illness at community level.¹ More efforts are required to identify and challenge the prejudices from within the healthcare professions.

Key messages

1. Stigmatizing opinions towards people with mental problems are held by both layman and healthcare professionals.
2. As an impediment to patients’ willingness to seek help, stigmatization is a noteworthy public health issue.
3. Conflicting findings of overseas studies particularly those concerning the effect of medical education on attitude towards mental illness, together with a lack of local data, pointed to the demand for more research efforts in Hong Kong.
4. Self-awareness of personnel in medical field is the prerequisite to fighting against stigma in the community.