Attitudes toward consumer involvement in mental health services: a cross-sectional survey of Indian medical and nursing undergraduates

Actitudes hacia la participación de los consumidores de los servicios de salud mental: un estudio transversal en estudiantes de medicina y enfermería de la India

Atitudes para a participação dos consumidores dos serviços de saúde mental: um estudo transversal em estudantes de medicina e enfermagem da Índia

Vijayalakshmi Poreddi¹;Sailaxmi Gandhi²; Rohini Thimmaiah ³;Suresh BM⁴

¹RN, RM, BSN,MSN. College of Nursing, Department of Nursing, National Institute of Mental health and Neurosciences, India. email: pvijayalakshmireddy@gmail.com.

²RN, RM, BSN, MSN, PhD, Associate Professor, Department of Nursing, National Institute of Mental Health & Neurosciences, India. email: sailaxmi63@yahoo.com.

³MD. Psychiatry, Registrar, Toowoomba base hospital, Toowoomba, Queensland, Australia. email: drtrohini@gmail.com.

⁴MD. Additional Professor, Department of Psychiatry, National Institute of Mental Health and Neurosciences (Institute of National Importance), Bangalore, India. email: nimhans@gmail.com.

Receipt date: January 8, 2016 Approval date:April 28, 2016.

Conflicts of interest: none.

ABSTRACT

Objective.To understand the views of medical and nursing undergraduates regarding consumer involvement in mental health services. Methods. A descriptive cross sectional survey was conducted in Bangalore, South India, among medical (n=155) and nursing (n=116) undergraduates using self-reported the Mental Health Consumer Participation Questionnaire of Happell et al. ''Mental health consumer'' or ''consumer'' is defined as a person who is currently using mental health services as either an in-patient or out-patient. Results. The overall mean score on Mental Health Consumer Participation Questionnaire (54.1±6.7) implies that 64% of the participants hold positive attitudes towards consumer involvement in mental health services. Medical students possessed more positive attitudes than nursing in: consumer capacity (p<0.001), consumer as staff (p< 0.001) and overall score on mental health consumer participation questionnaire (t=6.892, p<0.001). Conclusion. The findings suggest that majority of the participants hold positive attitudes towards mental health consumer involvement in health care services. However, additional research is urgently required from developing countries to understand the effectiveness of involving mental health consumers in academic programs at undergraduate level.

Key words: attitude; students, nursing; students, medical; mental health services.

RESUMEN

Objetivo.Describir las actitudes de los estudiantes de medicina y de enfermería con respecto a su participación como consumidores de los servicios de salud mental. Métodos. Se realizó un estudio descriptivo de corte transversal en Bangalore, sur de la India, en estudiantes de medicina (n=116) y de enfermería (n=155) utilizando el Mental Health Consumer Participation Questionnaire de Happell et al. contestado por autorreporte. Se definió ''consumidor de salud mental'' o ''consumidor'' como aquella persona que estaba utilizando los servicios de salud mental pero no era paciente hospitalizado ni de consulta externa. Resultados. La puntuación media global en la salud mental, cuestionario de participación de los consumidores (54.1±6.7), implica que el 64% de los participantes tiene actitudes positivas hacia la participación como consumidores de los servicios de salud mental. Los estudiantes de medicina poseían una actitud más positiva que los de enfermería en: la capacidad de consumo (p<0.001), consumidor como parte del staff (p<0.001) y la puntuación global del cuestionario (p<0.001). Conclusión. Los hallazgos sugieren que la mayoría de los participantes tienen una actitud positiva hacia su participación como consumidores en los servicios de salud. Sin embargo, se requiere con urgencia una investigación adicional para comprender la efectividad de la participación de los consumidores de programas académicos a nivel de pregrado.

Palabras clave: actitud; estudiantes de enfermería; estudiantes de medicina; servicios de salud mental.

RESUMO

Objetivo.Descrever as atitudes dos estudantes de medicina e de enfermagem com respeito a sua participação como consumidores dos serviços de saúde mental. Métodos. Se realizou um estudo descritivo de corte transversal em Bangalore, sul da índia, em estudantes de medicina (n=116) e de enfermagem (n=155) utilizando o Mental Health Consumer Participation Questionnaire de Happell et al. contestado por auto-reporte. Se definiu ''consumidor de saúde mental'' ou ''consumidor'' como aquela pessoa que estava utilizando os serviços de saúde mental mas não era paciente hospitalizado nem de consulta externa. Resultados. A pontuação média global na saúde mental questionário de participação dos consumidores (54.1±6.7) implica que 64% dos participantes têm atitudes positivas à participação como consumidores dos serviços de saúde mental. Os estudantes de medicina possuíam uma atitude mais positiva que os de enfermagem em: a capacidade de consumo (p<0.001), consumidor como parte do staff (p<0.001) e a pontuação global do questionário (p<0.001). Conclusão. As descobertas sugerem que a maioria dos participantes têm uma atitude positiva a sua participação como consumidores nos serviços de saúde. Embora, se requere com urgência uma investigação adicional para compreender a efetividade da participação dos consumidores de programas acadêmicos a nível de graduação.

Palavras chave:atitude; estudantes de enfermagem; estudantes de medicina; serviços de saúde mental.

INTRODUCTION

Involvement of consumers in mental health services is growing priority in contemporary psychiatry practice as this approach is critical to provide quality services.¹ This approach has been shown to be empowering to both the individuals with mental illness and the organisations involved.² In addition, published literature indicates that fostering better care, higher levels of consumer satisfaction and improved health outcomes were the widely acknowledged benefits of consumer involvement.³ Health professionals are increasingly being encouraged to adopt a collaborative approach in making health care decisions.⁴ However, health professionals' attitudes have been identified as a barrier to inclusion of consumers into mental health services.⁵ Research suggests that there is a need to change the mental health professionals' attitudes in encouraging clients to participate actively in planning, development, delivery and evaluation of mental health services.^6,7 On the other hand, emerging evidence suggests that mental health education influences positively on attitudes of nursing^8,9 and medical¹⁰ undergraduates towards persons with mental illness.

In general, attitudes influence professional and personal behavior of the health care professionals.¹¹ Hence, there is a need to address health professionals' attitudes towards consumer involvement in mental health services. Very few studies from India have mainly focused on attitudes of medical¹² and nursing^13,14 students towards persons with mental illness and mental health nursing.⁹ However, research that examined the influence of education on health care professionals' attitudes towards consumer participation in mental health care is limited.¹⁵ Further, training process could be the right time to influence upcoming health professionals' beliefs and attitudes to support consumer participation in mental health services. Therefore, current research was carried out to understand the views and perceptions of medical and nursing undergraduates regarding consumer involvement in mental health services.

METHODOLOGY

Research setting. This study was carried out among medical and nursing undergraduates from two universities, Bangalore, South India, during October to December 2014.

Participants. This study adopted a descriptive research method among non- randomly selected final year undergraduates from nursing and medical courses. The inclusion criteria for the present study was; nursing and medical students from 4^th year of their course, and those who have completed Psychiatry and mental health nursing course. We have excluded students from 1^st , 2^nd and 3^rd years, since they had no exposure or not completed the psychiatry course. In India, mental health education content is included in 3rd year of BSN and Medicine (6th term) courses.

Measures. The Mental Health Consumer Participation Questionnaire¹⁶ was used to assess the students' attitudes towards consumer participation in mental health services. This tool consisted of 17 items with 5 point likert scale (originally the tool had 7 point likert scale) with three domains namely; Consumer capacity (8 items), Consumer involvement (5 items) and Consumer as staff (4 items). Respondents were given the choice of five response categories to tick based on their feelings from disagree strongly (1) to agree strongly (5). In this study, ''Mental health consumer'' or ''consumer'' is defined as a person who is currently using mental health services as either an in-patient or out-patient. A ''Consumer academic'' is defined as a person with lived experience of mental health service use, who is employed in an academic position, and is actively involved in the education of mental health professionals (Medical and nursing undergraduate students).¹⁶ Furthermore, this tool has good psychometric properties for the respective scales: 0.70 for consumer capacity, 0.76 for consumer as staff, and 0.82 for consumer involvement.¹⁶

Data collection procedure. The above described questionnaires along with socio-demographic sheet  was pilot tested among a small group of participants (n=25) and found that the study was feasible. Thus, no major modifications have been done. Then the final questionnaires were distributed to the study participants at the end of their regular lectures. On introduction,verbal explanation of the research aims and methods provided by the researcher (primary author) to all participants. It was unambiguously explained to the students that their responses would have no influence on their semester exams. The participants could complete the questionnaires in about 20-30 minutes.

Ethical considerations. Permission was obtained from the administrators of the colleges where the study was conducted. Participants were introduced to the aims and procedures of the study to decide if they would like to participate. After they agreed to participate verbally, the researcher administered the confidential questionnaires. Data collection tools contained no identifying information and therefore kept the individual responses confidential.

Statistical analysis. Responses of the negatively worded items were reversed before data analysis. The data were analyzed using appropriate statistics and results were presented in narratives and tables. Descriptive (frequency,percentage,mean and standard deviation) and inferential statistics (t- test) was used to interpret the data. The results considered statistically significance if the p value is less than 0.05.

RESULTS

Two hundred and seventy one out of 286 students were returned the questionnaires with 94.7% response rate. The mean age of the participants was 20.9±1.12 yrs (M±SD). A majority of the students were women (80.9%) and were from urban background (67.9%). More than half of the sample consisted of medical students (57.2%) (Table 1).

Table 1.

Table 2 represents the participants' responses to mental health consumer participation questionnaire. With regard to consumer capacity, a majority (44.2%) of the participants endorsed that the medications used in mental health are very complex and persons with mental illness should only have limited input in to deciding the most appropriate medication to be used. Similarly, most of the sample (40.9%) felt that persons with mental illness can't handle too much responsibility. However, 43.6% of the participants opined that mental health services work as well as they can and we should use valuable resources trying to change them. Although, 39.1% of the students agreed, almost equal (33.6%) of them disagreed to the item ''mental health services would not change significantly if persons with mental illness were employed by the services''. A majority (43.2%) of the participants approved that ''increased involvement of consumers in mental health services would not increase the stress levels for service providers. Most of the students accepted that persons with mental illness do understand the language and complexities of mental health services (43.5%) and have enough self-confidence to become involved in the planning and delivery of mental health services (38.7%). The mean score of this domain (24.53±3.07, M±SD) indicates that 61% of the participants hold positive attitudes towards consumer capacity to participate in mental health services. A vast majority of the students (88%) had encouraging attitudes about involvement of persons with mental illness in identifying the goals (63.9%), planning (62.3%) and evaluation and diagnosis (52.4%). Mixed opinions were expressed by the participants to the items in ''consumer as staff'' domain. However, more than half (52.4%) of the participants believed that persons with mental illness to be encouraged to contribute to the writing of their own notes and records. While 37.3% of the students agreed, 35.4% differed with the item related to persons with mental illness academic should be a member of staff in all psychiatric courses The mean score (11.91±3.15, M±SD) suggest that nearly three fourths of the students had positive attitudes in ‘consumer as staff' domain. Never the less, the overall mean score on mental health consumer participation questionnaire (54.06± 6.70, M±SD) implies that 64% of the participants hold positive attitudes towards consumer involvement in mental health services.

Table 2.

Independent t test analysis revealed significant differences between domains of mental health consumer participation questionnaire with selected socio- demographic variables (age, education and background) (Table 3). Medical students possessed more positive attitudes than nursing in consumer capacity (t-9.133,p<0.001), consumer as staff (t=2.924, p< 0.001) and overall score on mental health consumer participation questionnaire (t=6.892, p<0.001). Correspondingly participants from urban than rural back ground hold optimistic attitudes in consumer involvement in mental health services (t=2.988, p<0.01).

Table 3.

DISCUSSION

This was the first study from India that examined future health professionals' attitudes towards consumer involvement in mental health services using internationally standardized questionnaire. The present study revealed that 64% of the students had encouraging attitudes towards persons with mental illness involvement in planning, diagnosis and evaluation. Further, education and back ground of the participants proved to be the influential factors about consumer involvement in mental health services.  In the present study, 44.2% of the sample confirmed that psychiatric medications are very complex and persons with mental illness should only have limited input in deciding the most appropriate medication to be used. These findings were dissimilar to a study that was conducted among nursing students showed merely 19.8% of the participants agreed to this item.¹⁷ Similarly, 40.9% of the participants opined that persons with mental illness can't handle too much responsibility. These findings reflect a recent study from India among nursing students.9 The mean score of ‘Consumer capacity' domain (24.53±3.07, M±SD) indicates 61% of the participants hold positive attitudes towards consumer capacity to participate in mental health services. These findings were in concordance with previous research.¹⁶ However, a recent reviews on psychiatric patients' mental capacity and consent to treatment revealed that although studies in psychiatric patients indicate incapacity is common (20-30%), majority of psychiatric in-patients were capable of making treatment decisions.¹⁸ However, these reviews suggested more research to determine the clinical parameters related to the lack of capacity to make treatment decisions in psychiatric patients.

Health professionals are increasingly being encouraged to adopt a collaborative approach to making health care decisions.4 A vast majority (88%) of the participants hold encouraging attitudes towards involvement of consumers in mental health services. These findings were consistent with a study among nursing students in Australia which showed the average rating for the consumer involvement scale was 5.96 on a possible range of one to seven.¹⁶ Earlier research also report that patient involvement in the decision-making process is a key element for good clinical practice  as it enhances self determination and empowerment of patients.¹⁹ Studies also highlighted that a majority of psychiatric patients want to be informed about their treatment and consequences, and their preferences and values should be taken into account in the decision-making process.²⁰ Further, a recent review of patient preference for involvement in treatment decision making for both mental disorders and non-mental disorders showed that 71% of the studies (published 2000 to 2007) preferred shared decision roles in their treatment.²¹ Hence, it is imperative for mental health professionals to conquer their own discriminatory attitudes about the capacity of consumers to participate in mental health services.²² Moreover, in the wake of the Patient Self Determination Act in the developed countries, mental health advocates anticipated that the advance directives would give persons with severe mental illness greater autonomy and control over their own lives.²³ Widely published literature also suggests that increased psychiatric patients participation in clinical decision making could increase patient adherence to treatment.²⁴ Thus, menatl health professionals should actively encourage psychiatric patients to play an active role in making therapeutic decisions.  

In line with previous findings,^16,25 though a majority (52.4%) of the students agreed that persons with mental illness to be encouraged to contribute to the writing of their own notes and records, 42.4% of them disagreed to involve people with mental illness in the process for hiring new staff and in planning and delivery of staff education and professional developmental sessions. Documented literature report that actively involved mental health consumers in academic programs proved to be a major strategy to inculcate positive attitudes towards persons with mental illnesses.^26,27 Furthermore, a number of studies had discussed positive benefits when students were taught from a lived experience perspective.^15,28 However, unfortunately merely 37.3% of the participants supported the involvement of persons with mental illness as academic in psychiatric courses. These findings were similar to previous research.²⁵ In a recent comparative study, it was observed that lived experience-led education was more beneficial in changing attitudes of nursing students to consumer capacity. However, both types (Mental health nursing education and Lived experience-led education) had similar positive effects on attitudes to consumers as staff.¹⁷ However, satisfaction with consumer involvement in mental health education of nurses²⁹ and other health professionals²⁹ have been well documented.  In the present study, medical students showed better attitudes than nursing in consumer capacity (t-9.133, p<0.001), consumer as staff (t=2.924, p<0.001) domains. Currently, there are no studies to compare and contrast these findings. However, these findings could be due to different roles performed by the health professionals. For example, medical students are involved in interacting the persons with mental illness right from outpatient department to till they discharge as well during their follow-up. This could be one possible reason for this hypothesis.
This study presents certain limitations such as non random sample, smaller sample size and cross-sectional survey design. Further, data was collected using self reported questionnaires and there could be possibility of bias. Thus, the findings may not be representative of Indian medical and nursing undergraduates. However, sample from two universities with high response rate and the findings may provide valuable insights regarding the future health professionals' attitudes towards involvement of mental health consumers in treatment process from developing countries.

In summary, majority of the participants embraced encouraging attitudes towards consumer participation in mental health services. However, there is a room for improvement of future health professionals' attitudes by involving mental health consumers in academic programs at undergraduate level. Hence, additional research in this area is urgently required from developing countries.  

Acknowledgements: Researchers sincerely thank the participants for their valuable contribution.

REFERENCES

1. Happell B, Roper C. Consumer participation in mental health research: Articulating amodel to guide practice. Australas. Psychiatry. 2007; 15(3):237-41.         [ Links ]