Knowledge And Attitude And Associated Factors To Ward Mental Illness Among Health Professionals Working In Government & Private Health Facilities At Dilla Town, South Ethiopia


 Background: - Mental illness is an important determinant of the quality of life of individuals. The negative attitude and negative beliefs toward mental illness even among health professionals is still persisting and lead to widespread stigma and poor help seeking behavior among people with mental illness. In Ethiopia, there is little research done on assessing the knowledge and attitudes of health professionals and this study will narrow this great gap.Objective: -To assess the knowledge and attitude of health professionals toward mental illness at governmental and private health facilities at Dilla town.Methods: Facility based cross-sectional study design was employed. The data were collected by using self-administered questionnaire with a total of 126 health professionals. Study participants were drawn using a simple random sampling method. Statistics investigation was done by using SPSS version 21. Descriptive statistics & logistic regression was done and the result was discussed and presented by frequency tables, graphs, and charts. Variables with p-value < 0.05 were declared as having substantial association between factors and the outcome variables. THE Result: The level of knowledge on mental illness among health professionals was 43.8%. Regarding Attitude of Health professionals toward mental illness, 59.6% were holding an unfavorable attitude. Respondents who have had high awareness have 0.025 times better attitude than those who have no control group. However, this association is not significant. (AOR=0.025, 95% C.I: 0.035, 0.085). In this study the level of literacy, contact with a mental ill, individual level of qualification, psychiatric training experience, and long duration of working experience have a strong positive impact on the attitude of health professionals to the psychiatric ills.Conclusion and Recommendation: The outcome of the study revealed the studied participants had an apparently unfavorable attitudes regarding psychiatric illness associated with lower levels of literacy. This finding was used as the screening attitude by empowering health professionals regarding their knowledge toward mental illness. Over half of the health professionals held an unfavorable attitude toward mental illness. This gives a direction to do more on emphasizing of developing awareness creation and expanding psychiatric training to empower attitude of health professionals toward mental illness.


Background
"Mental illness is a behavioral or psychological syndrome or pattern that occurs in an individual and re ects an underlying psychobiological dysfunction, the consequences of which are clinically signi cant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning). It must not be merely an inevitable result of common stressors and losses (for example, the death of a loved one) or a culturally sanctioned response. (1). 350 million people worldwide suffer from mental lines, which are more commonly associated with burden, in rmity, and rapid loss (2,3). While some countries have been successful in ghting stigma and increasing acceptance of mental illness, India and other emerging countries have a lack of knowledge. People who are experiencing mental distress are seen as "odd" and "harmful" by others. The majority of studies have found that people with mental illnesses have more undesirable characteristics and are more likely to be rejected regardless of their behavior. (3) Non-psychiatric health-care workers in the public and private sectors accept responsibility for the fundamental nature of these interferences; they may diagnose psychiatric conditions incorrectly due to a lack of awareness. Discriminatory and defamatory attitudes expressed by health care employees have been linked to the client's mental disorder, resulting in the loss of a mental disorder diagnosis inside a public or private health service. (3) plus (4).
In both public and private facilities, mentally ill people are regarded as having the capacity to harm others. Despite the ability of district health staff to control mental illness, society's negative stereotypes of people with psychiatric problems cause additional negative feelings, which exacerbate the disease's effects on the affected individual.
Many African people believe that mental disease is caused by a shortage of malevolent spirits in the home. Another commonly held attitude is that mentally ill people are to blame for their own di culties, particularly those brought on by alcohol or other narcotics. (5) and (6) In most cases, this discrimination denies mental illnesses, the sympathy and consideration that terminally ill people in less developed societies receive. Discrimination indicates that someone is less valuable than others, and this attitude grows among public and private professional health providers in money societies.
Psychiatric problems do not always change district health professionals' attitudes about stigma and prejudice. (6).

Statement of problem
Psychiatric disorders are thought to play a signi cant role in the global impact of illnesses (14 percent). In 2002, 153 million people worldwide suffered from depression, 23 million from schizophrenia, and 91 million from excessive alcohol consumption, according to the World Health Organization (WHO). In both industrialized and developing countries, about 20% of people suffer from two or more psychiatric or emotional illnesses.
Although only a few nations have been effective in eliminating discrimination and raising awareness about mental health concerns, China and other developing countries have a lack of knowledge. Patients with psychiatric diseases are labeled as "altered" and evaluated adversely by the general public. The bulk of studies have found that people with mental illnesses have more negative characteristics and are more likely to be abandoned (3). Those in Europe and America have similar attitudes about people with mental illnesses, which leads to stigma and prejudice. Psychiatric health facilities are still in the straggler stage, possibly due to a lack of information among public and private health workers about the environmental and physiological factors that in uence psychiatric issues. (3), (4), (5), (6).
As a result, the goal of this scholarship is to evaluate the knowledge and attitudes of health professionals regarding psychiatric diseases, this knowledge would be valuable in thinking in health facilities in the east gojam zone because there is a large gap in referring psychiatric patients to hospitals where at least one mental health expert is available.
Despite the signi cant prevalence of mental illness and the profound unfavorable attitude toward people who have it, which may be due to a lack of awareness about the condition, little research on KAP toward PWMI has been done. And the ndings of this study will contribute to closing this vast gap.

Study period and place
The study was held from April 16-30, 2016, at Dilla town, two health centers, Dilla university referral hospital, and privet clinics in Dilla town. Dilla town is one of the two city administrations in Gedio zone which was established in 1904 E.C. and it is found at a distance of 365 km/s from the capital city, Addis Ababa and it has one main road that passes through the town from Addis Ababa to Moyle. The climatic condition is Woynadega. Its average rainfall is from 1200-1800mm per year. The town is surrounded in the north by Sidama, in the south by Wonago, in the east by Bule and Oromia, and in the west by Oromia regional state. The entire area of the region is 135 square kms and the general population is 94,189 of this 46,058(49.9%) are males and 48,131 (50.1%) are females. The major dominant ethnic group in Dilla town is Gedio followed by others and most of the people speak Gediogna language. The major dominant religious belief in the town is Protestant followed by Orthodox, Muslim and others. The main sources of income for people in the town are trading, micro economic enterprises like cobble stone construction, coffee processing industries, our processing factory, and pottery work. In the town, there are three governmental and four private banks, three insurance company, and eight micro nance enterprises that support the economic development of the people. The town has 1 DU. referral hospital, 2,Governmental health center,1,Non-Governmental health center, 14 private clinics, 4, pharmacy, and 12 drug stores; clean pipe water supply, 1, university, 2,Govermmental college, 2 private colleges, 3, preparatory Schools and 3,high schools, 3, elementary and junior schools, postal, hydroelectric power and telecommunication services.

The Study design
Organization based time-limited (cross-sectional study) design was held.

Sampling procedure
Systematic random sampling after strati ed health facilities at Dilla town by using simple randomization using heterogeneity of Government and Privet health facility technique was implemented. If a health professional is found ineligible (based on the inclusion and exclusion criteria), the next health professional was considered.

Data collection tool
The instrument is self-administered and contains three sections. The rst component of the survey consisted of 11 questions about socio-demographic variables, health worker experiences, practice, and rank. Section 2 will examine: a) health workers' opinions of the likelihood of psychiatric illness in people they know who are psychiatrically ill; and b) overall health professional interaction and their reported need for it. It includes (a 'yes' or 'no' response format) on the issues that must be addressed in order to continue medical education. Section 3 looks at health care workers' attitudes about psychiatric diseases and the stigma that still exists around depression. There are two ways to code these objects. Some attitude questions are "yes" or "no" questions on a three-point scale (agree=1, neutral=2, disagree=3). Both the Amharic and English versions of the instrument have a total of 60 items. Scores above the mean score indicate a positive attitude/knowledge regarding mental illness, scores below and at the mean value indicate a negative attitude toward mental disease.

Data Collection procedure
Data was collected by using self-administered questioner which is composed of a question on knowledge and attitude toward mental illness among health professionals. The data was collected using structured questionnaires through selfadministered inquiry methods. If the selected patient refused participation, the next eligible respondents ll the questionnaire. Trained supervisors assisted the respondents.

Data processing, analysis & presentation
After the data was obtained, it was thoroughly examined for completeness and consistency. Before being saved as epidata and then imported to SPSS window version 20 for analysis, it was input, cleaned, and rechecked for completeness, anomalies, and consistency. A descriptive statistics were utilized to compress the outcome and independent factors. Bivariate and multiple logistic regressions were used to evaluate the relationship between socio demographic factors and other independent variables and health professionals' attitudes about mental illness. The variables with a P-value of less than 0.05 con rm the existence of a signi cant relationship between the independent and dependent variables. The results are provided in the form of frequency tables and graphs, and they are compared to earlier ndings. Finally, depending on the study's ndings, a complete recommendation is made.

Ethical approval
Ethical clearance and approval was obtained from joint Dilla Town Administration and Dilla University, RDC ethical committee. All Participants in the study was asked for their willingness. The respondents know the reasons why this research was done and explained in the questionnaires to the study participants and provide con dentiality. All the data was gain its great con dentiality is respected.

Socio demographic characteristics of the studied participants
The study included 126 health professionals with an average age of 33.60 and a standard deviation of 9.59 years. There was a 100% response rate. More than the usual number of people, 49 (38.9%), were between the ages of 18 and 24, 41 (32.1%) were between the ages of, 25 and 34, and 36 (28%) were between the ages of 35 and 49. In terms of gender, males made up 76.3% of the participants in the study. The data also shows that 58 (45.7%) of the participants had a diploma, 61 (48.3%) had a rst degree, and 8 (6.6%) of the participants had a postgraduate or specialty level education.

Relation between Knowledge and Attitudes toward mental illness among Health professionals
As the knowledge score increased by one unit in the studied participants, the attitude scores of them shifted toward favorability by 0.025 times. However, these associations were not statistically signi cant (AOR=0.025, 95% CI: 0.035, 0.085). Knowledge was entered in the nal model; multiple logistic regression by controlling confounding factors. However, the association did not reach statistical signi cance. Regarding the correlation between Knowledge and attitude, the knowledge scores were directly correlated with attitude scores (r=0.032) (2 Tables).
2 Table: correlation between attitude and knowledge of studied participants towards mental illness (N=126)

Other Factors affecting the attitude of studied participants
As depicted in Table 3, multiple logistic regressions were used to determine the relationship between health professional knowledge and attitude in life while controlling for relevant variables. In terms of gender, female health professionals were more likely than their male counterparts to have a negative attitude (COR =-1.31, 95% C.I:-2.4,-0.82Those with a higher educational level in the study had a more favourable attitude about mental illness than those with a lower educational level. Respondents with postgraduate and specialist degrees were more optimistic than those with only a bachelor's degree (COR =3.24, 95 present). 4.87, C.I.:1.23 Respondents who had got their rst degree had a more favourable attitude than those who had received a diploma (COR =3.91, 95% C.I:2.53, 4.45). Participants who interacted and got care from psychiatric patients had a more positive attitude toward mental illness than those who did not (COR=2.32, 95 percent C.I:1.91, 2.73). Those who had received psychiatric training exhibited a more positive attitude than those who had not (COR=2.72, 95 percent C.I:0.41, 2.89). Health professionals with more professional experience had a more positive attitude about mental illness than those with less. Respondents with more than ten years of job experience had a three-fold better attitude than those with ve to ten years of work experience. (Table 3)

Discussion
According to the ndings, 43.8 percent of health workers had a low awareness of mental illness. This nding is in line with the ndings of a 2011 study in the Netherlands called "Do mental health professionals stigmatize their patients?" which found that the most encouraging representations were seen as less characterizing people with psychiatric disorders, while the most negative descriptions were seen as more symbolizing these people (7). This nding is supported by the ndings of a study in Nigeria on health professionals' attitudes toward the care of psychiatric patients, which found that health professionals in a district hospital setting expressed concern about caring for mentally ill patients and favored apartheid in the wards (21). The conclusions of this study differ from previous research conducted in England, India, and Columbia (17, 18, and 19). This discrepancy could be explained by the fact that previous studies focused on mental health professionals, who are regarded to be more aware of mental illness than non-psychiatric professionals in my current study. A high percentage of the participants in the survey had a negative attitude about mental illness in terms of overall sentiment among health professionals. It was predicted that increasing awareness of mental illness would enhance health professionals' attitudes toward preventing mental illness when looking at the relationship between amount of knowledge and attitudes toward mental illness, but the data does not support this theory Although various research ndings using various methods revealed a signi cant relationship between the level of literacy and health professionals' attitudes toward mental illness, a snapshot evaluation of studied participants using a crossectional method over a short period of time revealed a small or non-signi cant relationship (14). There is no evidence in this study that knowing about mental disease has a signi cant positive impact on health workers' attitudes toward mental illness. Knowledge may not be an important predictor of attitude level in this study, according to the results. This could be due to the limitations of a short data collection period and the use of a crossectional approach to assessing research participants. This result is in line with those of a previous study. The paper "Other People Stigmatize" has been peer-reviewed A lack of awareness and behavior on the part of a few psychiatry practitioners toward people with psychiatric disorders and their families may have contributed to our profession's poor public image and stigma associated with mental illness, according to the study "Attitudes of Mental Health Professionals Toward Patients with Schizophrenia." Surprisingly, their unfavorable views have an impact on how they seek assistance for their own issues (15). However, other investigations in England and India have produced outcomes that are diametrically opposed to those obtained in this study. (11). This paradoxical conclusion is attributed to the better discrimination and stigma reduction strategies, as well as a positive attitude toward psychiatric disease than in Ethiopia.
Other confounding factors in uencing survey participants' attitudes are addressed in the following arguments: Females showed a substantially more pessimistic attitude toward mental disease than males. This nding is consistent with ndings from research in the United Kingdom on the di culty of acute care for people with comorbid mental illness (11).
The psychological backgrounds of women are mirrored in their limited access to resources, their limited position in culturally varied countries like Ethiopia, and their limited role and options in the mental health services seeking behavior and treatment compliance. This consensus report demonstrated that comorbidity increases in prevalence and severity in females, resulting in a higher level of disability. Respondents with higher educational levels have a more favorable view about mental illness than those with lower educational levels, according to the study. This nding matches that of an Indian study on health workers' attitudes about mental illness (16).
This study's ndings contradict previous research. "Other People Stigmatize" is a peer-reviewed piper. Attitudes of Mental Health Professionals toward Patients with Schizophrenia" revealed that certain psychiatry professional workers' lack of awareness and behavior toward people with psychiatric disorders and their relatives may contribute to our mental health workers' negative public image and discrimination related to psychiatric disorders (14,15). The ndings of this study imply that health workers with more experience in their employment had a more positive attitude toward mentally ill people than those with less experience, based on the participants' perceptions. The ndings of a previous identical study conducted in the Netherlands con rm this hypothesis (7).
Study participants who have regular contact and exposure with psychiatric patients have a more favorable view regarding mental illness than those who have less frequent contact. And also this result which is similar with the previous ndings of research done in Sweden (15) the authors identi ed that factors impact staff's awareness and views in a positive way; employer and work area and knowledge and personal contact have an effect on staff's awareness towards the persons they are anticipated to help.

Conclusion
Over half of health professionals hold an unfavorable attitude towards mental health problems. Factors related to an unfavorable attitude toward the psychiatric problems among health professionals need to be addressed by mental health intervention programs to improve the life of PWMI.

Recommendations of the study
Based on the above ndings, the following recommendations are advised Expertise and talent individuals in the department of psychiatry in Dilla University in particular & in other universities in a general should do great effort to incorporate the research ndings as input for policy making and modi cation on mental health and to expand the training programs which could empower non-psychiatric health professionals to help people with mental illness. Implement and plan of community awareness platforms to increase the direction toward the nature of psychiatric disorders, this program should reach all social classes and cultures in: schools, universities, social clubs, religious institutions, and mass media through an outreached health education program.
Psychiatric institutions should do more roles not only in psychiatric management of patients but also in the expanding of outreach programs and information transmission to non-psychiatric health professionals about the approaching and managing of psychiatric cases holding a positive attitude.
Ministry of Health should do much on mental illness awareness creation, stigma prevention, and expansion of mental health services to the ground level.
Expansion of a training program on mental illness to general health professionals   Figure 1 From the studied participants, 43.8 % have low level of knowledge based on total knowledge score. The mean for the overall knowledge score is 14.36 and with standard deviation of 0.49 With regard to level of attitude, 59.6% of the studied participants have favorable attitude toward mental illness while 44.4% of the respondents have unfavorable attitude considering the mean attitude score (≤12.3).