Prejudice And Misconception In Singapore

[Dimple Belousson]

Factoranalysis revealed a 4-factor structure for the Attitudes to Mental Illness questionnaire among the Singapore general population, namely social distancing, tolerance/support for community care, social restrictiveness, and prejudice and misconception. Older age, male gender, lower education and socio-economic status were associated with more negative attitudes towards the mentally ill. Chinese showed more negative attitudes than Indians and Malays (except for prejudice and misconception).

Copyright: 2016 Yuan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The authors' funding agency or government law only permits sharing of human participant data with researchers with whom they have a written agreement. The restrictions have been imposed by our Institutional Review Board (IRB) and Institutional Committee (NHG Domain Specific Review Board and IMH Clinical Research Committee). Our IRB guidelines suggest that a Research Collaboration Agreement (RCA) be signed with collaborating parties. However, data sharing with clear research purposes are available upon request to this contact: Assistant Professor Mythily Subramaniam (Myt...@imh.com.sg).

Funding: This study was funded by Ministry of Health, Health Services Research Competitive Research Grant (HSRG/0036/2013). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The current study aimed: 1) to explore the factor structure of the AMI questionnaire among the multi-ethnic general population in Singapore; and 2) to explore the socio-demographic correlates of each AMI factor and identify how these characteristics affect public attitudes to mental illness among this population.

Face-to-face interviews were conducted by trained interviewers; and the respondent could choose the language for the interview: English, Chinese, Malay or Tamil. Data was captured via iPad, which was programmed to display a dual language screen, allowing bi-lingual interviewers to translate terms or phrases as required (by the respondent) in a consistent way; this method minimized the potential for misinterpretation or ad hoc translations by interviewers. Individuals who were out of the country during the recruitment period, unable to be contacted due to incomplete or incorrect addresses, and unable to complete the interview in one of the specified languages were excluded from the current study. In total 4,231 people were contacted, of which 3,006 completed the survey which yielded an overall response rate of 71.1%.

The survey measures were translated into Mandarin, Malay and Tamil. To ensure the conceptual equivalence of the instruments in the different languages, the whole translation procedure followed a process that was adapted from guidelines of the World Health Organization, which had been used among two previous national studies in Singapore [22, 23]. This included 1) single forward translation by a professional firm; 2) review by an expert panel comprising the professional translators, content experts and a layperson to identify and resolve any inadequate expressions in the translation and discrepancies between the translated and original version; 3) pre-testing and cognitive interviews among individuals representing the target population in term of the age-groups, gender, ethnicities, and socio-demographics; and 4) development of the final version [22].

The cognitive interviews refer to a common means of applying the cognitive model in a manner that may ultimately improve the quality of survey questions through the study of comprehension, retrieval, judgment, and response processes [24]. During this process, respondents were interviewed by trained researchers who systematically probed on whether they could repeat the questions and what came to their mind when they heard a particular phrase or term and they were asked how they decided on their response. Respondents also reported any word they did not understand and any word or expression that they found offensive or unacceptable; and where alternative words or expressions exist for one item or expression, the respondent was asked which of the alternatives conforms better to their usual language. Minor changes were made to the questions based on the cognitive interview findings; this was to ensure the items of the instrument would be understood in the manner they were intended to be and to avoid potential misinterpretation. More information on this process is available in a previous publication [25].

All estimates were weighted to adjust for over sampling and post-stratified for age and ethnicity distributions between the survey sample and the Singapore resident population in 2012. Descriptive analysis was conducted for the socio-demographic variables. Weighted mean and standard error (SE) were presented for continuous variables; while for categorical variables, they were presented as frequencies and percentages.

Multivariate linear regression was conducted to examine the socio-demographic correlates (i.e. age, gender, ethnicity, marital status, education level, employment status and personal income) for each of the AMI factor scores (dependent variables). A two-sided p-value below 0.05 was considered as statistically significant. The descriptive and the multivariate linear regression analyses were conducted using SAS 9.3.

These limitations notwithstanding, this is the first study that has systematically studied AMI outside UK. Based on rigorous methodologies, a different factor structure was identified among the Singapore sample, which indicates potential cultural differences between Western and Asian populations in their perceptions of mental illness. It also has a large sample size with a good overall response rate (71.1%) which is representative of the general population. Lastly, before applying the questionnaire to the local population, necessary changes were made based on cognitive interviews to ensure its comprehension and local relevance.

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Background: Similar to the general public, mental health professionals sometimes also have negative attitudes towards individuals with mental illness; which could ultimately affect the quality of care received by the patients. This study aims to explore attitudes to mental illness among mental health professionals in Singapore; make comparisons with the general population; and investigate the significant correlates.

Methods: A cross-sectional design was used. Eligible participants were recruited from the Institute of Mental Health, Singapore. Attitudes to mental illness among the mental health professionals were measured using an adapted 26-item Attitudes to Mental Illness questionnaire (AMI). An earlier study amongst the general population in Singapore had used the same tool; however, factor analysis suggested a 20-item, 4-factor structure (AMI-SG) was the best fit. This 4-factor structure was applied among the current sample of mental health professionals to allow comparisons between the professionals and the general population. Data were collected through an online survey tool 'Questionpro' from February to April 2016, and 379 participants were included in the current analysis. Attitudes to mental illness among these professionals were compared to those of the general population, which were captured as part of a national study conducted from March 2014 to April 2015.

Results: The 20-item, 4-factor structure AMI-SG derived from the general population was applicable among the mental health professionals in Singapore. Compared to the general population, mental health professionals had significantly more positive attitudes to mental illness; however their scores on 'social distancing' did not differ from the general population. Indian ethnicity was negatively associated with 'social distancing' and 'social restrictiveness' among the professionals; while higher education was negatively related to 'prejudice and misconception'. Compared to nurses, doctors showed significantly more positive attitudes on 'social restrictiveness' and 'prejudice and misconception'. Having family or close friends diagnosed with mental illness was negatively associated with 'social distancing' among the professionals.

Conclusion: The AMI-SG is an effective tool to measure attitudes to mental illness among mental health professionals in Singapore. Although the professionals had significantly more positive attitudes to mental illness than the general public in Singapore, their attitudes on 'social distancing' resembled closely that of the general public. Professionals tended to have more negative attitudes if they were nurses, less educated, and of Chinese ethnicity. More studies are needed to explore the underlying reasons for the differences and to generalize these findings among mental health professionals elsewhere.

I grew up in Bulgaria and had to move to London with my family at 12 years old. For me, being proud of my culture means colourful dresses, dancing and beautiful roses. It also means standing up to those that degrade our identity and country.

Common prejudice includes the anti-Chinese rhetoric that spread during the Covid-19 pandemic. Islamophobia continues to be a problem in the UK and young Muslims face rising racism. Homophobic attacks, often committed by people with extreme religious views, have also increased in recent years.

This is where I want to introduce the notion of celebrating difference and promoting diversity and tolerance. The more we understand each other and recognise our unique characteristics, the more we will be able to reach a mutual understanding.

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