Attitudes to Psychiatry in Malawi medical students following an undergraduate course

Julie E. Platt*, Anna L. Beaglehole, Benjamin J. Baig, Johan Leuvennink, John M. Eagles.

Total Word Count 1362Abstract 147Tables 1Figures 0

* Author for Correspondence: Julie E. Platt, Specialist Registrar in Psychiatry,Royal Cornhill Hospital, Aberdeen. email: julieplatt@doctors.org.uk ,

Anna L. Beaglehole, Specialist Registrar in Old Age Psychiatry, South East Scotland Rotation, Leith Community Treatment Centre, Leith, Edinburgh, Benjamin J. Baig, Clinical Lecturer, Royal Edinburgh Hospital, Morningside Park, Edinburgh, Robert C. Stewart, Specialist Registrar in Psychiatry, Manchester Royal Infirmary, Manchester, James Strachan, Consultant Psychiatrist, Royal Edinburgh Hospital, Morningside Park, Edinburgh, Felix Kauye, Chief Psychiatric Officer, Blantyre School of Medicine, Blantyre, Malawi, Leonie Boeing, Consultant Psychiatrist,St Johns Hospital at Howdon, Livingston , Johan Leuvennink, Consultant Psychiatrist, Crichton Royal Hospital, Dumfries, Scotland, Professor John M. Eagles Consultant Psychiatrist, Royal Cornhill Hospital Aberdeen

Abstract

Background Negative attitudes to psychiatry and mental illness may exist in

undergraduate medical students and low to middle income countries. The purpose of

this study was to investigate the impact of delivering an undergraduate psychiatry

course to a cohort of Malawian medical students.

Methods All 4th year Malawian Medical students attending their first 4th year lecture

on psychiatry were asked to anonymously complete an attitude scale, the Attitudes

Towards Psychiatry-30 Items (ATP-30). The students then completed the same at the

end of a five-week teaching block. The results were analysed to ascertain any changes

in attitudes to psychiatry as result of their psychiatric experience.

Results After the undergraduate course in psychiatry, students showed significant

changes to attitudes with regard to psychiatry including wanting to be a psychiatrist,

believing that their medical training was valuable to psychiatry and believing that

psychiatrists could improve the health of their patients.

Discussion An undergraduate psychiatry course has positively impacted on the views

and attitudes of 4th year medical students towards the field of psychiatry. The role of

education and exposure to psychiatry has the potential to improve the future delivery

of psychiatric care in Malawi and potentially to increase the number of doctors

choosing to pursue a career in psychiatry in Malawi

Introduction

Malawi is a land locked country in South East Africa with a population of 12.8

million, 40% of whom live in poverty. The country performs poorly on all health

outcome measures and the average life expectancy at birth is 47 years for males and

46 years for females (WHOSIS 2005). There are 2 psychiatric hospitals in Malawi: St

John of God, a Non Governmental Organisation (NGO) run hospital and the

government-run, Zomba Mental Hospital, which serves a population of 8 million.

There is one psychiatrist to provide care and treatment to psychiatric patients in

Malawi (Kauye et al 2007). Retainment of medical staff in Malawi is poor, with many

doctors choosing to leave Malawi to work in developed countries. Currently there is

no post-graduate training programme in Malawi for doctors wishing to pursue a career

in psychiatry.

In 2007, the Scottish Malawi Mental Health Education Project (SMMHEP)

assisted Malawi’s only medical school, the College of Medicine, University of

Malawi, in providing psychiatric teaching and examination to their 4th year medical

students (Beaglehole A L et al, 2008).

The attitudes of medical students to psychiatry have been assessed in several

different countries including the United Kingdom, Chile, U.S.A, Germany, Saudi

Arabia, Kenya, Malaysia and India and in general, students display a more positive

attitude to psychiatry after their placement in psychiatry. This potentially could

improve the delivery of psychiatric care by other specialist and generalist doctors.

Improvement in attitudes to a subject has the ability to influence career choice in a

speciality, which may influence recruitment to psychiatry.

Methods

In February 2007, all 4th year medical students attending their first 4th year lecture on

psychiatry were invited to complete the ATP-30 (Attitudes Towards Psychiatry-30

Items) anonymously.

The ATP-30 scale is a 30-item Likert scale, which has been validated (Burra et al,

1982) to assess attitudes to psychiatry. It measures participants’ views and the

strength of these views to various aspects of psychiatry, including beliefs about

psychiatric patients and illness, views about psychiatrists and psychiatry and thoughts

about psychiatric knowledge and teaching. There are 5 response options to the

statements: “Strongly Agree”, “Agree”, “No opinion/neutral”, “Disagree”, “Strongly

Disagree”. There were 15 negatively phrased statements which were scored from 1 to

5 respectively and the 15 positively phrased items were scored from 5 to 1

respectively. This allowed us to obtain a total attitude score. The higher the score, the

more positive the attitude towards psychiatry. The range of scores is from 30-150. A

total mean score of 90 indicates a neutral attitude to the field of psychiatry.

The students were asked to indicate their gender on the questionnaire. The

questionnaire took 5-10 minutes to fill in. In addition, there was a statement asking

students to define the field of psychiatry.

Students who were not present for the first lecture were asked at a subsequent lecture

to fill in the questionnaire. Following completion of the first questionnaire, students

had two weeks of theoretical teaching, which consisted of lectures, seminars and case

vignettes covering the main psychiatric illnesses. The curriculum was based on the

undergraduate programme from Edinburgh University. Other topics covered were

included such as, Culture and Psychiatry and Mental Health Services in Malawi,

(Baig et al awaiting publication).

Students completed a written exam testing their theoretical knowledge before

commencing clinical teaching. This consisted of 40 Multiple Questions, 15 Single

Best Answer Questions and 3 Short Answer Questions. Feedback of the written exam

results was given to the students before clinical teaching started at Zomba Mental

Hospital. Each of the six clinical tutors was appointed to a group of nine students.

Clinical teaching consisted of tutorials, interviews with patients (supervised and

unsupervised), presentation of cases at business and academic ward rounds. Students

were then asked to complete the ATP 30 for a second time at the end of their clinical

attachment.

Some of the statements from the students prior to their teaching included beliefs that

psychiatrists could become mentally ill as a result of exposure to patients. One student

commented on the lack of importance of psychiatry whilst another stated that

psychiatry was “interesting in practice but disgusting in theory”. After the theoretical

teaching, the comments from the students were generally more positive however some

negative views persisted and some identified a lack of effective treatment for patients

with mental health problems. Other students expanded and drew attention to the lack

of resources available to psychiatric patients in Malawi.

Results

There were 57 students in the year. In total, 53 students completed the first

questionnaire. This gave an overall response rate of 93%. 20 of the students were

female and 31 were male. 2 students did not indicate their gender.

51 students completed the second questionnaire. The response rate for the second

questionnaire was 89%. This time 20 females and 29 males completed the

questionnaire. Again 2 students did not indicate their gender.

The mean attitudinal score was 105 for the first questionnaire, which increased to 118

after the five-week teaching course. This improvement was statistically significant.

(p<0.05)

There were seven statements in which there were statistically significant changes in

the students’ attitudes. At the end of the five-week teaching block, the students felt

that psychiatry was a useful and valuable part of their medical training which could be

taught effectively. There was a shift for the better with students believing that

psychiatry was important on the medical curriculum and that psychiatrists could do a

lot for their patients. Finally more students wished to become a psychiatrist at the end

of their teaching. Mention p values for each statement as indicated by star sign.

Discussion

There are several international studies looking at changes in attitudes to psychiatry in

medical students.and only one looking at African medical students attitudes to

psychiatry (which was based in Kenya). There was a high response rate from students,

which indicates a true reflection of changes in perceptions of the medical students in

Malwai. There was a statistically significant improvement in the general views of the

students as a whole and in particular the students felt that psychiatry was a useful and

valuable part of their training which could be taught effectively. Beliefs of the

students that psychiatry is important on the curriculum may potentially ensure that

psychiatry is kept on the curriculum when there is continuing pressure to remove it

from the medical curriculum.

A belief by students that psychiatrists could do a lot for their patients potentially could

encourage students in their future careers to actively treat and seek appropriate help

for their patients with mental illness.

More students wished to become a psychiatrist at the end of their training. A positive

undergraduate teaching experience in psychiatry may influence career choice which is

important in a country where there is only one psychiatrist providing care and

treatment to a population of 12.8 million.However other factors may influence career

decisions such as career opportunities, conditions for further education and income

potential.

Despite the limited facilities in the main hospital in Malawi in terms of resources for

psychiatric patients, students’ believed that a lot could be done to help psychiatric

patients

There are limitations to this study. A small cohort of students participated and the

study may not be generalisable to other developed countries but it may reflect changes

in countries with similar demographics. No information was gained from the students

on their previous exposure to mental illness nor was any information gathered about

the impact of cultural beliefs (such as the attitudes to witchcraft and the traditional

doctor) on attitudes to psychiatry. . This study has not been repeated at a later stage in

the training of the students and the changes attitudes may be transient in nature. .

Previous studies have shown a deterioration in attitudes tot psychiatry with the

passage of time. Although general improvement is shown in attitudes, how many

students will become psychiatrists in Malwai in the longer term with many students

opting to leave Malwai to further their careers.. Stigma about mental illness could be

reduced by empasizing the effectiveness of pharmacological interventions and

psychotherpautic interventions.

Change in attitudes and career intentions can be dependent on the actions of the

clinical teachers and this study should be repeated in Malwai with a different cohort

of teachers.

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Tables and Figures

Table 1 displays the questions the students responded to in the ATP30

Question Mean Score Before Course

Mean Score After Course

Significance (p)

1) Psychiatry is unappealing because it makes little use of medical training. .019* 2) Psychiatrists talk a lot but do very little.

.060

3) Psychiatric Hospitals are little more than prisons..866

4) I would like to be a psychiatrist..026*

5) It is quite easy for me to accept the efficacy ofpsychotherapy .520

6) On the whole, people taking up psychiatric training are running away from participation in real medicine. .486

7) Psychiatrists seem to talk about nothing but sex. .785

8) The practice of psychotherapy basically is fraudulent since there is no strong evidence that it is effective. .841

9) Psychiatric teaching increases our understanding ofmedical and surgical patients. .412

10) The majority of students report that their psychiatricundergraduate training has been valuable. .026*

11) Psychiatry is a respected branch of medicine..903

12) Psychiatric illness deserves at least as much attention as physical illness. .884

13) Psychiatry has very little scientific information to go on.763

14) With the forms of therapy now available, most psychiatric patients improve. 1.000

15) Psychiatrists tend to be at least as stable as the average doctor. .243

16) Psychiatric treatment causes patients to worry too much about their symptoms. .755

17) Psychiatrists get less satisfaction from their work than other specialists. .395

18) It is interesting to try and unravel the cause of psychiatric illness .570

19) There is very little that psychiatrists can do for their patients. .012*

20) Psychiatric Hospitals have a specific contribution tomake to the treatment of the mentally ill. .715

21) If I were asked what I considered to be the three most exciting medical specialities, psychiatry would be excluded. .367

22) At times it is hard to think of psychiatrists as equal to other doctors. .129

23) These days psychiatry is one of the most important parts of the curriculum in medical schools. .016*24) Psychiatry is so unscientific that even psychiatrists can’t agree as to what it’s basic applied sciences are. .341

25) In recent years psychiatric treatment has become quite effective. .906

26) Most of the so called facts in psychiatry are really just vague speculations .117

27) If we listen to them, psychiatric patients are just ashuman as other people. .249

28) The practice of psychiatry allows the development of really rewarding relationships with people. .392

29) Psychiatric patients are often more interesting to workwith than other patients. .804

30) Psychiatry is so unstructured that it cannot really be taught effectively. .022*

31) I would consider a career in psychiatry after completing my medical undergraduate studies. .084

32) It is essential to have thorough medical knowledge in order to work in the field of psychiatry. .038*

33) When thinking of a psychiatrist, I am reminded of my teacher/s during my medical training rather than psychiatrist/s as portrayed in films/books/the media. .435

34)Psychiatric inpatient units provide a less effective setting for training in psychiatry than a lecture hall.

.302

35) Lecture halls provide a less effective setting for training in psychiatry than small group discussions. .782

Declaration of interest:None. Funding detailed in Acknowledgements

Acknowledgements: The project received a grant from the Scottish Executive and a Seedcorn grant from the Tropical Healthcare Educational Trust (THET). We would also like to thank all the students who cooperated in the study. Thanks also to Rob S, Leonie Boeing and Johan Leuv who are members of the steering committee and were instrumental in organising the project, raising funds and getting the project approved by the Royal College of Psychiatrists. Appreciation is extended to James Strachan who provided Consultant supervision during the project in Malawi and to Felix Kauye who is Malawi’s only psychiatrist