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Impact of perceived course of illness on the desire for social distance towards people with symptoms of schizophrenia in Hanoi, Vietnam
Psychiatry Research 268 (2018) 206–210
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Impact of perceived course of illness on the desire for social distance towards people with symptoms of schizophrenia in Hanoi, Vietnam
T
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Lara Kim Martensena, , Eric Hahna, Tien Duc Caob, Georg Schomerusc, Main Huong Nguyena, Kerem Bögea, Tat Dinh Nguyenb, Aditya Mungeea, Michael Dettlinga, Matthias C Angermeyerd, Thi Minh Tam Taa a
Department of Psychiatry and Psychotherapy, Charité University Hospital, Campus Benjamin Franklin, Berlin, Germany Department of Psychiatry and Psychological Medicine, 103 Military Hospital, Military Medical University, Hanoi, Vietnam c Department of Psychiatry, Ernst Moritz Arndt University, Greifswald, Germany d Center for Public Mental Health, Untere Zeile 13, Gösing am Wagram A-3482, Austria b
A B S T R A C T
In Vietnam, stigmatisation and discrimination of patients with mental illness are highly prevalent. This study explores whether the perception of course of illness of people with symptoms indicating schizophrenia is associated with the desire for social distance in the Vietnamese public. A population-based survey (n = 455) using unlabelled vignettes for schizophrenia was carried out in the Hanoi municipality in 2013. First, a factor analysis was performed to group items indicating perception of prognosis. Second, a linear regression analysis was used to search for correlations between these expectations and desire for social distance. The factor analysis revealed three independent factors of perception of course of illness: (1) loss of social integration and functioning, (2) lifelong dependency on others, and (3) positive expectations towards treatment outcome. Both factors with negative prognostic perceptions (1&2) were associated with more desire for social distance. The results indicate a link between social acceptance and the perceived ability to maintain a social role including a capability of reciprocity within the Vietnamese society. Additionally, these findings highlight the importance of preserving social functioning in any treatment approach for patients with schizophrenia, which includes psychosocial intervention and rehabilitation programs.
1. Introduction Adding to the individual burden of suffering from a mental illness, discrimination and stigmatisation of psychiatric patients and their families is a common phenomenon leading to delayed mental health care seeking and delayed treatment initiation (Dockery et al., 2015; Lauber and Rössler, 2007). In many cases, this results in a chronic course of illness (Amminger et al., 2002) as well as impaired social functioning and social isolation (Barnes et al., 2008). Public stigmatisation compromises stereotypes, prejudices, labelling and discriminative behaviour (Link et al., 2004; Rüsch et al., 2005). Self-stigma occurs when a person with mental illness identifies with the stigmatized group, is aware of the prejudices and agrees with that perception (Corrigan and Watson, 2002). High levels of self-stigma can lead to low self-esteem or low-self efficacy, promoting social withdrawal and reluctance to disclose ones mental illness (Livingston and Boyd, 2010; Rüsch et al., 2005). Research on public attitudes towards people with psychiatric illnesses within specific cultural and national contexts is therefore of great importance as it is relevant in various ways for those who develop a mental disorder (Corrigan et al., 2011;
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Link, 1987; Link et al., 2004). Desire for social distance is often used as a proxy measure of public stigma and has been used in various unlabelled and labelled vignettebased studies in the past (Angermeyer et al., 2014; Kermode et al., 2009; Link, 1987; Reavley and Jorm, 2011; G Schomerus et al., 2014). Fearful emotional reactions and the perception of dangerousness or strangeness were associated with a stronger desire for social distance (Schomerus et al., 2013; Speerforck et al., 2014). Further, higher levels of education and familiarity with mental illnesses were commonly associated with less desire for social distance (Adewuya and Makanjuola, 2008; Corrigan et al., 2001; von dem Knesebeck et al., 2013). Epidemiological and stigma related data concerning mental illness in Vietnam is scarce. The combined prevalence of the ten most common psychiatric disorders in 2001–2003 was estimated to be approximately 14.9%, with alcohol addiction (5.3%), depression (2.8%), and anxiety disorders (2.6%) being the three most prevalent. The prevalence of schizophrenia was estimated around 0.5%, yet this disorder is the most commonly treated disorder in psychiatric hospitals in Vietnam (Vuong et al., 2011). The WHO DALY report (WHO, 2014) estimated that 7.3% of the disability-adjusted life-years (DALYs) worldwide were
Corresponding author. E-mail address: [email protected] (L.K. Martensen).
https://doi.org/10.1016/j.psychres.2018.05.046 Received 29 September 2017; Received in revised form 1 April 2018; Accepted 21 May 2018 Available online 18 June 2018 0165-1781/ © 2018 Elsevier B.V. All rights reserved.
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caused by mental and behavioural disorders, equally to a total amount of more than 199 million years in 2012. The absolute number of DALYs in low- and middle-income countries is even higher than those in developed nations; yet, less than 1% of these countries’ health budget is spent on mental health care services (Patel et al., 2015). Especially in Vietnam, there is still an enormous gap between treatment needs and treatment accessibility for mental disorders, which is further complicated by challenging treatment and help-seeking barriers related to stigmatisation (Maramis et al., 2011; Nguyen et al., 2010). As a reaction to this mental health care gap, as well as to the harsh social reality patients have to face, improving mental health services has become a national priority in Vietnam's health care system (Vuong et al., 2011) and more research has been conducted. A recent study by Vuong et al. (2015) carried out in central Vietnam assessed stigmatisation experiences by patients diagnosed with schizophrenia (Vuong et al., 2015). The results showed that discrimination in Vietnam is highly prevalent and the most commonly reported experiences of stigma were being perceived as less competent or unfavourable. Moreover, there is some evidence that a rural setting or familiarity with mental illness may be associated with lower levels of perceived discrimination and stigmatisation by the public in Vietnam (Ta et al., 2016). The authors argued that due to the continually changing environment in Vietnamese megacities, everyday life demands high levels of flexibility and adaptability. People with mental illnesses often lack such a capacity to adapt to or cope with new surroundings. More investment to reduce stigma in Vietnam is needed and additional research can help to understand the origin of stigma in the cultural specific context of Vietnam. The current study aims for the first time to identify whether public expectations about the course of illnesses of persons showing psychotic symptoms are related to the desire for social distance.
Table 1 Socio-demographic data for Hanoi, Vietnam and survey sample. Socio-demographic data
Gendera [%] male female Urbanitya [%] urban rural Ageb [years, %] 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 Household sizeb [%] 1 2–4 5–7 7+ Marital statusb [%] never married married/previously married Unemployment ratec [%] total urban rural
Total population Hanoi (n = 6,936,900)
Survey Sample Hanoi (n = 455)
49.8 50.2
51 48.8
42.5 57.5
43.1 56.9
14.9 14 13 11.4 11.1 10.2 9.2 7.7 5.2 3.3
15.41 16.5 13.2 13.8 12.7 11.4 7.3 7.5 1.5 0.7
9.1 70.2 18.7 2
6.2 60.9 26.8 6.2
24.5 75.5
35.4 64.6
2.5 5.1 1.6
2.4 1.5 3.1
a
Data from micro-census 2013. Data from full census 2009. c Report on Labour force survey 2013 (Investment Ministery of Planning & Office General Statistics, 2014). 1 Only respondents aged 16 or older were allowed to complete the questionnaire. b
2. Methods 2.1. Study participants The study was carried out between April and August 2013 in the greater Hanoi area. Including several surrounding provinces, today's municipality of Hanoi amounts to more than seven million inhabitants. The study participants were recruited in collaboration with the Department of Psychiatry of the Hospital 103, Military Academy of Medicine, Hanoi. Participants were contacted via the staff's extensive personal network throughout all rural and urban districts of Hanoi. The quota sample selection was adjusted to the population distribution data taken from the microcensus 2013. Not more than one person per household was included in the study. All participants received written information about the study and its procedures and had to give their signed and informed consent. No financial or any other kind of compensation was given for participating. All completed questionnaires were controlled for systematic error by the staff of Hospital 103, as well as by LM, TT and EH. The stratified quota sample (n = 455) can be regarded as representative concerning gender, age, and urbanity according to the Hanoi Census 2009 and the more recent micro-census conducted in 2013 (see Table 1). The ethics committee of the Military Academy of Medicine, Hanoi, reviewed and approved the study design.
questionnaire. 2.3. Translation procedure First, TT, who is a native speaker of Vietnamese and speaks German on an academic level, translated the vignette and the structured questionnaire from German to Vietnamese language. Second, this Vietnamese version has been retranslated into German and controlled by two independent reviewers. Lastly, the questionnaire was re-examined by Vietnamese psychiatrists of the Hospital 103, Military Academy of Medicine in Hanoi, to further ensure that the translations conform with contextual and linguistic specifications of Vietnamese living in Hanoi. 2.4. Desire for social distance Several items were used to determine the desire for social distance towards a person with a mental illness in different social situations. Link et al. (1987) developed the applied scale as a variation of the Bogardus Social Distance Scale (Bogardus, 1925). Participants were asked to what extent they would accept the depicted person as a subtenant, colleague at work, neighbour, family member in-law, or a person who takes care of their children, and further if they would introduce such a person to a friend or recommend them for a job. The agreement on each item was scored on a five-point Likert scale with anchor points ‘very likely’ (1) and ‘very unlikely’ (5). The answers were added up to a sum score ranging from 5 (lowest desire for social distance) to 35 (highest desire for social distance). This approach of measuring social distance has been used in several studies before and
2.2. Questionnaire All participants received an unlabelled vignette depicting a person suffering from symptoms typical for schizophrenia. The presenting symptoms were in line with the diagnostic criteria for schizophrenia according to ICD-10. The vignettes which were used are well-established and have been employed in several studies before (Angermeyer and Matschinger, 2005; Schomerus et al., 2013). After reading the vignette, respondents were asked to complete a structured 207
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regular job’ and ‘will neglect him- or herself’; (2) lifelong dependency on others, including the two items that the person ‘will always need help from others’ and ‘will always need someone to tell him or her what to do’; (3) a positive attitude towards treatment outcome and course of illness, including the two items that ‘with treatment the person's condition will significantly improve’ and ‘after treatment, he or she may be able to live a normal life’. Moreover, in the light of a small number of items, all the factors showed acceptable internal consistencies with Cronbach's alphas of (1) 0.652, (2) 0.670, and (3) 0.614, respectively.
the same method was used without changes apart from the translation procedure (Angermeyer et al., 2014; Speerforck et al., 2016). For this Vietnamese sample, a Cronbach's alpha of 0.997 states excellent internal consistency and thereby permitted further statistical analysis. 2.5. Perception of course of illness Respondents were asked to state their agreement with seven statements on illness course perception on a five-point Likert scale with anchor points ‘totally agree’ (1) and ‘totally disagree’ (5). A theoretically derived approach was used to select the items. The items covered perceived progress and remission of symptoms regardless of treatment as well as perceived changes of social functioning in every day's life. For the statistical analysis, responses were grouped together to ‘agree’ (1 & 2), ‘undecided’ (3), or ‘disagree’ (4 & 5).
3.2. Regression analysis For analysing the impact of these expectations, a linear regression analysis was performed. The overall model was significant with p = 0.01. The regression analysis showed that two out of three factors had a significant effect on the desire for social distance. Agreement with the first-factor loss of social integration and functioning significantly correlated with higher scores on the social distance sum score (β = −0.128; p = 0.006). Also, the factor of perceived lifelong dependency on others correlated significantly with a higher desire for social distance (β = −0.092; p = 0.049). The third factor, combining two items of a positive attitude towards outcome and course of illness, had no significant effect on the desire for social distance in this Vietnamese sample. For a summary of the regression analysis for independent factors of illness course perception on the desire for social distance see Table 3.
2.6. Statistical analysis A factor analysis including the seven items of illness perception using principal factor extraction and a varimax rotation was conducted to define underlying groups. Only factors with an eigenvalue greater than one were extracted. As a Kaiser-Meyer-Olkin measure of sampling adequacy (KMO), a value of 0.599 was calculated rendering the sample acceptable for factor analysis. Individual factor scores for each participant were saved as Anderson-Rubin variables. In the next step, a regression analysis was carried out using social distance as the dependent variable and the personal factor scores as the independent variable. An association of factors with desire for social distance was set at p < 0.05.
4. Discussion Both factors representing negative attitudes towards course of illness, expected loss of social integration and functioning and expected lifelong dependency on others, were correlated with more desire for social distance. Concerning the first factor, expected loss of social integration and functioning, the findings emphasise the importance of fulfilling a social role in society and the ability to live independently. Being unable or being perceived as unable to meet these expectations might mark a person as less favourable or competent, thus possibly leading to further isolation. A significant number of patients with schizophrenia, despite receiving some form of treatment, are unable to maintain their premorbid lifestyles, level of autonomy, and social roles, with illness onset, often presenting as a turning point in their biography (Huber et al., 1975; Owen et al., 2016). In most low- or middle-income countries such as Vietnam, with insufficient psychiatric coverage as well as higher social and institutional barriers to receive treatment, it seems likely that even fewer patients experience adequate symptom control. Therefore, more patients may lack the ability to maintain their premorbid level of social functioning followed by social exclusion. More desire for social distance to persons with mental illness, in turn, may impair the course of illness and the efficacy of therapy and prevent efficient social rehabilitation and social reintegration. This was also shown in a systematic review, where high levels of stigmatisation in the general public
3. Results 3.1. Factor extraction for perception of course of illness Seven items concerning the public perception of course of illness of the person depicted in the vignette were included in the factor analysis. Table 2 shows that three independent factors of course of illness perception had an eigenvalue greater than Kaiser's criterion of 1 and were extracted. In sum, the extracted factors explained 69.15% of the variance. The distribution pattern of the included items implies that the three factors represent: (1) loss of social integration and functioning, including the three items that the person ‘will never be able to make important decisions on his or her own’, ‘will never be able to have a Table 2 Exploratory factor analysis for illness course perception. Item
The person will never be able to make important decisions by himself/herself The person will never be able to have a regular job The person will neglect himself/herself The person will always be in need of help from others The person will always need someone to tell him/ her what to do With treatment his/her condition will significantly improve After treatment, he/she will be able to live a normal life Initial Eigenvalues % of variance Cronbach's α
Rotated factor loadings 1
2
3
0.680
0.148
−0.117
0.647 0.528 0.185
0.105 0.042 0.768
−0.227 0.116 0.149
0.063
0.656
−0.056
−0.029
0.054
0.720
−0.074
0.004
0.623
2.053 29.33 0.652
1.594 22.77 0.67
1.194 17.05 0.614
Table 3 Regression analysis for illness course perception on social distance with beta scores and their 95% confidence intervals in brackets, standardized beta values, and their significance value. b Constant Loss of social functioning and integrity Lifelong dependency on others
1. loss of social integration and functioning 2. lifelong dependency on others 3. positive attitude towards treatment outcome and course of illness
Positive treatment attitude
* p < 0.05; ** p < 0.01. 208
22.30 (21.94, 22.67) −0.51 (−0.88, −0.15) −0.37 (−0.74, −0.001) −0.80 (−0.45, 0.29)
β
p
−0.128
0.000** 0.006**
−0.092
0.049*
−0.020
0.671
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Following this line of argumentation, it would be central to improve psychiatric services in Vietnam and extend the focus of treatment from merely symptom control towards an improvement of social functioning and integration. One integrative treatment approach in Vietnam might also include different psychotherapeutic interventions to strengthen social skills and everyday life competencies as well as occupational therapy, opening a opportunity for a meaningful contribution to the community and overcoming the perceived failure of reciprocity. The mentioned therapies showed promise concerning the level of social functioning in several studies, and there is an ongoing discussion to which extent they could improve treatment outcome of schizophrenia (Bejerholm and Eklund, 2005; Kern et al., 2018; Roberts and Penn, 2009; Zhang et al., 2017). A meta-analysis focusing on low-and-middle income countries, including ten studies from China, found a large positive effect of psychosocial interventions on social functioning. However, the authors criticised a overall poor quality of the studies and emphasised a need for further research (De Silva et al., 2013). In the light of the results of this study and the available literature, strengthening the level of social functioning of patients with schizophrenia might hold the potential to reduce the desire for social distance among the general population in Vietnam. Several limitations to the results of the study need to be mentioned. As the survey was conducted in the Hanoi municipality, it cannot be considered representative of larger regions of Vietnam. Due to the social diversity, a countrywide survey could potentially produce heterogeneous results. Secondly, all data were collected cross-sectionally and do not allow any insight into possible diachronic dynamics. Third, the use of self-reported questionnaires may lead some respondents to answer questions in a less well-considered manner than would be the case in a face-to-face interview. On the other hand, it may encourage respondents to answer more honestly, as anonymity liberates from social pressure (Spector, 1994). The same questionnaire has been used in other countries before, which opens the opportunity for future crosscultural comparisons (Angermeyer et al., 2016, 2014; Schomerus et al., 2014). The Social Distance Scale has been transferred without prior validation in Vietnam. Yet, it showed excellent internal consistency in this study. In addition, a theoretically derived method was used to estimate the expectation of course of illness without a previous qualitative validation of items. All statistical analysis performed display mere correlations that allow no implications of causality. The regression analysis explained only a small proportion of variance. Consequently, other factors than those discussed in this paper are expected to contribute to the model as well and have to be investigated further. To conclude, the current study showed that adverse expectations of course of illness represented by the two derived factors loss of social integration and functioning as well as a lifelong dependency on others were significantly correlated with a greater desire for social distance towards a person with symptoms typical for schizophrenia. However, positive attitudes towards treatment outcome were not associated with differences in the desire for social distance in any direction. In a socio-centric society as in Vietnam, a person's capacity to contribute to the society and family may be even more critical than perceived treatment outcome. A perceived incapacity to live independently may lead to a reluctance to entrust responsible tasks to the affected person, possibly leading to diminished social acceptance. These findings add a new perspective and support a transition from a treatment approach mainly focused on symptom control towards an approach of psychosocial intervention strengthening social functioning and integration, and by this a capability of reciprocity of patients with mental illness in Vietnam.
were significantly associated with lower help-seeking behaviour (Schnyder et al., 2017). However, data concerning the actual outcome of schizophrenia in Southeast Asian countries and Vietnam is scarce. The International Study of Schizophrenia, which included seven centres in India, China, Hong-Kong, and Japan, reported that overall about 60% of patients improved clinically with treatment and slightly less showed functional improvement. Yet, the differences between the centres were large, ranging from 60% of patients with good or excellent functioning in Agra, India, to only 25% in Beijing, Hong-Kong, and Nagasaki (Holla and Thirthalli, 2015). The second factor, representing the expectation that the depicted person will always be dependent on someone else, was also significantly correlated with higher social distance. Several items that were used to survey the desire of social distance assessed whether the respondent would assign responsible tasks to the described person, e.g., a job or taking care of children. If the individual is perceived as dependent on others him- or herself, it might directly result in a reluctance to trust him or her with tasks demanding responsibility. Additionally, it might affect the willingness to engage in closer relationships, e.g., a dependent person might be considered unfit as a family member in-law. In that context, Vietnamese culture is still strongly influenced by Confucian philosophy, which highlights the importance of cultural reciprocity (Yum, 1988). A perception, that the depicted person will always dependent on help from others without sufficiently recompensing society, could be interpreted as a failure to comply with the fundamental Confucian principle of reciprocity. Another facet to this perception of dependency, might be the belief that the depicted situation is permanent. Both items of the second factor were phrased as expected lifelong conditions, reducing the likelihood of future acts of reciprocity, which might have led to more desire for social distance. Despite this cultural specification, there is some evidence that expected dependency also influences the desire for social distance in other cultural settings (Angermeyer and Matschinger, 2003). Concerning the third factor, positive expectations towards treatment outcome, a vignette-based study conducted by Angermeyer et al. (2016) in Germany and Tunisia found that the perception of a likely recovery from mental illness was associated with more pro-social reactions and less desire for social distance (Angermeyer et al., 2016). In contrast to the study by Angermeyer et al., the third factor, representing positive expectations towards treatment outcome and course of illness, showed no such correlation in this sample. This finding suggests that desire for social distance might not be reduced by merely controlling those symptoms but may remain attached to a person even if symptomatic treatment is available. Even though unlabeled vignettes were used in this study, so that no primary label was given, the depicted symptoms may have elicited a label as severely mentally ill. Yet, a perceived association of symptoms of schizophrenia with reduced social competence and life-long dependency may play a more significant role in Vietnamese context. As to this day, Vietnamese society is predominantly characterised by socio-centric attitudes in contrast to mainly individualistic attitudes found in most Western societies (Lauber and Rössler, 2007). Thus, a fundamental ability to contribute to the family and society and through this ability, being perceived as a respected member of society, might be considered even more relevant in Vietnam. The Vietnamese concept of face (“thể diện”) implies a socially approved image of a person, that is related to belonging to various social groups. The concept of a social face is further associated with concepts of respect, social capital, social influence, pride and dignity. Thus, an emphasis on “keeping ones face” due to being integrated in society and function according to social expectations remains an essential value in Vietnamese societies and the matter of how one is perceived in others eyes (Nguyen, 2015). A perception of neglecting oneself, while reading the vignette depicting a person with schizophrenia, may be linked with the concept of face preserving and could explain the association with more desire for social distance in case of perceived social disintegration.
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Impact of perceived course of illness on the desire for social distance towards people with symptoms of schizophrenia in Hanoi, Vietnam
T
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Lara Kim Martensena, , Eric Hahna, Tien Duc Caob, Georg Schomerusc, Main Huong Nguyena, Kerem Bögea, Tat Dinh Nguyenb, Aditya Mungeea, Michael Dettlinga, Matthias C Angermeyerd, Thi Minh Tam Taa a
Department of Psychiatry and Psychotherapy, Charité University Hospital, Campus Benjamin Franklin, Berlin, Germany Department of Psychiatry and Psychological Medicine, 103 Military Hospital, Military Medical University, Hanoi, Vietnam c Department of Psychiatry, Ernst Moritz Arndt University, Greifswald, Germany d Center for Public Mental Health, Untere Zeile 13, Gösing am Wagram A-3482, Austria b
A B S T R A C T
In Vietnam, stigmatisation and discrimination of patients with mental illness are highly prevalent. This study explores whether the perception of course of illness of people with symptoms indicating schizophrenia is associated with the desire for social distance in the Vietnamese public. A population-based survey (n = 455) using unlabelled vignettes for schizophrenia was carried out in the Hanoi municipality in 2013. First, a factor analysis was performed to group items indicating perception of prognosis. Second, a linear regression analysis was used to search for correlations between these expectations and desire for social distance. The factor analysis revealed three independent factors of perception of course of illness: (1) loss of social integration and functioning, (2) lifelong dependency on others, and (3) positive expectations towards treatment outcome. Both factors with negative prognostic perceptions (1&2) were associated with more desire for social distance. The results indicate a link between social acceptance and the perceived ability to maintain a social role including a capability of reciprocity within the Vietnamese society. Additionally, these findings highlight the importance of preserving social functioning in any treatment approach for patients with schizophrenia, which includes psychosocial intervention and rehabilitation programs.
1. Introduction Adding to the individual burden of suffering from a mental illness, discrimination and stigmatisation of psychiatric patients and their families is a common phenomenon leading to delayed mental health care seeking and delayed treatment initiation (Dockery et al., 2015; Lauber and Rössler, 2007). In many cases, this results in a chronic course of illness (Amminger et al., 2002) as well as impaired social functioning and social isolation (Barnes et al., 2008). Public stigmatisation compromises stereotypes, prejudices, labelling and discriminative behaviour (Link et al., 2004; Rüsch et al., 2005). Self-stigma occurs when a person with mental illness identifies with the stigmatized group, is aware of the prejudices and agrees with that perception (Corrigan and Watson, 2002). High levels of self-stigma can lead to low self-esteem or low-self efficacy, promoting social withdrawal and reluctance to disclose ones mental illness (Livingston and Boyd, 2010; Rüsch et al., 2005). Research on public attitudes towards people with psychiatric illnesses within specific cultural and national contexts is therefore of great importance as it is relevant in various ways for those who develop a mental disorder (Corrigan et al., 2011;
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Link, 1987; Link et al., 2004). Desire for social distance is often used as a proxy measure of public stigma and has been used in various unlabelled and labelled vignettebased studies in the past (Angermeyer et al., 2014; Kermode et al., 2009; Link, 1987; Reavley and Jorm, 2011; G Schomerus et al., 2014). Fearful emotional reactions and the perception of dangerousness or strangeness were associated with a stronger desire for social distance (Schomerus et al., 2013; Speerforck et al., 2014). Further, higher levels of education and familiarity with mental illnesses were commonly associated with less desire for social distance (Adewuya and Makanjuola, 2008; Corrigan et al., 2001; von dem Knesebeck et al., 2013). Epidemiological and stigma related data concerning mental illness in Vietnam is scarce. The combined prevalence of the ten most common psychiatric disorders in 2001–2003 was estimated to be approximately 14.9%, with alcohol addiction (5.3%), depression (2.8%), and anxiety disorders (2.6%) being the three most prevalent. The prevalence of schizophrenia was estimated around 0.5%, yet this disorder is the most commonly treated disorder in psychiatric hospitals in Vietnam (Vuong et al., 2011). The WHO DALY report (WHO, 2014) estimated that 7.3% of the disability-adjusted life-years (DALYs) worldwide were
Corresponding author. E-mail address: [email protected] (L.K. Martensen).
https://doi.org/10.1016/j.psychres.2018.05.046 Received 29 September 2017; Received in revised form 1 April 2018; Accepted 21 May 2018 Available online 18 June 2018 0165-1781/ © 2018 Elsevier B.V. All rights reserved.
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caused by mental and behavioural disorders, equally to a total amount of more than 199 million years in 2012. The absolute number of DALYs in low- and middle-income countries is even higher than those in developed nations; yet, less than 1% of these countries’ health budget is spent on mental health care services (Patel et al., 2015). Especially in Vietnam, there is still an enormous gap between treatment needs and treatment accessibility for mental disorders, which is further complicated by challenging treatment and help-seeking barriers related to stigmatisation (Maramis et al., 2011; Nguyen et al., 2010). As a reaction to this mental health care gap, as well as to the harsh social reality patients have to face, improving mental health services has become a national priority in Vietnam's health care system (Vuong et al., 2011) and more research has been conducted. A recent study by Vuong et al. (2015) carried out in central Vietnam assessed stigmatisation experiences by patients diagnosed with schizophrenia (Vuong et al., 2015). The results showed that discrimination in Vietnam is highly prevalent and the most commonly reported experiences of stigma were being perceived as less competent or unfavourable. Moreover, there is some evidence that a rural setting or familiarity with mental illness may be associated with lower levels of perceived discrimination and stigmatisation by the public in Vietnam (Ta et al., 2016). The authors argued that due to the continually changing environment in Vietnamese megacities, everyday life demands high levels of flexibility and adaptability. People with mental illnesses often lack such a capacity to adapt to or cope with new surroundings. More investment to reduce stigma in Vietnam is needed and additional research can help to understand the origin of stigma in the cultural specific context of Vietnam. The current study aims for the first time to identify whether public expectations about the course of illnesses of persons showing psychotic symptoms are related to the desire for social distance.
Table 1 Socio-demographic data for Hanoi, Vietnam and survey sample. Socio-demographic data
Gendera [%] male female Urbanitya [%] urban rural Ageb [years, %] 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 Household sizeb [%] 1 2–4 5–7 7+ Marital statusb [%] never married married/previously married Unemployment ratec [%] total urban rural
Total population Hanoi (n = 6,936,900)
Survey Sample Hanoi (n = 455)
49.8 50.2
51 48.8
42.5 57.5
43.1 56.9
14.9 14 13 11.4 11.1 10.2 9.2 7.7 5.2 3.3
15.41 16.5 13.2 13.8 12.7 11.4 7.3 7.5 1.5 0.7
9.1 70.2 18.7 2
6.2 60.9 26.8 6.2
24.5 75.5
35.4 64.6
2.5 5.1 1.6
2.4 1.5 3.1
a
Data from micro-census 2013. Data from full census 2009. c Report on Labour force survey 2013 (Investment Ministery of Planning & Office General Statistics, 2014). 1 Only respondents aged 16 or older were allowed to complete the questionnaire. b
2. Methods 2.1. Study participants The study was carried out between April and August 2013 in the greater Hanoi area. Including several surrounding provinces, today's municipality of Hanoi amounts to more than seven million inhabitants. The study participants were recruited in collaboration with the Department of Psychiatry of the Hospital 103, Military Academy of Medicine, Hanoi. Participants were contacted via the staff's extensive personal network throughout all rural and urban districts of Hanoi. The quota sample selection was adjusted to the population distribution data taken from the microcensus 2013. Not more than one person per household was included in the study. All participants received written information about the study and its procedures and had to give their signed and informed consent. No financial or any other kind of compensation was given for participating. All completed questionnaires were controlled for systematic error by the staff of Hospital 103, as well as by LM, TT and EH. The stratified quota sample (n = 455) can be regarded as representative concerning gender, age, and urbanity according to the Hanoi Census 2009 and the more recent micro-census conducted in 2013 (see Table 1). The ethics committee of the Military Academy of Medicine, Hanoi, reviewed and approved the study design.
questionnaire. 2.3. Translation procedure First, TT, who is a native speaker of Vietnamese and speaks German on an academic level, translated the vignette and the structured questionnaire from German to Vietnamese language. Second, this Vietnamese version has been retranslated into German and controlled by two independent reviewers. Lastly, the questionnaire was re-examined by Vietnamese psychiatrists of the Hospital 103, Military Academy of Medicine in Hanoi, to further ensure that the translations conform with contextual and linguistic specifications of Vietnamese living in Hanoi. 2.4. Desire for social distance Several items were used to determine the desire for social distance towards a person with a mental illness in different social situations. Link et al. (1987) developed the applied scale as a variation of the Bogardus Social Distance Scale (Bogardus, 1925). Participants were asked to what extent they would accept the depicted person as a subtenant, colleague at work, neighbour, family member in-law, or a person who takes care of their children, and further if they would introduce such a person to a friend or recommend them for a job. The agreement on each item was scored on a five-point Likert scale with anchor points ‘very likely’ (1) and ‘very unlikely’ (5). The answers were added up to a sum score ranging from 5 (lowest desire for social distance) to 35 (highest desire for social distance). This approach of measuring social distance has been used in several studies before and
2.2. Questionnaire All participants received an unlabelled vignette depicting a person suffering from symptoms typical for schizophrenia. The presenting symptoms were in line with the diagnostic criteria for schizophrenia according to ICD-10. The vignettes which were used are well-established and have been employed in several studies before (Angermeyer and Matschinger, 2005; Schomerus et al., 2013). After reading the vignette, respondents were asked to complete a structured 207
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regular job’ and ‘will neglect him- or herself’; (2) lifelong dependency on others, including the two items that the person ‘will always need help from others’ and ‘will always need someone to tell him or her what to do’; (3) a positive attitude towards treatment outcome and course of illness, including the two items that ‘with treatment the person's condition will significantly improve’ and ‘after treatment, he or she may be able to live a normal life’. Moreover, in the light of a small number of items, all the factors showed acceptable internal consistencies with Cronbach's alphas of (1) 0.652, (2) 0.670, and (3) 0.614, respectively.
the same method was used without changes apart from the translation procedure (Angermeyer et al., 2014; Speerforck et al., 2016). For this Vietnamese sample, a Cronbach's alpha of 0.997 states excellent internal consistency and thereby permitted further statistical analysis. 2.5. Perception of course of illness Respondents were asked to state their agreement with seven statements on illness course perception on a five-point Likert scale with anchor points ‘totally agree’ (1) and ‘totally disagree’ (5). A theoretically derived approach was used to select the items. The items covered perceived progress and remission of symptoms regardless of treatment as well as perceived changes of social functioning in every day's life. For the statistical analysis, responses were grouped together to ‘agree’ (1 & 2), ‘undecided’ (3), or ‘disagree’ (4 & 5).
3.2. Regression analysis For analysing the impact of these expectations, a linear regression analysis was performed. The overall model was significant with p = 0.01. The regression analysis showed that two out of three factors had a significant effect on the desire for social distance. Agreement with the first-factor loss of social integration and functioning significantly correlated with higher scores on the social distance sum score (β = −0.128; p = 0.006). Also, the factor of perceived lifelong dependency on others correlated significantly with a higher desire for social distance (β = −0.092; p = 0.049). The third factor, combining two items of a positive attitude towards outcome and course of illness, had no significant effect on the desire for social distance in this Vietnamese sample. For a summary of the regression analysis for independent factors of illness course perception on the desire for social distance see Table 3.
2.6. Statistical analysis A factor analysis including the seven items of illness perception using principal factor extraction and a varimax rotation was conducted to define underlying groups. Only factors with an eigenvalue greater than one were extracted. As a Kaiser-Meyer-Olkin measure of sampling adequacy (KMO), a value of 0.599 was calculated rendering the sample acceptable for factor analysis. Individual factor scores for each participant were saved as Anderson-Rubin variables. In the next step, a regression analysis was carried out using social distance as the dependent variable and the personal factor scores as the independent variable. An association of factors with desire for social distance was set at p < 0.05.
4. Discussion Both factors representing negative attitudes towards course of illness, expected loss of social integration and functioning and expected lifelong dependency on others, were correlated with more desire for social distance. Concerning the first factor, expected loss of social integration and functioning, the findings emphasise the importance of fulfilling a social role in society and the ability to live independently. Being unable or being perceived as unable to meet these expectations might mark a person as less favourable or competent, thus possibly leading to further isolation. A significant number of patients with schizophrenia, despite receiving some form of treatment, are unable to maintain their premorbid lifestyles, level of autonomy, and social roles, with illness onset, often presenting as a turning point in their biography (Huber et al., 1975; Owen et al., 2016). In most low- or middle-income countries such as Vietnam, with insufficient psychiatric coverage as well as higher social and institutional barriers to receive treatment, it seems likely that even fewer patients experience adequate symptom control. Therefore, more patients may lack the ability to maintain their premorbid level of social functioning followed by social exclusion. More desire for social distance to persons with mental illness, in turn, may impair the course of illness and the efficacy of therapy and prevent efficient social rehabilitation and social reintegration. This was also shown in a systematic review, where high levels of stigmatisation in the general public
3. Results 3.1. Factor extraction for perception of course of illness Seven items concerning the public perception of course of illness of the person depicted in the vignette were included in the factor analysis. Table 2 shows that three independent factors of course of illness perception had an eigenvalue greater than Kaiser's criterion of 1 and were extracted. In sum, the extracted factors explained 69.15% of the variance. The distribution pattern of the included items implies that the three factors represent: (1) loss of social integration and functioning, including the three items that the person ‘will never be able to make important decisions on his or her own’, ‘will never be able to have a Table 2 Exploratory factor analysis for illness course perception. Item
The person will never be able to make important decisions by himself/herself The person will never be able to have a regular job The person will neglect himself/herself The person will always be in need of help from others The person will always need someone to tell him/ her what to do With treatment his/her condition will significantly improve After treatment, he/she will be able to live a normal life Initial Eigenvalues % of variance Cronbach's α
Rotated factor loadings 1
2
3
0.680
0.148
−0.117
0.647 0.528 0.185
0.105 0.042 0.768
−0.227 0.116 0.149
0.063
0.656
−0.056
−0.029
0.054
0.720
−0.074
0.004
0.623
2.053 29.33 0.652
1.594 22.77 0.67
1.194 17.05 0.614
Table 3 Regression analysis for illness course perception on social distance with beta scores and their 95% confidence intervals in brackets, standardized beta values, and their significance value. b Constant Loss of social functioning and integrity Lifelong dependency on others
1. loss of social integration and functioning 2. lifelong dependency on others 3. positive attitude towards treatment outcome and course of illness
Positive treatment attitude
* p < 0.05; ** p < 0.01. 208
22.30 (21.94, 22.67) −0.51 (−0.88, −0.15) −0.37 (−0.74, −0.001) −0.80 (−0.45, 0.29)
β
p
−0.128
0.000** 0.006**
−0.092
0.049*
−0.020
0.671
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Following this line of argumentation, it would be central to improve psychiatric services in Vietnam and extend the focus of treatment from merely symptom control towards an improvement of social functioning and integration. One integrative treatment approach in Vietnam might also include different psychotherapeutic interventions to strengthen social skills and everyday life competencies as well as occupational therapy, opening a opportunity for a meaningful contribution to the community and overcoming the perceived failure of reciprocity. The mentioned therapies showed promise concerning the level of social functioning in several studies, and there is an ongoing discussion to which extent they could improve treatment outcome of schizophrenia (Bejerholm and Eklund, 2005; Kern et al., 2018; Roberts and Penn, 2009; Zhang et al., 2017). A meta-analysis focusing on low-and-middle income countries, including ten studies from China, found a large positive effect of psychosocial interventions on social functioning. However, the authors criticised a overall poor quality of the studies and emphasised a need for further research (De Silva et al., 2013). In the light of the results of this study and the available literature, strengthening the level of social functioning of patients with schizophrenia might hold the potential to reduce the desire for social distance among the general population in Vietnam. Several limitations to the results of the study need to be mentioned. As the survey was conducted in the Hanoi municipality, it cannot be considered representative of larger regions of Vietnam. Due to the social diversity, a countrywide survey could potentially produce heterogeneous results. Secondly, all data were collected cross-sectionally and do not allow any insight into possible diachronic dynamics. Third, the use of self-reported questionnaires may lead some respondents to answer questions in a less well-considered manner than would be the case in a face-to-face interview. On the other hand, it may encourage respondents to answer more honestly, as anonymity liberates from social pressure (Spector, 1994). The same questionnaire has been used in other countries before, which opens the opportunity for future crosscultural comparisons (Angermeyer et al., 2016, 2014; Schomerus et al., 2014). The Social Distance Scale has been transferred without prior validation in Vietnam. Yet, it showed excellent internal consistency in this study. In addition, a theoretically derived method was used to estimate the expectation of course of illness without a previous qualitative validation of items. All statistical analysis performed display mere correlations that allow no implications of causality. The regression analysis explained only a small proportion of variance. Consequently, other factors than those discussed in this paper are expected to contribute to the model as well and have to be investigated further. To conclude, the current study showed that adverse expectations of course of illness represented by the two derived factors loss of social integration and functioning as well as a lifelong dependency on others were significantly correlated with a greater desire for social distance towards a person with symptoms typical for schizophrenia. However, positive attitudes towards treatment outcome were not associated with differences in the desire for social distance in any direction. In a socio-centric society as in Vietnam, a person's capacity to contribute to the society and family may be even more critical than perceived treatment outcome. A perceived incapacity to live independently may lead to a reluctance to entrust responsible tasks to the affected person, possibly leading to diminished social acceptance. These findings add a new perspective and support a transition from a treatment approach mainly focused on symptom control towards an approach of psychosocial intervention strengthening social functioning and integration, and by this a capability of reciprocity of patients with mental illness in Vietnam.
were significantly associated with lower help-seeking behaviour (Schnyder et al., 2017). However, data concerning the actual outcome of schizophrenia in Southeast Asian countries and Vietnam is scarce. The International Study of Schizophrenia, which included seven centres in India, China, Hong-Kong, and Japan, reported that overall about 60% of patients improved clinically with treatment and slightly less showed functional improvement. Yet, the differences between the centres were large, ranging from 60% of patients with good or excellent functioning in Agra, India, to only 25% in Beijing, Hong-Kong, and Nagasaki (Holla and Thirthalli, 2015). The second factor, representing the expectation that the depicted person will always be dependent on someone else, was also significantly correlated with higher social distance. Several items that were used to survey the desire of social distance assessed whether the respondent would assign responsible tasks to the described person, e.g., a job or taking care of children. If the individual is perceived as dependent on others him- or herself, it might directly result in a reluctance to trust him or her with tasks demanding responsibility. Additionally, it might affect the willingness to engage in closer relationships, e.g., a dependent person might be considered unfit as a family member in-law. In that context, Vietnamese culture is still strongly influenced by Confucian philosophy, which highlights the importance of cultural reciprocity (Yum, 1988). A perception, that the depicted person will always dependent on help from others without sufficiently recompensing society, could be interpreted as a failure to comply with the fundamental Confucian principle of reciprocity. Another facet to this perception of dependency, might be the belief that the depicted situation is permanent. Both items of the second factor were phrased as expected lifelong conditions, reducing the likelihood of future acts of reciprocity, which might have led to more desire for social distance. Despite this cultural specification, there is some evidence that expected dependency also influences the desire for social distance in other cultural settings (Angermeyer and Matschinger, 2003). Concerning the third factor, positive expectations towards treatment outcome, a vignette-based study conducted by Angermeyer et al. (2016) in Germany and Tunisia found that the perception of a likely recovery from mental illness was associated with more pro-social reactions and less desire for social distance (Angermeyer et al., 2016). In contrast to the study by Angermeyer et al., the third factor, representing positive expectations towards treatment outcome and course of illness, showed no such correlation in this sample. This finding suggests that desire for social distance might not be reduced by merely controlling those symptoms but may remain attached to a person even if symptomatic treatment is available. Even though unlabeled vignettes were used in this study, so that no primary label was given, the depicted symptoms may have elicited a label as severely mentally ill. Yet, a perceived association of symptoms of schizophrenia with reduced social competence and life-long dependency may play a more significant role in Vietnamese context. As to this day, Vietnamese society is predominantly characterised by socio-centric attitudes in contrast to mainly individualistic attitudes found in most Western societies (Lauber and Rössler, 2007). Thus, a fundamental ability to contribute to the family and society and through this ability, being perceived as a respected member of society, might be considered even more relevant in Vietnam. The Vietnamese concept of face (“thể diện”) implies a socially approved image of a person, that is related to belonging to various social groups. The concept of a social face is further associated with concepts of respect, social capital, social influence, pride and dignity. Thus, an emphasis on “keeping ones face” due to being integrated in society and function according to social expectations remains an essential value in Vietnamese societies and the matter of how one is perceived in others eyes (Nguyen, 2015). A perception of neglecting oneself, while reading the vignette depicting a person with schizophrenia, may be linked with the concept of face preserving and could explain the association with more desire for social distance in case of perceived social disintegration.
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