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.
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* 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
1) Psychiatry is unappealing because it makes little use of
medical training.
2) Psychiatrists talk a lot but do very little.
3) Psychiatric Hospitals are little more than prisons.
4) I would like to be a psychiatrist.
5) It is quite easy for me to accept the efficacy of
psychotherapy
6) On the whole, people taking up psychiatric training are
running away from participation in real medicine.
Mean
Score
Before
Course
Mean
Score
After
Course
Significance (p)
.019*
.060
.866
.026*
.520
.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 of
medical and surgical patients.
.412
10) The majority of students report that their psychiatric
undergraduate training has been valuable.
11) Psychiatry is a respected branch of medicine.
12) Psychiatric illness deserves at least as much attention as
physical illness.
13) Psychiatry has very little scientific information to go on
14) With the forms of therapy now available, most
psychiatric patients improve.
15) Psychiatrists tend to be at least as stable as the average
doctor.
16) Psychiatric treatment causes patients to worry too much
about their symptoms.
17) Psychiatrists get less satisfaction from their work than
other specialists.
18) It is interesting to try and unravel the cause of
psychiatric illness
19) There is very little that psychiatrists can do for their
patients.
.026*
.903
.884
.763
1.000
.243
.755
.395
.570
.012*
20) Psychiatric Hospitals have a specific contribution to
make 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.
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
.129
.117
27) If we listen to them, psychiatric patients are just as
human 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 work
with than other patients.
.804
30) Psychiatry is so unstructured that it cannot really be
taught effectively.
31) I would consider a career in psychiatry after completing
my medical undergraduate studies.
32) It is essential to have thorough medical knowledge in
order to work in the field of psychiatry.
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.
.022*
.084
.038*
.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