|Year : 2022 | Volume
| Issue : 3 | Page : 102-109
Attitudes of Indian undergraduate occupational therapy students toward mental health and psychiatry: A cross-sectional survey
Nidhi N Dave, SG Praveen
KMCH College of Occupational Therapy, Coimbatore, Tamil Nadu, India
|Date of Submission||31-Jan-2022|
|Date of Acceptance||03-Oct-2022|
|Date of Web Publication||16-Nov-2022|
Nidhi N Dave
35/1, K. G. Layout, Church Road, K. K Pudur, Coimbatore - 641 038, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: In India, the number of occupational therapy practitioners currently working in mental health settings is lower than most other specialties. The attitudes of students influence their interest in any field and their desire for working in it. Objectives: The objective of this study was to examine the attitudes of Indian undergraduate occupational therapy students toward mental health and psychiatry, and to explore the differences in attitudes across different years of study, gender, resulting from personal experiences, and educational coursework, and to examine if the attitudes influence future career choices. Study Design: This was a cross-sectional survey. Methods: Permission was obtained from heads of institutions of 14 occupational therapy colleges and the survey link was sent. In order to obtain a representative sample, the link was also shared on social groups. The purpose of the study, voluntary participation, and confidentiality were explained on the landing page. The subsequent sections consisted of the demographic questionnaire, the Attitudes toward Psychiatry-30 (ATP-30) Questionnaire, and the Career Preference Questionnaire. A total of 402 responses were obtained within the stipulated period. Statistical analysis was performed, and the odds ratio using logistic regression and Pearson's correlation coefficient were determined. Results: Gender and contact with persons with mental illness were significant predictors of positive ATP. Females are 5.387 times more likely to have positive ATP (odds ratio [OR] = 5.387, 95% confidence interval [CI]: 2.101–13.814, P = 0.000). Furthermore, those in contact with persons with mental illness are 2.883 times more likely to have positive ATP (OR = 2.883, 95% CI: 1.076–7.724, P = 0.035). Moderately high positive correlations existed between ATP and career preference in psychiatry. Conclusions: Overall, positive attitudes were found. Significant correlations were seen across the domains of the ATP-30 and career preference in psychiatry. Female students are five times more likely to have positive attitudes than male students. Those in contact with persons with mental illness were almost thrice more likely to have positive attitudes than those without any contact.
Keywords: Attitudes toward Psychiatry, Career Preferences, Indian Undergraduate Occupational Therapy Students
|How to cite this article:|
Dave NN, Praveen S G. Attitudes of Indian undergraduate occupational therapy students toward mental health and psychiatry: A cross-sectional survey. Indian J Occup Ther 2022;54:102-9
|How to cite this URL:|
Dave NN, Praveen S G. Attitudes of Indian undergraduate occupational therapy students toward mental health and psychiatry: A cross-sectional survey. Indian J Occup Ther [serial online] 2022 [cited 2023 Feb 6];54:102-9. Available from: http://www.ijotonweb.org/text.asp?2022/54/3/102/361346
| Introduction|| |
The National Mental Health Survey of India (2016) findings indicate that the weighted lifetime prevalence of mental morbidity is 13.67%. Inaccessibility of mental health services, lack of awareness of mental health at multiple levels, the lack of acceptance of neurodivergence as a normal human experience, the violence against people with mental illnesses, and the stigma are significant causes of misery and impairment for the mentally ill, their families and friends, and the society at large. Psychiatric patients, mental illness, and psychiatry are still stigmatized and viewed negatively by the general public and medical professionals. Stigma and prejudices also influence young people's study and career choices. Mental health, especially psychiatry, is not a specialty that health-care professionals highly prefer.
As per the Mental Health ATLAS 2017 (Published by the WHO)-Member State Profile for India, per 1,00,000 population, there are 0.29 psychiatrists, 0.80 mental health nurses, 0.07 psychologists, 0.06 social workers, and 0.03 occupational therapists. Several factors, such as low pay, role blurring, the ambiguity of the occupational therapist's role in mental health, lack of research evidence concerning the practice of psychosocial occupational therapy, and limited work opportunities, are known to influence the choice of practice areas. Studies have also found that because of poor psychosocial fieldwork experiences, occupational therapy students were less likely to choose mental health practice. Findings also suggest that the number of occupational therapists working in mental health in India is relatively lower than in other practice areas.
The current mental health demands cannot be fulfilled exclusively by medical experts. With a shift from the biomedical model to the biopsychosocial model, the focus of comprehensive health care has expanded from mere symptomatic relief to broader aspects, including functional recovery and enhancement in quality of life. Occupational therapists are an integral part of the mental health-care delivery system, focusing on functional recovery. Despite their significant and unique role, they find no mention in the Indian Mental Healthcare Act, 2017.
Indian undergraduate curriculum has psychology, psychiatry, and occupational therapy in psychiatry as core subjects with dedicated theory and clinical hours. The student's underlying beliefs and attitudes, abilities, and personality attributes serve as the matrix onto which academic and clinical instruction is superimposed. Having a positive attitude is essential for students and recent graduates who rely on their personal experiences, stereotypes, and prejudices to guide their interactions with patients and manage patients with mental health comorbidities. In contrast to medical students, no information regarding Indian occupational therapy students' attitudes toward mental health and psychiatry is available. This study explores the attitudes of Indian undergraduate occupational therapy students and their influence on future career choices.
| Methods|| |
The research work was planned, conducted, and reported, adhering to the “Declaration of Helsinki” guidelines.
A cross-sectional, online survey design was adopted. Convenience sampling and snowball sampling techniques were used to approach the subjects. The study included students currently enrolled in the bachelor of occupational therapy (BOT) program in any Indian college/university (II year and above) and interns, and excluded students who did not provide voluntary consent to participate in the study, those who had discontinued the course, and those with prolonged absence/break of study.
The survey instrument consisted of the demographic questionnaire, the Attitudes toward Psychiatry-30 (ATP-30) Scale by Burra et al., and the Career Preference Questionnaire. The demographic questionnaire consisted of questions to obtain identifying information such as age, gender, current year of study, level of exposure to psychiatry/psychology as a subject in the academic program, and the duration of contact with family members who have/had any psychiatric/mental illness if any.
The ATP-30 Scale by Burra et al. is a 30-item ordinal scale. It has been widely used in attitudinal studies involving medical, nursing, physiotherapy, and occupational therapy students, with established psychometric properties. For a sample of occupational therapy students, Burra et al. have found the split-half reliability as 0.94 and the test–retest reliability between 0.67 and 0.89. The range item-total correlation ranged between 0.10 and 0.64. The median item-total correlation is 0.38. The authors also state that the instrument has adequate face, concurrent, and construct validity. In response to the 15 positively worded and 15 negatively worded statements, respondents are asked to mark their agreement or disagreement toward each statement on a five-point scale. The score is reversed for each positively worded statement by subtracting the marked choice from 6. The total score is calculated by adding together the scores of all 30 statements. A higher score on the ATP-30 indicates more favorable/positive attitudes. With 90 as the logical neutral point, scores below 90 indicate negative attitudes, and scores above 90 indicate positive attitudes.
In the Career Preference Questionnaire which was used specifically for this study, an open-ended question: “What is your preferred future career choice?” was asked. In addition, the respondents were asked to rate their preferences for each of the practice areas, on a scale of 1–10, where 0 indicated the least preferred choice and 10 indicated the most preferred choice for each of the practice areas, namely rehabilitation, pediatrics/developmental disabilities, neurology, mental health/psychiatry, orthopedics, hand, musculoskeletal, geriatrics, oncology, and others (e.g., public health, burns/plastic surgery).
“Declaration of Helsinki” guidelines were reviewed, and due permission was obtained from concerned authorities. Heads of institutions/department heads from various parts of India (14 institutions) were approached via electronic mail, and the purpose of the study was explained. A link to the survey was sent in the same E-mail, and a request to circulate the same among the students meeting the inclusion criteria was made. To have a representative sample, the link to the survey was also circulated in various social groups in which occupational therapy students are members. The participants receiving the link were informed regarding the study, voluntary participation, and confidentiality. They were also given a choice not to mention their names for anonymity. The responses obtained were maintained securely in a password-protected electronic format.
| Data Analysis and Results|| |
Statistical analysis was done using IBM SPSS Statistics for Windows, Version 20 (IBM Corp., Armonk, N.Y., USA). Independent t-test, ANOVA, Pearson's correlation, Chi-square test, and logistic regression were used.
A total of 402 responses were obtained, out of which 76.4% (N = 307) were from females, and 23.65 (N = 95) were from males. The total ATP-30 score for the entire sample ranged between 72 and 145, with a mean score of 112.35 (standard deviation [SD] = 14.165). The scores ranged between 83 and 139 for males, with a mean of 106.76 (SD = 13.502). For females, the scores ranged between 72 and 145, with a mean score of 114.08 (SD = 13.936). The distribution of scores based on year of study and gender is seen in [Table 1]. With 90 as the neutral point of the scale, 4.98% (N = 20) had scores below 90, indicating negative attitudes. Neutral attitudes were shown by 1.24% (N = 5) of the respondents. 93.78% (N = 377) of the students possessed positive attitudes.
|Table 1: Mean Attitudes toward Psychiatry-30 Scores of Respondents Across Various Years of Study in the BOT Program|
Click here to view
The statements on the ATP-30 Scale were mapped on eight domains: psychiatric patients, psychiatric illness, psychiatrists, psychiatry knowledge, psychiatric treatments, psychiatry as a career choice, psychiatric institutions, and psychiatry teaching. The scores are seen in [Figure 1]. Independent t-tests and ANOVA were performed to analyze significant differences among various comparison groups. Significant differences exist between male and female respondents for the total ATP score (t = 4.583, P = 0.000) and the domain scores for attitudes toward psychiatrists (t = 4.318, P = 0.000) and psychiatry as a career choice (t = 4.487, P = 0.000). No significant differences in the total ATP score and domain scores were seen due to the influence of contact with persons with psychiatric/mental illness or due to having had psychology/psychiatry as a subject of the study. No statistically significant differences in attitudinal scores were seen among students across different years of study [Table 2].
|Figure 1: Comparison of ATP-30 Domain Scores of Male and Female Respondents|
Click here to view
|Table 2: Comparison of Psychiatry Career Preference Scores of Respondents Based on Various Comparison Groups|
Click here to view
The mean and SD for the “psychiatry” specialty preference are 8.20 and 1.98, respectively, on the Career Preference Questionnaire [Figure 2]. No statistically significant differences, accountable to differences in gender, year of study contact with persons with mental illness, or psychology/psychiatry as a subject of study, exist for psychiatry as a career preference, as measured by the Career Preference Questionnaire.
|Figure 2: Career Preference Rating for Specialty Areas on the Career Preference Questionnaire|
Click here to view
The correlation of ATP-30 total score and subscale scores with outcome variables: “I would like to be a psychiatrist/occupational therapist working in psychiatry” (ATP-30 item) and “career preference in psychiatry” (measured by the Career Preference Questionnaire) is seen in [Table 3]. Statistically significant correlations exist for both the outcome variables with the total ATP score and most of the domain scores. Both the outcome variables show the moderate levels of positive correlation with the “psychiatry as a career choice” domain.
|Table 3: Correlation of Attitudes toward Psychiatry-30 Total Score and Subscale Scores with Outcome Variables|
Click here to view
Chi-square analysis was done to find the association between attitude toward psychiatry and career interest in psychiatry, with gender, contact with person(s) with mental illness, and psychiatry as a subject of study. A significant association was found between gender differences and attitude toward psychiatry (χ2 = 15.425, significant = 0.000). The findings from the logistic regression analysis suggest that females are 5.387 times more likely to have positive ATP (odds ratio [OR] = 5.387, 95% confidence interval [CI]: 2.101–13.814, P = 0.000). Furthermore, those in contact with persons with mental illness are 2.883 times more likely to have positive ATP (OR = 2.883, 95% CI: 1.076–7.724, P = 0.035) [Table 4].
| Discussion|| |
Attitudes toward Psychiatry
A significant majority of the respondents possess positive attitudes. The mean ATP-30 score for the respondents was 112.35 (SD = 14.165), which is very similar to the results of Burra et al., and Gilbert and Strong, who have examined the attitudes of occupational therapy students in Canada and Australia, respectively. Compared to medical and physiotherapy students, the ATP-30 mean score for the current sample is significantly higher.,,,,, This is a positive finding for occupational therapy education, and can be attributed to the curriculum and methodology adopted in OT education. Out of the total 402 responses obtained, the majority of the responses (76.4%) were from females. This can be explained by the fact that the profession of occupational therapy has gender disparity, with more preference among females. Similarly, when the responses received were compared for the year of study, the least number of responses were obtained from II BOT students. Based on an understanding of the undergraduate occupational therapy curriculum in India, it is seen that exposure to the subjects of psychiatry and occupational therapy in psychiatry is mainly in the 3rd and 4th years of study. The word “psychiatry” in the survey title could have possibly dissuaded the 2nd-year BOT students from responding in larger numbers. A small portion of the sample (2%, N = 8) stated that they did not have psychology/psychiatry/mental health as a subject of study until the time of responding to this study. In contrast, a vast majority (98%) of the respondents had undergone some form of coursework in this area. The occupational therapy coursework in India has psychosocial elements right from the preclinical phase. Thus, a majority of the students have had exposure to psychology/psychiatry/mental health even in their initial years of education.
Significant differences were found in attitudes toward psychiatrists, psychiatry as a career choice, and the total ATP-30 score between male and female respondents. This is in significant agreement with the findings of previous researchers.,,,, The possible explanation for this could be that females place a higher value on relational-emotional characteristics, likely due to the unique role that women continue to play in society.
Previous researchers have shown a progressive increase in positive attitudes from the initial years to the final year of undergraduate education. In this study, no such statistically significant trends were observed. However, the highest mean score (113.17) was seen for the 3rd-year BOT students. This finding is not in agreement with the results of Burra et al., who have found that occupational therapy students who were exposed to a series of lectures in psychiatry as a part of their coursework showed no significant improvement in the ATP-30 score, in comparison to the scores obtained before the coursework. However, the present results are similar to the findings of Balhara and Mathur, who found 3rd-year nursing students who underwent coursework in psychiatry to have the most positive attitudes. Psychiatry is mostly a major subject in the 3rd year of the BOT program. The immediate influence of this coursework is a probable reflection on the ATP-30 score.
Comparing domain scores and total ATP scores between respondents with and without psychology/psychiatry subjects shows no statistically significant differences. This is in stark contrast to the findings from previous studies.,,, However, this result was likely due to the vast difference in numbers (only 2% of the respondents stated the lack of education in psychology/psychiatry).
22.9% of the respondents had been in contact with a family member or relative who had/have any form of psychiatric/mental illness. However, this personal exposure did not significantly influence their attitudes. This is in contrast to the findings of previous researchers., As a part of the questionnaire, respondents were also asked to indicate the duration of contact. The responses were highly inconsistent and incomplete. Hence, this factor could not be analyzed statistically and requires further investigation.
As a part of the Career Preference Questionnaire, participants were asked an open-ended question, “What is your preferred career choice?” Most respondents gave multiple responses.
Quantitatively, respondents were asked to rate their career preferences for various specialty areas on a 10-point scale. Interestingly, the specialty which received the highest rating was psychiatry, with a mean of 8.2. This could be attributed to the title of the study and social desirability bias. It is also well known that positive attitudes are linked with an increased likelihood of practicing in a specialty. For this sample under study, which has moderately high positive attitudes, the high ratings for psychiatry as a career preference could be associated with the positive attitudes. However, logistic regression analysis for the outcome variable “I would like to become a psychiatrist/occupational therapist working in psychiatry” did not identify this as a significant predictor.
Analysis using Pearson's correlation showed statistically significant correlations among the various domains with both “I would like to be a psychiatrist/occupational therapist working in psychiatry” and the score of career preference in psychiatry on the Career Preference Questionnaire taken as outcome variables. Moderately positive correlations were found for both the outcome variables with the domain of “psychiatry as a career choice” as measured by the ATP-30. It can thus be understood that those with positive ATP as a career choice are more likely to choose a career in psychiatry.
Chi-square analysis was done to understand the association between attitude toward psychiatry, career interest in psychiatry, gender, contact with person(s) with mental illness, and psychiatry as a subject of study. For analysis, the outcome variable attitude toward psychiatry was split as a dichotomous variable: positive and negative attitudes, with 90 as the neutral point of the scale. Similarly, the outcome variable of liking a career in psychiatry was also split into a dichotomous variable, as done in the studies by Farooq et al. and Ong et al. A significant association was found only between gender and attitude toward psychiatry.
Logistic regression analysis was performed to understand the influence of the covariates such as gender, year of study, psychiatry as a subject of study, and contact with persons with mental illness, on attitude toward psychiatry and liking a career in psychiatry. Female students are 5.387 times more likely to have a positive attitude toward psychiatry than male students. These findings highlight the requirement for exploring the various factors to which this could be attributed and also the need for sensitization among male students. Students who are/were in contact with persons with mental illness are 2.883 times more likely to have positive ATP. Exposure to persons with mental illness as a part of the coursework can also positively influence students' attitudes, concordant to the findings of Norris et al. Attitudes are likely to shape professional practice in all areas of practice, and not just mental health. Hence, student experiences during their undergraduate training period should be planned and designed to facilitate skill acquisition and shape and mold their attitudes and personality in a holistic sense.
Implications for Occupational Therapy Education
All facets of the educational environment, including the value of good clinical teachers, the educational setting's conduciveness, self-perception of learning opportunities, the atmosphere, and social self-perception, significantly influence attitude formation. Kuhnigk et al. found that a problem-based learning curriculum was associated with higher positive attitudes, especially among male medical students. Similar strategies can be implemented in occupational therapy education, where feasible. The attitudes that tomorrow's occupational therapists will carry shall influence how they care for their patients with mental illnesses and relate to, and work with, psychiatrists. Organized efforts put in by academicians and clinical educators ensure that the experiences gained by students in their formative years shape their careers in a positive direction.
Limitations and Recommendations
Although several institutions were approached and links to the survey were sent to all students meeting the selection criteria, the response rate was lower than expected. The sample, despite being representative, is limited in size. This was a self-administered online survey with the option for anonymity. Despite the same, there was a high likelihood for response bias/social desirability bias. The ATP-30 Questionnaire used in this study is piloted for medicine and occupational therapy students and has also been used for students of health-care disciplines. However, it is more aptly worded for medical students. The existing ATP-30 Scale can be modified, or a specific questionnaire can be developed for occupational therapy students for future research. Similarly, a career preference questionnaire can be developed and standardized for use in the occupational therapy profession. A pre–post type of study design can help determine the impact of educational programs in shaping students' attitudes. Differences in attitudes with diversity in caste, class, sexuality, their own experiences of their own mental health, religion, indigeneity, etc., could also be explored in the future. This study offers a snapshot, as do all cross-sectional research designs. It would be interesting to track this group of students over time to see how they have changed and what career paths they have chosen in the future. Qualitative research such as focus group discussions with open-ended questions can help identify specific factors influencing occupational therapy students' career choices.
| Conclusions|| |
Overall, the attitudes of Indian undergraduate occupational therapy students toward mental health and psychiatry are positive. Significant differences attributable to gender are noted. Females have more positive attitudes than males. It is also seen that females are 5.387 times more likely to have positive attitudes than males. Differences in attitudes resulting from personal experiences are not observed in the overall ATP-30 scores. However, those in contact with mentally ill relatives or patients are 2.883 times more likely to have positive attitudes than those without any contact. No significant differences in attitudes are seen due to differences in the year of study or due to educational coursework/clinical postings in psychiatry. In general, the preference for psychiatry as a career choice is high, and a modest positive correlation is found between the attitudes and career preferences.
We would like to thank the heads of institutions for their kind permission to conduct this study and the students who voluntarily participated in the study.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
Presentation: Presented at the 59th Annual National Conference of AIOTA, Virtual OTICON' 2022.
Award: Won Vijay Suple Award for Best Scientific Paper in Mental Health in Virtual OTICON 2022
| References|| |
Gautham MS, Gururaj G, Varghese M, Benegal V, Rao GN, Kokane A, et al.
The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity. Int J Soc Psychiatry 2020;66:361-372.
Probst M, Peuskens J. Attitudes of Flemish physiotherapy students towards mental health and psychiatry. Physiotherapy 2010;96:44-51.
Paul S. Mental health: An endangered occupational therapy specialty? Am J Occup Ther 1996;50:65-68.
Acharya VA. Psychosocial occupational therapy practice in India: Where is the evidence? A review of IJOT publications. Indian J Occup Ther 2013;45:8-12.
Christie BA, Joyce PC, Moeller PL. Fieldwork experience, Part I: Impact on practice preference. Am J Occup Ther 1985;39:671-674.
Samuel R, Jacob KS. Occupational therapy in India: Focus on functional recovery and need for empowerment. Indian J Psychiatry 2017;59:242-246.
] [Full text]
Duffy RM, Kelly BD. Concordance of the Indian Mental Healthcare Act 2017 with the World Health Organization's Checklist on Mental Health Legislation. Int J Ment Health Syst 2017;11:48.
Warnke I, Gamma A, Buadze M, Schleifer R, Canela C, Strebel B, et al.
Predicting medical students' current attitudes toward psychiatry, interest in psychiatry, and estimated likelihood of working in psychiatry: A cross-sectional study in four European countries. Front Psychiatry 2018;9:49.
Connaughton J, Gibson W. Physiotherapy students' attitudes toward psychiatry and mental health: A cross-sectional study. Physiother Can 2016;68:172-178.
Hooblaul M, Cobbing S, Daniels KJ. The knowledge, attitudes and perceptions of physiotherapists in KwaZulu-Natal, South Africa, towards mental health. S Afr J Physiother 2020;76:1483.
Bhise MC, Marwale AV, Deshmukh AS, Saoji SG. Impact of differences in psychiatry curriculum of undergraduate medical and physiotherapy students on their attitude towards psychiatry. Indian J Psychiatry 2016;58:208-211.
] [Full text]
Kuhnigk O, Hofmann M, Böthern AM, Haufs C, Bullinger M, Harendza S. Influence of educational programs on attitudes of medical students towards psychiatry: Effects of psychiatric experience, gender, and personality dimensions. Med Teach 2009;31:e303-e310. Available from: https://doi.org/10.1080/01421590802638048
. [Last accessed on 2021 Sep 09].
Balhara YP, Mathur S. A comparative study of attitudes toward psychiatry among nursing students across successive training years. Indian J Psychol Med 2013;35:159-166.
] [Full text]
Poreddi V, Thimmaiah R, Math SB. Attitudes toward people with mental illness among medical students. J Neurosci Rural Pract 2015;6:349-354.
] [Full text]
Farooq K, Lydall GJ, Malik A, Ndetei DM, ISOSCCIP Group, Bhugra D. Why medical students choose psychiatry – A 20 country cross-sectional survey. BMC Med Educ 2014;14:12.
Ong HL, Seow E, Chua BY, Xie H, Wang J, Lau YW, et al
. Why is psychiatric nursing not the preferred option for nursing students: A cross-sectional study examining pre-nursing and nursing school factors. Nurse Educ Today 2017;52:95-102. Available from: https://www.sciencedirect.com/science/article/pii/S026069171730045X
. [Last accessed on 2021 Aug 16].
Norris S, Bunger T, Courchesne K, Smith KA, Willoughby MM. Future of mental health occupational therapy: Student perspective and concerns. Occup Ther Health Care 2007;21:239-253.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]