Medical student attitudes toward mental illness: a cross-sectional study from the Gaza Strip, Palestine

Mental illness is a significant public health concern globally. It affects approximately 25% of the world's population at some point in their lives, with an estimated one billion people suffering from some form of mental illness in the year 2019 [1]. In 2022, there were an estimated 24765 mentally ill patients in the Gaza Strip, with a ratio of 11.3/1000 population [2]. Further, a psychological condition survey in November of 2022 showed that depressive symptoms were common among Palestinian adults (18 years and over), with a higher prevalence rate in the Gaza Strip than in the West Bank (50% and 71%, respectively) [3]. Post-traumatic stress disorder is also more common in the Gaza Strip compared to the West Bank, according to the Palestinian Central Bureau of Statistics (PCBS) [4].

Stigma is defined as “the process by which the reaction of others spoils normal identity.”[5] It implies intolerance and exclusion. Negative attitudes and beliefs about mentally ill patients are common, often due to false stereotypes and a lack of knowledge and understanding of mental illness [6‐8]. False beliefs and myths about mental illness can also lead to patients being viewed as outcasts or "bewitched" [6, 9, 10]. Although the first hospitals in the history of psychiatry were built circa the eighth century in Baghdad, Cairo, and Fes [11, 12], stigma toward mental illness represents a significant issue in the modern Middle East compared to other regions and higher-income countries [13].

The stigma associated with mental illness can have significant negative consequences for individuals with mental health conditions, including structural discrimination, social isolation, limited access to healthcare services, and propagation of self-stigmatization [14]. The impact of stigma extends beyond individuals to affect their families, who may report feeling ashamed of a relative’s mental illness or suffer from discrimination by the community. Family members may also reflect stigmatizing beliefs against their kin, discouraging help-seeking [13]. Stigmatization can also affect healthcare professionals' ability to provide high-quality care to patients with mental health conditions and impact patients’ accessibility. As future providers of healthcare services, medical students' attitudes towards mental illness and mentally ill patients are crucial and could shape how they interact with their patients and the quality of the care they will provide through the course of their careers.

Several studies have examined the attitudes of medical students from different regions and cultures towards mental illness, with varying findings. Nonetheless, there is a dearth of literature on this issue among Palestinian medical students. Medical schools should impart proper attitudes toward mental illness and psychiatric patients and practice. This is especially significant because negative attitudes conveyed by healthcare professionals may impact how well they relate to, communicate with, and care for their patients [15, 16] and may hinder patients' efforts to get help [17]. Additionally, harboring such negative attitudes may result in prolonged waiting times, subpar treatment, verbal or physical abuse [18], and worse prognoses [19]. Therefore, this study aimed to assess the attitudes of Palestinian medical students toward mental illness and to identify factors influencing their attitudes.

Attitude is a theoretical construct that describes a person’s learned tendency to evaluate or perceive something or someone in a certain way [27]. It has affective, behavioral, and cognitive components rooted in individual experiences and cultural exposures. Medical students' attitudes, accumulated throughout their medical education, shape how they interact with mentally ill patients during their careers and the quality of care they can offer. Negative attitudes toward mentally ill people contribute to their feeling of stigma and discrimination [28], which in turn leads to several unwanted psychological outcomes [29, 30] such as withdrawal behavior [30], low self-esteem [30, 31], increasing levels of depressive symptoms [30, 32], and reducing their self-efficacy [32, 33]. Furthermore, some studies found that stigma leads to delays in seeking treatment [34, 35] and lowers patients’ quality of life [31, 36, 37]. Moreover, Pinheiro and colleagues added that mental illness and stigmatization have negative economic effects as are among the leading causes of job loss as they increase the rates of absenteeism, presenteeism, and the number of sick leave days [38].

The current study is the first from Palestine to examine medical students' attitudes toward people with mental illness. The researchers found that four out of five participants fell closer to the positive end of the attitude toward mental illness spectrum. The lack of similar local studies limits the scope for comparisons. Internationally, however, a study from India found that medical students had better attitudes toward mentally ill patients and against separatism and stigmatization than nursing students [39]. Meanwhile, another study from the same country demonstrated neutral attitudes toward psychiatry and mental illness among medical students [27].

On the other hand, other studies from different regions have demonstrated high rates of negative attitudes toward mental illness among medical students. For instance, a recent survey among students of health sciences faculty in Istanbul found high rates of negative beliefs and stigmatization [40]. Another study from southwestern Nigeria also found significant stigmatizing attitudes among medical students towards individuals with mental health conditions [41]. Similarly, Kihumuro [42] and Chukwujekwu [43] reported poor attitudes toward mental illness among medical students in Uganda and Nigeria, respectively. Meanwhile, a comparative study from Qatar and the United States revealed that medical students from Qatar demonstrated less positive attitudes towards mental illness than medical students from the United States who received the same curriculum [44]. Medical schools and health education institutions globally should address this cultural issue and design programs that facilitate a shift towards more favorable attitudes.

In our study, male sex and having a friend or a family member suffering from mental illness were significantly correlated with better attitudes. The association with sex is not unusual and other studies have previously demonstrated significant correlations with either male [40] or female sex [45], although others found no such correlations [27]. Similarly, familiarity with mental illness, such as having a personal experience or a friend or relative with a history of mental illness, has also been linked to better attitudes in other studies [45]. This is not unexpected since, as mentioned earlier, personal experiences play a central role in shaping perceptions and modifying attitudes.

The results revealed no significant differences in attitude between students from the basic science versus clinical phases. Also, the results did not show significant differences in medical students’ attitudes between students who have had the clinical psychiatry course and those who have not. In this regard, a study from Australia reported a significant decrease in negative views toward mental illness among fourth-year medical students after the psychiatry clerkship [46]. Similar findings were reported in India [45]. On the other hand, a study on 1372 students from 12 Chinese medical schools found that education did not increase non-stigmatizing attitudes among participants [47]. Stigma is a byproduct of the triad of ignorance, discrimination, and prejudice [48]. Medical schools are tasked with ameliorating the third component (prejudice) by addressing the lack of knowledge and the culture of discrimination at the individual and systematic levels. They also have the advantage of instilling positive attitudes in younger generations. The absence of a significant correlation between students having undergone the psychiatry rotation and developing more positive attitudes calls for revising current medical curricula and teaching methods to address this lacune in training.

Mental health is an indispensable aspect of contemporary medical services. Thus, adequate numbers of well-trained and skilled personnel must be available to guarantee high-quality services. In this regard, the Gaza Strip is particularly poorly equipped, as there is a single psychiatric hospital and only a handful of psychiatrists [49, 50]. Stigmatization of mental illness may negatively impact the future preferences of medical students. While a recent meta-analysis of studies from seven Eastern Mediterranean countries found that medical students demonstrated an overall positive attitude towards the psychiatry discipline, psychiatry was absent from the list of preferred specialties for medical doctors and students from Gaza who were surveyed in 2018 [51, 52]. This further underscores the need for a fundamental change, starting with appropriate knowledge and leading to better practice and proper culture.

This study’s findings should inspire further studies among other health sciences students and graduate doctors in Palestine to formulate a clearer picture of the prevalence and magnitude of stigma in the country. Subsequently, based on evidence derived from prevalence surveys such as the present study, specific interventions should be implemented, and their impacts should be evaluated regularly. Possible interventions include mental health literacy campaigns, contact-based strategies, and peer support and supervision [53]. Also, to guide such interventions, other studies are encouraged to investigate the cultural, social, and religious beliefs contributing to the negative stereotypes.

The strengths of this study include its stratified random sampling method, large sample size, and meticulous data collection with minimal missing information. Additionally, it is the first such study from Palestine, and it employed a well-validated tool in assessing medical students’ beliefs towards mental illness. This study is not without limitations, however. It surveyed students from a single university, limiting the generalizability of the results. Additionally, the cross-sectional design prevents inferring causal associations from the findings.

Medical students are not absolved from the negative stereotypes of the community towards mentally ill patients, and they may carry these convictions into their professional lives. Medical schools should attempt to systematically mitigate this cultural and ethical issue and equip students with the appropriate knowledge and exposure to ensure higher levels of healthy attitudes toward mental illness.