Social cognitive elements of mental illness stigma among healthcare professionals currently working in general hospitals: A cross‐sectional study from Jordan

Abstract Aim To assess the social cognitive elements of the stigma of mental illness (knowledge, attitudes and behaviours) among healthcare professionals (HCPs) in Jordan. Design A cross‐sectional descriptive design. Methods A total of 206 HCPs were conveniently recruited from general hospitals in Jordan. The mental attitude, knowledge and intended behaviours scales were used to measure stigma elements. Results Participants reported a moderate level of knowledge, a moderate negative attitude and a moderate or not greater interest to deal with people with mental health illnesses. The bivariate correlation revealed a negative significant correlation between HCPs' knowledge and attitude, indicating that HCPs with more knowledge significantly have more positive attitude (lower average score) towards those suffering from the illness. A more significant correlation was found between HCPs' knowledge and behaviour. The HCPs who had more knowledge were holding more interest and willingness towards dealing with persons with mental illness. Patient or Public Contribution Negative attitudes among HCPs demand awareness programmes pertaining to the stigma of mental illness to afford higher standards of practice for patients with mental problems.

illness appears in two main forms. Public stigma refers to the perception of negative stereotypes of people with mental illness by public (Angermeyer & Dietrich, 2006), whereas self-stigma occurs when persons with mental illnesses concur with and internalize such negative stereotypes (Corrigan et al., 2006;Livingston & Boyd, 2010).
Evidence has shown that stigma perceptions among HCPs could vary considering the mental healthcare contexts and personal and public attitudes surrounding mental illnesses.
Studies showed that HCPs working at general hospitals reported poor skills and knowledge of mental health issues resulting in uncertainty and a perception of dangerousness when caring for mentally ill patients (Giandinoto & Edward, 2015). The false or negative perceptions among HCPs that stigmatizes the mentally ill as dangerous, unpredictable, violent, and bizarre may give rise to fearful attitudes.
Therefore, HCPs may engage in avoidance behaviours to minimize the perception of dangerousness (Giandinoto & Edward, 2015).
Despite HCPs' contact with patients with mental illness and the belief that mental health care is an essential component of holistic patient care, HCPs reported negative attitudes and stereotypes towards patients with mental illness (Gronholm et al., 2017). Such negative attitudes may negatively impact the quality of care provided leading to a poor quality of life of patients (Gronholm et al., 2017).
Of further concern is the quality of care and the consequences of negative attitudes on HCPs and services users.
Stigma perpetuated by HCPs against clients with mental illnesses has been conceptualized as an overarching social cognitive term of three components: ignorance (problems of knowledge), prejudice (problems of attitude) and discrimination (problems of behaviour; Thornicroft et al., 2007). Healthcare professionals often hold negative stigmatizing perceptions, attitudes and behaviours towards clients with mental illnesses (Gronholm et al., 2017;Thornicroft et al., 2007).

| Stigma associated with mental illness: Perceptions from Jordan
In Jordan, patients with mental illness and their families suffer from the stigma associated with their illness Rayan & Aldaieflih, 2019). Stigma among people with mental illness coupled with negative attitudes and behaviours of HCPs would hinder those people to seek mental health care services (Al Ali et al., 2017;Dalky et al., 2020;Hamdan-Mansour & Wardam, 2009). This explained why the majority of Jordanian patients tend to use informal or traditional health services instead of formal ones (Al Ali et al., 2017).
Stigma does not serve only as a barrier to access and utilize mental health services, but it has a significant impact on patients and their family caregivers in terms of quality of life (Dalky, 2012;Dalky et al., 2017). To the researcher's knowledge, few research studies have been conducted in Jordan to address experiences of stigma among HCPs while caring for patients with mental illness (Dalky et al., 2020;Hamdan-Mansour & Wardam, 2009). Few if no study has been conducted or targeted hospital-working HCPs (physicians and nurses). Therefore, this study aimed to assess the levels of social cognitive stigma elements (knowledge, attitudes, and behaviours) among hospital-working HCPs and to identify factors that correlate with or possibly predict those elements. In this study, hospitalworking healthcare professionals are nurses or physicians who are currently working in general hospitals in Jordan.

| Social cognitive theoretical model of stigma
Conceptually, stigma has a long history in social science.
Goffman ' (1963) book, "Stigma: Notes on the Management of Spoiled Identify," is seen as a classic example of research into the consequences, nature of and sources of stigma (Link et al., 2004).
As a term, "mental illness stigma" is not limited to one definition and varies in meaning and conceptual definitions among scientists (Link et al., 2004). Furthermore, a variety of contexts and populations have been tested using multiple theoretical models.
Three paradigms have been identified in the literature that try to explain stigma: the sociocultural perspective, the motivational perspective and the social cognitive theories (Crocker & Lutsky, 1986).
According to the sociocultural perspective, stereotypes and other stigmatizing beliefs and cognitions are functions of the culture; the stigma of mental illness is transmitted from one generation to another through the process of socialization. According to the motivational perspective, prejudice or other certain beliefs about a stigmatized group have individual origins. In addition, in the social cognitive theories, stereotypes are considered normal responses to the cognitive operations.
In this study, the authors utilized Thornicroft et al. (2007) social cognitive theory of stigma to guide the definition and measurement of stigma perception. Accordingly, stigma is defined in terms of knowledge, namely ignorance; attitude, or more exactly prejudice and behaviour, more specifically discrimination (Thornicroft et al., 2007). In effect, stigma manifests because of inaccurate knowledge regarding mental issues, which in turn allows negative attitudes to develop in the individual. This negativity consequently causes unacceptable behaviour, for example discrimination.
This can be further illustrated. False beliefs about the mentally ill, for example, they pose a danger, may result in negative attitudes towards those people. In turn, this results in behavioural response or discrimination. For example, "I will not allow dangerous people to get close to me." The instruments developed by Thornicroft and colleagues (Evans-Lacko et al., 2010;Evans-Lacko et al., 2011;Gabbidon et al., 2013); are being used in this study to assess knowledge, attitudes, and reported or intended behaviours for a sample of HCPs in selected general hospitals in Jordan.

| Design and sample
A cross-sectional descriptive design was used to assess the components of stigma; knowledge, attitudes, and behaviours. The study adhered to the STROBE guidelines (Cuschieri, 2019) for cross-sectional studies. A convenience sample of 206 HCPs (physicians and nurses) were recruited from general hospitals in Jordan from June 2020 to June 2021. Data collection duration time extended due to the COVID-19 pandemic and the restrictions it imposed in the healthcare system and working duties. The names of hospitals are kept confidential. The sample size was determined using G-power analysis 3.0.10 using the Pearson correlation coefficient test with large effect size of 0.3, power of 0.90 and alpha at 0.05 two-tailed level significance. The least needed sample size was 196. To compensate for possible response rate, 240 HCPs were approached and 206 returned the completed survey with a response rate of 86%. The criteria for inclusion were any physician or nurse working in a general hospital in Jordan and able to comprehend Arabic.

| Procedure
Approvals for conducting the study were obtained from the institution review committees at the authors' academic institution (Ref.: 10/124/2019). Data were collected using an electronic (online) format of surveys. The study, its purpose and significance of the research were announced via networking and social media. Information relating to the title, confidentiality, information privacy and anonymity of the survey was also included. Respondees who agreed to participate were provided with the link to the online survey, and the contact information of the researchers was also shared in case participants wished to make inquiries or ask related questions. A digital consent form was enclosed in the online survey which the HCP had to sign in order to be linked to the original surveys. Collected electronic information was saved to a password-secured computer.

| Study instruments
The participants reported their demographic data (age, gender, marital status, educational level, specialization, years of experience, previous training and education in mental health), in addition to their knowledge, attitude and behaviour.
To measure the HCPs' knowledge about mental illness, the mental health knowledge Schedule (MAKS) was administered (Evans-Lacko et al., 2010). The MAKS is a 12-item tool. The first 6 items measure stigma-related mental health knowledge on a 5-point Likert scale ranging from 1 = totally disagree to 5 = totally agree. The other 6 items (7-12) assess opinions about which conditions are types of mental health problems, measured on 3-point responses. The total score is the sum of the responses to the first 6 items and ranges from 6 to 30 to which, a higher score indicates more knowledge. The MAKS is of a good test-retest reliability evidence 0.71 (Evans-Lacko et al., 2010).
The Mental Illness: Clinicians' Attitudes-version 4 (MICA v4; Gabbidon et al., 2013) was used to measure the attitudes of HCPs towards clients with mental illness. It is a 16-item scale on a 6-point Likert scale ranging from 1 = totally agree to 6 = totally disagree.
Scores range from 16 to 96; lower score means less stigma. The MICA v4 was found to have good internal consistency (α = 0.72) and item-total correlations (Gabbidon et al., 2013).
The Reported and Intended Behaviour Scale (RIBS) is used to measure the reported and intended behaviours of HCPs towards clients with mental illness (Evans-Lacko et al., 2011). RIBS examines four contexts of intended and reported behaviour, namely those living with, working with, living nearby and having a relationship with a person suffering mental health issues. RIBS is an 8-item survey. In the first four items, the prevalence of the four previously mentioned contexts is assessed, while the second four items examine the intended behaviour in the same contexts. It is important to note that because the respondents' experience of the behaviours in items 1 to 4 may vary the data is not included in the final score and is instead used only for measuring prevalence (Evans-Lacko et al., 2011). Items 5-8 were measured on a 5-point Likert scale. Total score ranges from 4 to 20; a higher score indicates greater willingness to contact people with mental illness. The RIBS overall test-retest reliability was 0.75 (Evans-Lacko et al., 2011). For this study, the mentioned stigma-components scales have been previously tested and evaluated and the Arabic versions by Dalky et al. (2020) were used.

| Data analysis
Data analysis was conducted using the IBM-SPSS 25. Descriptive statistics was carried out initially before conducting the main analysis. The variables (MICA v4, MAKS and RIBS) were assessed for normality, sample mean and standard deviation. To assess the association between variables, including characteristics relating to demographics, Pearson's correlations were conducted.
A series of t-tests for two independent samples and ANOVA were conducted to detect the differences in study variables (knowledge, attitudes and behaviours) based on participants' characteristics. Further, regression analysis was conducted to identify factors that predict stigma components in this study. Significance level was set at 0.05.

| Knowledge: MAKS
Participants' knowledge about stigma was moderate, with an average score of 42.9 (± 4.78), indicating a good understanding of stigma-related mental health. The lowest score was reported concerning grieves and stress, 2.47 (± 1.3) and stress 2.11 (± 1.22) respectively (  (Table 3) and a range between (21 and 70). A high negative attitude (Mean > 3.5) was indicated in 8 out of 16 items of the survey. The highest negativity was reported in item "Health/social care staff know more about the lives of people treated for a mental illness than do family members and friends" (means score 4.69, ±1.21).
Another high negativity score was reported in item "Being a health/ social care professional in the area of mental health is not like being a real health/social care professional" (means score 4.27, ±1.34).
On the other hand, least negativity score was reported in item "It is important that any health/social care professional supporting a person with mental illness also ensures that their physical health is assessed" (Mean score 2.09, ±1.24) ( Table 3).

| Behaviours: RIBS
The average score of the behaviour scale was 13.91 (±3.48), which indicated a moderate or not greater interest to deal with people with mental issues. This average score in behaviour could be related to the fact that half of the participants (48.5%) are currently working with such patients, and 48 (40%) of participants live with relatives with mental illness.

| Bivariate analysis
The bivariate correlation revealed no significant correlation between stigma and age. However, negative significant correlation was found between HCPs knowledge and attitude indicating that HCPs with more knowledge were significantly have more positive attitude (lower average score) towards those suffering from the illness. A more significant correlation was found between HCPs' knowledge and behaviour. The HCPs who had more knowledge were holding more interest and willingness towards dealing with persons with mental illness.
Further, t-tests and ANOVA were conducted to assess the differences in perceived stigma based on participants' characteristics (Table 4). Participants with 5 to 9 years of experience significantly had more negative attitudes than other experience categories (p = 0.003). Participants with 10 to 15 years of experience had a more significant interest in mentally ill people. Also, a significant difference in PHCs knowledge and attitude was revealed based on specialty. As such, participants with prior psychiatry training had a significantly higher interest score than those with no training (p < 0.001). No other significant differences were revealed (Table 4).

| DISCUSS ION
Stigma is still a major barrier towards seeking and utilizing healthcare services, in particular concerning mental illness and associated patients. This study emphasized the perception of stigma elements (knowledge, attitudes, and behaviours) among hospital-working TA B L E 1 Sociodemographic characteristics of participants (N = 206).

TA B L E 2
Participants' knowledge about stigma using MAKS (N = 206).

Item Mean (SD)
It is important that any health/social care professional supporting a person with mental illness also ensures that their physical health is assessed  (Dalky et al., 2020).
Indeed, more is needed concerning attitudes towards mental illness and overcoming associated mental health stigma among HCPs. This is a more specialized topic that requires further involvement of HCPs in general healthcare settings while caring for TA B L E 4 Univariate analysis of the association with stigma components and study variables.  One form of stigma that we have found in this study is related to fears to confess having mental illness to their peers and colleagues.
Due to the stigma and negative attitudes, those with mental illness believe that disclosing their issues will result in differential treatment, loss of privileges, loss of responsibilities and even their job. These fears could be related to employment restricted context and difficulties related to management and treatment of mental illness which could influence their opportunities or career development. This is in consistent with other studies that addressed public concerns to disclose their mental illness fearing stigma (Chen et al., 2020;Hudson et al., 2021). HCPs do believe that persons suffering from mental illnesses are often dangerous and HCPs working with such patients do not have the same personality traits as other healthcare professionals. This may increase concerns among HCPs towards willingness to specialize in mental health or working directly with patients with mental illness. Another possible factor to consider for future nursing or medical graduates and their choice to practice or do their residency programme on.
As indicated by the high scores on the MICA scale, HCPs displayed negative attitudes towards mental illness. Similar negative attitudes were reported in a previous Jordanian study among nurses and physicians working in the community outpatient healthcare settings (Dalky et al., 2020). Further, the meta-analysis report by Giandinoto et al. (2018) on mental health attitudes among general hospital staff concluded the existence of high levels of stigma due to inadequate mental health care, lack of skills, poor knowledge and lack of resources. Indeed, earlier intervention studies directed towards stigma reduction concluded that stigma related to mental health issues could be reduced entirely by providing specialized training programmes that are focused on enhancing knowledge, attitudes and behaviours successfully (Giandinoto et al., 2018;Li et al., 2014). In other studies, knowledge linked to mental health care has been combined with behaviour and attitudes, and progress has been achieved in determining the change in knowledge, attitude, and behaviour through training interventions (Petersen et al., 2016;Thornicroft et al., 2016).
Regarding experience, HCPs with longer years of work experience showed significantly lower levels of negative attitudes and higher frequency of positive behaviours towards mental illness compared to others with less experience. On the contrary, a systematic review concluded that HCPs with more years of experience showed higher negative attitudes towards mental illness in comparison to less experienced colleagues and were more pessimistic about the capability of people with mental illness to adhere to treatment protocol and recovery (Vistorte et al., 2018).

| CON CLUS ION
This study evaluated stigma perception among hospital professionals. The results highlighted that HCP reported varied attitudes towards the mentally ill which could be due to prior special knowledge training. This knowledge was predicted to result in positive at- titudes; yet in this study, the majority of HCPs are found to have negative attitudes which also reflect on their intended behaviours.
This negativism raises the need to call for more specialized awareness programmes to tackle stigma and its components pertaining to mental illnesses. Doing so would likely assure higher standards of practice and proper quality of care provided for people with such problems.

AUTH O R CO NTR I B UTI O N S
Conceptualization, methodology and data collection: Heyam F. Writing -review and editing: Heyam F. Dalky and Ayman M. Hamdan-Mansour.

ACK N O WLE D G E M ENTS
We would like to thank all participants who took part in the study and enabled this research to be possible. Special thanks to Rob Miles, Higher Colleges of Technology, Sharjah, UAE for the great help in editing the paper for grammatical and editorial corrections.

FU N D I N G I N FO R M ATI O N
No external funding was required to support this work. The study method, writing of the report and the decision to submit for publication were made by the authors. The contributing members were not paid for their efforts.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request due to privacy/ethical restrictions.

E TH I C S S TATEM ENT
Approvals for conducting the study were obtained from the institution review committees at Jordan University of Science & Technology (Ref.: 10/124/2019).