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International Journal of Culture and Mental Health

ISSN: 1754-2863 (Print) 1754-2871 (Online) Journal homepage: http://www.tandfonline.com/loi/rccm20

Public perception of mental illness in Oman: a


cross sectional study

Mohammed Al-Alawi, Hamed Al-Sinawi, Samir Al-Adawi, Lakshmanan


Jeyaseelan & Sathiya Murthi

To cite this article: Mohammed Al-Alawi, Hamed Al-Sinawi, Samir Al-Adawi, Lakshmanan
Jeyaseelan & Sathiya Murthi (2017): Public perception of mental illness in Oman: a cross sectional
study, International Journal of Culture and Mental Health, DOI: 10.1080/17542863.2017.1325916

To link to this article: http://dx.doi.org/10.1080/17542863.2017.1325916

Published online: 24 May 2017.

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Download by: [University of Western Ontario] Date: 05 June 2017, At: 01:39
INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH, 2017
https://doi.org/10.1080/17542863.2017.1325916

Public perception of mental illness in Oman: a cross sectional


study
Mohammed Al-Alawia, Hamed Al-Sinawia, Samir Al-Adawia, Lakshmanan Jeyaseelanb and
Sathiya Murthic
a
Department of Behavioral Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat,
Sultanate of Oman; bDepartment of Statistics and Health Information, Sultan Qaboos University Hospital, Muscat,
Sultanate of Oman; cDepartment of Studies and Research, Oman Medical Specialty Board, Muscat, Sultanate of Oman

ABSTRACT ARTICLE HISTORY


Studies worldwide have shown that people with mental illnesses (PWMI) Received 7 June 2016
tend to be stigmatized and thus suffer social exclusion. The authors Accepted 28 April 2017
investigated the attitudes of Omani people toward PWMI, and classified
KEYWORDS
their responses on the basis of socio-demographic variables (age, Attitude towards mental
gender, place of residence, place and type of employment, and previous illness; survey; online
exposure to PWMI) that were expected to correlate with their research methods; public
perceptions and attitudes towards PWMI. The data were collected by perception; Attitude towards
means of an online cross-sectional survey among the general Omani Mental Illness (AMI)
public, using the Attitude toward Mental Illness (AMI) Questionnaire. The questionnaire; stigma; Oman
online method via social media was selected in view of the high levels
of literacy (93.97%), Internet usage (66.4%), and social media
participation among Omanis. Of the 601 participants, 41.4% were men
and 58.6% were women. The subjects were categorized in the age
groups of 20–30 years (48%) and 31–45 years (46%). Nearly 90% of the
participants were employed, while 10% were college students. The
results indicated that Omanis share the worldwide tendency to harbor
stigmatizing attitudes towards PWMI. The results further suggested that
socio-demographic variables (such as urban–rural dichotomy and
previous encounters with PWMI have significant correlation with
Omanis’ attitudes towards the mentally ill.

Introduction
World Health Organization’s Mental Disorders Fact sheet for 2016 (WHO, 2016) reveals that there
are 478.5 million people worldwide with mental illnesses (PWMI). This figure includes depressive
illnesses (350 million); bipolar affective disorder (60 million); schizophrenia and other psychoses
(21 million); and dementia (47.5 million). This still excludes many millions of sufferers of develop-
mental disorders such as autism, ADHD, and others. There are also studies which suggest that men-
tal illnesses represent 50% of the global burden of disease (Mathias, Kermode, Sebastian, Koschorke,
& Goicolea, 2015). By the year 2020, affective mental illnesses such as depressive disorders are
expected to become the second leading cause of mortality and morbidity after cardiovascular diseases
(WHO, 2012). Due to their dependency and the compromised quality of life, people with mental ill-
nesses often cause significant social and economic burden to the society (Mathias et al., 2015). A
recently published long-term study has reported that the Eastern Mediterranean Region (which
includes the Arab countries) has higher mental disorder burdens compared to global levels (Charara
et al., 2017).

CONTACT Samir Al-Adawi adawi@squ.edu.om; samir.al-adawi@fulbrightmail.org


© 2017 Informa UK Limited, trading as Taylor & Francis Group
2 M. AL-ALAWI ET AL.

A paradox of modernity is that people afflicted with once-feared physical diseases – such as pla-
gue, leprosy, and even AIDS – enjoy vastly improved social inclusion (despite it not being vital to
their recovery), while the mentally ill, for whom social inclusion is an essential part of their therapy
and rehabilitation, are still subjected to ancient prejudices (Al-Adawi et al., 2002). Part of the reason
may be the refractory nature of most mental illnesses and the perceived unpredictability of the
behavior of PMWI, giving the impression of innate character default (Rogers & Pilgrim, 2014).
The consequent social stigma steeply raises the bar of social inclusion for PWMI (Corrigan, 2004;
Gureje, Lasebikan, Ephraim-Oluwanuga, Olley, & Kola, 2005; Mathias et al., 2015).
Studies from different parts of the world have explored the public awareness of mental illnesses
and attitudes towards PWMI. Schomerus et al. (2012), in their systematic review of two decades of
literature from Western Europe, United Kingdom, and North America, found that despite a general
increase in mental health literacy and increased acceptance of professional help for mental health
problems, ‘no changes or changes to the worse were observed regarding attitudes towards people
with mental illness.’ Lauber and Rössler’s (2007) review of Asian literature from 1996 to 2006,
found Asian societies to be prejudiced against the PWMI, perceiving them to be dangerous and
aggressive. More recently, Seeman, Tang, Brown, and Ing’s (2016) extensive worldwide study on
596,712 ‘random global web users’ in 229 countries found suboptimal awareness towards PWMI.
These studies indicate that the majority of people harbor negative views towards PWMI (Anger-
meyer & Dietrich, 2006; Aydin, Yigit, Inandi, & Kirpinar, 2003; Barke, Nyarko, & Klecha, 2011;
Gras et al., 2015; Hinshaw & Cicchetti, 2000; Kingdon, Sharma, & Hart, 2004; Lyons & Janca,
2015; Stefanovics et al., 2016; Tzouvara, Papadopoulos, & Randhawa, 2016).
Various studies have examined the stigma towards PWMI in the Arab/Islamic population (Alma-
zeedi & Alsuwaidan, 2014; Amini, Majdzadeh, Eftekhar-Ardebili, Shabani, & Davari-Ashtiani, 2013;
Kadri, Manoudi, Berrada, & Moussaoui, 2004; Mohamed-Kaloo & Laher, 2014). Initially it had
appeared that social stigma towards PWMI was less prevalent in Islamic societies (Fabrega, 1991),
however, later it became apparent that stigma is common but modified by specific socio-cultural fac-
tors (Scior, Hamid, Mahfoudhi, & Abdalla, 2013). In Egypt, mental illnesses assumed to be caused by
culturally proscribed behavior such as being non-conformist are stigmatized more (Sewilam et al.,
2015). Therefore, more studies are needed to explore the specificities of awareness and attitudes
of the Arab/Islamic populations towards PWMI.
In addition to gauging levels of attitude, some studies have explored the correlates of attitude.
Schomerus, Van der Auwera, Matschinger, Baumeister, and Angermeyer (2015) have conducted
longitudinal studies on the change brought about by age on attitudes towards PWMI. This study
used age-period-cohort analyses to compare the change in attitude of the same subjects between
1990 and 2001. It was found that negative attitudes towards PWMI increased over the 11-year
period. The perspective is that older generations are likely to harbor more prejudices against
PWMI than younger generations. This could be due to a complex interplay of factors including gen-
eration gap and increasing resistance to new ideas, particularly in the fields of psychological and
spiritual matters. Even here there are likely to be societal differences. A study from an Arab/Islamic
population could shed light on whether there is age related hardening of attitudes towards PWMI.
Many studies in Western societies indicate that female respondents exhibit less stigmatizing atti-
tudes towards PWMI than males do (Venkatesh, Andrews, Mayya, Singh, & Parsekar, 2015). There
is a dearth of studies in Arab/Islamic countries with a few exceptions. Savrun et al. (2007)’s study
among Turkish students suggests that women show less stigmatizing attitudes towards PWMI
than their male counterparts. It is not clear whether such associations can be generalized to other
Arab/Islamic societies.
Weich, Twigg, and Lewis (2005) have indicated that urban areas tend to have higher rates of men-
tal disorders. The converse has also been reported. In China, for example, the recent rapid pace of
modernization has increased the incidence of mental illness in the rural areas (Sun & Ryder, 2016).
Within the discussion of the rural–urban dichotomy, some studies have suggested that rural popu-
lations tend to be less stigmatizing towards PMWI (Angermeyer & Dietrich, 2006). Here again, there
INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 3

is a lack of studies examining residential location and attitude towards PWMI in the Arabic Islamic
population.
Regarding workplace stigma faced by PWMI, various Western studies have confirmed the same
(Yildirim, Demirbuken, Balci, & Yurdalan, 2015). It is also reported that stigmatizing attitudes pre-
vail in all occupations (Bedaso, Yeneabat, Yohannis, Bedasso, & Feyera, 2016). However, where
workers have mental health information or have been previously exposed to PWMI, workplace
stigma is significantly less (Pettigrew, Tropp, Wagner, & Christ, 2011).
Within such a discussion two things arise. First, studies are needed to explore whether prior
exposure to PWMI has a moderating effect on attitude towards PWMI in Arab/Islamic countries
as postulated by contact hypothesis (Binder et al., 2009). In some Omani workplaces, previous con-
tact with PWMI has been found to reduce stigma towards PWMI (Al-Adawi et al., 2002; Furnham &
Blythe, 2012). Wider applicability of this finding is not known and requires more study. Secondly, it
should be acknowledged that there are seminal works that have examined the relationship between
occupations and attitude towards PWMI (Psarra et al., 2008; Totic et al., 2012). Empirical scrutiny is
also needed on whether type of employment and place of work has direct bearing on perception of
people with mental illness. Studies are needed to explore if there are differences between those work-
ing in public versus private sectors. Thus, within the background that suggests that negative attitudes
towards PWMI are a worldwide phenomenon, we aimed to explore whether negative attitudes
towards PWMI occur also in the Arabian state of Oman. This study aims to gauge public perception
in Oman toward people with mental illness. Socio-demographic correlates of public perception will
also be explored.

Method
We recruited participants via an online survey. The protocol employed closely followed those pub-
lished elsewhere (Angermeyer, Millier, Rémuzat, Refaï, & Toumi, 2013) but with consideration for
the specific situation in Oman. The online survey method was selected because of Oman’s high lit-
eracy of 93.97% (UNESCO, 2015) and Internet usage of 66.4% (Masters, 2015). Because 80 to 86% of
Internet users subscribed to social media applications Facebook and WhatsApp (Zowawi et al., 2015)
these were used to communicate with the subjects. The targeted population was collapsed into a
regional presentation to represent people residing in different regions of Oman. To ensure that
the sample was representative of the general adult population of Oman, the sampling was stratified
to reflect the socio-demographic composition of the general population in Oman.

The socio-demographic characteristics of the sample


The web links containing AMI and socio-demographic information were dispensed to potential par-
ticipants via Facebook and WhatsApp. Given the total population of 2.3 million (Sambidge, 2014), a
confidence interval of 95% was deemed to reflect the situation of the country. If a potential partici-
pant failed to respond to the initial contact, he or she was re-prompted after seven days. This study
was conducted over a three-month period between March 2015 and July 2015.
Oman has 11 governorates and the bulk of the population is concentrated in the north and the
south. These two regions are separated by a vast desert known as Rub’ al Khali, the ‘Empty Quarter.’
The major part of population distribution occurs in the north along the coastal strip of the Gulf of
Oman. For brevity, the governorates closest to the capital were operationalized as urban (Muscat, Al
Batinah North, Al Batinah South) while the rest were deemed to be rural (Al Buraimi, Ad Dakhiliyah,
Ash Sharqiyah North, Ash Sharqiyah South, Dhofar, and Musandam). The age groups were col-
lapsed into three age groupings [(i) 20–30, (ii) 31–45 and (iii) 46–60]. The rationale for such under-
taking is based on Erik Erikson’s theory of psychosocial development which posits the view that there
is a specific life-stage view of the world (Erikson, 1994). This, in turn, is speculated here to influence
one perception of mental illness.
4 M. AL-ALAWI ET AL.

Assessment measure
The Attitude towards Mental Illness (AMI) questionnaire was derived and adapted from Weller
and Grunes (Weller & Grunes, 1988). The instrument measures four domains. The first part seeks
the participants’ personal opinions as to causes of mental illness (‘Mental illness is genetic,’ ‘Men-
tal illness is caused by spirits’). The second part solicits their knowledge about mentally ill people.
(‘One can always tell a mentally ill person by his physical appearance,’ ‘the mentally ill, with a
number of exceptions, cannot tell the difference between good and bad,’ ‘very few, if any, mentally
ill people are capable of true friendships.’) The third part of the instrument gauges attitudes of the
participants towards people with PWMI (‘Life has no value for the mentally ill,’ ‘the mentally ill
should be prevented from having children,’ ‘the mentally ill should not get married,’ ‘mentally ill
people should be prevented from walking freely in a public places,’ ‘one should avoid all contact
with the mentally ill,’ ‘the mentally ill should not be allowed to make decisions, even those con-
cerning routine events.’) The final part of AMI taps into care and management of PWMI (‘One
should hide his/her mental illness from his/her family,’ ‘the mentally ill should live only among
themselves,’ ‘psychiatric hospitals should not be located in residential areas,’ ‘there are people who
were never in a mental hospital and are more disturbed than those who are in a mental hospital,’
‘mental illness cannot be cured,’ ‘every mentally ill person should be in an institution where he/
she will be under supervision and control.’) For the present purposes, the composite scores are
analyzed.
AMI has been widely utilized in studies from different linguistic groupings around the world
(Failde et al., 2014; Shen et al., 2014). The present modified Arabic version AMI consisted of a
16-item Likert-type scale as reported elsewhere (Al-Adawi et al., 2002). The scores range from 0
to 32. A score of more than 20 is considered a ‘favorable attitude,’ with a higher score suggesting
‘more favorable attitude.’ AMI has a reliability of 0.79 (Weller & Grunes, 1988).
In addition to AMI, socio-demographic variables including age and gender were sought from
the participants. Place of residence was also sought and this was later dichotomized into rural vs
urban. Occupation and place of work were also sought in order to examine whether there are any
differences in attitudes in people working in different conditions – such as public (government)
sector, private sector, or student. Participants were also asked whether they have relatives with
mental illness. This was in view of previous findings that social contact erodes stigma toward
PWMI.

Consent and ethical approval


Participants were required to read and electronically sign a printable consent form prior to their par-
ticipation. All efforts were made to adhere to the World Medical Association’s Declaration of Hel-
sinki (1964–2008) for Ethical Human Research, which encompasses confidentiality and data storage
(World Medical Association Declaration of Helsinki, 2008). In brief, the potential participants were
explicitly assured that their participation was anonymous and voluntary, that the data gathered
would be aggregated, and that they could withdraw from the study at any time without prejudice.
If undue distress was experienced by the participant while responding to sensitive questions, coun-
seling support was offered if needed.
The study protocol was approved by the local Institutional Review Board (IRB), Research and Ethi-
cal Committee of College of Medicine & Health Sciences, Sultan Qaboos University (MREC# 1057).

Data analysis
The AMI scores followed a normal distribution, which were summarized as mean and SD. When
the explanatory variable had two categories (the genders) the outcome variable was continuous
(AMI Score) and followed normal distribution, which was verified using the student’s t test.
INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 5

However, when the explanatory variable had more than two categories (the age groups), ANOVA
was used to compare the means. In both the student t test and ANOVA tests the categories
(groups) should have nearly the same variances. Homogeneity of variance was measured using
Levene’s test. We have used multiple regression analysis using Generalized Linear Models
using a likelihood estimation method for the estimation of parameters. As the observations
were independent and the outcome variable followed normal distribution, multiple regression
analysis was done. We also used Variance Inflation Factor (VIF) statistics to diagnose whether
the multiple regression analysis generated multicollinearity. However, to validate whether mul-
tiple regression analysis met the assumptions, we used the residuals of the regression model to
validate the assumption by evenly distributing residuals over the range of predicted y values. It
was seen that they followed normal distribution. We have used enter method as there are only
four explanatory (covariates) variables to be considered in the model. SPSS software version
22.0 was used to analyze the data.

Results
The distribution of socio-demographic variables of the study subjects is presented in Table 1 which is
collapsed by gender. Out of the 601 subjects studied 249 (41.4%) were men and 352 (58.6%) women.
Nearly 6% of the subjects were older than 45 years. Otherwise, subjects aged 20–30 years accounted
for 48% of the sample, while those aged 31–45 years were 46% and those over 45 years constituted
5.7% of the sample.
As occupation or job status, of the total, 20% of the participants were private-sector employees
and 10% were college-going students, while the majority (70%) were working in the public sector
(government employees). Nearly 42% of the subjects had relatives with mental illnesses. Most
respondents were from the capital city of Muscat, making up to 41.5% of the total participants.
Regarding composite score, the mean AMI score of all participants is 22.83 (Median = 23.00; SD
= 4.509). Based on the unadjusted analyses, the mean (SD) of AMI scores according to socio-demo-
graphic variables (Table 2). The younger age group (20–30 years) had a significantly lower mean
(SD) 22.1 (4.17) as compared to others whose mean score was about 24 (p < 0.001). When compared
to private-sector employees and college-going students, public-sector employees had significantly
higher AMI mean scores (p < 0.001). The subjects who have relatives with mental illnesses had sig-
nificantly higher positive attitudes (23.29 vs. 22.48) as compared to others (p = 0.023).

Table 1. Distribution of socio-demographic variables by gender.


Gender
Male Female Total
Variables n(249) % n(352) % n(601) %
Age
20–30 117 47.4 171 48.7 288 48.2
31–45 113 45.7 163 46.4 276 46.2
46–60 17 6.9 17 4.8 34 5.7
Region
Urban 130 53.3 253 72.9 383 64.8
Rural 114 46.7 94 27.1 208 35.2
Occupation/Job status
Public sector 191 77.0 228 65.0 419 69.9
Private sector 40 16.1 77 21.9 117 19.5
College Students 17 6.9 46 13.1 63 10.5
Social contact (Do you have relative with mental illness?)
Yes 96 39.2 153 43.6 249 41.8
No 149 60.8 198 56.4 347 58.2
6 M. AL-ALAWI ET AL.

Table 2. Univariate and multivariate regression analyses for attitude toward mental illness (AMI) questionnaire mean scores
according to demographics.
Univariate analysis Multivariate analysis
95%CI
Parameter Mean ± SD P value Coefficient Lower Upper P value
Age
20–30 22.1 ± 4.17 <0.001 −1.39 −3.01 0.22 0.091
31–45 23.6 ± 4.74 0.08 −1.52 1.68 0.922
46–60 23.6 ± 4.02 0
Gender
Male 23.2 ± 4.66 0.108 0.66 −0.07 1.40 0.077
Female 22.6 ± 4.40 0
Region
Rural 22.3 ± 4.57 0.026 −0.90 −1.66 −0.14 0.020
Urban 23.1 ± 4.44 0
Occupation
Public sectors 23.33 ± 4.49 <0.001 0.58 −0.66 1.81 0.359
Private sector 21.69 ± 4.72 −0.86 −2.25 0.54 0.229
Students 21.86 ± 3.68 0
Those who have relative with mental illness
Yes 23.29 ± 4.52 0.032 0.78 0.06 1.49 0.033
No 22.48 ± 4.47 0
Note: Univariate analysis – for comparing two groups independent t-test and more than two groups ANOVA were used. The differ-
ence in likelihood ratio between the model with intercept and model with intercept plus five variables was 42.45 for seven
degrees of freedom (p < .001).

Based on the multiple regression analyses the following results were obtained. The young age
group subjects (20–30 years) had −1.39 (95% CI: −3.0, 0.22) units lower score compared to the
middle age group (40–60 years) subjects (p = 0.064) after adjusting for other independent variables.
Although the male subjects had marginally higher AMI score, that is, 0.66 (−0.07, 1.40) than female
participants, the difference was not statistically significant (p = 0.134). In multiple regression ana-
lyses after adjusting for other variables the rural subjects had significantly lower score −0.9
(−1.66, −0.14) as compared to urban subjects (p = 0.02). The subjects who have relatives with mental
illnesses had significantly 0.78 (0.06, 1.49) units higher AMI mean as compared to others who did
not have a family member with mental illness (p= 0.032).
The subjects who have relatives with mental illnesses had significantly 0.71 units higher AMI
mean as compared to others who did not have a family member with mental illnesses (p = 0.032).
The power analyses showed that the power was about 80% of the variable area of residence and
was about 100% for the variables occupation and age of the subjects.

Discussion
To our knowledge, this is the first study in Oman that examines social attitudes towards people with
mental illnesses. The mean AMI score of 22.83 of our subjects is comparable to those observed by
others (Kingdon et al., 2004). This study thus confirms that the global trend of negative stance
toward PWMI is also prevalent among the general public in Oman. Therefore, in addition to the
descriptive studies that have explored attitudes towards PWMI, attention is needed to devise inter-
ventions to reduce stigma and discrimination. Some studies are indicating the benefit of such under-
takings (Thornicroft et al., 2016).
The related aim of this study was to examine the relationship between the performance in AMIQ
and demographic variables including age, gender, job status (private, public, and college student),
and the urban–rural dichotomy as well social contact. The association between a participant’s endor-
sement in AMI and demographic variables are recapitulated within available literature detailed
below in tandem.
INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 7

The first aim of the study was examining the relationship between age and AMI. According to the
2014 census, the distribution of 20–30, 31–45, and 46–60 year-olds was 44%, 39.5%, and 16.4%
respectively. However, the study sample’s distribution is 48.2%, 46.2%, and 5.7% respectively.
Thus the study had over-sampled the 46–60 year-old subjects by 10%. However, in the other age
groups the difference was about 5%. The gender distribution in the census was 49.4% male and
50.6% female; our study sample was 41.4% male and 58.6% female, thus oversampling women by
6%. However, as a whole the study demography reasonably represents the census data.
In this study young people in the age group of 20–30 years tend to harbor less favorable attitudes
towards PWMI compared to an older age group but the trend was not significant. Such endorsement
differs from the studies reported from the Euro-American populations (Jorm & Oh, 2009; Scho-
merus et al., 2015) where negative attitudes towards PWMI increased with age. Thus, this study
advances the hypothesis that younger Omanis are perhaps more likely to hold more negative
views towards PWMI than older Omanis. It is worthwhile to speculate factors that could contribute
to age-dependent differences towards PWMI in different populations.
Secondly, in contrast to Europe, the Omani demography has a youthful, pyramid-like structure. It
is possible that the difference in population structures could account for age differences between
Omani and Western populations. Thirdly, it is possible that only recently, affluence and moderniz-
ation that have been embraced by the new generation in Oman might have played a part in the age-
specific endorsement. Traditional Omani society subscribes to a collective mindset (Viernes et al.,
2007) which promotes social solidarity. In addition, anecdotal reports suggest that such societies
may harbor less negative attributes towards PWMI. It is possible that such social solidarity may
have started eroding due to the recent modernization and globalization and the increased negativity
expressed by younger Omanis may reflect that erosion. However, as this trend is not supported by
significance, more studies are needed to examine the trajectory of culture and age in the expression of
attitudes towards PWMI. It is possible that perceptions vary according to the diagnosis. Some studies
have indicated that psychotic illnesses are more ostracized compared to depression. The latter tends
to trigger more tolerance among young generations (Makowski et al., 2016; Oliffe et al., 2016). The
present study did not define the types of diagnosis of mental illness.
The second aim of this study was to explore trajectory of gender and AMI. The relation between
gender and the attitude towards mental illness has previously been reported to be inconsistent (Cor-
rigan et al., 2016). In this study, there was no gender difference in composite score of AMI. Some
studies have indicated that men tend to harbor more positive attitude towards PWMI (Venkatesh
et al., 2015). However, some studies have indicated dissenting views (Barney, Corser, & White,
2010; Girma et al., 2013; Wilson, Nairn, Coverdale, & Panapa, 1999). Higher negative perceptions
of women towards PWMI have been speculated to be related to their inadequate exposure to health
education relevant to mental health, but other reasons were given to account for positive endorse-
ment by women (Savrun et al., 2007).
The third aim was to explore the relationship between endorsement in AMI and the urban–rural
dichotomy. There is indication that in urban areas traditional coping strategies and resources are
largely absent as ‘city life’ reduces social connections often found in rural regions. This study has
extended urban–rural dichotomy by examining the attitude towards PWMI in Oman. Until the
last three decades, the majority of Omanis lived in the rural regions. However, recent affluence
has triggered urbanization. This study indicates that rural populations harbor more negative atti-
tudes towards PWMI compared to urban. It is possible that urban regions tend to have amalgama-
tion of different spheres of life and people of different ethnic and racial backgrounds. It is possible
therefore Omani in urban setting have learned to be tolerant to those who are different including
those with mental illness. With increased urbanization and modernization in Oman, traditional
forms of sustaining life have been replaced with a modern economy based on hydrocarbons. This
has led to the development of two-tier employment in the country (Al Hakmani & & Bashir,
2014). In the local vernacular, Omanis are either employed with public sectors or private sectors
(Al Hakmani & & Bashir, 2014). The public-sector or government-run organizations appear to be
8 M. AL-ALAWI ET AL.

the most preferred sources of employment in the country. In contrast, there is less preference to pri-
vate sectors due to rigid working hours and less opportunity for self-development. Private sectors
tend to have preponderance of non-Omani of different nationalities. The place of work has been pre-
viously associated with higher stress in Oman (Al-Salmani et al., 2015). In the present multivariate
analysis, there is no statically significant difference in the endorsement among the three groups: stu-
dent, public, and private sectors.
The related aim of this study is to examine whether those who have relatives with mental illness
might harbor different stances from those who do have relatives. There is a plethora of studies indi-
cating that previous interpersonal contact with PWMI has direct bearing in harboring positive
awareness towards PWMI (Yoshii, Watanabe, Kitamura, Nan, & Akazawa, 2011) as well as those
deemed to be having a ‘culturally devalued condition’(Weller & Grunes, 1988). This study suggests
having relatives with mental illness is a strong predictor of harboring a positive stance towards
PWMI.
There are several limitations that are common with this type of study that ought to be highlighted.
Firstly, this study employed an online survey. This approach tends to over-represent particular
populations and those who have access to the Internet and social media platforms, and enjoy spend-
ing time online. This means that online research tends not to give the number of non-respondents.
Mechanisms are needed to overcome such limitations. Secondly, soliciting one’s awareness which, by
definition is tapping into one subjective entity and is likely to be hampered by social desirability, even
though the Internet’s anonymity may mitigate it to an extent. Thirdly, some continuous variables
(e.g. age) were measured as categorical variables (e.g. age groups).

Conclusion
This study has examined Oman’s public attitudes towards PWMI and how the public perception var-
ies with socio-demographic factors. This study suggests that rural–urban residency has a strong
association whether one harbors negative or suboptimal attitudes toward PWMI. The data also
suggest that having a family member with mental illness tends to moderate one’s attitude toward
mental illness. As our study and existing literature suggest, social attitudes towards PWMI are a com-
plex and fluctuating phenomenon. More studies are therefore warranted to decipher accurately the
underlying trend in the apparently complex attitudes toward PWMI, so that anti-stigma measures
could be tailor-made for specific societies or cultures. Future studies with robust methodology
would be paramount to scrutinize the present findings so that more concerted anti-stigma education
could be implemented.

Acknowledgements
The authors wish to thank all participants in this study.

Notes on contributors
Mohammed Al-Alawi is psychiatry resident with the Oman Medical Specialty Board. His interests in research include
issues pertinent to stigma toward people with mental health.
Hamed Al-Sinawi is senior consultant at the Department of Behavioral Medicine and Psychiatry, Sultan Qaboos Uni-
versity Hospital. He has research and health education interests in old age psychiatry.
Samir Al-Adawi is professor of Behavioral Medicine at the College of Medicine, Sultan Qaboos University. His
research and publications have specifically focused on psychosocial determinants of health and ill-health. He believes
that relying fully on biological sciences to prevent and treat disease is unlikely to be effective in tradition-steeped
societies as in Oman even if they are modernizing rapidly.
Jeyaseelan is a professor with the Bio-statistics Research & Training Center (BRTC) in Christian Medical College, Vel-
lore, India. Dr. Jeyaseelan has conducted numerous publications in public health, and has expertise in conducting
INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 9

clinical trials. He is also the course coordinator for the courses conducted by BRTC on biostatistics, epidemiology, stat-
istical packages, and advanced analytical methods.
Sathiya Murthi works in the Department of Studies and Research, Oman Medical Specialty Board, Oman.

References
Al-Adawi, S., Dorvlo, A. S. S., Al-Ismaily, S. S., Al-Ghafry, D. A., Al-Noobi, B. Z., Al-Salmi, A., & Chand, S. P. (2002).
Perception of and attitude towards mental illness in Oman. International Journal of Social Psychiatry, 48(4), 305–
317.
Al Hakmani, K., & Bashir, H. (2014). Investigation into issues related to the productivity of employees in an oil and gas
industry. Retrieved from http://iieom.org/ieom2014/pdfs/381.pdf
Almazeedi, H., & Alsuwaidan, M. T. (2014). Integrating Kuwait’s mental health system to end stigma: A call to action.
Journal of Mental Health, 23(1), 1–3.
Al-Salmani, A., Juma, T., Al-Noobi, A., Al-Farsi, Y., Jaafar, N., Al-Mamari, K., & Al-Adawi, S. (2015). Characterization
of depression among patients at urban primary healthcare centers in Oman. The International Journal of Psychiatry
in Medicine, 49(1), 1–18.
Amini, H., Majdzadeh, R., Eftekhar-Ardebili, H., Shabani, A., & Davari-Ashtiani, R. (2013). How mental illness is per-
ceived by Iranian medical students: A preliminary study. Clinical Practice and Epidemiology in Mental Health: CP &
EMH, 9, 62–68.
Angermeyer, M. C., & Dietrich, S. (2006). Public beliefs about and attitudes towards people with mental illness: A
review of population studies. Acta Psychiatrica Scandinavica, 113(3), 163–179.
Angermeyer, M. C., Millier, A., Rémuzat, C., Refaï, T., & Toumi, M. (2013). Attitudes and beliefs of the French public
about schizophrenia and major depression: Results from a vignette-based population survey. BMC Psychiatry, 13, 7.
doi:10.1186/1471-244X-13-313
Aydin, N., Yigit, A., Inandi, T., & Kirpinar, I. (2003). Attitudes of hospital staff toward mentally ill patients in a teach-
ing hospital, Turkey. International Journal of Social Psychiatry, 49(1), 17–26.
Barke, A., Nyarko, S., & Klecha, D. (2011). The stigma of mental illness in southern Ghana: Attitudes of the urban
population and patients’ views. Social Psychiatry and Psychiatric Epidemiology, 46(11), 1191–1202.
Barney, S. T., Corser, G. C., & White, L. H. (2010). Service-learning with the mentally ill: Softening the stigma.
Michigan Journal of Community Service Learning, 16(2). Retrieved from http://quod.lib.umich.edu/m/mjcsl/
3239521.0016.205?rgn=main;view=fulltext
Bedaso, A., Yeneabat, T., Yohannis, Z., Bedasso, K., & Feyera, F. (2016). Community attitude and associated factors
towards people with mental illness among residents of worabe town, silte zone, southern nation’s nationalities
and people’s region, Ethiopia. PLoS One Mar 1, 11(3), e0149429.
Binder, J., Zagefka, H., Brown, R., Funke, F., Kessler, T., Mummendey, A., … Leyens, J. P. (2009). Does contact reduce
prejudice or does prejudice reduce contact? A longitudinal test of the contact hypothesis among majority and min-
ority groups in three european countries. Journal of Personality and Social Psychology, Apr; 96(4), 843–856.
Charara R., Forouzanfar M., Naghavi M., Moradi-Lakeh M., Afshin A., et al. (2017) The Burden of Mental Disorders in
the Eastern Mediterranean Region, 1990–2013. Retrieved from http://journals.plos.org/plosone/article?id=10.1371/
journal.pone.0169575
Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625.
Corrigan, P. W., Kosyluk, K. A., Markowitz, F., Brown, R. L., Conlon, B., Rees, J., & Al-Khouja, M. (2016). Mental
illness stigma and disclosure in college students. Journal of Mental Health, 25(3), 224–230.
Erikson, E. H. (1994). Identity and the life cycle. New York: WW Norton & Company.
Fabrega, H. (1991). Psychiatric stigma in non-western societies. Comprehensive Psychiatry, 32(6), 534–551.
Failde, I., Salazar, A., Elorza, J., Casais, L., Pérez, V., Martínez, L. C., & Gilaberte, I. (2014). Spanish medical students’
attitudes and views towards mental health and psychiatry: A multicentric cross-sectional study. Academic
Psychiatry: Journal of the American Association of Directors of Psychiatric Residency Training and the
Association for Academic Psychiatry, 38(3), 332–338.
Furnham, A., & Blythe, C. (2012). Schizophrenia literacy: The effect of direct experience with the illness. Psychiatry
Research, 198(1), 18–23.
Girma, E., Tesfaye, M., Froeschl, G., Möller-Leimkühler, A. M., Müller, N., & Dehning, S. (2013). Public stigma against
people with mental illness in the gilgel gibe field research center (GGFRC) in southwest Ethiopia. PloS One, 8(12),
e82116. doi:10.1371/journal.pone.0082116
Gras, L. M., Swart, M., Slooff, C. J., van Weeghel, J., Knegtering, H., & Castelein, S. (2015). Differential stigmatizing
attitudes of healthcare professionals towards psychiatry and patients with mental health problems: Something to
worry about? A pilot study. Social Psychiatry and Psychiatric Epidemiology, 50(2), 299–306.
Gureje, O., Lasebikan, V. O., Ephraim-Oluwanuga, O., Olley, B. O., & Kola, L. (2005). Community study of knowledge
of and attitude to mental illness in Nigeria. The British Journal of Psychiatry, 186, 436–441.
10 M. AL-ALAWI ET AL.

Hinshaw, S. P., & Cicchetti, D. (2000). Stigma and mental disorder: Conceptions of illness, public attitudes, personal
disclosure, and social policy. Development and Psychopathology, 12(4), 555–598.
Jorm, A. F., & Oh, E. (2009). Desire for social distance from people with mental disorders. Australian and New Zealand
Journal of Psychiatry, 43(3), 183–200.
Kadri, N., Manoudi, F., Berrada, S., & Moussaoui, D. (2004). Stigma impact on Moroccan families of patients with
schizophrenia. The Canadian Journal of Psychiatry, 49(9), 625–629.
Kingdon, D., Sharma, T., & Hart, D. (2004). What attitudes do psychiatrists hold towards people with mental illness?
Psychiatrist, 28(11), 401–406.
Lauber, C., & Rössler, W. (2007). Stigma towards people with mental illness in developing countries in Asia.
International Review of Psychiatry, 19(2), 157–178.
Lyons, Z., & Janca, A. (2015). Impact of a psychiatry clerkship on stigma, attitudes towards psychiatry, and psychiatry
as a career choice. BMC Medical Education, 15, 34. doi:10.1186/s12909-015-0307-4
Makowski, A. C., Mnich, E. E.2, Ludwig, J., Daubmann, A., Bock, T., Lambert, M., … von dem Knesebeck, O. (2016).
Changes in beliefs and attitudes toward people with depression and schizophrenia - results of a public campaign in
Germany. Psychiatry Research, 237, 271–278.
Masters, K. (2015). Social networking addiction among health sciences students in Oman. Sultan Qaboos University
Medical Journal, 15(3), e357–e363. doi:10.18295/squmj.2015.15.03.009
Mathias, K., Kermode, M., Sebastian, M. S., Koschorke, M., & Goicolea, I. (2015). Under the banyan tree - exclusion
and inclusion of people with mental disorders in rural north India. BMC Public Health, 15(1), 1–11.
Mohamed-Kaloo, Z., & Laher, S. (2014). Perceptions of mental illness among muslim general practitioners in South
Africa. South African Medical Journal, 104(5), 350–352.
Oliffe, J. L., Ogrodniczuk, J. S., Gordon, S. J., Creighton, G., Kelly, M. T., Black, N., & Mackenzie, C. (2016). Stigma in
Male depression and suicide: A Canadian Sex comparison study. Community mental health journal, 52(3), 302–310.
Pettigrew, T. F., Tropp, L. R., Wagner, U., & Christ, O. (2011). Recent advances inintergroup contact theory.
International Journal of Intercultural Relations, 35, 271–280.
Psarra, V., Sestrini, M., Santa, Z., Petsas, D., Gerontas, A., Garnetas, C., & Kontis, K. (2008). Greek police officers’ atti-
tudes towards the mentally ill. International Journal of Law and Psychiatry, 31(1), 77–85.
Rogers, A., & Pilgrim, D. (2014). A sociology of mental health and illness. Berkshire: McGraw-Hill Education.
Sambidge, A. (2014). Oman’s population passes 4 million mark - Politics & Economics - ArabianBusiness.com.
Retrieved May 18, 2016, from http://www.arabianbusiness.com/oman-s-population-passes-4-million-mark-
547779.html#.VzwSiOQwCxY
Savrun, B. M., Arikan, K., Uysal, O., Cetin, G., Poyraz, B. C., Aksoy, C., & Bayar, M. R. (2007). Gender effect on atti-
tudes towards the mentally ill: A survey of turkish university students. Israel Journal of Psychiatry and Related
Sciences, 44(1), 57–61.
Schomerus, G., Schwahn, C., Holzinger, A., Corrigan, P. W., Grabe, H. J., Carta, M. G., & Angermeyer, M. C. (2012).
Evolution of public attitudes about mental illness: A systematic review and meta-analysis. Acta Psychiatrica
Scandinavica, 125(6), 440–452.
Schomerus, G., Van der Auwera, S., Matschinger, H., Baumeister, S. E., & Angermeyer, M. C. (2015). Do attitudes
towards persons with mental illness worsen during the course of life? An age-period-cohort analysis. Acta
Psychiatrica Scandinavica, 132(5), 357–364.
Scior, K., Hamid, A., Mahfoudhi, A., & Abdalla, F. (2013). The relationship between awareness of intellectual disability,
causal and intervention beliefs and social distance in Kuwait and the UK. Research in Developmental Disabilities, 34
(11), 3896–3905.
Seeman, N., Tang, S., Brown, A. D., & Ing, A. (2016). World survey of mental illness stigma. Journal of Affective
Disorders, 190, 115–121.
Sewilam, A. M., Watson, A. M. M., Kassem, A. M., Clifton, S., McDonald, M. C., Lipski, R., & Nimgaonkar, V. L.
(2015). Suggested avenues to reduce the stigma of mental illness in the Middle East. International Journal of
Social Psychiatry, 61(2), 111–120.
Shen, Y., Dong, H., Fan, X., Zhang, Z., Li, L., Lv, H., & Guo, X. (2014). What can the medical education do for elim-
inating stigma and discrimination associated with mental illness among future doctors? Effect of clerkship training
on Chinese students’ attitudes. The International Journal of Psychiatry in Medicine, 47(3), 241–254.
Stefanovics, E., He, H., Ofori-Atta, A., Cavalcanti, M. T., Neto, H. R., Makanjuola, V., & Rosenheck, R. (2016). Cross-
National analysis of beliefs and attitude toward mental illness Among medical professionals from five countries.
Psychiatric Quarterly, 87(1), 63–73.
Sun, J., & Ryder, A. G. (2016). The Chinese experience of rapid modernization: Sociocultural changes, psychological
consequences? Frontiers in Psychology, 7, 477. doi:10.3389/fpsyg.2016.00477
Thornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., Rose, D., … Henderson, C. (2016). Evidence for
effective interventions to reduce mental-health-related stigma and discrimination. The Lancet, 387(10023), 1123–
1132.
Totic, S., Stojiljkovic, D., Pavlovic, Z., Zaric, N., Zarkovic, B., Malic, L., … Maric, N. P. (2012). Stigmatization of ‘psy-
chiatric label’ by medical and non-medical students. International Journal of Social Psychiatry, 58(5), 455–462.
INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 11

Tzouvara, V., Papadopoulos, C., & Randhawa, G. (2016). Systematic review of the prevalence of mental illness stigma
within the Greek culture. International Journal of Social Psychiatry, 62(3), 292–305.
UNESCO. (2015). Data related to Oman. Retrieved from http://uis.unesco.org/en/country/OM
Venkatesh, B. T., Andrews, T., Mayya, S. S., Singh, M. M., & Parsekar, S. S. (2015). Perception of stigma toward mental
illness in south India. Journal of Family Medicine and Primary Care, 4(3), 449–453.
Viernes, N., Zaidan, Z. A. J., Dorvlo, A. S. S., Kayano, M., Yoishiuchi, K., Kumano, H., & Al-Adawi, S. (2007).
Tendency toward deliberate food restriction, fear of fatness and somatic attribution in cross-cultural samples.
Eating Behaviors, 8(3), 407–417.
Weich, S., Twigg, L., & Lewis, G. (2005). Rural/non-rural differences in rates of common mental disorders in britain:
Prospective multilevel cohort study. The British Journal of Psychiatry, 188(1), 51–57.
Weller, L., & Grunes, S. (1988). Does contact with the mentally ill affect nurses’ attitudes to mental illness? British
Journal of Medical Psychology, 61(Pt 3), 277–284.
Wilson, C., Nairn, R., Coverdale, J., & Panapa, A. (1999). Mental illness depictions in prime-time drama: Identifying
the discursive resources. Australian and New Zealand Journal of Psychiatry, 33(2), 232–239.
World Health Organization. (2012). Risks to mental health: An overview of vulnerabilities and risk factors.
Background paper by WHO secretariat for the development of a comprehensive mental health action plan.
Retrieved November 12, 2016, from http://www.who.int/mental_health/mhgap/risks_to_mental_health_EN_27_
08_12.pdf
World Health Organization. (2016). Mental disorders Fact sheet. Retrieved from http://www.who.int/mediacentre/
factsheets/fs396/en/
World Medical Association Declaration Of Helsinki Ethical Principles for Medical Research Involving Human
Subjects (2008). Retrieved from http://www.wma.net/en/30publications/10policies/b3/17c.pdf
Yildirim, M., Demirbuken, I., Balci, B., & Yurdalan, U. (2015). Beliefs towards mental illness in turkish physiotherapy
students. Physiotherapy Theory and Practice, 31(7), 461–465.
Yoshii, H., Watanabe, Y., Kitamura, H., Nan, Z., & Akazawa, K. (2011). Stigma toward schizophrenia among parents of
junior and senior high school students in Japan. BMC Research Notes, 4, 558. doi:10.1186/1756-0500-4-558
Zowawi, H. M., Abedalthagafi, M., Mar, F. A., Almalki, T., Kutbi, A. H., Harris-Brown, T, & Hasanain, R. A. (2015).
The potential role of social media platforms in community awareness of antibiotic use in the gulf cooperation coun-
cil states: Luxury or necessity? Journal of Medical Internet Research, 17(10), e233.