NURSES’ KNOWLEDGE, ATTITUDES AND PRACTICES

TOWARDS MENTAL ILLNESS IN THE MAFETENG DISTRICT, LESOTHO

BY

BERNADETT ‘MALEHLOHONOLO DAMANE

DISSERTATION

Submitted in accordance with the requirements for the degree

MASTERS IN SOCIAL SCIENCES IN NURSING

Faculty of Health Sciences

School of Nursing

University of the Free State

Supervisor: Dr Idalia Venter

February 2018

i
DECLARATION

I, Bernadett ‘Malehlohonolo Damane declare that the master’s research

dissertation or interrelated, publishable manuscripts / published articles that I
herewith submit at the University of the Free State, is my independent work
and that I have not previously submitted it for a qualification at another
institution of higher education.

I Bernadett ‘Malehlohonolo Damane hereby declare that I am aware that the

copyright is vested in the University of the Free State.

I Bernadett “Malehlohonolo Damane hereby declare that all royalties as

regards intellectual property that was developed during the course of and/or in
connection with the study at the University of the Free State, will accrue to the
University.

_______________________________

28 February 2018

ii
DEDICATION

I would like to dedicate this dissertation to my late mother Martha M. ‘Moso who passed
away when I was preparing this book and to my late sister Florence M. Sekotlo for
inspiring me. I will always cherish your love.

iii
ACKNOWLEDGEMENTS

My solemn gratitude to:

God Almighty for a healthy life and grace during the entire period of this study.

My Supervisor, Dr. Idalia Venter for being patient, my mentor, a counsellor and a mother
throughout whole study.

The Ethics Committees of the University of the Free State (UFS) and Ministry of Health,
Lesotho for granting me the permission to conduct this study.

Scott College Management for giving the opportunity to study and endlessly supporting
me throughout the entire duration.

Scott Hospital Management for allowing me to carry out a pilot study in their institution.

Mafeteng Hospital Management, Manager Hospital Nursing Services, District Health

Management Team and health centres’ nursing staff for giving me the opportunity to
utilize their time and facilities to conduct the study

All nursing staff who made this study a success by their participation.

Riona Delport for always offering help with a smile. Your support will always be
appreciated.

My husband Pitso for inspiring me, my sons Lehlohonolo and Mosebi, my daughters
Monica and Rethabile for the confidence they had in me even in difficult moments, the
endless support and ensuring that I progressed.

My colleagues at Scott College of Nursing for their endless support and encouragement.

The rest of my family and friends, whom they are too many to mention, thank you for the
encouragement and always being with me in this journey.

Many people who saw me through this journey for the endless motivation and support
they provided, without you this book would never be complete.

iv
ABSTRACT

Mental illness is a pervasive and disabling problem worldwide especially in low and
middle income countries. In Lesotho, people with mental illness are first attended at
primary health care settings by mostly non-psychiatric health personnel. Inadequate
mental health knowledge has been shown to result in negative attitudes towards mental
illness thereby affecting negatively the behaviour of health care providers towards people
with mental illness,

The aim of the study was to describe nurses’ knowledge, attitudes and practices (KAP)
towards mental illness in the Mafeteng district, Lesotho. A quantitative cross-sectional
descriptive design was adopted in this study with a convenience sample of 79
respondents. A four-part pilot tested structured questionnaire was utilised to collect data
from the nursing staff placed at Mafeteng district government and Christian Health
Association of Lesotho (CHAL) health facilities. Data was collected following approval by
Health Sciences Research Ethics Committee (HSREC) of the University of the Free State
(UFS) and Ministry of Health Research Ethics Committee, Lesotho.

Gaps in relation to the KAP of nurses towards mental illness have been identified. A
significant number of the nursing staff believes that mental illness is not a serious problem
and patients with mental illness do not deserve the same attention that other patients do.
These beliefs signify insufficient knowledge and inappropriate attitudes that impact on
how nurses react towards mental illness and patients with mental illness. Even though
majority of respondents endorsed that psychotropic medications are effective in treating
mental illness, they are not comfortable to be around these patients. Only 37% of the 79
respondents feel that they are adequately prepared to address mental illness

Recommendations made include initiation of mental health educational programmes for

nurses to empower them to increase their knowledge in order to gain of confidence in
issues of mental health and illness.

v
TABLE OF CONTENTS

Declaration……………………………………………………………..……………………….……….ii
Dedication………………………………………………………………….……..……………….……iii
Acknowledgements……………………………………………………………………………..……..iv
Abstract………………………………………………………………………………,……….………....v
List of figures………………………………………………...………………….……………….…..…x
List of tables…………………………………………………….………………….…………….…….x
Abbreviations…………………………………………………………………………………………..xi

CHAPTER 1: INTRODUCTION TO THE STUDY………………………………………..………...1

1.1 INTRODUCTION…………………………………………..……………,,,,,,,,,,..……………...6
1.2 PROBLEM STATEMENT……………………………………………………..………..…..…6
1.3 AIM OF THE STUDY……………………………………………………...………….………….7
1.4 OBJECTIVES OF THE STUDY…….………………………..……………………….………...7
1.5 RESEARCH QUESTION…………………………………..……………………....……..……..7
1.6 CONCEPTUAL FRAMEWORK……………….………………………………..………..………8
1.7 DEFINITIOON OF TERMS………………….…………………….......................……..……….9
1.7.1 Nurse……………………………………..............………………...………......……………9
1.7.1.1 Registered nurse…………………………….…..……….....……………..…………….…9
1.7.1.2 Registered psychiatric nurse……………..………....…………………………….….…9
1.7.1.3 Nursing assistant……………………………..…………………......…………………...10
1.7.2 Knowledge……………………………………...………………….…..………………….10
1.7.3 Attitude………………………………………….……………………………..…………...10
1.7.4 Practice……………………………………...……..…………………………….……......11
1.7.5 Mental illness……………………………...…..…………………,,,,,,,,,,,,,……..…….....11
1.8 RESEARCH METHODLOGY…………………………………………………….……………12
1.8.1 Research design…………………..………………………………………………..…...…12
1.8.2 Research technique………………………………….……………........……..………….12
1.8.3 Population and sample………………………….……………...............………..………13

vi
1.8.4 Pilot study………………………………….……..…………………..…......…..…………13
1.9 DATA COLLECTION……………………………………..............................……...………...13
1.10 VALIDITY AND RELIABILITY………….………………………………………..…………….14
1.10.1 Validity…………………………….…………………………………………………..………14
1.10.2 Reliability………………………………………………………………...................……….14
1.11 ETHICAL CONCERNS………………………………………..………………………………14
1.11.1 Justice……………………………………………………………………………………….15
1.11.2 Respect for people………………………………………..……………………..………….15
1.11.3 Beneficence………………………………………………………………………..….……..16
1.11.4 Non-maleficence……………………………………...…………..…………………..……..16
1.12 DATA ANALYSIS………………………………………………………….………..…………..16
1.13 SCHEDULE OF EVENTS……………………………………………………..…………....….16
1.14 BUDGET…………………………………………………………………………………..……...16
1.15 VALUE OF THE STUDY……………………..………………………………………..…….…17
1.16 CONCLUSION…………………………………………….……………………………..………17

CHAPTER 2: LITERATURE REVIEW………………………………………………………………18

2.1 INTRODUCTION AND OVERVIEW…………………………………………………………..18

2.2 MENTAL HEALTH AND MENTAL ILLNESS………………………………………………...19
2.2.1 Mental health…………………………………………………………………………………19
2.2.2 Mental illness…………………………………………………………………………………20
2.3 CLASSIFICATION OF MENTAL ILLNESSES………………………………………………21
2.4 DSM-5 DIAGNOSTIC CRITERIA……………………………………………………..……….22
2.5 AETIOLOGY OF MENTAL ILLNESS…………………………………………………………25
2.5.1 Biological factors…………………………………………...………………………………..25
2.5.2 Psychological factors ………………………………………………………………...…….26
2.5.3 Environmental factors…………………………………………………..…………………..26
2.6 THE PREVALENCE OF MENTAL ILLNESS….…………………………..………………….27
2.7 THE BURDEN OF MENTAL ILLNESS ON INDIVIDUALS, FAMILIES AND
COMMUNITIES………………………………………………………………………………………….28

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2.8 STIGMA…………………………………………………………………………………………..30
2.8.1 Defining stigma…………………………………………………………………………..…..30
2.8.2 Stigma and mental illness……………………………………………………...…………..30
2.8.3 Effects of stigma on persons with mental illness and mental health services…...32
2.8.4 Combating stigma……………………………………………………………………………33
2.9 MENTAL HEALTH CARE IN LESOTHO……………………………………………………..34
2.10 KNOWLEDGE, ATTITUDESAND PRACTICES OF NURSES TOWARDS MENTAL
ILLNESS…………………………………………………………………………………………………37
2.11 SUMMARY……………………………………………………………………………………….40

CHAPTER 3: RESEARCH METHODOLOGY……….………………………………………………42

3.1 INTRODUCTION…………………………………………………………………………………42
3.2 RESEARCH DESIGN……………………………………………………………………………42
3.2.1 Descriptive research design…………………………………………………………….....43
3.2.2 Cross sectional design……………………………………………………………………..43
3.2.3 Quantitative research design………………………………………..…………………….44
3.3 THE RESEARCH TECHNIQUE……………………………………………………………….44
3.3.1 Questionnaires……………………………………………………………………………….44
3.3.1.1 Mailing questions…………………………………………………………………………..46
3.3.1.2 Distributing questions electronically…………...……………………………………….46
3.3.1.3 Hand-delivered questionnaire…………………………………...………………………..46
3.3.2 Development of a questionnaire………………………………………………………….48
3.3.2.1 Features a good questionnaire……………………………………..…………………….48
3.3.2.2 Structure of the questionnaire……………………………………..……………………..49
3.4 POPULATION AND SAMPLING………………………………………………………………49
3.5 PILOT STUDY……………………………………………………………………………………50
3.6 VALIDITY…………………………………………………………………………………………51
3.6.1 External validity………………………………………………………………………………52
3.6.2 Content validity…………………………………………………………………..…………..52
3.7 RELIABILITY…………………………………………………………………………………….52

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3.8 DATA COLLECTION……………………………………………………………………………53
3.9 ETHICAL ISSUES………………………………………………………………………………54
3.9.1 Acquiring permission……………………………...………………………………………..55
3.9.2 The right to consent…………………………………………………………………………55
3.9.3 Justice…………………………………………………………………………………………56
3.94 Confidentiality…………………………………………………………………………………56
3.9.5 Beneficence and non-maleficence………………………………………………………..57
3.10 DATA ANALYSIS………………………………………………………………………………58
3.11 CONCLUSION……………………………………………………………………….………….58

CHAPTER 4: DATA ANALYSIS AND DISCUSSION OF RESULTS…………………………..59

4.1 INTRODUCTION……………………………………………………………….……………….59
4.2 BIOGRAPHICAL DATA OF RESPONDENTS………………………………………………59
4.2.1 Gender, age, marital status and language of respondents……..………………….59
4.2.2 Qualifications of respondents……………………………………………………………..61
4,3 FREQUENCY OF MENTAL HEALTH LECUTRES AND REFRESHER COURSES…...63
4.4 KNOWLEDGE ON MENTAL ILLNESS…………………………………….………………….64
4.5 ATTITUDES TOWARDS MENTAL ILLNESS………………..……………………………….70
4.6 PRACTICES TOWARDS MENTAL ILLNESS………………………………………………74
4.7 SUMMARY OF FINDINGS……………………………………………………………………..76

CHAPTER 5: RECCOMMENDATIONS, LIMITATIONS AND CONCLUSION…………………..78

5.1 LIMITATIONS OF THE STUDY………………………………………………………………78

5.2 RECOMMENDATIONS………………………………………………………………………….79
5.2.1 Knowledge…………………………………………………………………………………….79
5.2.2 Attitudes………………………………………………………………………………...…….80
5.2.3 Research………………………………………………………………………………………82

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LIST OF FIGURES

FIGURE 1.1 Map of Lesotho………..………………………………………………………….…..4

FIGURE 1.2 Conceptual framework………………………………………………………………..8

FIGURE 5.1 Age of respondents……………………..…………………………………………..61

LIST OF TABLES

TABLE 1.1 Distribution of health facilities by levels and ownership……………….2

TABLE 2.1 Classification of mental illnesses………………………………..………..23

TABLE 4.1 Biographic data of respondents……………….…………………………..60

TABLE 4.2 Distribution of respondents by qualification, duration of practice and

type of health facility …………………………………………………….….62

TABLE 4.3 Lectures during training and refresher courses in practice………..63

TABLE 4.4 Distribution of frequency and percentages of respondents regarding

knowledge……………………………………………………………………………………..65

TABLE 4.5 Distribution of frequency and percentages of respondents’ attitudes

towards mental illness………………………………………………………………………71

TABLE 4.6 Distribution of frequency and percentages of respondents’ practices

towards mental illness………………………………………………………………...…….72

LIST OF REFERENCES…………………………………………………………...…………84

ANNEXURES

ANNEXURE A: QUESTIONNAIRE………………………………………………………….96

ANNEXURE B: INFORMATION LEAFLET…………………………...………………….102

ANNEXURE C: APPROVAL DOCUMENTS……………………………………………..105

x
ABBREVIATIONS

APA American Psychiatric Association

CHAL Christian Health Association of Lesotho

DHMT District Health Management Team

DSM Diagnostic and Statistical Manual of Mental Disorders

ICD International Classification of Disease

KAP Knowledge, attitudes and practices

LNC Lesotho Nursing Council

MHNS Manager Hospital Nursing Services

MOTU Mental Observation and Treatment Unit

NA Nursing Assistant

RN Registered Nurse

RNM Registered Nurse Midwife

RPN Registered Psychiatric Nurse

UFS University of the Free State

WA Ward Attendant

WHO World Health Organization

xi
 CHAPTER 1

INTRODUCTION AND BACKGROUND

1.1 INTRODUCTION

Lesotho, also known as the Mountain Kingdom, is one of the world’s small developing
countries. It has an estimated population of 2 203 821 (World Bank, 2016: Online). Its
lowest point is 1 000m above sea level, and it is a landlocked country entirely surrounded
by the Republic of South Africa. Lesotho is divided into two major areas, namely, the
highlands and lowlands. The highlands are elevated mountainous regions located along
the Drakensberg chain and the Maluti Mountains, while the lowlands are located at a
lower elevation, along the banks of the Orange and Caledon Rivers.

The two major health service providers in Lesotho are the Lesotho government and a
non-governmental organization, the Christian Health Association of Lesotho (CHAL). The
network of health facilities within the country consists of 21 general hospitals and four
specialised hospitals, namely, a mental hospital (Mohlomi), a leprosarium hospital
(Bots’abelo), an HIV and AIDS centre (Senkatana), and an HIV and AIDS paediatric
centre (Baylor Centre of United Nations Excellence) (WHO, 2011:21). In addition, there
are four private hospitals and four filter clinics. Furthermore, there are 192 health centres
sometimes called clinics that are administered by different bodies. To be specific, the
government administers 12 hospitals and 85 health centres, while CHAL manages eight
hospitals and 73 health centres, one general hospital is privately-owned, the Lesotho Red
Cross Society has four health centres and the Maseru City Council owns two health
centres. There are 33 privately-owned health centres. These healthcare facilities are
distributed throughout the country (Lesotho Review, 2015: Online). About 90% of the
private for profit health facilities are situated in the four large districts of Maseru, Berea,
Mafeteng, and Leribe (Ministry of Health, 2014). However statistics regarding health
facilities in Lesotho is presented or documented in varying numbers in different research
papers and/or documents. Table 1.1 depicts the composition of the health facilities by
levels and ownership.

1
Table 1.1: Distribution of health facilities by levels and ownership

GENERAL PRIVATE SPECIALISED HEALTH FILTER TOTAL

PROPRIETOR
HOSPITALS HOSPITALS HOSPTITALS CENTRES CLINICS FACILITIES

GOVERNMENT 12 0 4 85 4 105

CHAL 8 0 0 73 0 81

RED CROSS 0 0 0 4 0 4

MASERU CITY 0
0 0 0 2 2
COUNCIL

PRIVATE 1 4 0 33 0 38

TOTAL 21 4 4 195 6 230

According to the Lesotho Health Sector Strategic Plan of 2012/13-2016/17 (2013: 8), the
formal system of Lesotho health facilities is divided into the national (tertiary), district
(secondary) and community (primary) levels. The national level comprises of referral and
specialised hospitals inclusive of a Mental hospital. Specialised hospitals provide
specialised services, such as psychiatric and leprosy care. District level is comprised of
filter clinics and district hospitals. These facilities provide both inpatient and outpatient
care services though they vary widely as the services are determined by or dependent on
factors such as finances, equipment, and human resources. Generally, services include
diagnostic and treatment services, minor and major operative services, ophthalmic care,
counselling and care of rape victims, radiology, dental services, mental health services,
and blood transfusions as well as preventive care. Some specialised care is also available
for TB, HIV, and non-communicable diseases. Community level comprises health posts
and health centres which are the first point of care within the formal health system.
Managed by nurse clinicians (advanced nurse practitioners) with comprehensive skills in
preventive and curative care and in the dispensing of medication, health centres offer
curative and preventative services, including immunizations, family planning, antenatal
and postnatal care. The nurse clinician is working with registered nurses (RNs), registered

2
nurse midwives RNMs and nursing assistants NAs. The mandate of the nurse clinician
also extends to supervising the community public health efforts and training volunteer
community health workers (CHWs). Health posts provide community outreach services
and are typically managed by volunteers. Services in health posts are different from
health centres in that they are not running on daily basis but on regular intervals.

Filter clinics are a first point of care intended to lighten the load of district hospitals and
function as “mini-hospitals,” offering preventive and curative services and limited inpatient
care. These clinics are especially important in Maseru district, where the national referral
hospital serves as a district-level hospital as well. Unlike health centres, filter clinics are
staffed by doctors and some even have pharmacy technicians. Additionally, selected
laboratory and radiology services (administered through the hospitals) are also offered in
these clinics.

Regarding people with mental health problems in Lesotho, the first step of care is
consultation at primary government, CHAL or privately owned health facilities. If
necessary, they are referred to the Mental Observation and Treatment Unit (MOTU) as
the second step. For further management, referral is made to the mental hospital. MOTUs
are located at each district government hospital except for Thaba- Tseka district as it does
not have a government hospital. These units are under the supervision of the district
general hospital while the Mental hospital provides supportive professional mental
services to the units. The units offer similar services to the mental hospital inclusive of but
not limited to counselling, observations, diagnostic, treatment and admissions though with
brief stay. Ideally, MOTUs are staffed by at least five people: one being a registered
psychiatric nurse (RPN), others can be RN/RNMs, NAs or ward attendants (WA). At
CHAL hospitals, there are PNs (at least one per hospital) who are assigned as overseers
of mental health services. Services are to some extend similar to those offered at the
units. In Thaba-Tseka district, mental health services are offered at CHAL hospitals and
health centres.

The study site is Mafeteng district. It is located in the lowlands, has a variety of health
facilities of interest and also a satisfactory population density. The majority of its health

3
facilities are easy to reach compared to other districts in the lowlands, or the highlands,
where population is sparse. Mafeteng is composed of one government hospital, eight
primary health facilities that are government owned and nine CHAL-owned primary health
facilities. The following is the map of Lesotho showing where Mafeteng is located.

Figure 1.1 Map of Lesotho (adopted from WorldAtlas)

Lesotho is classified as a least developed country, which is a country that exhibits the
lowest indicators of socioeconomic development, with the lowest Human Development
Index ratings (UN, 1971:52). Least developed countries have to work hard in order to
graduate from this unfortunate position, and must strive to have a healthy population
through prevention and treatment of, among other disorders, mental illness.

According to the World Health Organization (2011a:1-4), the following facts pertaining to
Lesotho’s mental health legislature have been identified:

• Dedicated mental health legislation exists and was initiated in 1964; however, an
officially approved mental health policy does not exist, even though mental health
is specifically mentioned in the country’s general health policy. The mental health
4
 policy has been drafted but not officially approved, and mental health legislation
has been under revision since 2010.
• A mental health plan does not exist.
• Prescription regulations authorise primary health care doctors to prescribe
psychotropic medicines.
The Ministry of Health authorises primary health care nurses to prescribe and/or to
continue prescription of psychotropic medicine, though with restrictions. On the other
hand, the official policy does not permit primary health care nurses to independently
diagnose and treat mental disorders within the primary care system.

• Officially approved manuals on the management and treatment of mental disorders

are not available in the majority of primary health care centres.

While mental illness is very common all over the world and Lesotho is no exception,
mental health expenditure for the country accounts for only 1.8% of the total budget of
the Ministry of Health. Of this allocation, the Mohlomi mental hospital consumes 82.11%
of the budget (WHO, 2011: Online). Essentially, all nurses come into contact with people
with mental illness. The country is operating mostly with contracted psychiatrists from
other countries. Nonetheless, in recent years the country spends most of the time without
psychiatrists as they do not stay long. During their service, they are stationed at the
mental referral hospital, which is the only one in the whole country. In addition, the
Psychiatric Mental Health Nursing Programme was discontinued at the National Health
Training College in 2009, though the programme resumed in 2016 with four students and
still running to date. Ideally, based on its total population, the country should be operating
with 6 000 nursing personnel. This number of staff is not on the ground – there are less
than 4 000 nurses (Lesotho Review, 2015: Online). According to Lesotho Nursing Council
(LNC) records available during conduction of this study, of all nurses registered with LNC
108 were PNs though majority of them were reported to be serving outside psychiatry.
According to Mental Health Atlas country profile report (2014), there was 181 reported
mental health inpatient and outpatient staff in the country. These include different cadres
delivering mental health services.

5
1.2 PROBLEM STATEMENT

Mental illness and mental retardation also called intellectual disability are among the most
common types of disabilities found in the population of Lesotho (Nkhoma, 2013:Online).
Psychiatric disorders are a major burden of disease worldwide, and people suffering from
these disorders are often treated by non-psychiatric health workers in general health
facilities (Ndetei, Khasakhala, Mutiso & Mbwayo: 2011:225). On World Mental Health
Day, 2011, the World Health Organization’s regional director stated that studies
conducted in Africa, to date, indicate that at least one in six people who visit primary
health care facilities suffer from some form of mental illness (WHO 2011b:Online). There
are no indications that Lesotho is an exception.

Reed and Fitzgerald (2005:249) recognize that the need for care of people with mental
problems in general hospitals has increased and nurses are the important resource not
only in hospital care but in the delivery of mental health care as well. Their study revealed
that one of the basic factors that are generally considered to contribute to the
administration of total therapeutic nursing care is nurses’ attitudes towards patients. It is
explained in conclusion of their study that these attitudes are, to a great extent develop
as the result of nurses’ exposure to mental health environment and experiences in
working and interacting with patients with mental illness. Conversely, it is of concern that
research suggests that health professionals, including nurses, have negative attitudes
towards people with mental illness (Chow, Kam & Leung 2007:357). Negative attitudes
towards mental illness imply that people with any mental illness will be targets of unfair
discrimination. Individuals and families will suffer stigmatization resulting in reluctance or
delay in seeking medical help. This can lead to high rates of treatment defaulters thereby
increasing rates of hospitalization and poor patient care. Moreover absenteeism from
work, poor performance in activities or unemployment will also add to the challenges.

Due to these reasons it is important to explore knowledge, attitudes and practices of

nurses towards mental illness and people with mental illness, as well as the factors that
might influence their attitudes in Mafeteng, Lesotho since little research has been done
in relation to this issue.

6
1.3 AIM OF THE STUDY

The study aimed to describe the knowledge, attitudes and practices of all registered
nurses and nursing assistants towards mental illness and people with mental illness in
the Mafeteng district, Lesotho.

1.4 OBJECTIVES

The objectives of the study are to:

• Describe the demographic profile of nurses in the Mafeteng district, Lesotho;

• Describe the knowledge of, attitudes towards and practices of nurses towards
mental illness in the Mafeteng district, Lesotho; and
• Make recommendations, if necessary, to address any identified problems towards
mental illness.

1.5 RESEARCH QUESTION

What are the knowledge, attitudes and practices of nurses towards mental illness in
Mafeteng district, Lesotho?

7
1.6 CONCEPTUAL FRAMEWORK

The conceptual framework provided in Figure 1.1 will be utilised to guide the study.

NEGATIVE
CONSEQUENCES
LACK OF NEGATIVE • Discrimination
KNOWLEDGE ATTITUDES
• Misdiagnosis
• Poor patient care

Figure 1.2: Conceptual framework of the study

As has been explained in the problem statement, nurses are the professional group that
has the most contact with people who make use of the health facilities in Lesotho. People
seeking out health services include people with mental health care needs. The fact that
very few of the nurses are trained as mental health care nurses causes concern. The
assumption is that nurses with better knowledge of mental health are likely to have a more
positive attitude towards people with mental illnesses, which will enhance the central
activity of the nurse-patient relationship, resulting in delivery quality care. Nonetheless,
Ndetei et al. (2011:226) argue that having knowledge about mental illness does not
always improve the attitudes of nurses, which could involve stigmatisation.

Morris, Scott, Cocoman, Chambers, Guise, Valimaki and Clinton (2011:460) point out that
the harbouring of negative attitudes by healthcare professionals towards any patient can
have implications for the patients’ recovery; therefore, providing nurses with relevant
information and education has the potential to improve attitudes towards people with
mental illness by reducing fear and stigma among nurses. Research indicates that there
is a significant positive relationship between nurses’ attitudes and their practice (Jiang,
He, Zhou, Shi, Yin & Kong, 2013: Online).

The study will, therefore, explore nurses’ knowledge, attitudes and practices (KAP)
towards mental illness and mentally ill people based on the above mentioned arguments.

8
1.7 DEFINITION OF TERMS

The following key concepts will be clarified: nurse, registered nurse, nursing assistant,
knowledge, attitude, practice and mental illness.

1.7.1 Nurse

Lesotho Government Gazette No. 49 (1998:106) defines a nurse as any person certified
as such by the LNC. For the purpose of the study, a nurse is referred to as a person who
obtained a qualification for the nursing profession and who works at health facilities in
Mafeteng district, Lesotho. A nurse in this context can be a RN, RPN, RNM or NA

1.7.1.1 Registered nurse

According to the Lesotho Government Gazette No. 49 (1998:2), an RN is an individual

who has completed a programme of basic nursing education and training and has
obtained a diploma qualification, and practices nursing in Lesotho.

For the purpose of this study, an RN refers to an individual who has undergone training
and has obtained a qualification as an RN/Midwife or hold other nursing qualifications
higher than diploma level, has been licensed by the LNC and practices within government
or CHAL health care facilities in Lesotho as a nurse.

1.7.1.2 Registered Psychiatric Nurse

Townsend (2015: 211) defines a Psychiatric Nurse as an RN with hospital diploma,

associate degree or baccalaureate degree in psychiatry or has a national certification.
The individual should provide assessment of client condition both mentally and physically
as well as offering care in all aspects. In this study, a Psychiatric Nurse is a RN with a
psychiatric nursing qualification and licensed by the LNC as a Registered Psychiatric
Nurse (RPN) and practices in government or CHAL health facilities in Lesotho.

9
1.7.1.3 Nursing assistant

The Nurses and Midwives Act (Lesotho, 1998:107) refers to a person who has undergone
training for the Certificate in Nursing Assistant programme, has qualified, is listed by the
LNC, and who practices in Lesotho as a nursing assistant.

For the purpose of this study, an NA refers to a person who has undergone either a two
year or 18 or 15 months training in Nursing Assistant Programme, has obtained the
Certificate in Nursing Assistant, listed by the LNC and practices as an NA in any
government or CHAL health facility in Lesotho.

1.7.2 Knowledge

The Oxford Advanced Learner’s Dictionary (Hornby, Cowie & Lewis, 2010: 827) defines
knowledge as facts, information and skills acquired through experience or education.
Badran (1995:8) defines knowledge as a combination of understanding the acquired
information from a given experience, which is retained and applied to form a certain skill.

For the purpose of this study, knowledge refers to a combination of facts and information
acquired through experience and that can be translated into a skill that can be utilised
when dealing with mental illness. This encompasses the understanding of mental illness,
including causes, symptoms, and treatment.

1.7.3 Attitude

According to Badran (1995:8), attitude refers to the way an individual feels and organises
opinions in order to react in a certain way to a given situation. Fishbein (in Spring, 2002:
Online) concurs, and defines attitude as an accumulation of information about an object,
person, situation or experience; a predisposition to act in a positive or negative way
toward some object. It is further stipulated that attitude is basically the information that
individuals acquire and develop an opinion about someone or something. James, Isa and
Oud (2011: 130) emphasize that attitude is ‘a predisposition toward any person, idea or
object and contains cognitive, affective and behavioural components’.

10
For the purpose of the study, attitude refers to how individuals perceive and react towards
mental illness and people with mental illness

1.7.4 Practice

Badran (1995:8) describes practice as the application of rules and knowledge, which
results in an individual taking a certain action, while the Oxford Advanced Learner’s
Dictionary (Hornby et al., 2010:1148) defines practice as a way of doing something, either
in a typical or unusual way, in a specific organisation or situation.

In this study, practice refers to the cognitive representation of readiness and the
observable response of a nurse in a given situation, together with the actual ease or
difficulty of dealing with this situation relating to mental illness.

1.7.5 Mental illness

Mental illness refers to a syndrome that has multiple causes and may represent several
different disease states that have not yet been defined. The term is used interchangeably
with mental disorder. Mental disorders are defined as clinically significant disturbances in
cognition, emotion regulation, or behaviour that reflect a dysfunction in the psychological,
biological or developmental processes underlying mental dysfunction. (Boyd 2015:13).
The diagnosis of mental illness is made based on the criteria according to the Diagnostic
and Statistical Manual of Mental Disorders 5th Edition (DSM-5) and/or the International
Classification of Diseases-10th version (ICD-10).

In this study, mental illness refers to the state in which an individual portrays persistent
signs and symptoms of mental disturbance that affect his or her daily functioning
negatively. Such an individual has been diagnosed with mental illness based on the
criteria described above.

1.8 RESEARCH METHODOLOGY

Methodology refers to the theory or strategies that researchers follow in order to get
answers to the research question (Botma, Greef, Mulaudzi & Wright, 2010:287).The

11
subsections of Section 1.8 describe how the researcher went about exploring the KAP of
nurses towards mental illness and people with mental illnesses.

1.8.1 Research design

Polit and Beck (2012:58) and Grove, Burns and Gray (2013:195) define research design
as the architectural backbone or blueprint of a study. The researcher will use a
quantitative, cross-sectional survey design, since the study wishes to explore the
characteristics of RNs and NAs in terms of their KAP towards mental illness. The design
will further enable the researcher to compare knowledge, attitudes and behaviour of
respondents towards people with mental illness.

1.8.2 Research technique

The researcher will use a questionnaire that is a combination of two relevant, tested
questionnaires. The reason for combining the two questionnaires is that there is no single
questionnaire that addresses all the variables that need to be evaluated. The first
questionnaire was used in a study that was carried out in Zambia by Kapungwe, Cooper,
Mayeya, Mwanza, Mwape, Sikwese, Lund and The Mental Health and Poverty Project
Research Programme Consortium (2011: 292-295). The aim of this study was to explore
health care providers’ attitudes towards people with mental illness in Zambia. The second
questionnaire was used in a study by Bennett (2012: 88-95) on the effects of a mental
health training programme on health care workers’ knowledge, attitudes and practice in
Belize. The questionnaire that is compiled from these two above mentioned
questionnaires is attached as Annexure A.

1.8.3 Population and sample

Burns and Grove (2009:42) define population as all elements that meet the inclusion
criteria in a given situation. A sample is a subset of the accessible population that is
selected for a particular study (Botma et al., 2010:124).

In this study, the population of interest is all nurses in Lesotho; however, only one of 10
districts, Mafeteng, has been chosen for its convenience. All RNs and NAs who are placed

12
in the Mafeteng district government- and CHAL-owned health facilities will be invited to
participate, irrespective of gender, nationality, religion or political affiliation. There were a
total of 154 RNs and NAs practicing at CHAL- and government-owned health facilities in
the health system of Mafeteng district during the time of proposal writing.

1.8.4 Pilot study

A pilot study is a smaller version of a proposed study (Burns & Grove 2009:44). The pilot
study will be carried out at Scott Hospital, Morija. Scott Hospital is a CHAL institution
located in the Maseru district. It offers health services similar to those rendered at
Mafeteng and other government hospitals though in different scale. The hospital is easily
accessible to the researcher. Two RNs and two NAs who work at this hospital will be
invited to participate in a pilot study. This institution is not part of the study, and the results
of the pilot study will not be included in the actual study findings.

The purpose of the pilot study is to determine if the questionnaire is easy to understand,
and to ascertain the time that will be taken to complete it (De Vos, Strydom, Fouché &
Delport 2014:73).

1.9 DATA COLLECTION

Data collection is defined as the precise and systematic gathering of information to

accomplish the research aim (Botma et al, 2010:131; Burns & Grove, 2009:43). In this
study, data will be collected by means of a self-administered questionnaire that will be
delivered by the researcher to the respective areas of the study. Fieldworkers will not be
utilised. The questionnaire is compiled in English as it is commonly used in nursing. The
training is conducted in English and all written communication in the health care services
is done in English. Consent from the prospective respondents to participate in the
research will be obtained during a staff meeting. At the meeting, the purpose of the study
will be explained and questionnaires distributed. The researcher will remain in the
background and only avail herself to address concerns where necessary. The
questionnaires will be collected immediately upon completion.

13
1.10 VALIDITY AND RELIABILITY

Influencing factors that could weaken the validity and reliability of the study need to be
considered. Methods of enhancing validity and reliability in this study are explained in
subsections below.

1.10.1 Validity

Validity is defined as the degree to which a measurement represents a true value (Botma
et al., 2010:174). Questionnaires based on two standardised questionnaires will be
utilised. The mode of administration will be the same as in the pilot study in that it will be
completed by the intended target group within the same allocated time.

1.10.2 Reliability

Reliability refers to the consistency of measures obtained in the use of a particular

instrument and indicates the extent of random error in the measurement method (Burns
& Grove 2009:377). To ensure reliability, all respondents will complete the same
questionnaire.

1.11 ETHICAL CONCERNS

All research must adhere to the principles of beneficence, non-maleficence, justice and
respect for people. Before commencement of the study, approval will be obtained from
the Evaluation Committee of the School of Nursing, University of the Free State (UFS),
and the Health Sciences Research Ethics Committee of the UFS. The researcher will
then submit the approved proposal to Ethics Committee, Ministry of Health, Lesotho, for
subsequent approval.

Data collection will commence following approval of the proposal and receiving consent
from the relevant authorities. An open invitation for participation will be extended to all
nurses placed at government and CHAL health facilities in Mafeteng district. The
information sheet (Annexure B) covering the contents of the study will be distributed to
prospective respondents for them to make an informed choice about participation.

14
Respondents will be guided through the information sheet by the researcher. No one will
be coerced into participation, and respondents will be informed that withdrawal is
permitted at any time, without any penalty.

The following ethical principles were observed (Botma et al., 2010:17-21).

1.11.1 Justice

In order to observe justice, fair selection of respondents will be ensured. All RNs and NAs
in Mafeteng will be invited to participate, as long as they meet the inclusion criteria. Any
changes or interventions that might occur will be communicated to respondents. Data
collected will be kept confidential.

1.11.2 Respect for people

Respect for people is attained when the researcher observes anonymity and
confidentiality. In this study respect for people will be ensured by providing all possible
and adequate information about the study in order for respondents to make a decision
regarding participation. In addition, approval to carry out the study will be sought from
the ethics committees of the UFS and Ministry of Health of Lesotho respectively as
mentioned earlier, following which permission will be obtained from relevant authorities
at the relevant health centres through district health management team (DHMT) at the
Mafeteng district hospital.

1.11.3 Beneficence

There are no direct advantages for respondents to take part in the study; however, should
the study reveal a problem in relation to the KAP of the nurses, and corrective measures
implemented, they will benefit. At the same time, there are no anticipated risks in relation
to participation.

15
1.11.4 Non-maleficence

This principle states that participants will not be harmed. The researcher is not
anticipating any harm; however some of the answers in the questionnaire might contradict
the nurses’ professional code and could lead to disciplinary actions or adversely affect
employment conditions. Nevertheless, this threat will be avoided as the questionnaire is
anonymous and as a result there will be no link between the respondents and the
collected data.

1.12 DATA ANALYSIS

Descriptive statistics, namely, frequencies and percentages for categorical data and
means and statistical variations or medians and percentiles for continuous data, will be
calculated. The analysis will be done by the Department of Biostatistics at the UFS.

1.13 SCHEDULE OF EVENTS

The researcher planned to carry out and complete the study within a period of 15 months.
The time is scheduled in such a way that it accommodates the various activities
comprising the study, starting from submission of the protocol to the UFS Ethics
Committee and ending with submission of the dissertation.

1.14 BUDGET

The funds required to support the project are estimated.

16
1.15 VALUE OF THE STUDY

The significance of the study is that, following data analysis, findings and
recommendations will be made to the relevant stakeholders. The expectation is that
results will inform planning in relation to psychiatric mental health nursing training and
nursing education. More research will further be pursued to enhance mental health
services.

1.16 CONCLUSION

In this chapter, the problem statement, the aim and objectives of the study were
introduced. The conceptual framework and research methodology have been discussed.
Ethical principles to adhere to were also highlighted. The next chapter discusses the
literature review.

The following represents the structure of the study in sequence:

Chapter 2: Literature review;

Chapter 3: Research methodology used;

Chapter 4: Data analysis and interpretation of the findings;

Chapter 5: Conclusions reached, limitations and recommendations made.

17
 CHAPTER 2

LITERATURE REVIEW

2.1 INTRODUCTION AND OVERVIEW

The following chapter presents a review of literature in relation to the problem statement.
Various data sources were consulted to obtain information about knowledge, attitudes
towards and practices relating to mental illness.

Based on the postulation that mental illnesses, also known as psychiatric disorders,
present a major disease burden worldwide (Ndetei et al., 2011:225), and the assertion
that the most frequent types of disabilities found in the population of Lesotho emanate
from mental illness and intellectual disability (Nkhoma, 2013:Online), it can be argued
that mental illness is a major burden of disease in Lesotho, specifically; one of which the
treatment is often the responsibility of non-psychiatric health workers.

Like in some other countries of the world, Lesotho provides free mental health services.
Due to a scarcity of qualified personnel in Lesotho, nurses play a major role in delivering
these services. This involvement of nurses leads to several questions: Have the nurses
acquired adequate knowledge about mental illness? What are nurses’ attitudes towards
mental illness and people with mental illnesses? How do nurses translate their feelings
into behaviour towards people with mental illnesses, that is, what is the nature of practices
by nurses in relation to mental illness? It is believed that nurses’ KAP determine the
outcome of the care they are rendering to people with mental illnesses. According to
Foster, Usher, and Baker (2009: 72), attitudes have an impact on both professional and
personal behaviour.

Research conducted in different areas of the world about the KAP of nurses towards
mental illness has found that health care providers, including nurses, hold negative
attitudes that influence the utilisation of mental health care services and the quality of
care being rendered adversely. These attitudes can serve as barriers in seeking mental
health services with the consequences such as treatment defaulters, high rates of relapse
and trying out other non-scientific treatment modalities thereby increasing rates of mental

18
illness (Ndetei et al., 2011:225; Tei-Tominaga, Asakura & Asakura, 2014:317). The
researcher, therefore, wanted to explore these three related factors in nursing personnel
who render care at all levels to people with mental illnesses in Lesotho, because few
studies about mental health and illnesses have been conducted in Lesotho.

In this chapter, the background of mental health and mental illnesses will be explained.
Mental illnesses, its aetiology and the prevalence of illnesses will be explored. The burden
of mental illness on individuals, families and communities, as well as a definition and the
impact of stigma will be presented. Mental health care in Lesotho, knowledge, attitudes
and practices of nurses in relation to mental illness and people with mental illnesses will
be discussed.

2.2 MENTAL HEALTH AND MENTAL ILLNESS

An understanding of mental health and mental illness is important for this study. In this
section a brief overview of mental health and mental illness is provided.

2.2.1 Mental health

While the study is about nurses’ KAP towards mental illness, it is worth looking at mental
health first, in order to understand what mental illness encompasses.

According to Boyd (2015:12), mental health is,

“The emotional and psychological well-being of an individual who has the capacity
to interact with others, deals with ordinary stress, and perceives one’s
surroundings realistically”.

Certain indicators should be present for a person to be regarded as mentally healthy.

These indicators are characteristics that confirm that an individual is mentally sound, and
include a positive attitude toward self; growth, development, and the ability to achieve
self-actualisation; integration; being independent; being able to perceive and interpret
ones surroundings as they are, as well as mastering and controlling ones’ environment.
The indicators imply that mental health is, therefore, essential for various benefits
including personal wellbeing, social interaction, as well as being a citizen who can

19
contribute to a community. World Health Organisation and other service providers claim
that there is no health without mental health. However, indicators such as a positive
attitude towards the self, or the ability to master one’s environment, can be exhibited while
someone possesses neither mental nor physical health (Boyd 2015:12; Sorsdahl, Stein
and Lund 2012:168; Townsend, 2015:14-15).

2.2.2 Mental illness

Mental illness is a common phenomenon in all cultures and has existed since time
immemorial; though different literature sources provide different descriptions of this
concept. People have been utilising different treatment modalities, depending on their
perception of the illness. Historically, mental illness was associated with witchcraft, or
being possessed by the devil or evil spirits. While mental health explains the wellbeing of
an individual, the topic of mental illness evokes feelings of fear, embarrassment or even
disgust, thus, fostering negative attitudes towards mental illness and mentally ill people
(Feldman, 2015: 507; Shyangwa, Singh & Khandelwal, 2003:27).

The concept of mental illness has various synonyms, including mental disorder,
psychological disorder, abnormal behaviour, psychiatric disorder or illness, mental health
problems and psychopathology. In this study, mental illness and mental disorder are used
interchangeably. In Chapter One, section 1.7.5, mental illness has been described from
different perspectives.

Mental illness has various definitions, and only few are described here. Frisch and Frisch
(2002:4) describe mental illness as:

“State in which an individual shows deficits in functioning; cannot view self clearly
or has distorted image of self, is unable to maintain personal relationships, and
cannot adapt to the environment”.

Townsend (2015:907), on the other hand, views mental illness as:

“The maladaptive responses to stressors from the internal or external milieu,

evidenced by thoughts, feelings and behaviours that are contrasting with the local

20
 and cultural norms, and interfere with the individual’s social, occupational and or
physical functioning”.

The American Psychiatric Association (APA, 2013: 20) states that a mental disorder is a
“syndrome characterised by clinically significant disturbances in cognition, emotion
regulation, or behaviour that reflects a dysfunction in the psychological, biological, or
developmental processes underlying mental functioning”. The disturbances are usually
associated with distress or impairment in different areas of life, including social and
occupational functioning. WHO (2014: Online) states that mental disorders comprise a
broad range of problems, with different symptoms. They are generally characterised by
some combination of abnormal thoughts, emotions, behaviour and relationships with
others. Based on the above descriptions, mental illness can be explained as a state in
which an individual portrays a significant disturbance in mental processes that leads to
distress and impairment of functioning.

2.3 CLASSIFICATION OF MENTAL ILLNESSES

Various classification systems for mental illnesses have been proposed. The two most
important psychiatric classifications are the Diagnostic and Statistical Manual of Mental
Disorders (DSM), which was developed by the APA, and the International Classification
of Diseases (ICD), that was developed by the WHO. The first edition of the DSM (DSM-
1) was published in 1952. Over time, the criteria underwent review several times, until
2013, when the current version, the DSM-5, was published. In this study, the disorders
will be described in terms of DSM-5 diagnostic criteria. The DSM-5 is designed such that
it is similar and corresponds to the 10th edition of ICD, to ensure standardised reporting
of international health statistics. Furthermore, DSM and ICD are similar in that the criteria
for mental illness are based on the given clinical picture that is associated with impairment
in functioning (Bulbulia & Laher, 2013: 52; Sadock, Sadock & Ruiz, 2015:290-1). This
study will refer to the DSM, as it is the classification system that is used in Lesotho.

2.4 DSM-5 DIAGNOSTIC CRITERIA

21
The DSM was introduced to provide clear diagnostic criteria to enable clinicians to
diagnose mental illnesses. Its main function is to assist in diagnosing and classifying
abnormal behaviour, by providing a relatively precise definition of such behaviour
(Feldman, 2015:510; Townsend, 2015:902). According to Sadock et al. (2015:291), the
DSM-5 lists 22 major categories of mental disorders, comprising of more than 150
distinctive illnesses. The DSM also provides the associated features, such as age,
culture, gender-related features, prevalence, incidence, risk, course, complications,
predisposing factors, and differential diagnoses that form the basis of describing each
disorder. The disorders are organised to follow the lifespan pattern, such that disorders
that occur in childhood are listed first, followed by those appearing during adulthood.

Table 2.1 lists examples of mental disorders appearing in both childhood and adulthood.
Some conditions that are common during childhood can persist until adulthood. Some
conditions are easy to diagnose, since a patient will be portraying obvious abnormal
behaviour, while others are often missed, because they mimic physical conditions, and
does not exhibit any symptoms of abnormal behaviour. Some conditions are more
common than others, for example, depression is so common that it is known as “the
common cold of psychiatry” (Uys & Middleton, 2014:359).

Table 2.1: Classification of mental illnesses

CATEGORY MENTAL ILLNESS

Neurodevelopmental Intellectual disability or intellectual developmental disorder,

disorders communication disorders, autism spectrum disorder,
attention-deficit/hyperactivity disorder, specific learning
disorders and motor disorders

Schizophrenia Schizophrenia, delusional disorder, brief psychotic disorder,

spectrum and other schizoaffective disorder, substance/medication-induced
psychotic disorders psychotic disorder, psychotic disorder due to another medical
condition and catatonia

22
Bipolar and related Bipolar I disorder, bipolar II disorder, cyclothymic disorder,
disorders bipolar disorder due to another medical condition and
substance/medication-induced bipolar disorder

Depressive disorders Major depressive disorder and persistent depressive disorder

or dysthymia

Anxiety disorders Panic disorder, agoraphobia, specific phobia and social

anxiety disorder or social phobia

Obsessive compulsive Obsessive-compulsive disorder, body dysmorphic disorder,

and related disorders hoarding disorder, trichotillomania, excoriation or skin-picking
disorder, obsessive-compulsive disorder due to another
medical condition and other specified obsessive-compulsive
and related disorders

Trauma- or stressor- Reactive attachment disorder, disinhibited social engagement

related disorder disorder, posttraumatic stress disorder, acute stress disorder,
adjustment disorder and persistent complex bereavement
disorder

Dissociative disorder Dissociative amnesia, dissociative fugue, dissociative identity

disorder and depersonalisation/derealisation disorder

Somatic symptom and Somatic symptom disorder, illness anxiety disorder, functional
related disorders neurological symptom disorder, psychological factors
affecting other medical conditions, factitious disorder and
other specified somatic and related disorders

Feeding and eating Anorexia nervosa, bulimia nervosa, binge-eating disorder,

disorders pica, rumination disorder and avoidant/restrictive food intake
disorder

Elimination disorders Enuresis and encopresis

Sleep wake disorders Insomnia disorders, hypersomnolence disorder, parasomnias,

narcolepsy, breathing-related sleep disorders, restless leg
syndrome, substance/medication-induced sleep disorder and
circadian rhythm sleep-wake disorders

Sexual dysfunction Delayed ejaculation, erectile disorder, female orgasmic

disorder, female sexual interest/arousal disorder, genitor-
pelvic pain/penetration disorder

23
 Gender dysphoria Characterized by a persistent discomfort with one’s biological
sex and in some cases, the desire to have sex organs of the
opposite gender

Disruptive, impulse- Oppositional defiant disorder, intermittent explosive disorder,

control, and conduct conduct disorder, pyromania and kleptomania
disorders

Substance-related Substance-induced disorders, substance use disorders,

disorders gambling disorder, alcohol-induced disorders

Neurocognitive Delirium, mild and major neurocognitive disorders

disorders

Personality disorders Paranoid personality disorder, histrionic personality disorder

and dependent personality disorder

Paraphilic disorders Paraphilia, exhibitionism, voyeurism, frotteurism, paedophilia

and paraphilia and sexual masochism

Other mental Other specified mental disorders due to another medical

disorders condition, unspecified mental disorder due to another medical
condition

(Sadock et al., 2015:291-298)

Following this list of illnesses, it is imperative to describe the factors that are responsible
for their occurrence. Section 2.5 presents a discussion of the aetiology of mental illness,
namely, biological, psychological and environmental factors.

2.5 AETIOLOGY OF MENTAL ILLNESS

The exact cause of mental illness is not known, however, there are theories designed to
explain the causes. Characteristically, mental illness results from a multifaceted interplay
between biological, social and psychological factors. Biological factors include genetic
factors, physical factors and changes in the brain structure. Psychological factors
encompass individuals’ personality traits and personality types, while social or
environmental factors include but not limited to culture, religion, families, environmental
events, abnormal life events, and economic disadvantage. In most cases, a complex
24
interaction between biological, psychological and social or environmental factors
contributes to the emergence of mental health and neurological problems (Alhaidar,
Online; Medicinet Health Direct: Online). Causes of mental illness are broadly explored
from 2.5.1to 2.5.3 below.

2.5.1 Biological factors

According to Bhandari (2016: Online), some mental illnesses have been linked to abnormal
functioning of nerve-cell circuits or pathways that connect particular brain regions. Nerve
cells within these brain circuits communicate through chemicals called neurotransmitters,
thereby linking the nervous system and behaviour (Feldman, 2015:64). When describing
neurotransmitters, Feldman states that they are chemicals that carry messages across the
synapse to the dendrite of a receiving neuron. Hence, a deficiency or an excess of a
neurotransmitter can produce severe behaviour disorders. An example is the case of
schizophrenia, which involves an excess of the neurotransmitter dopamine, which leads to
distortion of reality, while in major depression, the dopamine activity is reduced, and in
mania, increased. Defects in or injury to certain areas of the brain have also been linked to
some mental illnesses. Neurotransmitters that are commonly involved in the occurrence of
mental illness are serotonin, dopamine and noradrenalin (Feldman, 2015:524; Sadock et
al., 2015:350).

Another biological factor that may be involved in the development of mental illness is
heredity, which suggests that some mental illnesses run in families – people who have a
family member with a mental illness may be somewhat more likely to develop a mental
illness (Feldman, 2015:527; Townsend, 2015:422). Susceptibility is passed on in families
through genes. Research indicates that many mental illnesses are linked to abnormalities
in several genes, rather than just one or a few. Not everybody who is susceptible will suffer
mental illness, but the occurrence is dependent upon the interaction of inherited genes and
the environment that an individual finds her/himself in (Bhandari, 2016 Online).

Other mental health problems that have purely biological basis are neurocognitive disorders.
For example, dementia which is referred to as a major neurocognitive disorder in DSM-5. It
can be caused by Alzheimer’s disease which is commonly diagnosed in people older than

25
65 years of age. Its prominent manifestations are emotional and behavioural changes,
impairment in cognition, memory and orientation (Boyd, 2015:723; Townsend, 2015:334).
Infections are also linked to brain damage and the development of mental illness or
worsening of its symptoms. The occurrence of autism spectrum disorders is, for example,
associated with disruption of early foetal brain development. Furthermore, long-term
substance abuse and malnutrition adversely affect the functioning of the body on a
biological level, resulting in conditions such as depression, anxiety and schizophrenia.
Apart from the above-mentioned factors, structural abnormalities in the brain also play a
role in the occurrence of some mental illnesses, including schizophrenia (Bhandari 2016:
Online; Feldman, 2015:527; Sadock et al., 2015:694).

2.5.2 Psychological factors

Psychological factors that may contribute to mental illness include severe psychological
trauma suffered in childhood, such as emotional, physical or sexual abuse or neglect, an
important early loss, such as the loss of a parent. The effect from these factors could be
poor ability to relate to others among others (Medicinet Health Direct: Online).

2.5.3 Environmental factors

Mindwise (2015: Online) views environmental factors as “Factors around us”, which
encompass the life and living circumstances of an individual. Family and community
support networks, employment status and work stressors can play a part in the
development of mental illness. All these factors provoke negative consequences that put
pressure on an individual’s mental health. Low socioeconomic status, for instance, is
linked to the occurrence of schizophrenia and other mental problems in a manner that
firstly, low socioeconomic status brings about poverty; thus, triggering symptoms of some
mental disorders or worsening already existing mental problems. Secondly, people with
schizophrenia who are engaged in some employment may fail to keep their jobs and fall
into poverty, thus impacting negatively on their health (Bhandari, 2016: Online; Townsend,
2015:425). Bhandari further states that certain stressors can trigger mental illness in a
person who is susceptible, for example, due to loss of a loved one, either through death
or divorce, which could lead to conditions such as elimination disorders and major

26
depressive disorders in children (Uys & Middleton, 2014:735). Lastly, while biological
factors can play a role in causing eating disorders, social or cultural expectations or
demands are also responsible for the development of eating disorders and other mental
conditions (Feldman, 2015:324). From the above views, it is clear that no single factor is
responsible for the causation of mental illness; instead, a combination of more than one
factor is associated with the occurrence of the illness.

2.6. THE PREVALENCE OF MENTAL ILLNESS

Mental illness accounts for a significant and growing proportion of the global burden of
disease, yet remains a low priority in many low- and middle-income countries, as
indicated in Chapter One. This section explores the global prevalence of mental illness.
According to the Mental Health Atlas country profile of 2014, Lesotho does not have clear
reports on the prevalence of mental illness, however, it was found in 2008 that the most
commonly diagnosed mental illnesses in Lesotho are depression and anxiety
(Commonwealth health: 2011: Online)

The onset of majority of mental illnesses is around early adulthood stage, the crucial time
when human beings are productive, pursuing careers and starting families among many
milestones and as a result causes disability (Uys & Middleton, 2014:409). A study by Lund
et al. (2008, cited by Samouilhan & Seabi, 2010:76) found a high prevalence of mental
illness in South Africa, and the rate seemed to be increasing rapidly and it was estimated
that 17% of the total population had psychological disorders in 2007. Studies carried out
subsequent to that of Lund et al. confirmed this trend. According to global surveys of
mental illnesses and studies carried out in South Africa, there is evidence that the
prevalence of mental illness is increasing (Sorsdahl et al., 2012:168).

It is anticipated that, by 2030, mental health problems will constitute 15% of the global
burden of disease. Regardless of the growing burden of mental illness and the resultant
suffering of individuals and society, efforts that have been employed to address mental
illness did not yield satisfactory results (Jack-Ide, Uys & Middleton, 2014:1; Shrestha,
2015:3). The WHO (2008) proposed a model for integrating mental health services into
primary health care, with the expectation of reducing stigmatisation of patients and

27
addressing staff shortages. The aim of this model is to improve access to mental health
care services nevertheless full integration is not yet attained in many countries. In 2013,
it was estimated that there were at least 450 million people in the world suffering from
some kind of mental illness, with 150 million affected by depression and 25 million by
schizophrenia (WHO, 2008: Online).

2.7 THE BURDEN OF MENTAL ILLNESS ON INDIVIDUALS, FAMILIES AND

COMMUNITIES

According to the WHO (2003: Online) mental illnesses are accompanied by direct and
indirect burden. The burden of distressing symptoms is amplified by stigma and
discrimination, which impair the individual’s ability to participate in work and leisure
activities. The WHO report also indicates that it is not only persons with mental illness
who suffer the consequences, but their families and caregivers too are also burdened by
stigma and discrimination due to their relationship with the ill person. Furthermore, an
unquantifiable burden of suffering and lost opportunities is compounded by time and
financial resources being expended. As a result, the ability of caregivers to provide
physical and emotional support to those who are ill is affected.

The burden that the family bears due to mental illness is considerable, and exacerbated
by stigma. Apart from being on the receiving end of stigma and discrimination, families
serve as caregivers, supporters of other families in similar situations, as teachers and
educators of the public, as well as advocates for better services, thus, increasing their
already unbearable burden. In addition, it is clearly pointed that caregiving responsibilities
involve being a treatment supporter and ensuring that relationships between the patient
and other people are maintained. They also have to bear financial costs to ensure the
survival of patients. These responsibilities result in caregivers being emotionally affected
(Uys & Middleton 2014:88).

Research confirm that persons with mental illness are denied their rights, including the
right to employment; thus, increasing the burden on individuals, families and communities
at large. Unemployment is one of the major burdens of individuals with mental illness, as
they cannot find or retain employment due to the mental illness, regardless of their

28
expertise. Unemployment negatively impacts government expenditure, as those with
mental illness are not contributing to the economy of their country. This imposes a huge
challenge, because, in many countries, mental health services are free. Lesotho is not an
exception, and the expectation is that mental health services expenditure will be
accommodated within a limited budget, as indicated in Chapter 1. People with mental
illness who are employed, are compelled to take early retirement, due to stigma and
prejudice in the workplace, as well as a decline in work performance owing to poor mental
functioning (Karpansalo, Kauhanen & Lakka, 2005:71).

According to Uys & Middleton (2014:84), the diagnosis of mental illness is the most
terrifying experience a person can tolerate because mental illness is viewed differently to
other illnesses by society. People diagnosed with or labelled as having mental illness
suffer the consequences of being discriminated and stigmatised. This is affirmed by
several studies that show evidence of negative attitudes, among the general public and
health care providers, towards undesirable conditions, including mental illness
(Kapungwe et al., 2011:290; Louis & Roberts, 2013:123). Due to negative consequences
that are brought about by stigma in various spheres of life, the researcher finds it worth
exploring the relationship between mental illness and stigma.

2.8. STIGMA

Stigma goes hand in hand with mental illness. There is evidence that one of the reasons
why people with mental illnesses and their families are without jobs, housing and even
friends is due to stigma (Uys & Middleton, 2014:85).

2.8.1 Defining stigma

The word stigma comes from the Greek word which means to tattoo or to brand. Broadly
speaking, stigma is a negative evaluation of a person who is tainted or discredited on the
basis of attributes, such as a mental disorder or illness, race, ethnicity, drug misuse or
physical disability. It is a mark of shame, disgrace, or disapproval, which results in an
individual being ignored by other people. It is also described as a collection of negative

29
attitudes, beliefs, thoughts, and behaviours that influence the individual, or the general
public, to fear, reject, avoid, prejudice and discriminate against people with mental illness.
Stigma signifies a mark indicating that someone is of a lesser value than others, and this
attitude exists among both health workers and community members. (Boyd 2015: 14;
Dictionary 2007: Online; Gary 2005:80; Ndetei et al. 2011:226; Shrestha, 2013:35).

2.8.2 Stigma and mental illness

Corrigan (2004: 615) explored the failure of patients with mental health problems to
engage in their treatment. Based on the results of his study, the reason is stigma. Mental
illness is among the phenomena that are characterised by intense stigma by the general
public as well as health professionals, inclusive of mental health professionals (Sadock
et al., 2015:1402). Sorsdahl et al. (2012:169) state that compared to other members of
the society, those with mental illnesses are viewed as being more unpredictable, tense
and dangerous, worthless, delicate, slow, weak, dirty, and foolish. Due to these labels,
patients with mental illness are being discriminated against, to the extent that they are
denied opportunities equal to that of other members of society. These characteristics are
portrayed and confirmed by abusive treatment that people with mental illness have always
endured. Historically, during the Middle Ages, treatment modalities were inhumane, and
included driving out evil spirits by means of whipping, trephination, immersion in hot
water, starvation and burning. Sometimes patients were even sent out to the sea to
search for their lost rationality – this is the origin of the expression “ship of fools”
(Townsend 2015:13; Uys & Middleton, 2014:4).

Historically, in Lesotho, like in many countries of the world, persons with mental illness
did not receive proper treatment. They were housed in what was known as the Detention
Centre situated at Mohale’s Hoek prison, where they were cared for by unskilled
personnel. People from neighbouring villages used to visit the place to tease and watch
patients when portraying abnormal behaviours. Some stigmatising behaviours are still
observable, even today, as some patients are brought to health facilities viciously beaten
and bound with materials that cause harm such as wires; the maltreatment is due to the
belief that they are possessed by evil spirits or they are evil spirits themselves. Deribew
and Tesfaye (2005) emphasise that, globally, many patients with mental illness are

30
victimised and have become the target of stigma and discrimination. A study carried out
in Zambia by Kapungwe et al. (2011:291) explains explicitly that stigmatising patients with
mental illness is a common phenomenon across all cultures. This matter is confirmed by
a study carried out in Nigeria (James, Omoaregba & Okogbenin, 2012), where the first
large-scale, community representative study of popular attitudes towards persons with
mental illness found stigma to be widespread, with most people indicating that they would
not tolerate even basic social interactions with someone with a mental illness. Bennett
(2012:12) also carried out a study on the prevalence of stigma and its pervasiveness
among the police, teachers and students, as well as health professionals. Bennett found
that stigma is prevalent among all these groups. It was also found to be present among
people working in the mental health field, including psychiatrists, who are credited with
advanced knowledge and training, and who are supposed to assist persons with mental
illness and protect their human rights (Thornicroft, Rose & Mehta, 2010:55).

The above-mentioned labels attached to mental illness affect individuals with mental
illness and their families negatively. Section 2.8.3 addresses the effects of stigma on
individuals with mental illness and relevant stakeholders.

2.8.3 Effects of stigma on persons with mental illness and mental health services

Literature indicates the existence of negative impacts by stigma on persons with mental
illness as well as mental health services. The following bears reference to this issue. The
WHO, World Health Report (2001:17) states that stigmatisation complicates access to
those who need help, treatment and care, and that stigma is responsible for a huge hidden
burden of mental problems. Stigma is a recognised barrier to the effective management
of mental illnesses in several parts of the world. It affects health professionals’ readiness
to provide effective interventions for individuals with mental illness. Shrestha (2013:35)
makes it clear that attitudes influence both professional and personal behaviour.

Stigma and discrimination associated with mental illness result in the underutilisation of
mental health services. This seems to be the opposite of the ideal situation, in which
mental health professionals should serve as advocates and role models in society; their

31
views towards people with mental illness should positively influence the behaviour of the
society instead of holding stigmatising attitudes (James, et al. 2012:32). In their research,
Sorsdahl et al. (2012:169) affirm that stigma is a barrier to scaling up services for persons
with mental illness. In addition, the burden is increased, due to various beliefs among the
general public about mental illness. These studies reveal the presence of varying degrees
and patterns of stigma towards persons with mental illness, which influence the
relationship between patients, family members, health professionals and the society at
large. According to Boyd (2015:14), persons with mental illness have been humiliated,
hanged and or even stoned to death because of stigma. Boyd further points out that
stigma leads to community misunderstandings, prejudice and discrimination, and it is one
of the major barriers to treatment facing individuals with mental health problems.

In summary, the literature is clear that stigma is a barrier to the full utilisation of mental
health services; thus affecting the lifestyle functioning of the affected persons and
resulting in increasing the burden of mental illness. This conclusion is confirmed by Ikeme
(2012:5), who stipulates clearly that stigma and discrimination can disrupt the lives of
individuals living with mental illness, preventing or slowing down their opportunities to
become productive citizens. The question is has the world done something to reduce
stigmatising behaviours? The following section explains efforts exercised to combat
stigma.

2.8.4 Combating stigma

Combating stigma has never been an easy task. Various efforts have been applied to
fight stigma, but little has been accomplished, since many studies show that stigma and
discrimination in relation to mental illness are still issues that the world is grappling with.

According to the World Psychiatric Association (WPA, 2000), several programmes have
been put in place to reduce the persistent stigma faced due to mental illness. The aim of
these programmes was to challenge negative stereotypes and discriminatory responses
that generate social disability around the world; nonetheless, these programmes are
rarely evaluated. In addition to the programmes, studies that were carried out in different
areas point out that there are three general approaches that can be followed in an effort

32
to combat stigma and these are education, contact and protest. It is argued that, although
each of these stigma-reducing approaches has some degree of validity on the surface,
they are not uniformly effective, however, short educational workshops are found to
produce positive changes in attitudes towards people with mental health problems. While
education is important, disclosure is vital in the process of reducing stigma (Corbiere,
Samson, Villotti, & Pelletier 2012:1; Corrigan & Penn 1999; Online; Pinfold, Toulmin,
Thornicroft, Huxley, Farmer & Graham 2003: Online). According to the WHO (2001),
governments are encouraged to move away from large mental institutions, towards
community health care, and rather to integrate mental health care in primary health care
services and the general health care system. This advice represents an effort to avoid
isolating patients, which would prevent people from engaging in negative labelling.
Furthermore, a recommendation by the WHO (2001:4), at the 65th World Health
Assembly, aimed to introduce human rights protection for people with mental health
problems. Among the strategies proposed were developing policies and laws that protect
and promote human rights, and establishing independent monitoring mechanisms. The
purpose of these mechanisms is to improve conditions in health facilities, in line with
international human rights standards, such as the United Nations Convention on the
Rights of Persons with Disabilities. Another recommendation was to involve people with
mental health problems in employment and income-generating programmes, to introduce
supported employment programmes, and to provide social protection grants. The
assumption is that the more supportive the environment, the less the probability of mental
problems being exacerbated; and the more stigmatising attitudes will be reduced. In
conclusion, reducing stigma requires a concerted effort from all relevant stakeholders in
order to overpower it. Furthermore, existing health care systems must be strengthened.
Section 2.9 below discusses health care systems in Lesotho.

2.9 MENTAL HEALTH CARE IN LESOTHO

In Lesotho, mental health services are the responsibility of the Ministry of Health and the
services are free. Lesotho has one mental referral hospital that admits men and women
of different ages, from 14 years upwards. In 2011 the hospital was renovated with the aim
of increasing bed capacity from 60 to 115 in order to accommodate children and

33
adolescents (Mental Health Atlas, 2011: Online). During the time of the study the hospital
had about 12 PNs, while the rest of the nursing staff comprised of RNs, RNMs, NAs and
WAs. A Medical Officer available at the time assumed the duties of a psychiatrist, served
at the hospital and supported all MOTUs.

The nursing staff is charged with the total care of patients within the health facilities. As
mentioned in Chapter 1, the WHO’s Mental Health Atlas (2011a: Online) states that, in
Lesotho, primary health care nurses are authorised by the Ministry of Health to care for
persons with mental illnesses even though there are restrictions in relation to prescription
of psychotropic medication, since there are no guiding manuals in health facilities.
Secondly, the official policy does not permit primary health care nurses to diagnose and
treat mental disorders independently in the primary care system. Practically, the nursing
staff is composed of a Nurse Clinicians RNs/RNMs, NAs and WAs.

As stated in Chapter 1, the basic nurses training include a mental health component in
various programmes. RNs/RNMs and NAs who trained in Lesotho are only introduced to
mental health nursing of the child, adolescent and adult – RNs had a semester course
while some NAs had a 1 year course and others a semester course during their training.
RNs/RNMs who are interested in mental health had to pursue a 1year programme to
specialise in psychiatric mental health nursing to obtain a qualification in psychiatric
nursing. RPNs are placed in MOTUs, where they have full responsibility of running the
units independently and ensuring that all mental health activities in the unit are occurring
together with those of primary health care facilities within their catchment areas. Ideally,
they are paired with RNs, NAs and WAs and work together to accomplish all duties
performed in the unit. The daily duties of RPNs include consultation of patients in the unit,
hospital and or at health centres, counselling, outreach services (for which they
sometimes travel long distances), school health services as well as mental health
awareness campaigns. The Psychiatrist or Medical officer visit the units as per scheduled
times. Based on the above information, it can be argued, therefore, that caring for people
with mental illnesses is done mostly by nursing staff that have little or inadequate training
in relation to issues of mental health and illness, since the majority received only a brief
introduction to matters related to mental health.

34
The need to care for people with mental health problems in general hospitals has
increased. While Uys and Middleton (2014:107) make it clear that a positive diagnosis of
a mental-health-related illness in terms of accepted diagnostic criteria should be made by
a mental health care practitioner authorised to make such a diagnosis, generalist nurses
are the major providers of hospital care and have become an important resource in the
delivery of mental health care (Reed & Fitzgerald, 2005:249). Lesotho is no exception, as
nurses with no speciality in psychiatry play a fundamental part in the care of patients with
mental illnesses, from primary to tertiary levels of care. In Lesotho, people with mental
illness are, first, consulted at the primary health care facility, mostly by nurses, before
they can be referred to any point of care for further management. Patients who warrant
observation at the MOTU are admitted and observed up to a period of about 28 days
before referring the patient to the hospital, if necessary.

According to literature, nurses’ responsibilities in relation to mental health in Lesotho are

similar to that of some parts of the world. Nurses face various challenges inclusive of
changing expectations and behaviours patient as well as shortage of staff. These
challenges may burden nurses and negatively affect the quality of nursing care based on
the mentioned responsibilities. There are changes in mental health services that impact
the role and practice of mental health nursing. While nurses attempt to provide a safe
environment, they struggle to provide therapeutic care due to the fact that patients with
mental illnesses are demanding, acute, and disturbed. Even though the nursing staff
struggle to deliver quality care, it is fair to acknowledge the dynamic role played by these
health workers in the diagnosis and management of patients with mental illness in the
face of these massive challenges. Nonetheless, research made it clear that, even though
they are playing an essential role in the absence of psychiatrists, mismanagement may
occur if they miss the diagnoses of mental illnesses, due to lack of knowledge and time
when evaluating patients presenting with psychiatric symptoms (Hamdan-Mansour &
Wardam, 2009:705; Cleary, Walter & Hunt, 2005; Rey, Walter, and Giuffrida, 2004;
O’Brien & Cole, 2003; Ndetei et al., 2011:225).

Uys & Middleton (2014: 45) indicate that comprehensive mental health care is essential
in order to meet the needs of individuals and families affected by mental illness. They

35
further explain an effective approach to follow that includes primary, secondary and
tertiary prevention strategies. Primary prevention strategies include health education that
is carried out in an effort to impart information and knowledge that assist to prevent mental
illness while secondary prevention aims to reduce the prevalence of the illness through
early detection and effective treatment. Ongoing education is important at this stage.
Tertiary prevention is about rehabilitation and enhancement of recovery. Ongoing
treatment and care is of the utmost importance at this level. It is at this juncture where the
multidisciplinary team work jointly for the betterment of the patient with mental illness. The
team consists of psychiatrists, occupational therapists, all categories of nurses, clinical
psychologists, social workers and pharmacists (Uys & Middleton, 2014: 39).

Clark, Parker and Gould (2005: 205) agree that nurses play an integral role in the delivery
of health care services to persons suffering from mental illnesses, especially in rural and
remote areas. Shortage of expertise in the mental health care field increases the burden
of mental illness on communities as confirmed in a study carried out by Kakuma, Minas,
Van Ginneken, Dal Poz, Desiraju, Morris, Saxena and Scheffler (2011:1665), who
estimated that there was a shortage of 1.18 million specialist mental health personnel in
low- and middle income countries of which Lesotho is included.

36
2.10 KNOWLEDGE, ATTITUDES AND PRACTICES OF NURSES TOWARDS MENTAL
ILLNESS

Knowledge can influence positively the way people feel and behave in response to such
feelings, though it is not always the case. It is believed that people who are well informed
can act effectively and produce favourable results. However, it is emphasised that the
possession of accurate information does not predict the ability of making wise judgments,
nor is misinformation necessarily an antecedent of bad decisions. Literature indicates that
knowledge has been consistently shown to be non-influential in predicting behaviour
(Ajzen, Joyce, Sheik and Cote, 2011:101; Wallace, 2002: Online).

The relationship between knowledge, attitudes and practices of nurses in relation to

mental illness will be discussed based mostly on the theory of Ajzen et al. (2011: 102).
According to the theory of planned behaviour people’s intention to perform a specific
behaviour emanates from an informational foundation that closely links with the
knowledge component of this study’s intended KAP survey. However, the knowledge
component will not necessarily reflect the degree of knowledge nurses show about mental
illness, but rather their beliefs, which ultimately determine their behaviour or practice.

Three groups of beliefs are identified, namely, behavioural, normative and control beliefs.
Behavioural beliefs depict the nurses’ behaviour in respect to a specific mental illness
and a consequence that leads from this behaviour. Normative beliefs reflect the nurses’
behaviour towards and expectation of a specific mental illness due to the enacted
behaviour. Flowing from normative beliefs are subjective norms. The subjective norm not
only provides a link between the nurses’ behaviour and mental illness, but also states that
the expectation is linked to the expectations of other relevant nurses in this field, who are
involved in the care of persons with mental illness. Control beliefs portray factors a nurse
perceives, which could either assist or hamper the control over mental-illness-related
issues. Lastly, nurses’ perceived behavioural control reflect the link between a specific
mental-illness-related behaviour and the nurses’ perception of their ability to manage the
specific behaviour.

37
In line with the KAP survey, specific attention is given to the attitudes of nurses, as an
element playing a role in the actual mental-illness-related behaviour or practice. The
nurses’ attitudes towards mental-illness-related issues, as well as their subjective norms
and perceived behavioural control of such issues, all strengthen or weaken their intention
to perform specific mental-illness-related behaviour. The behaviour equals what the KAP
survey refers to as Practice. Therefore, nurses’ behaviour in relation to mental illness will
depend on their intention to act out behaviour, as well as the actual behavioural control
the nurse has over performing such behaviour in the long run. Several researchers
validate this theory, as explained below.

In a study by Al-Rabeei, Dallak and Al-Awadi (2012: 222), the idea was that an important
factor driving the spread of HIV and AIDS in developing countries is lack of knowledge
about how the disease is spread and how it can be prevented. The argument is that the
high prevalence rate of mental illness can be attributed to a similar shortcoming. Ajzen et
al. (2011:102), however, make it clear that possession of the required knowledge is not
enough; instead, people must also be motivated to perform the behaviours in question.

Another contributing factor that can influence the knowledge and attitudes of health care
providers either positively or negatively has been found to be an adequacy of clinical
experience during training. This is affirmed by a study by Cleary, Horsefall, O’Hara-
Aarons, Mannix, Jackson and Hunt (2011:185), which found that adequate clinical
exposure increases undergraduate nursing students’ knowledge of and confidence in the
field. In Lesotho, the majority of the nursing staff who care for patients with mental illness
have limited exposure to mental health content and clinical practice during training. For
instance, RNs undergo one month of clinical exposure while NAs have the exposure of
two weeks during training.

It is clear, therefore, that several factors play a role in achieving a desired behaviour.
While knowledge is one of important factors, it cannot suffice to bring about positive
outcomes in relation to mental illness and people with mental illness. Attitudes and how
people act under the influence of their feelings about mental illness also play a vital role
in producing the desired outcomes.

38
Baron and Byrne (1987) state that attitudes are lasting, general evaluations of people,
including oneself, objects or issues, that persist over time. Furthermore attitudes guide
peoples’ experiences and determine the effects of experience on one’s behaviours. In
addition, attitudes determine a person’s personality; they influence the actions of an
individual towards the world. Most importantly, attitudes affect one’s social interactions.
According to Foster et al. (2009: 72), attitudes influence both professional and personal
behaviour. While positive attitudes are favoured, the consequences of possession of
negative attitudes are unpleasant especially in mental illness. Negative attitudes toward
mental illness as studied by Foster et al., (2009) appear to worsen the overall quality of
life of individuals with mental illnesses as they result in stigma and discrimination. They
declare that stigma and discrimination associated with mental illness, as explicated by
mental health professionals and the general public, lead to a situation whereby mental
health services are under-utilized. Nonetheless it is mentioned in their study that for the
past 50 years, programmes aiming to reduce the stigma about mental illness have been
introduced but the shortcoming is that these initiatives advocated for medical rather than
psychological explanations for mental illness.

Morris et al. (2011:460) agree that if healthcare professionals harbour negative attitudes
towards any patient, these attitudes can have implications for the patients’ recovery.
Venter (2014: Online) found that attitudinal problems regarding mental illness and a lack
of skills are among the factors that lead to failure of health providers to detect mental
illness. Therefore, providing nurses with relevant information and education has the
potential to improve their attitudes and behaviour towards mental illness and people with
mental illness, by reducing fear and stigma. Clark et al. (2005:205) state that nurses
require knowledge, skills and networks in mental health that will enable them to provide
effective mental health care. However, acquisition of knowledge about mental illness does
not always reduce the stigmatising attitudes of primary health care workers. Prejudice
towards people with mental illness has been shown to correlate with societal ignorance
and beliefs that mentally ill persons are dangerous and unpredictable, less competent
and unable to live productive lives.

39
Although many definitions of attitude have been proposed, most investigators would
agree that a person's attitude represents his evaluation of the entity in question as stated
earlier (Ajzen & Fishbein, 1977: 889). It is also recognised that knowledge may play a
significant role in shaping attitudes which in turn could determine responses to particular
situations or circumstances (Igbinomwanhia, James & Omoaregba, 2013: 196).

2.11 SUMMARY

It is clear that mental illness is common worldwide. In many African societies, mental
illness is believed to be either an outcome of a familial defect or the handiwork of evil
machinations. Another common societal belief is that patients are responsible for their
illness, especially when it is a problem related to alcohol and/or substance abuse (Ndetei
et al., 2011:226).

Even though mental illness is common, there are few studies on mental health issues,
particularly about the attitudes of nursing staff – the major health care providers,
especially in Lesotho – towards mental illness. Despite growing evidence of the
importance of mental health for economic, social and human capital, people with mental
health problems, mental health services and professionals, and even the very concept of
mental health, receive negative publicity and are stigmatised in public perceptions
(Vijayalakshmi, Reddy, Math & Thimmaiah, 2013:66). Literature indicates that people with
mental illnesses are stigmatised. Stigma signifies a mark, which indicates that someone
is of a lesser value than others. It is clear that a stigmatising attitude not only exists among
the general public, but also thrives among health workers in most cultures.

In this chapter, a literature review of matters pertaining to knowledge, attitudes and

practices of nurses in relation to mental illness was conducted. The methodology used
for this study will be discussed in Chapter 3.

40
 CHAPTER 3

RESEARCH METHODOLOGY

3.1 INTRODUCTION

Chapter 1 gave an overview of the study, starting with the problem statement and
context of the problem. Chapter 2 provided the reader with a literature review of
information pertaining to the KAP of nurses as it relates to mental illness worldwide.
This chapter will give a description of the research design and the method applied in
order to achieve the objectives of the study. Consideration will be given to the
quantitative, descriptive, cross-sectional research design used. The research
technique, namely the structured questionnaire used to collect data, will be explained,
and considerations relating to the population and sampling, pilot study as well as validity
and reliability, will also be described. Ethical concerns and the value of the study will be
looked into.

3.2 RESEARCH DESIGN

Research design is defined as development of the framework of the study or the overall
plan, strategy or structure that will assist the researcher to pursue and accomplish the
objectives of a study through responses to the research question. Furthermore, the
research design guides the researcher regarding the projections and the
implementation of the study processes. The research technique to be used is
determined by the research design followed, and guides the researcher in the selection
of the population, sample and data collection method to utilise. The framework,
therefore, serves as a plan of reference that ensures security against all unexpected
factors that could hinder or interfere with the validity of the findings (Botma et al.,
2010:39; Burns & Grove, 2009:218; De Vos et al., 2014:142; Grove et al., 2013:43; Polit
and Beck 2012:58). A descriptive, cross-sectional, quantitative design was used in this
study.

41
3.2.1 Descriptive research design

A descriptive design is a non-experimental design used to describe the variables without

manipulating the situation. The main aim of the descriptive design is to observe, count
and classify phenomena with the intention of, (i) identifying patterns in variables; (ii)
describing and defining variables; and (iii) identifying initial relationships among
variables. Descriptive research is generally preferred when there is limited knowledge
about the event or the situation of interest. This design was found to be relevant for this
study, as there was little or no evidence of studies having been done regarding the KAP
of nursing staff in relation to mentally ill patients in Lesotho. However, a shortcoming of
this design is that it cannot be used to infer causality; nonetheless, it is relatively less
time consuming and, as a result, cost-effective (Botma et al., 2010:110; Grove et al.,
2013:87; Polit & Beck 2012:226).

3.2.2 Cross-sectional design

A cross-sectional design involves a process of data collection from a specific sample at

a single moment in time. Furthermore, it gives the researcher the opportunity to
recognise problems and draw conclusions in relation to current practice (Botma et al.,
2010:110; Brink, Van Rensburg & Van Der Walt, 2009: 10; Grove et al., 2013:43; Polit
& Beck, 2012:184).

The advantages of this design are that it has been proven to be economical, as
participants are captured in a specific setting at the same time. It is also quick and easy
to conduct, as it is generally based on a questionnaire survey; furthermore, it is a once-
off activity, since no follow-up meetings are required (Botma et al., 2010:113; Polit &
Beck, 2012:186; Sedwick, 2014: Online). Due to these features, and the fact that some
of the respondents were stationed in inaccessible locations, and limited funds were
allocated to conduct the study a cross-sectional design was applicable for exploring the
nurses’ KAP.

42
3.2.3 Quantitative research

Polit and Beck (2012:739) define quantitative research as, “the investigation of
phenomena that lend themselves to precise measurement and quantification often
involving a rigorous and controlled design”. Control mechanisms are exercised to
reduce bias and optimise validity. The data that is gathered is attached to numbers,
which are statistically analysed and used to describe and deduce predictions about
events or behaviours. The results that are obtained may be generalised, due to the
objective nature in this approach. Quantitative research design enables description of
the prevailing situation and formation of relationship between variables. It focuses its
attention on measurable aspects of human behaviour and is only used if the data can
be measured in numbers (Botma et al., 2010:109; Bryman, 2012:159; Polit & Beck,
2012:14).

A quantitative research design was found to be relevant for this study, as the intention
was to explore and describe the behaviour of nursing staff towards mental illness. It is
a quick approach, since it uses a questionnaire. It is not expensive to administer, as it
permits data collection from the sample at a single event, without any subsequent
meetings for further data collection being required. The technique used is explained
below.

3.3 THE RESEARCH TECHNIQUE

3.3.1 Questionnaires

A research technique refers to methods or measurement strategies that are used to

collect data. A questionnaire is a document containing printed questions and other types
of items that require research subjects to provide answers or opinions. The aim of the
questionnaire is gathering information suitable for analysis from the written responses
given by the research subjects. There is evidence that, compared to interviews, there is
no difference between information gathered through questionnaires and interviews,
except that questionnaires sometimes give less detailed information (Burns & Grove,
2011:345; De Vos et al., 2014:186; Brink et al., 2009:102; Grove et al., 2013:425,

43
Hassan, 2016: 42; Polit & Beck, 2012:305). In this study, a structured questionnaire was
found suitable and was used to collect data.

Methods of administration of questionnaires vary. Questionnaires can be self-

administered, or responses can be taken down by the researcher. The researcher can
utilise either face-to-face or telephonic approaches to collect data. With face-to-face
interviews, the interviewer meets with the respondents to ask questions in person. The
face-to-face method is used when literacy levels of respondents are a problem (De Vos
et al., 2014: 356). This is not applicable in this study as respondents are literate.

In administering a telephonic questionnaire, the interviewer asks questions over the

telephone and records answers during the interview. The advantages of this method
are that it is fairly cost-effective in relation to travelling and time, as the researcher works
from one area. Information is collected in a short time and the level of literacy of the
respondent is not a factor. Challenges of this approach include the difficulty of collecting
sensitive data, and the possibility of the respondent ending the interview prematurely
(De Vos et al., 2014:187; Marshall, 2016: Online; Polit & Beck, 2012:265).

Self-administered questionnaires can be sent out by mail, electronically, or handed out

to respondents at a communal place. Advantages of self-administered questionnaires
are that they are economical, and quick to complete only if they are within recommended
length. Inadequate literacy of respondents poses a challenge, as the questionnaires are
completed individually in a form of writing. Another disadvantage is a low response rate,
however, if the questionnaires are handed out personally, a higher response rate is
possible and respondents have the opportunity to ask questions (Bowling, 2005; Polit &
Beck, 2012:310). Self-administered questionnaire method was intended to be used for
this study though it was not successful. Different methods of distributing these
questionnaires, as well as advantages and disadvantages of these methods are
explained from sections 3.3.1.1 to 3.3.1.3 according to De Vos et al. (2014:186-190)
and Polit & Beck (2012: 309 -312).

44
3.3.1.1 Mailing questionnaires

In this case, questionnaires are posted to the respondents, who complete them and
send them back to the researcher. An advantage is that this method is cost-effective,
as the researcher does not incur travelling expenses to meet with respondents. Some
people may find being in contact with the researcher threatening and this influences
their responses. With a mailed questionnaire, respondents feel liberated, as there is no
face-to-face contact with the researcher and they complete the questionnaire in their
own time. Limitations include a low response rate, an inability of the researcher to
ensure that the person is the intended respondent, and a high degree of bias.
Sometimes, it is difficult to track respondents’ failure to follow instructions until it is too
late, and they have submitted their questionnaires.

3.3.1.2 Distributing questionnaires electronically

This distribution method has four modes. An emailed survey involves the questionnaire
being sent to the respondent, who completes it and returns it using e-mail. The second
type uses a web-based survey, whereby the questionnaire is completed online. The
third way involves using computerised interactive voice response (IVR), which relies on
telephone calls, and the last type is through various ways of using computer, laptop or
desktop. The aim of this approach is to work electronically, and to avoid using paper-
based questionnaires. Advantages of electronic distribution include few mistakes,
elimination of paper, and the ability to collect data from even remote areas. It is also
easy to transfer data from the electronic devices to the central database for analysis.
Disadvantages of this type of distribution are that illiterate persons struggle to operate
electronic devices and are at risk of being excluded from participation.

3.3.1.3 Hand-delivering questionnaires

The questionnaire is delivered by hand and collected at a later stage, after being
completed – if possible, not more than 48 hours after distribution. The advantages are
that the response rate is high due to personal contact and since it does not take long to
complete, feedback is received within a short period of time. Furthermore, clarity can

45
be sought from the researcher as there is personal contact between the researcher and
the respondent. However, hand-delivering questionnaires have limitations, among
which limited coverage, due to travelling costs, as well as problems relating to
respondents’ literacy.

The initial plan in this study was to utilise the self-administered questionnaire approach,
owing to the fact that the health facilities are far apart and scattered throughout the
district. I had to travel long distances along gravel roads, some of which in poor
condition. Appointments were scheduled in such a way that health facilities located
along the same route or direction would be scheduled during a trip of one or two days,
to deliver questionnaires, have them completed and to collect them during the same
visit. This plan did not work, as the nursing staff could not avail themselves due to
various acceptable reasons while the researcher was at health facilities. The reasons
include being away from the facility for outreach services delivery, workload pressure
due to the number of patients/clients and limited staff, attending workshops or meetings
or being off duty. Due to these reasons, the alternative was to deliver questionnaires to
each facility by hand and to collect them on agreed dates. The distribution was done
within a short space of time. The information leaflet was read to respondents upon
distribution of the questionnaire. The mode of handing out the questionnaire was the
same at all health facilities.

The questionnaire was to be completed anonymously. Anonymity encourages

participation by and loyalty from respondents when giving feedback. This is in line with
what Botma et al. (2010:135) indicate, namely, that anonymous questionnaires
encourage respondents to give first-hand or honest information. In addition, this
approach was cost-effective, as the researcher worked alone, without any assistance.

This method also faced limitations. The health facilities, as mentioned earlier, are far
from each other, thus, increasing travelling costs. To address this challenge,
appointments were made with gatekeepers prior to delivery and collection of
questionnaires; they were also reminded telephonically. In spite of appointments and
reminders, the researcher had to make more than one trip to health facilities to collect
questionnaires, as some questionnaires were not available at the initial collection time.

46
Another challenge that was noticed during analysis of the completed questionnaires
was that some respondents misinterpreted some items.

3.3.2 Development of the questionnaire

The development of a questionnaire requires skill and effort to produce a valid and
reliable tool. Questionnaires can be extracted and adopted from existing literature, used
as they are, or modified. Modification includes addition or exclusion of items in the
existing questionnaire to address the needs of a specific study. Furthermore,
researchers sometimes combine modifications by using more than one questionnaire
depending on the needs of a study (Botma et al., 2010:134; Grove et al., 2013:426).
Features of a good questionnaire are explained below.

3.3.2.1 Features of good questionnaires

As stated in Chapter 1, a questionnaire is a document that contains printed questions.

The way questions are arranged is important. Questions relating to the same theme
should be grouped together, while the questions should start from a general perspective
and move towards more specific aspects. It is advisable to start with simple and
interesting questions that lead to more sensitive questions. Questions should be clear,
with no ambiguities, so that the respondent does not have to wonder what is being
asked. Items should be stated in a positive rather than a negative manner, and the
researcher should avoid asking two questions in one item. Lengthy questions or
statements will put respondents off; so long items need to be limited as far as possible
(Botma et al., 2010:134).

The researcher did not develop a questionnaire for this study, but, instead, adapted
existing questionnaires by selecting only information relevant to this study, to compile
one questionnaire. A combination of two relevant questionnaires was used. The first
questionnaire relates to a study that was carried out in Zambia by Kapungwe et al.
(2011). The aim of the study was to explore health care providers’ attitudes towards
people with mental illness in Zambia. The second questionnaire was used by a study
by Bennett (2012), on the effects of a mental health training programme on health care
workers’ KAP in Belize.

47
The questionnaire compiled for this study was only available in English, as this is the
language used during training as well as in actual practice (at work) in Lesotho. Closed-
ended and open-ended questions enabled the researcher to collect a variety of
information. In this study, closed-ended questions are mostly used for the purpose of
collecting ample information in a reasonable amount of time. The questions were
presented in a Likert scale where five options were provided to choose from.
Responses to closed-ended questions are easy to code. A data collecting instrument
should comprise certain basic characteristics, including feasibility, reliability, validity,
appropriateness and suitability (Babbie, 2004:245; Neuman 2007:181).

3.3.2.2 Structure of the questionnaire

The first section collected biographical data, including information on age, gender,
marital status and qualifications. Section B focuses on assessing knowledge about
mental illness and people with mental illness, while Section C examines attitudes, and
Section D assesses practices relating to mental illness.

Section 3.3 described the research technique used; the following section describes the
population, target population, accessible population and sampling.

3.4 POPULATION AND SAMPLING

Population refers to all cases that qualify to participate in a given research study,
whether events, persons, behaviours or records; while the target population refers to
the whole set of persons, behaviour, events or objects that can be chosen to represent
the accessible population for a certain study. Accessible population is a set of persons,
behaviour or events and objects that meet the sampling criteria and which are available
to participate in a given study. The sample is a subset, or a smaller portion, of the
accessible population that is selected for a particular study (Botma et al. 2010:124;
Burns & Grove, 2009:42; De Vos et al., 2014:223; Grove et al., 2013:351; Polit & Beck,
2012: 273).

In this instance, the target population comprised all nursing staff (RNs and NAs) in the
country. Some, health centres operate in the highlands as they are located across the

48
country, which means some centres are located in hard-to-reach areas. The
mountainous terrain, together with scattered and isolated rural villages, represent a
significant access barrier to both staff and patients, and the WHO estimates that around
three quarters of this rural population live beyond of walking distance of a health facility
(Lesotho Review, 2015:Online). The Review further mention that retaining health
workers in the remote parts of the country is also problematic, though measures have
been taken in motivating them to stay and work in the highlands.

Based on the above-mentioned facts, only one district, Mafeteng, was chosen as the
study site. This decision was due to its location in the lowlands and the structure of its
health facilities. Only government and CHAL institutions were considered for the study,
as mentioned in Chapter 1 the government owns one hospital and eight primary health
facilities while CHAL owns nine health centres.

All RNs and NAs who were working in the Mafeteng government hospital and all
government and CHAL health centres were invited to participate. Ideally, each health
centre should be run by five nursing staff, that is, nurse clinician (advanced nurse
practitioner), at least two RNs and/or two NAs, though this is not the case in practice.
Not all health facilities have the ideal personnel complement – some were found to be
run by three staff members, and some by four staff members. Only one had seven staff
members. Another observation is that the distribution of staff by qualifications is different
across facilities. According to the statistics presented to the researcher by the Manager
Hospital Nursing Services (MHNS) before commencement of data collection, there were
154 staff members for all health facilities identified for participation in the study.

3.5 PILOT STUDY

A pilot study is defined as a smaller version of a full-scale study, and specific pretesting
of a particular research instrument. It is also known as the dress rehearsal of the main
investigation. Pilot studies are not done as merely routine in research, but for various
reasons, including refinement of methodology, to find out whether the study is feasible,
and to ascertain the adequacy and ambiguity of the research instruments. It also helps
to measure the time required to complete the questionnaire. A pilot enables the

49
researcher to establish whether the sampling frame and technique are effective, and to
assess the likelihood of success of proposed recruitment approaches (De Vos et al.,
2015:73; Grove et al., 2013:46; Van Teijlingen & Hundley, 2001:Online). Due to these
benefits, a pilot study was carried out.

The pilot study was carried out at Scott Hospital after being granted permission by
MHNS at the hospital as is the person in charge of the nursing staff. Employees of the
hospital, two RNs and two NAs, were invited to participate in the pilot study. Pilot
subjects were employees of Scott Hospital, which offers the similar services as
Mafeteng Hospital and its primary health facilities. The information leaflet was read and
discussed with pilot subjects. They agreed to participate and completed the
questionnaires. The respondents were asked to assess the questionnaire for ambiguity
and to measure the time spent completing the questionnaire. The minimum time taken
to complete the questionnaire was 20 minutes, and the maximum 30 minutes.
Measuring the time taken to complete the questionnaire enables the researcher to
ascertain whether the tool is within reasonable length or not. If a questionnaire is too
long, it discourages people to complete it, while, if it is too short, it fails to address the
topic being explored in sufficient depth and as a result pose a threat to the instrument
validity (De Vos et al., 2011: 193; Grove et al., 2013: 429). Pilot study respondents were
not engaged in the actual study. The value of a pilot study for enhancing validity and
reliability has been discussed. Validity and reliability are discussed in the following
section.

3.6 VALIDITY

Validity refers to the degree to which a measurement represents a true value. Focus is
put on the usability of the instrument chosen. Usability refers to the simplest method by
which an instrument can be administered, interpreted by the respondent and scored or
interpreted by the researcher. There is a range of validity types including content,
predictive, criterion and construct validity (Biddix, n.d.: Online; Botma et al., 2010:174;
Grove et al., 2013:393). The following section briefly explains types of validity relevant
to the study undertaken.

50
3.6.1 External validity

External validity refers to the extent to which the results of the study can be generalised
from a sample to a population (Grove et al., 2013:202). The external validity of the
instrument used was established directly from the sampling, which represented the
population accurately.

3.6.2 Content validity

Content validity focuses on the relevance of the content of an instrument (Van Teijlingen
& Hundley, 2001: Online). Content validity was therefore used to establish whether the
questions asked accurately assessed what the researcher wanted to know, that is, the
KAP of nursing staff in relation to mental illness. For the purpose of this study, content
validity was achieved by using a questionnaire compiled from two pre-existing
questionnaires. The questionnaire was appraised by the evaluation committee of the
School of Nursing of the UFS. The committee assessed the relevance and sequence of
the content. Gaps were identified and recommendations were proposed for
amendments. Furthermore the pilot study was conducted to enhance the validity.

3.7 RELIABILITY

Reliability refers to the consistency of measures obtained by the use of a particular

instrument, and indicates the extent of random error in the measurement method
(Botma et al., 2010:177; Burns & Grove, 2009:377; Grove et al., 2013:389; Uys &
Basson 1991). Reliability assesses how consistently the measurement technique
measures a concept (Grove et al., 2013:45). Grove et al. further indicate that, even
when certain attribute is observed on different occasions, records from different
observers should be the same, as an indication of the reliability of the instrument used.
Reliability assists researchers to select a measurement method relevant to a particular
study.

Like validity, there are different types of reliability, namely, stability reliability,
equivalence reliability and internal consistency (Grove et al., 2013:389). Stability

51
reliability refers to consistency of results when the same attribute is repeatedly tested
over time using the same measuring instrument. To assess stability reliability in this
study, pilot study participants were asked to complete the same questionnaire two
weeks after they had initially completed the questionnaire. Their responses were mostly
the same, which lead me to assume that the initial assessment was reliable.

3.8 DATA COLLECTION

Data collection is a process that includes subject selection and collection of data from
these subjects. Data maybe collected using different approaches, depending on
research design and measurement methods. The methods are observation, testing,
measuring, questioning, recording or a combination of any of the methods (Grove et al.,
2013:523). As stated in section 3.3.1, in this study, data was collected using a
questionnaire. The procedure followed will be described.

Upon approval of the research proposal by relevant ethics committees, the researcher
reported to the office of MHNS, Mafeteng Hospital, to present the proposal. The office
of DHMT at the hospital was informed about my initiative of conducting a study, since
this office oversees operations of the health centres. The researcher had to make
appointments with gatekeepers, that is, RNs in charge in each individual health centre,
before travelling to any one of them, with the exception of the Hospital, where an
arrangement was made with the MHNS. The study was focused on 18 government- and
CHAL-owned health facilities.

As indicated in Chapter 1, the plan was to request an opportunity during monthly nurses
meeting, so as to introduce self and provide information about the intention and
processes of the study, administer questionnaires to those who agreed to participate,
and then stay in the background while staff completed the questionnaires, and collect
them upon completion. However this strategy was successful in one institution (hospital)
only. With other facilities unanticipated circumstances required the change of plan. The
alternative approach was to leave the questionnaires behind and collect them at a later
stage. In the end of this process, 120 questionnaires were delivered, of which only 79
were completed. The same mode of administration of the questionnaires was done with

52
all selected respondents, on the set dates at all health facilities, in spite of some
changes that were influenced by factors beyond the researcher’s control.

As it has been mentioned before, the landscape of the country interferes with some
activities, such as travelling. Even though Mafeteng is located in the lowlands, it has
health facilities that are located in remote, under developed areas. Two health centres
were not accessible by motor vehicle owing to the fact that at the time of data collection,
it was heavily raining and the roads were impassable. Another challenge was that some
personnel, who met the inclusion criteria, were not interested in participating, due to
various reasons, among which the need to be remunerated for participation.
Furthermore, appointments were made, but when the researcher reached the health
centres, the prospective respondents were not available due to various reasons as
highlighted before.

3.9 ETHICAL CONSIDERATIONS

The Belmont Report (1979) identifies three principles that must be adhered to when
research is conducted on human subjects, namely, respect for people, beneficence and
justice. Respect is reflected by keeping the respondents’ data confidential. The research
does not always have a direct benefit for respondents, but no person should be harmed
by a study. Justice is ensured by treating the respondents in a fair manner – that means
adhering to the protocol at all times (Botma et al., 2010:17-20). Acquiring permission to
conduct the study and the right to consent followed by the ethical principles are
discussed below.

3.9.1 Acquiring permission

Upon acquiring permission from the Ethics Committees, the researcher was granted a
letter of consent with an ethics research number and approval certificate from the UFS
and Lesotho’s Ministry of Health respectively. Both documents were then submitted to
the MHNS, Mafeteng Hospital, who referred the researcher to the DHMT office, which

53
is the office working directly with all primary health care facilities in the district. The office
informed the personnel in charge of the health facilities about the activity and authorised
the researcher to commence with data collection process. Entry into the field was gained
through “gatekeepers” and “key informants”, who were the RNs at the relevant health
facilities (Polit & Beck, 2013:61).

3.9.2 The right to consent

Informed consent means that participants are fully informed about the imminent study
(Grove et al., 2013:175; Polit & Beck 2012:15). An open invitation was extended by a
brief presentation made to the nursing staff about the study and its processes. Emphasis
was on the purpose and benefits of the study. The topic of the study was presented to
the nursing staff, using the information leaflet (refer to Appendix A). The leaflet
comprised the following:

• Invitation to participants;

• What the study involved;

• Risks of participating;

• Benefits of participating;

• The fact that participation was voluntary;

• Reimbursements;

• Confidentiality; and

• Contact details of the researcher and HSREC UFS

This information sheet was attached to the questionnaire as a reference, to assist

respondents to make an informed choice. No consent forms were filled in, because
completing the questionnaire indicated consent. No-one was coerced to participate nor
punished for not participating. Neuman (2007:54) stipulates clearly that the fundamental
principle of social research is that participation must be voluntary. It was also indicated

54
in the information leaflet that there would be no penalty for deciding to withdraw at any
moment before the end of the study

3.9.3. Justice

According to Botma et al. (2010:19), the principle of justice requires that respondents
are treated fairly. In order to observe the principle of justice, everyone who met the
inclusion criteria was given an equal opportunity to participate. All RNs and NAs in
Mafeteng district were invited to participate. All the conditions of the protocol were
observed. The pilot study was done to determine the length of time spent completing
the questionnaire. The information leaflet was also read and made accessible to
respondents, to assist them to make informed decisions about participation. The leaflet
also included the contact details of the researcher as well as the ethics committee, so
that they could report relevant matters or lodge complaints, if necessary.

3.9.4. Confidentiality

Respect for people is proven when the researcher observes anonymity and
confidentiality.

Anonymity is ensured by a secure means of protecting confidentiality and observing the

right to privacy of the respondent (Grove et al., 2013:172; Polit & Beck, 2012:162). It is
the duty of the researcher to safeguard the privacy and identity of the respondents. This
can be achieved by not linking participants with data and, in this case, by using
questionnaires lacking any identifying data that could be linked to the participant –
instead of names, numbers were used. The researcher personally distributed
questionnaires to all health facilities. Containers similar to ballot boxes and envelopes
were left at facilities for submission of completed questionnaires. Some respondents
submitted their questionnaires personally when the researcher arrived at facilities for
collection of questionnaires. No-one except the researcher had access to information
on the completed forms.

Confidentiality says information provided by participants to the researcher will not be

publicised or shared with other people without the permission of the participant, who

55
has the right to choose whom to share information with. In any case, the participant is
not compelled to disclose or to keep information (Grove et al., 2013:172; Moule &
Goodman, 2007:64; Polit & Beck, 2012:162).

Data that was collected was kept confidential by locking it up. Names were not used on
any documents or during reporting. No identifying information is kept on the computer
used for the purpose of this study to avoid the risk of exposing participants. All materials
used to collect data are kept under lock and key as a way of preventing information from
being accessed by unauthorised people. The respondents were assured that the
information would be treated as confidential as possible, and that measures would be
instituted so that no individual’s identity could be traced to a questionnaire or any
information. An arrangement for information sharing was made. The agreement
between the respondents and the researcher is that, upon completion of the study,
findings will be shared by the researcher, orally and through written material.

3.9.5 Beneficence and non-maleficence

In this study participation had no direct benefits to the respondents. Nevertheless, the
researcher had to ensure that participation did not bring any harm (Botma et al.,
2010:20; Polit & Beck 2012:152). The questionnaire was scrutinised by two ethics
committees and deemed not to pose any risk to the respondents. The contact details of
the researcher were available in the information leaflet for the convenience of the
respondents. Possibility of losing one’s job for participation and stating one’s opinions
about mental illness was guarded against as respondents are anonymous such that any
information gathered is not linked to anybody. Therefore the researcher did not
anticipate that any harm would befall respondents.

3.10 DATA ANALYSIS

Descriptive statistics, namely frequencies and percentages for categorical data and
means and statistical variations or medians and percentiles for continuous data, were
calculated. As stated earlier, 79 of 120 questionnaires were completed and analysed.

56
The analysis was done by the Department of Biostatistics at the UFS. The detailed
analysis is presented in Chapter 4.

1.17 CONCLUSION

Research methodology was discussed in this chapter, as were research design and
technique, validity and reliability, data collection methods and ethical concerns. Data
analysis will be discussed in Chapter 4.

57
 CHAPTER 4

DATA ANALYSIS AND DISCUSSION OF RESULTS

4.1. INTRODUCTION

The research methodology was discussed in the previous chapter. The aim of this chapter
is to provide a description of the analysed data as obtained from the structured
questionnaire. Descriptive statistics namely frequencies, and percentages for categorical
data and medians and percentages for continuous data were calculated. The data was
analysed and interpreted according to the sequence of the questionnaire and have the
following order: Biographic information, information regarding knowledge about mental
illness, information regarding attitudes towards mental illness and information regarding
practices towards mental illness and patients with mental illness. Data collection
commenced on the 25 October 2016 and ended on the 07 February 2017. This duration
was influenced by the factors stipulated in Chapter 3.

4.2. BIOGRAPHICAL DATA OF RESPONDENTS

The biographical information in this study entails aspects such as the nurses’ gender, as
both males and females provide services to patients in these institutions. It also includes
the age group of nurses, the home language as well as the position of employment.
Biographical information further includes the educational level of nursing staff, as the level
of education and the specific training regarding mental illness could influence the
knowledge, attitude and practice these personnel display.

4.2.1 Gender, age, marital status and language of respondents

The Lesotho gender ratio as estimated by World Data Atlas (2015: Online) was 94.18
males per 100 females, which means 48.5% for males to 51.5% females, a difference of
3%. However, in this study out of 79 respondents female nurses are almost three times
more than males, that is 81.0% (n=64) as compared to 18.9% (n=15) refer to table 4.1.
This can be attributed to the fact that nursing has historically been a female-dominated

58
profession. Ndetei et al. (2011:228) and Rappleye (2015: Online) assert that this ratio is
in line with several studies which have established that female nurses are found to be
dominating in several parts of the world. The age of respondents ranges between 22 to
66 years with the median age of 32 years. Most of respondents were married 59.5% (n-
47) followed by those that are unmarried with 29.1% (n=23). A relativity small number
were widowed 5.1% (n=4) or divorced 3.8% (n=3) and the smallest number living together
2.5% (n=2). The majority of people living in Lesotho speak Sesotho as is their mother
tongue which most of the nursing staff speak. Citizens of Lesotho who speak other
languages like Xhosa and Swati do understand and speak Sesotho well. Nurses who
speak English are mostly from outside the country. 95% (n=75) of the nursing staff speak
Sesotho, while English and other languages share the remaining five percent (English
2.5% and others 2.5%). See Table 4.1.

Table 4.1 Biographic data of respondents

DEMOGRAPHICS FREQUENCY PERCENTAGE (%)

(n=79)
GENDER
Male 15 18.99
Female 64 81.01
AGE
21-30 30 37.97
31-40 26 32.91
41-50 12 15.18
51-60 9 11.39
61-70 2 2.53
MARITAL STATUS
Married 47 59.49
Unmarried 23 29.11
Divorce/separation 3 3.80
Widow/widower 4 5.06
Living together 2 2.53
LANGUAGE
Sesotho 75 94.94
English 2 2.53
Other 2 2.53

59
Figure 5.1 below is an illustration of respondents’ age showing the minimum, median and
maximum age

Age of Participants
66
70
60
50
Age in years

40 32
30 22
Age of Respondents
20
10
0
minimum median age maximum
age age

Figure 5.1 Age distribution of respondents

4.2.2. Qualifications of respondents

The population of Lesotho attaches great importance to education, for instance, the
majority of the respondents 75% were RNs of which 29.1% (n=23) hold a Degree or
Masters in Nursing comprising of 4 males and 19 females. This category is followed by
those with Diploma in Midwifery by 40.5% (n=32) and occupies almost half of the
population of the sample. Females are dominating in this category by almost 40%.
Diploma in General Nursing has the least candidates, consisting of 3 females and 1 male.
Respondents holding the Certificate in Nursing Assistant has 25.3% (n=20) with 3 males
and 17 females. These make a total of 64 female and 15 male respondents. From this
analysis, the majority of respondents are RNs possessing a single qualification of diploma
in nursing to master’s degree level as compared to NAs. This profile is in line with the
distribution of nurses across Lesotho.

4.2.3. Health facility where respondents practice and duration of their experience

As mentioned in Chapter 1, the study was done in Mafeteng District concentrating on

government and CHAL health facilities only. The government has one hospital and eight
health centres while CHAL run nine health centres. The final overseer of all health care

60
lies with the district hospital, office of DHMT. Many respondents 75.95% (n=60) are based
at the primary health facilities while 24.1% (n=19) are hospital based

The majority of respondents, 61.5% (n=48) have been practicing for more than five years
while 25.6% (n=20) of the respondents’ clinical experience ranges from one to five years.
A total of 3.9% (n=3) represent respondents with clinical experience of between six
months and a year. The remaining 8.97% (n=7) represent those who have been in the
system for less than 6 months. One participant did not respond to this item hence (n=78).
See table 4.2.

Table 4.2 Distribution of respondents by qualification, duration of practice and type

of health facility

CHARACTERISTIC FREQUENCY PERCENTAGE (%)

(N=79)

QUALIFICATION
Degree/Master (in Nursing) 23 29.11
Diploma in Midwifery 32 40.51
Diploma in General Nursing 4 5.06
Certificate in Nursing Assistant 20 25.32

EXPERIENCE 8.97
˂6 months 7 3.85
>6 months 3 25.64
>12 months 20 61.54
>5 years 48

TYPE OF FACILITY
Hospital 19 24.05
PHC (Health centre) 60 75.95

4.3. MENTAL HEALTH LECTURES AND REFRESHER COURSES

Mental health is a component of nurses’ training curricula across all nursing programmes
from nursing assistant to degree level in Lesotho. In this section, respondents were asked
if they had received mental health lectures during their training. Majority of respondents
86.1% (n=68) indicated that mental health was among the courses in their curricula

61
therefore received lectures related to mental health during their training. In contrast 13.9%
(n=11) of respondents stated that they did not receive any. This seems incongruous not
unless there are other factors to this effect though the researcher is uncertain of such
since it has already been stated that mental health is an element across all programmes.
However the possible reason for this inconsistency is could be that respondents trained
outside the country where the curricula did not incorporate the element of mental health.
Regarding attendance of refresher courses and/or workshops, 59.5% (n=47) has never
had any during their practice. Those who attended a refresher course once comprise
20.3% (n=16) of respondents, while 5.1% (n=4) had two, 2.5% (n=2) had three and 12.7%
(n=10) had five or more within the past two years. See Table 4.3. In summary 59.5% of
nurses has had no training or information on mental health nursing during the past 2
years.

Table 4.3 Lectures during training and refresher courses in practice

CHARACTERISTIC FREQUENCY PERCENTAGE

(N=79) (%)
MENTAL HEALTH LECTURES
Yes 68 86.08
No 11 13.92
REFRESHER COURSES/WORKSHOPS
Nil 47 59.49
Once 16 20.25
Two times 4 5.06
Three times 2 2.53
More than three times 10 12.66

4.4 KNOWLEDGE ON MENTAL ILLNESS

In the context of this study, knowledge refers to the understanding of mental illness,
including predisposing factors, causes, symptoms, and treatment. The following section
describes the results obtained from the analysis of knowledge of respondents regarding
mental illness.

62
The questions on knowledge were 14 in number, the responses of which were based on
a 5-point Likert scale: Strongly agree; agree; undecided; disagree; and strongly disagree;
which will be discussed according to data analysed and presented in Table 4.4.
Numbering of items in the table tally with the sequence of items in annexure A. The items
in the questionnaire that reflect sufficient knowledge of mental illness are allocated a
score of one (1) while zero (0) are allotted responses reflecting insufficient knowledge.
Respondents who are unsure were also classified as lacking sufficient knowledge.

Table 4.4 Distribution of frequency and percentage of respondents regarding

knowledge of mental illness

ITEMS 0 1
Insufficient Sufficient Knowledge
knowledge

Frequency % Frequency (%)

3. I believe that my training adequately prepares me 12 29.27 29 36.73

to care for people with mental illness.

4. Medications are effective in treatment of mental 8 10.23 68 89.47

illness.

5. People with mental illness need constant care. 3 3.95 73 96.05

6. “Psycho” and “maniac” are correct terms for 49 64.47 27 35.53

mental illness

7. People with mental illness are hurt by “slang” 17 22.37 59 77.63

names for their disorders.

8. Mental illness is not a serious illness. 70 92.11 6 7.89

9. Patients with mental illness are often treated 27 35.53 49 64.47

unfairly.

10. Mental illness is often shown in negative ways 32 42.11 44 57.89

on televisions and movies.

11. Psychological treatment for mentally ill patients 1 1.32 75 98.68

is useful.

12. Mental Illness is often confused with effects of 15 19.74 61 80.26

drug abuse.

13. Mental Illness is caused by something 30 39.47 46 60.53

biological.

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14. Mental Illness and mental retardation are the 20 26.32 56 73.68
same.

15. A person with bipolar disorder acts overly 26 34.21 50 65.79

energetic.

16. Most people with severe form of mental Illness 30 39.47 46 60.53
do not get better even after treatment.

17 Schizophrenia involves multiple personalities. 62 81.58 14 18.42

Only 51.9% (n=41) of respondents attended item 3. One can assume that the rest 48%
(n=38) did not answer this question because they have never been exposed to any
training at all. Of the 41 respondents that had training 29 indicated that their training
prepared them adequately to deal with mental illness. This constitutes 36.7% of 79
respondents meaning that less than half of this sample feels adequately trained to deal
with mental illness. This rate is of great concern as literature describes that the amount
of information acquired in any subject matter develop the knowledge base which in turn
influences attitudes that are translated into the way individuals perform or behave (Ajzen,
2011).

The majority of respondents, 89.5% (n=68) are aware of the effectiveness of the
medication in the treatment of mental illness while 10.2% (n=8) of the nursing staff are
not certain about the medication effectiveness. Regarding the care of patients with mental
illness, 96.1% (n=73) state that patients need constant care. This belief does not consider
the fact that if medication is effective, patients can recover and lead productive lives.

Certain language can cause offence and may be inaccurate when used in news stories
that involve someone with a mental health problem (Nunn, 2014: Online). Boyd (2015:15)
points out that even jokes that portray people with mental illness as stupid, dangerous
and incompetent strengthen the stigmatizing attitudes and reinforce negativity towards
those with mental illness. Boyd further affirms that “Psycho” and “Maniac” are considered
to be falling under the offensive language for addressing people with mental disorders as
they reinforce negative associations. Only 35.5% (n=27) of the respondents indicated that

64
using terms like psycho and maniac is unacceptable while 64.5% (n=49) of respondents
did not consider these terms to be incorrect.

According to Rose, Pinfold, Thornicroft & Kassam (2007: Online) slang names used
against people with mental illness perpetrates the stigma which is always attached to
people with mental illness. Stigma poses a major barrier to help-seeking people and
particularly young people with mental health problems, A substantial number of
participants 77.6% (n= 59) were in agreement with the statement that people with mental
illness are hurt by slang names, while the remaining 22.4% (n= 17) felt that there is
nothing wrong in using slang names for patients. This is worrying because almost a fifth
of the sample does not understand how derogatory names can hurt their patients. When
one considers that over 64% of all respondents stated in question 6, that psycho and
maniac are correct terms for people with mental illness but in this question 77.6% felt that
one should not use derogatory terms towards patients, it may be an indication that they
truly think that these terms are scientifically correct.

Sandy Lewis, Head of Psychological Services at Akeso Psychiatric Clinics, attributes the
Life Esidimeni saga and tragic death of over 100 patients in South Africa with mental
illness to health professionals who do not take mental illness as a serious problem (Health
and wellness, 2017: Online). The majority of the respondents, 92.1% (n=70) do not
consider mental illness to be a serious problem, while only 7.9% (n=6) state that mental
illness is a serious problem. When one considers the burden of disease as explained in
Chapter 2 these respondents are not aware of the severe nature of the problem of mental
illness.

About 64.5% (n=49) of respondents supported the statement that patients with mental
illness are often treated unfairly, while just above a third of respondents 35.5% (n=27)
feel that patients with mental illness receive a fair treatment. Research suggests that most
media portrayals of mental illness are stereotypical and negative (Boyd, 2015:15). Boyd
gave a few examples whereby psychiatric hospitals are portrayed as dangerous and
inhospitable institutions in which the care was harsh and delivered by cold-hearted
workers. This picture is observed in the film of The Snake Pit (1948) and A Beautiful Mind

65
(2001). Around 57.9% (n=44) of the respondents are of the opinion that mental illness is
often shown in negative ways on television and movies, while also quite a notable number
of them, 42.1% (n=32) do not find anything wrong concerning this matter. This is of great
concern as over half of respondents could not identify problems from media regarding
how mental illness is perceived or defined. Regarding the importance of psychotherapy,
almost all but one participant 98.7% (n=75) are aware of the importance of psychological
treatment for patients with mental illness. Majority of respondents 80.3% (n=61) are on
the affirmative that mental illness is often confused with the effects of alcohol. However,
the minority 19.7% (n=15) have the opposite perception. This is a challenge that almost
20% will not be able to distinguish between the two conditions. This can lead to
diagnosing people with alcohol effects as mentally ill and as a result maltreat such people.

As mentioned in Chapter 2, mental illness has a biological cause (Boyd, 2015:340-1).

More than two thirds 60.5% (n=46) of respondents are of the opinion that mental illness
is caused by something biological, however, 39.5% (n=30) do not believe so. One can
only speculate what these nurses think of what they consider to be the cause of mental
illness. This is half of the sample and a cause for concern since appropriate treatment
goes together with knowledge of the root cause of the problem. However, one possible
reason could be that mental illness is not caused by a single factor so this item could be
somehow complicated or interpreted differently.

During the manic phase of a bipolar condition, a person may become highly energetic,
have a million ideas, become very talkative and stay up all night (Sadock et al. 2015:360;
Townsend, 2015: 499). The greater number of respondents, (n=50) 65.8% indicated that
a person with bipolar disorder acts overly energetic, whereas (n=26) 34.2% did not
associate this to be one of bipolar disorder symptoms. As this is a very clear sign of mania
it is of concern that more than a third of nurses do not know this and will miss this
important symptom.

Mental retardation, also known as intellectual disability refers to a condition where the
individual has a lower intelligence quotient (IQ) and has difficulty in coping with the
realities of day to day life (Feldman, 2017:262). While on the other hand, mental illness

66
as described in Chapter 2 refers to psychological condition that affects the thoughts,
behaviour and emotions of an individual. About 73.7% (=56) of respondents did not
consider mental illness and mental retardation to be the same, whereas 26.3% (n=20)
mistook the statement to be correct. More than a quarter of nurses do not understand the
difference between mental illness and mental retardation. Again this is serious as it
indicates a fundamental lack of knowledge where people with intellectual disability could
receive inappropriate treatment.

Research carried out at the National Empowerment Center by Fisher (2017: Online) has
shown that people can fully recover from even the most severe forms of mental illness.
The larger part of the respondents constituting 60.5% (n=46) are of the opinion that most
people with a mental illness can get better. This confirms the idea that with medication
and psychotherapy, mental illness can be controlled and people lead a normal life.
However 39.5% (n=30) did not believe that people with mental illness can get better after
treatment. A common misconception is that people with schizophrenia possess multiple
personalities and among these respondents this misconception is prevalent. Only 18.4%
(n=14) of the participants indicated that schizophrenia does not involve multiple
personalities. While over three quarters 81.6% (n=62) are of the opinion that people with
schizophrenia possess numerous personalities.

In conclusion, the study results indicate that only about 38% of the nursing staff claim that
they have adequate training to work with patients with mental illness. This is supported
by the evident insufficient knowledge as indicated in study findings.

According to Boyd (2015:338) schizophrenia is a serious mental disorder that affects

about 1% of the worldwide population. Boyd further explains that the symptoms of
schizophrenia are so severe that without early treatment, the life of the patient is totally
disrupted. It is therefore cause for alarm that nurses have such a fundamental flaw in their
understanding of this prevalent illness. It would seem that respondents are less informed
about schizophrenia, and this is supported by having only 18.4% (n=14) who are of the
opinion that it does not involve multiple personalities, while the vast majority of
respondents 81.6% (n=62) endorsed this notion.

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Regardless of the above stated shortcoming, almost all respondents recognise the
importance of psychological therapy as well as the effectiveness of psychotropic
medications, but at the same time about 40% felt that mental illness is not treatable. The
fact is with effective treatment, the prognosis is positive. This is again cause for concern
as the nurses might feel that to treat these patients is basically a waste of resources
including time.

The high percentage of nurses who do not consider terms like psycho and maniac to be
hurtful are of great concern and one can argue it to be an indication of nurses
discriminating against people with mental illness as has been indicated in the literature.
However as indicated earlier, they might be truly thinking that these terms are appropriate
as compared to the use of slang names. It is also a cause for concern to notice that over
a quarter of respondents are comfortable with use of slang names towards patients. This
can be linked to the fact that some respondents though with small portion (8%) regard
mental illness not serious. More than a quarter of nurses seem not to be informed about
the difference between mental illness and mental retardation. Again this is serious as it
indicates a fundamental lack of knowledge.

The above section focused on the results about knowledge of respondents towards
mental illness. Results about attitudes towards mental illness will be discussed in section
4.5 below.

4.5. ATTITUDES TOWARDS MENTAL ILLNESS

Attitude encompasses feelings and misconceptions the respondents may have towards
mental illness and persons with mental illness. Nurses’ Attitudes were tested on a set of
12 items as reflected in Table 4.5.

In a similar manner, the rule that was applied in Section 4.4 above in terms of scoring
items for knowledge will be applied in this section as well. While knowledge was explained
as sufficient or insufficient, attitudes are either appropriate or inappropriate. Appropriate
attitudes are given a score of one (1) and inappropriate attitudes are scored as zero (0).

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Table 4.5 Distribution of frequencies and percentages of respondents’ attitudes
towards mental illness (n=79)

ITEMS 0 1
Inappropriate Appropriate attitude
attitude
Frequency % Frequency (%)

18. I Find it hard to talk to someone with mental health 27 34.18 52 65.82
problems

19. Even after the treatment, I would be doubtful to be 17 21.52 62 78.48

around people who have been treated for mental
illness.

20. Mentally ill patients are entitled to the same 5 18.99 64 81.01
attention in the health centre as are general patients.

21. People with mental illness should not be allowed to 11 13.92 68 86.08
work

22. Political and individual rights of mentally ill persons 22 27.85 57 72.15
should be suspended while on treatment to help them.

23. Those with mental illness should not be allowed to 16 20.25 63 79.75
have children.

24. Mental hospital/s is/are the only place/s for people 19 24.05 60 75.95
with mental illness to be treated.

25. I would ask for exemption to treat those with mental 36 45.57 43 54.43
illness.

26. People with mental illness are usually dangerous. 37 46.84 42 53.16

27. People with mental illness are usually violent. 40 50.63 39 49.37

28. People with mental illness are usually 67 85.90 11 14.10

unpredictable

29. People with mental illness can lead a normal life 16 20.25 63 79.75

There is increasing evidence that disparities in healthcare provision contribute to poor

physical health of people with mental illness, which are attributed to among other things,

69
the separation of mental health services, healthcare provider issues including the
pervasive stigma associated with mental illness (Lawrence & Kisely, 2010: Online). This
is confirmed as stated earlier that personnel distribution is not balanced and some health
centres in Lesotho especially those in rural areas are managed by few people.

More than 65.8% (n=52) of respondents indicate that they can interact and communicate
comfortably with patients with mental illness while 34% find it difficult to talk to these
patients. Regarding interaction with patients after treatment, 21.5% of respondents
showed they cannot be comfortable to be around people with mental illness. Nevertheless
majority of respondents, 81.0% (n=64) demonstrated appropriate attitude by believing
that patients with mental illness are entitled to the same attention in the health centre as
are all other patients, whereas almost a fifth, 19.0% (n=15) of all nurses feel that people
with mental illness do not deserve the same treatment as other patients. It seems that
these nurses do not think that people with mental illness are entitled to equal treatment
as the rest of the population.

People with mental illness can lead a normal life: Almost 79.7% (n=63) respondents were
in agreement that people with mental illness can lead a normal life, while the minority of
20.3% did not endorse this view. This item supports the impression that even the worst
cases of mental illness can be treated as explained in section 4.4 and as a result persons
with mental illness can recover and lead a normal life. It differs from the fact that 93% feel
they need constant care. Possibly a misunderstanding of the question can explain the
apparent anomaly.

Regarding the patients’ rights, there is an indication of appropriate attitude though the
limitation is observed in a portion of respondents. The majority of respondents 86.1%
(n=68) stated that people with mental illness should be allowed to work while 13.9% felt
the opposite. The same goes with the suggestion that political and individual rights of
mentally ill persons should be suspended while on treatment to help them, was rejected
by the majority of respondents 72.2% (n=57) while only 27.8% supported the statement.
Furthermore the majority of 79.7% (n=63) discarded the idea that those with mental illness
should not be allowed to have children. When responding to the item that the hospital is

70
the only place for those with mental illness, 75.9% (n=60) claim that hospital is appropriate
for treatment while 24.0% is of the different opinion

Regarding the issue of nurses asking for exemption to treat those with mental illness,
almost half of the participants 45.6% indicated that they would prefer to be exempted from
treating people with mental illness while only 54.4% were prepared to manage these
patients. This might link to the question of people with mental illness being dangerous
and violent where 46.8% of respondents considered people with mental illness to be
dangerous and 50.6% believe that they are violent. These responses correspond with
knowledge section about negative media portrayals regarding mental illness in which
42.1% of respondents perceive mental hospitals as dangerous and patients being
dangerous and violent. The fact is people with mental illness are no more likely to be
violent than anyone else. Most people with mental illness are not violent and only 3 - 5%
of violent acts can be attributed to individuals living with a serious mental illness (Myths
and facts, 2017: Online). Despite the above mentioned research findings, only 49.4%
(n=39) of respondents rejected this idea. Therefore it is evident from the study that nurses
still maintain the idea that people with mental illness are dangerous and violent. The
common misconception about people with mental illness is rampant among these nurses.
The same goes with the notion that people with mental illness are usually unpredictable:
people with severe mental illnesses are over 10 times more likely to be victims of violent
crime than the general population (Myths and facts: 2017:Online). The minority of
participants about 14.0% (n=11) defied the statement, while the majority 86.0% (n=67)
supported the statement. It can be concluded that nurses maintain that persons with
mental illness are unpredictable.

Even though a portion of respondents demonstrated appropriate attitude in majority of

items, far too many nurses exhibit attitudes that are harmful towards people with mental
illness. More than 50% of respondents showed appropriate attitude towards patients with
mental illness but 34% felt that it is difficult to communicate or socialise with patients with
mental illness. Some respondents even indicated that even after the treatment, they
doubt that they can easily interact with these patients. It is a cause for concern and may
signify an inappropriate attitude and discrimination towards this patients or lack of

71
confidence. As indicated in Chapter 2, this might be one of the factors that lead to poor
utilisation of mental health services as patients fear stigma and discrimination. With
regard to the idea that hospitals are the only appropriate places for people with mental
illness, 75.9% of respondents asserted to this idea while 24.1% rejected this idea.

It is argued that those with a mental disability should be given equal opportunities like any
other person. If they want to work and are capable, qualified and fit for the job, then let
them work. According to the findings, there are nurses who felt that patients should be
denied some of their rights. Much as mental illness is considered a serious illness, it is
treatable with a positive prognosis resulting in individuals leading a normal life.

4.6. PRACTICES TOWARDS MENTAL ILLNESS

According to Bennett (2012:49), practice refers to actions based on knowledge and

attitude. Nurses and other professionals are required to assess, manage and provide
some form of intervention to persons with mental illness in their communities. In this
section, the assessment on nurses’ practice towards mental illness and people with
mental illness was based on five questions which are structured as shown in Table 4.6.
The first two questions are based on a, 5-point Likert scale, strongly disagreed, disagree,
undecided, agree and strongly agree. The last three are based on a “yes” or “no” response
the former indicating good practice. Practice is stated as effective or ineffective where
effective practice is given a score of one (1) while ineffective practice is scored zero (0).

Table 4.6 Distribution of frequency and percentages of respondents’ attitudes

towards mental illness (n=79)

ITEMS 0 1

Ineffective Effective practice

practice

Frequency % Frequency (%)

30. It is hard to talk to someone with mental health 26 32.9 53 67.1

problems

72
31. I am comfortable with attending to people with 38 48.1 41 51.9
mental illness.

32. Have ever referred anyone with a mental illness? 40 50.6 39 49.4

33. Did you receive feedback on the patients you have 49 62.0 30 37.97
referred? 3

35. Do you think the health facility where you work can 23 29.1 56 70.79
accommodate the care of persons with mental illness? 1

Almost a third of respondents 32.9% (n=26) find it hard to talk to a person with mental
illness which corresponds almost exactly with the answers given in question 18. While
67.1% of respondents feel comfortable talking to people with mental illness, this is not
enough since effective communication with patients is part of therapy. Furthermore, there
were about half of the respondents, 51.9% who assert that they are comfortable in
attending people with mental illness. There seems to be a disparity in findings between
feeling comfortable talking with the patient and being comfortable attending to the patient
as only 67% of respondents are comfortable talking to patients. The challenge is that
caring and communication occur simultaneously so this might adversely affect the quality
of care towards patients. Almost half 48.1% (n=38) indicated that they are uncomfortable
to do so.

Regarding the question of whether the participants have ever referred a patient with
mental illness, 49.2% (n=39) indicated that they had referred a patient while 50.6% (n=40)
had never referred a patient. It is accepted that in people attending a PHC facility, almost
20% have a certain mental illness (Ogunsemi, Oluwole, Abasiubong, Erinfolami, Amoran,
Ariba, & Alebiosu, 2010:46). Based on this fact, it is of great concern that less than half
of the respondents have never referred a patient. With respect to an opinion whether
participants think the health facility where they work can accommodate the care of
persons with mental illness, 70.9% (n=56) accepted that their health facilities can
accommodate the care of patient with mental illness, and the remaining 29.1% were
against the idea. One of the reasons mentioned is lack of expertise regarding mental
health and illness. This is line with the discussion in Chapter 2. It therefore implies that

73
even though the infrastructure can allow admission of patients, the challenge in relation
to the skill regarding care of persons with mental illness still remains. It is important to
mention that the structures of health centres in Lesotho are similar even though they
might differ in size.

4.7 SUMMARY OF FINDINGS

Knowledge was tested on a set of 14 items, therefore, could obtain a score from 0 to 14,
with higher scores signifying better knowledge. Most importantly, the median score was
10 that is about 71.4% which showed high knowledge with the lower quartile score of
almost 64.3% mark, that is 9 (out of 14).

With respect to attitude, nurses were tested on a set of 12 items, in a similar manner,
higher scores signified positive attitude. Respondents displayed moderately positive
attitudes with the median of 8, while the lower quartile score stood at 50% that is 6 (out
of 12), and the upper quartile was about 83.3%. This shows that there is still a possibility
of improvement in their attitude. Practice scores were calculated based on 5 items Likert
scale. Nurses could obtain scores from 0 to 5 with higher scores indicating better practice.
They showed fair practice scores with the median score of 60% that is 3 (out of 5), despite
the discouraging lower quartile score which is below 50%.

In combination of knowledge, attitudes and practice (KAP), the discussion is based on

the median figures reflected on the KAP Summary Statistics. With the median for
knowledge of 71.4%, which falls within the high region implies that relatively, the nursing
staff in Mafeteng district health facilities has basic knowledge regarding mental health
issues, despite the discrepancies shown in the analysis. Regarding attitude, the median
of 66.6%, it therefore means that some work needs to be done to change their attitudes.
With respect to practice, the median within the average score range of 60%, a lot of work
is to be done to influence practice.
This chapter looked at data analysis and findings. Chapter 5 will address limitations,
recommendations and conclusions.

74
75
 CHAPTER 5

RECOMMENDATIONS, LIMITATIONS AND CONCLUSION

The research findings were presented and discussed in Chapter 4. Limitations,

recommendations and conclusion are addressed below.

5.1. LIMITATIONS OF THE STUDY

The limitations identified involved the sample, completion of the questionnaire and the
questionnaire itself.

Due to logistical factors, the study was conducted in only one health district, Mafeteng
which is more similar to Maseru in terms of the topography and type of facilities so the
results should be more comparable to that district. However the districts in the highlands
are very different in that health facilities are hard to reach and are run by few personnel,
whether these results are representative of them is not so clear. The sample size was
small since one district was used due to limited funds and time. The question remains as
to whether the same study results would be yielded in other parts of the country?

A vast majority of KAP foreign studies towards mental illness have been produced but
there is no evidence that there has been any of the same scale in Lesotho. Additionally,
the researcher relied mostly on literature from other parts of the world. The researcher
does not know if it was applicable to Lesotho as there have not been other studies to this
effect in Lesotho – so the instrument may not be applicable. Another observation is that
some literature available about Lesotho is documented differently yet addressing the
same theme thus posing a challenge in selection of the most valid information.

According to the plan of events, data collection was to take a maximum duration of 6
weeks since health facilities are located in areas far apart from each other. As explained
in Chapter 3, the original plan was for respondents to complete the questionnaires at the
same time per health facility; while the researcher was available to answer questions, but
the plan did not work instead it took almost three months to collect data. This could have

76
led to contamination in that the respondents could have discussed the questionnaire
among themselves. Additionally, some challenges with the tool were identified during
analysis. For instance, one item was about causes of mental illness and only mentioning
one cause. Majority of respondents do not agree with this item. One would think that the
respondents know a combination of factors so to them only one might seem inappropriate.

5.2. RECOMMENDATIONS

The government of Lesotho through the Ministry of Health is reinstating the Diploma in
Psychiatric Mental Health Nursing Programme following its discontinuation for some
years. This is a positive turn of events as the country is depleted of psychiatric nurses
and furthermore it will help redress the lack of knowledge among nurses regarding mental
illness, found in this study. Generally, the study findings indicate good KAP of nurses in
Mafeteng however a lot needs to be done in relation to mental health in the country as a
whole and to catch up on those nurses that have missed out. The following are therefore
recommended:

5.2.1 Knowledge

Exposure to knowledge and the psychiatric practice does impact on attitudes in a good
way even though its mechanism of action still needs research (Holmes, Corrigan,
Williams, Conor & Kubiak, 1999). To close the gap identified in knowledge base, the
authorities should consider increasing the focus on mental health in the basic training
courses. That might convey to nurses the importance of mental health. Nurses who have
already been trained need regular refresher courses and or workshops. It has been
indicated that an amount of information acquired affects attitudes which in turn impacts
on the way people act. Training in psychiatry can influence peoples’ opinions about
mental illness. In a study done on students views on mental illness it was found that upon
completion of their training they viewed mental illness differently without the
discriminatory beliefs they possess prior training (Madianos, Priami, Alevisopoulos,
Koukia & Rogakou, 2005: Online).

77
Distribution of knowledge can also be done in the form of written materials. Advantage of
information and technology should be taken where electronic equipment like cell phones
could be used to spread the information about mental health and illness. Events like
mental health day celebrations should be held throughout the country and utilized as
opportune moments of spreading information to nurses and the public as well. Learning
and sharing forums should also be used regularly as another platform for spreading the
message.

The curricula of all levels of nurses at training institutions should be reviewed, ensuring
the balance between classroom teaching and clinical practice to produce competent and
confident nurses in terms of mental health issues. This can improve the nurses’ KAP.
However knowledge alone is not enough to influence people’s behaviour towards mental
illness, people should be motivated in relation to issues of mental health (Ajzen, 2011).

5.2.2 Attitude

Several research studies have examined the effects of education on attitudes about
severe mental illness. Cross sectional studies have shown that members of the general
public who have more knowledge about mental illness are less likely to endorse
stigmatizing attitudes (Roman & Floyd 1981; Link & Cullen 1986; Link, Cullen, Frank &
Wozniak, 1987; Brockington, Hall, Levings & Murphy. 1993). These studies suggest that
education programs that increase factual knowledge about mental illness may improve
attitudes about severe mental illnesses such as schizophrenia. Researchers who study
the social cognitive underpinnings of stigma and stereotype believe that education
challenges the misconceptions that support these stereotypes (Pruegger & Rogers,
1994:372). Persons are less likely to endorse these knowledge structures in the face of
contrary information.

Several research studies have examined the effects of education on attitudes about
severe mental illness. It is apparent that the education provided on mental health is
beneficial though the amount and quality of information matters as has been mentioned
in previous sections. This is confirmed by Wynaden, Orb, McGowan & Downie, (2000) in
their study that those who undergone training reported greater understanding,

78
confidence, and control as well as changed perception towards mental illness. Reed and
Fitzgerald (2005: 254) state that 50% of the respondents in their study pointed out that
lack of education is among reasons that generate negative attitudes towards mental
illness. With education regarding mental illness, attitudes can be influenced thus leading
to more appropriate practices.

To change attitudes of nurses the same recommendations made for knowledge are
needed. However the nurses must be exposed to persons who have a mental illness and
who are successful and leading a normal life.

If knowledge and attitudes are addressed the practice should be influenced. However
days like mental health celebrations mentioned before can be an opportune moment for
nurses to meet people with mental illness that are doing well. That way the nurses can
meet them as healthy individuals and not patients with mental illness.

Nurses in Lesotho need continuing development points to renew their registration

annually. The LNC should consider making a part of mental health compulsory in the
Continuing Professional Development programme to enhance learning of nurses on
mental health issues.

Mental Health Act and policies exist but are not implemented as they should. Nurses are
to a certain degree limited by the policy in terms of their roles when delivering mental
health services as indicated in Chapter 1. All these should be reviewed to clarify
individual’s roles so as to improve nurses’ confidence.

The example of the Government of Lesotho that is being set by allocating so few
resources to mental health sends a clear message to health care workers that mental
health is not important (refer to Chapter 1). Resources are limited but the impact of mental
health on the effect of other health treatments should be explored so that the Government
can understand how making mental illness a priority can lead to better usage of these
resources. For instance, when one is suffering from depression that particular individual
is prone to not relapse only but frequent hospitalisation and even death since compliance
to treatment is a struggle. Patients who are working are at risk of losing their jobs due to

79
a decline in performance or inability to perform as a result of the illness. When these
occur, the government expenditure on mental health is increasing or else the quality of
services deteriorates since mental health services are free yet this loss of resources could
be prevented through enhancement of nurses KAP.

Authorities should ensure smooth integration of mental health into PHC as this could
improve interaction between patients and staff. A guide or manual should be distributed
in all health facilities, by so doing, frustration among staff will be reduced as competence
will develop through the use of the manual.

5.2.3 Research

Further research is necessary to identify the needs of nurses to shape the training, the
impact of this training on their attitudes; what activities or events will have the most impact
on the KAP of nurses.

5.3. CONCLUSION

The purpose of the study was to explore the KAP of nursing staff at Mafeteng, Lesotho.
According to literature, mental illness is found to be contributing towards the burden of
disease in Lesotho and is being treated mostly by non-psychiatric personnel (see Chapter
2). Furthermore, several studies carried out in different countries indicated that health
professionals especially the nursing personnel have negative stigmatizing attitudes
towards mental illness and people with mental illness.

Data were analysed and the results indicate that the KAP of nursing staff towards mental
illness is not satisfactory as knowledge is rated around 70%, attitude at 67% and practice
at 60%. It is clear that being well informed does not necessarily determine the behaviour,
but there is a belief that somehow it causes an impact in the way a person perceives and
acts upon a situation or event. On the other hand no knowledge is damaging.
Recommendations have been done to address the identified shortcomings in order to
achieve confident nursing personnel with appropriate attitude and practice towards
mental illness.

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“THERE IS NO HEALTH WITHOUT MENTAL HEALTH”.

81
REFERENCE LIST

Ajzen, I. & Fishbein, M. 1977. Attitude-Behaviour Relations: A Theoretical Analysis and

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 ANNEXURE A

QUESTIONNAIRE

94
INSTRUCTION
S For Office Use Only
Mark the appropriate block with an X or write your
answer on
the space
provided.

A. BIOGRAPHIC DATA
1. Date questionnaire is completed (dd/mm/yy) 1-
........./......./......... 6
d d m m y y
2. What is your gender?
Male (1) Female(2) 7

3. How old are you?

............................................................ 8-
.........year 9

4. What is you marital status?

Married/traditional
marriage 1
Unmarried 2
Divorce/separation 3
Widow/widower 4
Living together 5 10

5. What is your home language?

Sotho 1
English 2 11
Other.................................
(specify) 3

6. What is the highest qualification you have acquired?

Degree/Masters (in
nursing) 1
Diploma in Midwifery 2
Diploma in General
Nursing 3
Certificate in Nursing
Assistant 4 12

7. In what type of health facility do you currently practice?

95
 Hospital Health center
(1) (2) 13

8. How long have you been

practicing?
< 6months 1
> 6 months 2
> 12 months 3
> 5 years 4 14

B. Items to assess knowledge about mental illness

and people with mental illness

1. Have you ever received lectures on mental health?

Yes 1
No 2 15
2. Approximately how many lectures have you received
over the past three years?
Nil 1
one time 2
two times 3
three times 4
1
more than three times 5 6
Disagree
disagree

disagree
Strongly

Strongly
Undecid

Agree
ed

Items

3. I believe that the lectures adequately

prepare me to care for people with mental
illness. 1 2 3 4 5 17
4. Medications are effective in treatment of
mental illness. 1 2 3 4 5 18
5. People with mental illness need constant
care. 1 2 3 4 5 19
6. "Psycho" and "maniac" are correct terms
for mental illness. 1 2 3 4 5 20
7. People with mental illness are hurt by
slang names for their disorders. 1 2 3 4 5 21
8. Mental illness is not a very serious
problem. 1 2 3 4 5 22

96
9. Patients with mental illness are often
treated unfairly
1 2 3 4 5 23
10. Mental illness is often shown in a
negative way on television and movies. 1 2 3 4 5 24
11. Psychological treatment (such as talking
to a psychologist or counsellor) is useful. 1 2 3 4 5 25
12. Mental illness is often confused with
effects of drug abuse. 1 2 3 4 5 26
13. Mental illness is caused by something
biological. 1 2 3 4 5 27
14. Mental illness and mental retardation are
the same. 1 2 3 4 5 28
15. A person with bipolar disorder acts overly
energetic. 1 2 3 4 5 29
16. Most people with severe forms of mental
illness don't get better even after treatment. 1 2 3 4 5 30
17. Schizophrenia involves multiple
personalities. 1 2 3 4 5 31

C. Items assessing
Attitude
Undecided
Disagree
disagree
Strongly

Strongly
Agree

agree

Items
18. Find it hard to talk to someone with mental
health problems. 1 2 3 4 5 32
19. Even after the treatment, I would be
uncomfortable to be around people who have
been treated for mental illness. 1 2 3 4 5 33
20. Mentally ill patients are entitled to the
same attention in the health center as are
general patients. 1 2 3 4 5 34
21. People with mental illness should not
be allowed to work. 1 2 3 4 5 35
22. Political and individual rights of
mentally ill persons should be suspended
while on treatment to help them. 1 2 3 4 5 36
23. Those with mental illness should not
be allowed to have children. 1 2 3 4 5 37
24. Mental hospital is the only place for
people with mental illness. 1 2 3 4 5 38

97
25. I would ask for exemption to treat
those with mental illness. 1 2 3 4 5 39
26. People with mental illness are usually
dangerous. 1 2 3 4 5 40
27. People with mental illness are usually
violent. 1 2 3 4 5 41
28. People with mental illness are usually
unpredictable. 1 2 3 4 5 42
29. People with mental illness can lead a
normal life. 1 2 3 4 5 43

D. Items assessing Practice

Undecided
Disagree
disagree
Strongly

Strongly
Agree

agree
Items
30. It is hard to talk to someone with
mental problems. 1 2 3 4 5 44
31. I am comfortable with attending to
people with mental illness. 1 2 3 4 5 45

32. Have you ever referred anyone with mental illness?

Yes 1
No 2 46

33. Did you receive feedback on the patients you have

referred?
Yes 1
No 2
Do not know 3 47

34. If not, why not? .................................. 48

35. Do you think the health facility where you work can
accommodate the care of persons with mental illness?
Yes 1
No 2
Do not know 3 49

98
36. If not, why
not?........................................................................... 50

THANK YOU FOR YOUR

PARTICIPATION

99
 ANNEXURE B

INFORMATION LEAFLET

100
INFORMATION DOCUMENT

STUDY TITLE: “NURSES KNOWLEDGE, ATTITUDES AND PRACTICES TOWARDS

MENTAL ILLNESS IN MAFETENG: LESOTHO”.
Introduction:
I, Bernadett ‘Malehlohonolo Damane, is doing research on the Knowledge, Attitudes and
Practices (KAP) of Nurses towards mental illness.
Mental illness is very common in our country and in most cases affecting people at their
prime time of their lives. Nurses have to care for people with mental illness and I want to
explore the knowledge, attitudes and practices of nurses towards mental illness.

Please note that completing this questionnaire is an indication of understanding as well

as giving consent. Upon completion of the study, you will get feedback through meetings
and written materials. Permission to carry out this study has been granted by the UFS
and Ministry of Health, Lesotho.

Invitation to participate: I am inviting you to participate in a research study.

What is involved in the study?

All you have to do is to complete a questionnaire. This should take at least 20-25 minutes.

Risks: There are no anticipated risks

Benefits: You may not benefit directly from this study but this information may help in
informing planning and training towards mental health issues that will subsequently
improve and strengthen mental health services in our country.
Participation is voluntary, and refusal to participate involves no penalty. You may
discontinue participation at any time without any punishment.

Reimbursements: You will not be remunerated for completing this questionnaire.

Confidentiality No identifying information is asked on the questionnaire so your

participation is completely anonymous.

Contact details of researcher(s) – for further information/reporting of study-related

adverse events: Cell number +266 58482925/ 62482925; Work +266 52500110; E-mail
address bmmoso@yahoo.com

Contact details of Secretariat: Health Sciences Research Ethics Committee of

University of the Free State (HSREC-UFS) for reporting of complaints and or problems:
Telephone number +27(0) 51 401 7795

101
 ANNEXURE C

APPROVAL DOCUMENTS FROM RESEARCH ETHICS

COMMITTEES:

102
103
104