A CROSS-SECTIONAL STUDY OF PERCEIVED HUMAN RIGHTS IN MENTALLY ILL

Table 1 : Distribution of sample characteristics: Comparison between MI group and Non-MI group (n=144)

Demographic Variables	MI group (n=72)		Non-MI group (n=72)		Chi- Square	p value
	F	%	F	%
Age 21-30 years 31-40 years 41-50 years Above 50 years	10 27 24 11	13.9 37.5 33.3 15.3	16 26 16 14	22.2 36.1 22.2 19.4	3.36	0.34
Gender Male Female	54 18	75.0 25.0	49 23	68.1 31.9	0.852	0.36
Religion Hindu Muslim Christian	47 17 8	65.3 23.6 11.1	54 11 7	75.0 15.3 9.7	1.838	0.40
Education Primary Secondary Higher secondary Graduation	15 39 14 4	20.8 54.2 19.4 5.6	13 33 15 11	18.1 45.8 20.8 15.3	3.944	0.27
Type of Family Nuclear Extended	39 33	54.2 45.8	51 21	70.8 29.2	4.267	0.04
Marital Status Single Married Separated/Widowed/Divorced	30 36 5	41.7 50.0 8.4	8 63 1	11.1 87.5 1.4	23.976	0.01
Occupation Unemployed Unskilled Skilled	18 40 14	25.0 55.6 19.4	22 25 25	30.6 34.7 34.7	6.96	0.03
Socioeconomic Status BPL APL	53 19	73.6 26.4	34 38	47.2 52.8	10.48	0.001
Diagnosis Schizophrenia BPAD in remission	32 40	44.4 55.6	-- --	-- --	-	-

Perceived Human Rights	MI group (n=72)		Non-MI group (n=72)		Z- Score	p value
	Median	Inter quartile range	Median	Inter quartile range
Interindividual- Dignity (Family and Friends)	83.33	50	100	33.33	3.02	0.003
Interindividual- Participation (Family and Friends)	66.66	66.66	100	0	6.46	0.001
Interindividual- Equity (Family and Friends)	83.33	33.33	100	0	5.6	0.001
Interindividual- Justice (Family and Friends)	50	50	100	33.33	4.73	0.001
Interindividual- Justice (Other People)	50	50	83.33	33.33	4.68	0.001
Interindividual- Equity (Other People)	83.33	50	100	0	6	0.001
Health Care - Equity	83.33	45.83	100	0	5.27	0.001
Health Care - Justice	83.33	50	100	33.33	2.15	0.031
Health Care - Participation	100	33.33	83.33	50	1.8	0.070
Health Care - Dignity	83.33	33.33	83.33	50	1.38	0.169
Community - Participation	66.66	66.66	66.66	83.33	0.57	0.567
Community – Equity	100	29.166	100	0	3.14	0.002
Community – Justice	59.17	33.33	83.33	33.33	3.06	0.002
Community – Dignity	83.33	50	83.33	66.66	0.31	0.755

Work-related Perceived Human Rights: Significantly low scores were reported in MI group (p=<0.001) on overall work-related perceived human rights (HR-Work Sum) (Table 4). HR-Work items in dignity from colleagues (p=0.016), participation (p=0.001), justice (p=0.046) and equity (p=0.001) too showed significantly low scores in the MI group. The groups were comparable on dignity from supervisors (Table 4).

Table 4: Comparison of work-related perceived human rights between MI group and Non-MI group: Mann-Whitney U Test (n=54*+50*=104)
*People who were employed.

Perceived Human Rights	MI group (n=54)		Non-MI group (n=50)		Z- Score	p value
	Median	Inter quartile range	Median	Inter quartile range
HR -Work Sum	81.66	25	93	20.9	3.34	0.001
Work -dignity (Colleagues)	83.33	41.66	100	16.66	2.4	0.016
Work - dignity (supervisors)	83.33	50	100	16.67	0.89	0.375
Work – participation	66.67	45.83	83.33	16.67	3.2	0.001
Work – justice	66.67	50	100	33.33	2	0.046
Work – equity	83.33	41.67	100	37.5	4.44	0.001

Relationship between perceived human rights and demographic variables in the MI group: We also analyzed if there is any relationship between perceived human rights and any sociodemographic variables of the MI group like gender, SES, family type, occupation, marital status and religion. Significant difference was found between mean HR-14 Sum score and different categories of family type (p=0.005), as shown by a better perception of human rights among MI group from nuclear families when compared to extended or joint families. Similarly, there was significant difference between mean HR-14 Sum score and different marital status categories (p=<0.001) as shown by a higher score in married participants, than in unmarried participants and in Widowed/Divorced/ Separated participants. However, overall perceived human rights were independent of variables like gender, socioeconomic status, occupation and religion (Table 5).

Variable		n	HR-14 Sum Score		Test statistic	p-value
			Mean	S.D
Gender	Male Female	54 18	72.05 66.53	17.5 14.91	t-test 1.198	0.235
SES	BPL APL	53 19	69.91 72.81	17.46 15.86	t-test 0.63	0.52
Family Type	Nuclear Extended	39 33	75.74 64.69	16.07 16.29	t-test 2.88	0.005
Occupation	Unemployed Unskilled Skilled	18 40 14	64.21 72.54 73.65	15.1 16.66 19.19	ANOVA 1.79	0.17
Marital Status	Single Married Widowed/Divorced/ Separated	30 36 6	64.14 78.18 58.35	16.94 14.49 11.05	ANOVA 8.94	<0.001
Religion	Hindu Muslim Christian	47 17 8	69.61 70.38 77.55	18.12 13.16 17.66	ANOVA 0.744	0.479

Demographic Variables: In this study, though the two groups were comparable on age group, gender, religion and education; there were marginal differences between the two groups on the variables occupation and family type. A previous study has also reported similar results.¹⁴ When marital status was compared, the two groups were significantly different — with a higher number of married persons in Non-MI group (87%) than the MI group (50%). This should be read in the context that epidemiological studies have consistently found high unmarried status among people with serious mental illness. This may be because the mental illness lessens the chances of marriage and increases the chance of divorce.¹⁵ Considering socioeconomic status (SES), a high number of participants (74%) in the MI group belonged to BPL (Below Poverty Line) category, an economic benchmark and poverty threshold used by the government of Kerala.¹⁶ On the other hand, majority (53%) in the Non-MI group belonged to APL (Above Poverty Line) category. A previous study too had reported such a relationship between SES and mental illness.¹⁷

Perceived human rights and mental illness: Comparison of the scores for perceived human rights on the full score of 100 revealed significant deficits in fulfillment of overall perceived human rights in the MI group. Similar findings have been reported by a previous study in which majority of the participants reported feeling apprehensive that others would avoid them due to their mental illness, and most frequently in the domain of interpersonal interaction.¹⁸

On the interindividual domain, significant infringements were reported by our MI group on areas of dignity, participation, equity, justice from family and friends, as well as justice and equity from other people. A previous multicenter study had reported similar results of discrimination experienced by people with mental illness.¹⁹ Negative discrimination was experienced by most of their participants (47%) in making or keeping friends, from family members, in finding a job, in keeping a job, and in intimate or sexual relationships. That study also reported anticipated discrimination among majority of the participants (64%) in applying for work, training, or education; and in looking for a close relationship. Majority in that study also experienced their diagnosis as labeling¹⁹. These findings are consistent with our own findings.

In contrast to the earlier reported evidence, this study did not find any significant difference between the two groups on overall health care related human rights.²⁰ But the MI group reported significant deficits in some items within this domain like equity and justice. There were no significant differences in the areas of participation or dignity. From this, we may assume that human rights violations are less severe in community mental health care settings in India compared to the situation abroad. It may also be concluded that mentally ill may not be experiencing much human rights violations from health care workers. However, this finding cannot be generalized to more restrictive facilities like mental hospitals. These findings should also be read in the context of a qualitative study done in a developed country which examined the experience of persons recovering from serious and persistent mental illness, and highlighted the need for patients to be active participants in their care so as to develop independence and sense of self. ²¹

Similarly, this study did not find any significant difference in fulfillment of community related human rights. However, HR-Community domain items showed significantly low scores on areas of equity and justice. But no significant differences were found in the areas of participation or dignity. In a previous study on perceptions of discrimination among persons with serious mental illness in a developed country, more than half of the participants had reported some experience with discrimination, mostly in occupation, housing, and from legal system.¹⁴

In our study, the MI group reported significantly low overall work-related human rights, as well as low scores in dignity from colleagues, participation, justice, and equity. The groups were comparable on dignity from supervisors. These findings are consistent with previous studies highlighting discrimination faced by the mentally ill at work place and in getting employment.^22,23

Our results indicate considerable deficits in the fulfillment of human rights in various areas among the mentally ill. Measurement of perceived fulfillment of human rights helps to identify deficits within societies and also across societies. In this study, two groups were compared, one of them being more likely to be subjected to different kinds of human rights violation. These results are relevant in many respects: They suggest that there is an imperative need to take necessary steps to defend, promote, and fulfill human rights of people with mental illness through education of the public and interventions targeting close relatives and health care personnel. Quantifying perceived human rights status and putting it into perspective will help to scientifically identify areas for action and to monitor progress.

The limitations of this study include the use of purposive sampling technique and the use of a questionnaire which was relatively brief to cover the broad field of human rights.

CONCLUSION

This study shows that mentally ill persons perceive significantly lower human rights in comparison to those without mental illness from similar socioeconomic and cultural background. On the interindividual domain, deficits were seen in all areas — dignity, participation from family and friends, and equity and justice from family and friends as well as other people. In the health care domain, significant deficits were seen in the areas of justice and equity. Overall health related human rights scores were comparable. In the community domain, there were significantly low scores in equity and justice. There was no difference between the scores obtained by the two groups in the overall community domain score. On the work-related human rights domain, significant deficits were reported on overall score and items on dignity from colleagues, participation, justice, and equity. The differences in the socioeconomic, marital and employment status of the two groups may have influenced these results, and that aspect needs to be investigated in future research.

REFERENCES

1. World Health Organization. Investing in Mental Health, Geneva.2003 [cited 2015 Jan 15] Available from: http://www.who.int/mental_health/media/investingmnh.pdf
2. Channabasavanna SM, Murthy P. The National Human Rights Commission Report 1999: A Defining Moment. In, Agarwal, S P. eds. Mental Health: An Indian Perspective - 1946–2003. Directorate General of Health Services, Ministry of Health & Family Welfare, New Delhi, 2004.
3. World Health Organization. Mental Health, Human Rights & Legislation. WHO Geneva. [cited 2015 Jan 15]. Available from: http://www.who.int/mental_health/policy/legislation/policy/en/
4. Vijayalakshmi P, Ramachandra, Reddemma K, Math SB. Perceived human rights violation in persons with mental illness: role of education. Int J Soc Psychiatry 2013; 59(4):351-64.
5. Poreddi V, Ramachandra, Reddemma K, Math SB. People with mental illness and human rights: A developing countries perspective. Indian J Psychiatry 2013; 55(2):117-24.
6. Wildner M, Fischer R, Brunner A. Development of a questionnaire for quantitative assessment in the field of health and human rights. Soc Sci Med 2002; 55(10):1725-44.
7. King IM. King's conceptual system, theory of goal attainment, and transaction process in the 21st century. Nurs Sci Q 2007; 20:109-11.
8. World Health Organization. International Classification of Diseases, Diagnostic Criteria for Research. Geneva: WHO; 1993.
9. Shamsunder C, Sriram TG, Muraliraj SG, Shanmughan V. Validity of a short 5-items version of the General Health Questionnaire. Indian J Psychiatry 1986; 28:3,217-19.
10. Denise FP, Beck CT. Nursing Research: Principles and Methods. Philadelphia; Lippincott Williams and Wilkins: 2004.
11. Cohen J. Statistical Power Analysis for the Behavioral Sciences (2nd ed.), New Jersey: Lawrence Erlbaum Associates: 1988.
12. Fischer R , Wildner M , Brunner A . Health and human rights--development of a questionnaire for measuring perceived human rights status. Soz Praventivmed 2000; 45:4.
13. Harkness J. Questionnaire Translation. In Harkness JA, van de Vijver FJR, Mohler PM, editors. Crosscultural Survey Methods. New York: John Wiley, 2003.
14. Corrigan P, Thompson V, Lambert D , Sangster Y , Noel JG , Campbell J . Perceptions of discrimination among persons with serious mental illness. Psychiatr Serv 2003; 54(8):1105-10.
15. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:8.
16. Government of Kerala.Civil Supplies Department: Schemes and Programmes. Available from http://www.civilsupplieskerala.gov.in/index.php/acts-and-rules
17. Regier DA, Boyd JH, Rae DS, Burke JD, Locke BZ, Myers JK, et al. One-month prevalence of mental disorders in the U.S.: Based on five epidemiologic catchment area (ECA) sites. Arch Gen Psychiatry 1988; 45:977.
18. Holzinger A , Beck M , Munk I , Weithaas S , Angermeyer MC . Stigma as perceived by schizophrenics and depressives. Psychiatr Prax 2003; 30(7):395-401.
19. Thornicroft G , Brohan E , Rose D , Sartorius N , Leese M , INDIGO Study Group . Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 2009; 373(9661):408-15.
20. Thornicroft G , Rose D , Kassam A . Discrimination in health care against people with mental illness. Int Rev Psychiatry 2007; 19(2):113-22.
21. Bradshaw W, Roseborough D, Armour MP. Recovery from severe mental illness: the lived experience of the initial phase of treatment. Int J Psychoso Rehabil 2006; 10(1):123-31.
22. Krupa T, Kirsh B, Cockburn L, Gewurtz R. Understanding the stigma of mental illness in employment. Work 2009; 33(4):413-25.
23. Manning C, White PD. Attitudes of employers to the mentally ill. Psych Bull 1995; 19:541-3.