精神病患者遭受的社会歧视、感知的病耻感及影响因素的研究
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摘要
近年来,精神疾病病耻感问题已成为全球关注的重大公共卫生问题。公众对精神病患者普遍存在歧视,致使精神病患者大多有病耻感,病耻感的存在严重影响了患者的心理状态、社会功能、治疗依从性、疾病康复。在我国文化背景下精神病患者遭受的社会歧视,感知的病耻感问题是当前亟待研究的重要问题。
目的
1、描述公众(精神病患者家属、护士、学生)对精神病患者的歧视状况,探讨其影响因素及降低歧视的策略；
2、描述精神病患者感知的病耻感水平,分析社会人口学因素、临床因素、社会支持、一般自我效能感、应对方式对患者病耻感的影响,探讨降低病耻感的策略；
3、探讨精神病患者感知的病耻感对其生存质量的影响及提高其生存质量的策略。
本研究将为减轻公众对患者的偏见与歧视、降低患者病耻感,为政府制定精神卫生工作方针政策、促进患者生理、心理、社会层面康复、提高生存质量,提供科学依据。
方法
1、对公众的调查：本研究类型为描述性研究,采用问卷调查法,方便抽样进行调查。共调查1864名公众,包括精神病患者家属202人,学生1064人(中专生、大专生、本科生),护士598人(精神病医院护士、综合医院护士)。调查工具包括：一般资料调查问卷,歧视精神疾病患者评估量表,后者得分越高,表示对精神病患者的歧视程度越严重。
2、对精神病患者的调查：采用方便抽样法对广州市三家医院精神科符合纳入标准的住院康复期精神病患者进行问卷调查。患者诊断为精神分裂症及情感障碍。调查工具包括：调查对象一般资料问卷、Link病耻感系列量表、精神分裂症病人生存质量量表、社会支持评定量表、一般自我效能感量表、简易应对方式问卷。患者在知情同意,自愿参加的情况下接受问卷调查,共发放问卷430份,回收问卷428份,有效问卷为406份,有效率94.42%。
结果
1、公众对精神病患者的歧视状况及其影响因素
(1)公众对精神病患者的歧视状况
经两独立样本t检验发现,歧视精神病患者评估量表总分与量表编制者曾庆枝调查结果无显著差异(P=1.000)。隔离维度和能力维度得分显著低于曾庆枝的调查结果(P<0.001),而危险维度得分显著高于曾庆枝的调查结果(P<0.001)。
对不同调查对象(患者家属、护士、学生)歧视精神病患者评估量表的评分进行比较,除能力维度评分外,三组人群在量表总分、隔离维度以及危险维度评分存在显著差异(P<0.001)。进一步多重比较发现：护士和毕业班学生的量表总分、隔离维度、危险维度评分均显著高于患者家属(P<0.001),护士的隔离维度评分显著高于毕业班学生(P<0.001),但护士和毕业班学生在量表总分以及其它维度评分均没有显著差异(P>0.05)。
精神病医院护士与综合医院护士歧视精神病患者评估量表总分和能力维度评分没有显著差异(P值分别为0.391、0.404),精神病医院护士的隔离维度评分显著高于综合医院护士(P<0.001),而危险维度评分则显著低于综合医院护士(P<0.001)。
理科大专生和护理大专生歧视精神病患者评估量表的评分比较,两组在量表总分、隔离维度和危险维度评分均无显著差异(P>0.05),但理科大专生的能力维度评分显著高于护理大专生(P<0.001)。
对护理专业中专、大专、本科生歧视精神病患者评估量表的评分进行比较,发现除能力维度外,不同层次护理专业学生的量表总分、隔离维度以及危险维度评分均存在显著差异(P<0.001),进一步多重比较发现：护理本科学生的量表总分和隔离维度评分显著低于护理中专和大专学生。护理中专生的隔离维度评分显著低于大专生,但危险维度评分显著高于大专生和本科生。
对临床医学专业与护理专业本科生歧视精神病患者评估量表的评分进行比较发现,护理专业本科生在量表总分和隔离维度评分显著高于临床医学专业本科生(P值分别为0.030、0.003),但在危险维度和能力维度,两类学生之间无显著差异(P值分别为0.141,0.828)。
(2)公众对精神病患者歧视状况的影响因素
多元线性回归分析结果显示：影响歧视精神病患者评估量表总分的因素包括调查对象类别、性别、年龄、文化程度、是否参加过精神/心理知识讲座、与精神病患者的接触程度和生活联系程度。护士和学生的量表总分均高于患者家属；男性量表总分低于女性；年龄越大者量表总分越高；文化程度越高、参加过精神/心理知识讲座、与精神病患者接触越多、生活联系越紧密的调查对象的量表总分越低,即对精神病患者的歧视程度越低。
2、精神病患者感知的病耻感及其影响因素
(1)精神病患者感知的病耻感及社会人口学因素、临床因素对病耻感的影响
精神病患者Link病耻感系列量表得分与国外常模(量表中点2.5分)之间存在显著差异(P<0.05)。除了不同/羞耻维度的得分高于国外常模外,其他维度得分均显著低于国外常模(P<0.001)。
精神病患者Link病耻感系列量表中条目6、7、9、11、12、44、46的平均分高于中点分2.5分,条目16、45的平均分等于中点分,其它37个条目的平均分都低于中点分。除了第16、22、25、28、37、45条目之外,其它40个条目得分均与中点分2.5有显著差异(P<0.05)。
精神分裂症与情感障碍患者Link病耻感系列量表的评分比较：精神分裂症患者的贬低一歧视感知、教育、挑战、误解4个维度的评分显著高于情感障碍患者(P<0.05),不同/羞耻维度的评分显著低于情感障碍患者,但两种类型精神病患者的保密、退缩、分离维度评分以及病耻感总分均没有显著差异(P>0.05)。
经方差分析发现,住院时间分别在3个月以下,3-6个月,6个月～1年以及1年以上的精神病患者,其病耻感总分以及退缩维度得分存在显著差异(P值分别为0.049,0.033),而四组患者之间,量表的其它维度得分均无显著差异(P>0.05)。对住院时间3个月以下及住院时间3个月以上的患者进行比较,发现前者的病耻感总分和退缩维度得分显著高于后者(P值分别为0.013,0.021),两组患者量表其它维度得分没有显著差异。
经回归分析发现,对于精神病患者而言,年龄越大、入院前不与家人同住的患者病耻感评分越高；住院时间越长的患者其病耻感评分越低。单独对精神分裂症患者进行分析,发现女性、已婚、入院前不与家人同住的患者病耻感总分更高；对于情感障碍患者而言,没有发现独立的社会人口学危险因素。
(2)精神病患者的社会支持、一般自我效能感、应对方式及其对病耻感的影响
①社会支持：精神病患者社会支持量表总分与国内常模比较,差异有统计学意义(P<0.001),精神病患者社会支持低于全国常模。精神分裂症患者和情感障碍患者的社会支持总分以及各维度评分均存在显著差异(P<0.05),精神分裂症患者的社会支持量表总分、客观支持、主观支持以及社会支持利用度均显著低于情感障碍患者(P<0.05)。
②一般自我效能感：经两独立样本t检验,精神病患者的一般自我效能感评分显著低于全国常模(p<0.001)。精神分裂症和情感障碍患者的一般自我效能感评分没有显著差异(P=0.562)。
③应对方式：精神病患者积极应对维度平均分与全国常模比较,没有显著性差异(P=0.758)。患者消极应对维度平均分与全国常模比较,显著低于全国常模(P<0.001)。精神分裂症患者的积极应对评分显著低于情感障碍患者(P=0.049),但两种类型精神病患者的消极应对评分无显著差异(P=0.408)。
④社会支持、一般自我效能感、应对方式对病耻感的影响：相关分析发现,病耻感与社会支持总分、社会支持利用度、一般自我效能感评分之间存在显著的负相关关系(P<0.05),与消极应对存在显著正相关关系(P<0.01)。多元线性逐步回归分析发现,消极应对为病耻感的显著影响因素(P<0.05),采用消极应对方式越多的患者,则病耻感越严重。
(3)精神病患者的生存质量及其影响因素
精神分裂症患者和情感障碍患者生存质量量表总分及各维度得分均无显著差异(P>0.05)。
逐步线性回归分析发现以下因素对精神病患者生存质量有显著影响：患者年龄、性别、居住地、入院前是否在工作、婚姻状况、入院前是否与家人同住、自知力。年龄偏小、女性、居住在城市、入院前不在工作、与配偶分居、入院前不与家人同住、自知力越差的患者其生存质量量表总分越高,即生存质量越差。不同类型精神病患者生存质量的影响因素有所不同,对于精神分裂症患者而言,女性、与配偶分居的患者其生存质量量表总分较高,即生存质量较差。对于情感障碍患者,年龄越小、家庭人均月收入越低者其生存质量量表总分越高,即生存质量越差。
相关分析发现,生存质量总分与贬低-歧视感知维度评分存在显著正相关关系(P<0.01),与社会支持总分、客观支持、社会支持利用度、一般自我效能感以及积极应对方式评分均存在显著负相关关系(P<0.01)。经逐步回归分析发现,社会支持、一般自我效能感和消极应对均为生存质量的显著影响因素(P<0.05)。一般自我效能感越强、社会支持越多的患者,生存质量量表总分越低,即患者自我评价生存质量越好,而消极应对方式越强的患者,自我评价生存质量越差。
结论：
1、公众对精神病患者的歧视状况及其影响因素的研究
(1)公众(精神病患者家属、护士、学生)对精神病患者存在歧视,不同类别的调查对象对患者的歧视程度、歧视的维度(隔离、危险、能力维度)存在差异。
(2)对精神病患者歧视程度的影响因素为：调查对象类别、性别、年龄、文化程度、是否参加过精神／心理知识讲座、与精神病患者接触程度和生活联系程度。护士和学生对精神病患者的歧视程度比家属严重；男性对患者的歧视程度比女性轻；年龄越大者,对患者歧视越严重；文化程度越高、参加过精神／心理知识讲座、与精神病患者接触越多、生活联系越紧密的调查对象对患者的歧视程度越轻。
(3)公众对精神病患者的歧视现象普遍存在,需引起各级政府的高度重视,应采取有针对性的干预措施,降低或消除对患者的歧视,从而降低或消除患者的病耻感,促进其康复。
2、精神病患者感知的病耻感及其影响因素的研究
(1)406例精神病患者存在病耻感,但比西方国家精神病患者病耻感水平低。精神分裂症患者病耻感水平较情感障碍患者的高。患者的社会支持、一般自我效能感、消极应对方式均显著低于全国常模。精神病患者病耻感的影响因素为：年龄、入院前是否与家人同住、应对方式、住院时间。年龄越大,入院前不与家人同住,采用消极应对方式越多的患者,感知的病耻感越严重；住院时间越长,感知的病耻感越轻。此外,病耻感与社会支持、一般自我效能感存在显著负相关关系。精神分裂症患者病耻感的影响因素为：性别、婚姻状况、入院前是否与家人同住。女性、已婚、入院前不与家人同住的患者病耻感更严重；对于情感障碍患者,没有发现影响其病耻感的独立的社会人口学危险因素。
精神病患者生存质量的影响因素包括患者年龄、性别、入院前是否在工作、居住地、婚姻状况、入院前是否与家人同住、自知力、应对方式、社会支持及一般自我效能感。精神病患者年龄越小、女性、入院前不在工作、居住在城市、离异或丧偶或分居、入院前不与家人同住、自知力越差、采用消极应对方式越多的患者,其生存质量越差；社会支持、一般自我效能感越强的患者,其生存质量越好。
(3)病耻感对生存质量没有显著影响,但两者存在相关关系。Link病耻感系列量表贬低一歧视感知维度得分与生存质量总分存在显著正相关关系,病耻感量表贬低一歧视感知维度得分越高,则生存质量越差。
(4)由于精神病患者存在病耻感,且社会人口学因素,临床因素、社会心理因素对患者病耻感有影响,故应采取有针对性干预措施,降低其病耻感,促进患者生理、心理、社会层面的全面康复。
Stigma among patients with mental disorders is increasingly recognized as a global public health problem. Public discrimination against patients with mental disorder is very common, which leads to the stigma in most psychiatric patients. Stigma has a severe impact on the patient's psychological status, social function, compliance with treatment, and recovery. In Chinese culture, psychiatric patients suffer from social discrimination, so perceived stigma has become an important issue to be studied on.
Objectives:
1. To describe the public (relatives of the psychiatric patients, nurses, students) discrimination against patients with mental disorders, and to explore its influencing factors and strategies of reducing discrimination.
2. To describe the stigma levels perceived by patients with mental disorders, to analyze the influencing factors such as social demographic factors, clinical factors, social support, general self-efficacy, and coping style etc. on the patient's stigma, and to explore the strategies of reducing stigma.
3. To investigate the influence by perceived stigma on quality of life of the patients with mental disorders. To explore the strategies used to improve patients' quality of life.
This study will provide a scientific basis for reducing the public's prejudice and discrimination towards the psychiatric patients, reducing the patients'stigma, improving quality of life of the patients, formulating mental health work policies by the government, in order to promote physiological, psychological, and social aspects of rehabilitation of patients with mental disorders.
Methods:
1. The survey of the public
This study is a descriptive study, used questionnaire method and convenience sample survey. A total of1864public received the survey, including relatives of patients with mental disorders, students (secondary professional school students, associate degree program students, undergraduate), nurses (psychiatric hospital nurses, nurses in comprehensive hospitals). The survey instruments include:general information questionnaire and assessment scale of discrimination against patients with mental disorders. For the latter scale, higher scores may indicate more serious discrimination against the patients.
2. The investigation of the patients with mental disorders
The survey was carried out at psychiatric departments of3hospitals in Guangzhou. By using convenience sampling method, the patients meeting the inclusion criteria were recruited in the survey. Patients'diagnosis was schizophrenia and affective disorder. The instruments used in the survey were:general information questionnaire, Link stigma series scale, social support assessment scale, schizophrenic quality of life scale, general self-efficacy scale, simplified coping style questionnaire. Patients suffering from mental disorders in the survey were given written informed consent after being fully informed about the study procedures. A total of430copies of questionnaires were given to the patients, and effective questionnaires were406, so efficiency was94.42%.
Results:
1. The public discrimination against patients with mental disorders and its influencing factors.
(1) The public discrimination against patients with mental disorders
Two independent sample t test showed no significant difference (P=1.000) between the total scores of the scale of discrimination against patient with mental disorders in this research and that of scale editor Zeng Qingzhi's finding. Scores of isolation dimensions and ability dimension were significantly lower than Zeng Qingzhi's findings (P<0.001), but score of dangerous dimensions was significantly higher than Zeng Qingzhi's survey results (P<0.001).
The scores of the scale of discrimination against patients with mental disorders were compared among the subjects of patients'relatives, nurses and students. In addition to the ability dimension scores, the three groups total scores of the scale, isolation dimension score and risk dimension score had significant difference (P<0.001). Multiple comparison showed that as compare to the patient's relatives, total scores of the scale, isolation dimension scores, dangerous dimension scores were significantly higher in nurses and students (P<0.001). Isolation dimension score of nurses was significantly higher than that of the students (P<0.001). However, there were no significantly differences in total scores of the scale, dangerous dimension scores and ability dimension scores between nurses and students (P>0.05).
There were no significant difference in total scores of the scale and ability dimension scores between nurses in psychiatric hospitals and comprehensive hospitals (P=0.391,0.404). The isolation dimension scores of psychiatric hospital nurses were significantly higher than that of nurses in comprehensive hospitals (P<0.001), but the dangerous dimension scores were significantly lower than that of the nurses in comprehensive hospital (P<0.001).
There was no significant differences in total scores of the scale, isolation dimension scores and dangerous dimension scores between associate degree program students majoring in science and nursing (P>0.05), but ability dimension score of the students majoring in science was significantly higher than that of the students majoring in nursing (P<0.001).
In addition to the ability dimension, there were significant differences in total scores of the scale, isolation dimension scores and dangerous dimension scores among nursing students in certificate program, associate degree program and bachelor's degree program (P<0.001). Multiple comparisons showed that the total scores of the scale, isolation dimension score of nursing students in bachelor's degree program was significantly lower than that of the nursing students in certificate program and associate degree program. The isolation dimension score of the nursing students in certificate program was significantly lower than that of the nursing students in associate degree program; but the dangerous dimension score was significantly higher than that of the nursing students in associate degree program and bachelor's degree program.
The total score of the scale and isolation dimension score of nursing students in bachelor's degree program was significantly higher than that of the students majoring in clinical medicine (P=0.030,0.003), but there was no significant difference in dangerous dimension score and ability dimension score between the two students groups (P=0.141,0.828).
(2) Factors that influence the public discrimination against patient with mental disorders
Multiple regression analysis showed:factors influence the total score of the scale were type of investigation objects, gender, age, educational background, attended psychiatric/psychological lectures or not, contact degree and life connection degree to the patients with mental disorders. Nurses and students' total scores of the scale were higher than those of family members of the patients. Male's total score of the scale was lower than that of females. The older of the age, the higher total score of the scale would be. The public with higher educational background attended psychiatric/psychological lectures, with higher contact degree, and with higher life connection degree would have lower total scores of the scale, which indicate lower degree of discrimination against the patients.
2. Perceived stigma of psychiatric patients and its influencing factors
(1) Perceived stigma of patients with mental disorders, influence of social demographic factors, clinical factors on patient's stigma.
There was significant difference in the scores of Link stigma series scale between the patients with mental disorders and the norm (mid point2.5)(P<0.05). Except different/shame dimension score was significantly higher than the norm, scores of other dimensions were significantly lower than the norm (P<0.01).
As to the Link stigma series scale of the patients with mental disorders, the average scores of item6,7,9,11,12,44,46were higher than midpoint2.5. The average scores of item16and45were equal to the midpoint2.5. Other37items' average scores were lower than the midpoint2.5. In addition to item16,22,25,28,37,45, the average scores of other40items had significant difference as compare to the midpoint2.5(P<0.05).
Comparison of the scores of Link stigma series scale between patients with schizophrenia and affective disorder:scores of perceived devaluation-discrimination, education, challenge and misunderstanding dimensions in the patients with schizophrenia were significantly higher than that of the patients with affective disorders (P<0.05). Score of different/sham dimension of patients with schizophrenia was significantly lower than that of the patients with affective disorders. But scores of confidentiality, withdrawal, separation dimensions showed no significant difference between the two kinds of mental disorders (P>0.05).
Analysis of variance showed:there were significant differences in total scores of the scale and score of withdrawal dimension among patients with mental disorders whose hospitalization time were within3months,3to6months,6months to1year and more than1year respectively (P=0.049,0.033), however scores of other dimensions showed no significant difference among the patients with4different length hospitalization time (P>0.05). Comparing patients whose hospitalization time is within3months and more than3months, we found that the former patients'total score of the scale and score of withdrawal dimension were significantly higher than that of the latter patients (P=0.013,0.021), and there were no significant difference in other dimensions between patients whose length of hospitalization time was within3months and more than3months.
Regression analysis showed, general speaking, to patients with mental disorders, the older age, not living with family members before hospitalization, the higher score of stigma scale the patient would have. The longer of hospitalization time, the lower score of stigma scale the patients would have. Regression analysis of patients with schizophrenia showed, female, married, not living with family members before hospitalization would have higher total scores of stigma scale; as for the patients with affective disorders, regression analysis showed that no independent social demographic risk factors were found.
(2) Patients'social support, general self-efficacy, coping style and its influence on the stigma
①Social support:There was significant difference in the total score of social support scale between the patients with mental disorders and that of the national norm (P<0.001). Patients with mental disorder got lower social support than normal persons. There were significant differences in total score of social support scale and scores of each dimension between patients with schizophrenia and affective disorders (P<0.05). Total scores of social support scale of patients with schizophrenia, scores of objective support, subjective support and utilization of social support were significantly lower than that of patients with affective disorders (P<0.05).
②General self-efficacy:Two independent sample t test showed that the score of general self-efficacy scale in patients with mental disorders was significantly lower than national norm (P<0.001). There was no significant difference in the scores of self-efficacy between patients with schizophrenia and patients with affective disorders (P=0.562).
③Coping style:As compare to the norm, there was no significant difference in the average score of positive coping style dimension in patients with mental disorders (P=0.785), but significantly lower in the average score of negative coping style dimension than the national norm (P<0.001). Average score of positive coping style in patients with schizophrenia was significantly lower than that of patients with affective disorders (P=0.049), but there was no significant difference in negative coping style of the two kinds of mental disorders (P=0.408).
④Influencing of social support, general self-efficacy, coping style on the stigma:Correlation analysis showed that stigma had significant negative correlation with total score of social support, utilization of social support, general self-efficacy (P<0.05), stigma had positive correlation with negative coping style (P<0.01). Multiple linear stepwise regression showed, negative coping style was the significant influence factor to the stigma (P<0.05). The more negative coping style adopted by the patients, the more serious stigma the patient would perceive.
(3) Quality of Life (QOL) and its influencing factors on the patients with mental disorders
There were no significant difference in the total scores of QOL and the scores of each dimension between patients with schizophrenia and affective disorders (P>0.05).
Stepwise linear regression analysis revealed the following factors has significant influence on the QOL of patients with mental disorders:age, gender, place of residence, being work or not before hospitalization, marriage status, living with family or not before hospitalization, insight. Patient with younger age, female, living in city, not at work before hospitalization, separate from spouses, not living with the family before hospitalization, and with poor insight had higher total score of QOL, which means poor QOL. The influencing factors that influence the QOL of the patients with schizophrenia and affective disorders were different. As for the patients with schizophrenia who were female, separated from spouses had higher total score of QOL, namely had poor QOL. As for the patients with affective disorders, those with younger age, lower family income had higher total score of QOL, namely had poor QOL.
Correlation analysis showed:Total score of QOL had significant positive correlation with score of perceived devaluation-discrimination dimension (P<0.01); had significant negative correlation with total score of social support, score of objective support, utilization of social support, general self-efficacy and positive coping style (P<0.01). Stepwise regression revealed that social support, general self-efficacy and negative coping style were significant influencing factors on patients'QOL (P<0.05). Patients with higher general self-efficacy, more social support would have lower total score of QOL, namely better QOL. Patients adopted more negative coping style, would have poor QOL.
Conclusion:
1. Study on public discrimination against patient with mental disorder and its influencing factors
(1) Discrimination against patients with mental disorders by the public (relatives of psychiatric patients, nurses, and students) indeed existed. The degree of discrimination, and discrimination dimensions (isolation, dangerous, ability dimension) were different in different investigation objects.
(2) Factors influence discrimination degree against patients with mental disorders were types of investigation objects, gender, age, educational background, participated in psychiatric/psychological lectures or not, degree of contact and life connection with the patients. The discrimination attitude of nurses and students was more serious than that of the relatives of the patients; male's discrimination against patients with mental illness is less serious than females; the older of the patients'age, the more serious discrimination against the patients. Patients with higher level of education, having attended the psychiatric/psychological lectures, with higher degree of contact, and with close life connection to the patients, would have less discrimination against the patients with mental disorders.
(3) Because the public's discrimination against patients with mental disorders are popular, government should pay more attention to it, and effective intervention should be taken to reduce or eliminate the discrimination toward the patients, in order to reduce or eliminate the patients stigma, as the result to promote recovery of the patients.
2. Study on psychiatric patients'stigma, quality of life and its influencing factors
(1)406patients with mental disorders had perceived stigma, but less serious than psychiatric patients in western countries. Schizophrenic patients'stigma was more serious than that of patients with affective disorders. The patients'social support, general self-efficacy, negative coping style were significantly lower than that of the national norm. Factors influence the psychiatric patients'stigma were age, living with the family or not, coping style, length of hospitalization time. Those with older age, not living with the family before hospitalization, adopted more negative coping styles would perceive more serious stigma; those with longer hospitalization time, would perceive less serious stigma. Further more, patients'stigma had significant negative correlation with social support and general self-efficacy. Factors influence schizophrenic patients'stigma:those who were female, married, not living with the family before hospitalization would have more serious stigma. As for the patients with affective disorder, no independent social demographic risk factors that influence the stigma were found.
(2) Factors influence psychiatric patients'QOL were age, gender, being work or not before hospitalization, place of residence, marriage status, living with the family or not before hospitalization, insight, coping style, social support and general self efficacy. Psychiatric patients who were younger, female, not being work before hospitalization, living in city, divoice or died of the spouse or being separated from the spouses, not living with family before hospitalization, with worse insight, and adopted more negative coping styles would have poor QOL. Psychiatric patients with good social support, general self-efficacy would have better QOL.
(3) Stigma had no significant influence on psychiatric patient's QOL, but there was correlation between them. Score of perceived devaluation-discrimination dimension of the stigma scale had significant positive correlation with QOL of psychiatric patient. The higher score of perceived devaluation-discrimination dimension of stigma scale, the poor QOL the patient would have.
(4) Because psychiatric patient had perceived stigma, and social demographic factors, clinical factors, social and psychological factors could influence patient's perceived stigma, effective intervention should be taken to reduce patients'stigma, in order to promote their physiological, psychological, social aspects of recovery.
目的
1、描述公众(精神病患者家属、护士、学生)对精神病患者的歧视状况,探讨其影响因素及降低歧视的策略；
2、描述精神病患者感知的病耻感水平,分析社会人口学因素、临床因素、社会支持、一般自我效能感、应对方式对患者病耻感的影响,探讨降低病耻感的策略；
3、探讨精神病患者感知的病耻感对其生存质量的影响及提高其生存质量的策略。
本研究将为减轻公众对患者的偏见与歧视、降低患者病耻感,为政府制定精神卫生工作方针政策、促进患者生理、心理、社会层面康复、提高生存质量,提供科学依据。
方法
1、对公众的调查：本研究类型为描述性研究,采用问卷调查法,方便抽样进行调查。共调查1864名公众,包括精神病患者家属202人,学生1064人(中专生、大专生、本科生),护士598人(精神病医院护士、综合医院护士)。调查工具包括：一般资料调查问卷,歧视精神疾病患者评估量表,后者得分越高,表示对精神病患者的歧视程度越严重。
2、对精神病患者的调查：采用方便抽样法对广州市三家医院精神科符合纳入标准的住院康复期精神病患者进行问卷调查。患者诊断为精神分裂症及情感障碍。调查工具包括：调查对象一般资料问卷、Link病耻感系列量表、精神分裂症病人生存质量量表、社会支持评定量表、一般自我效能感量表、简易应对方式问卷。患者在知情同意,自愿参加的情况下接受问卷调查,共发放问卷430份,回收问卷428份,有效问卷为406份,有效率94.42%。
结果
1、公众对精神病患者的歧视状况及其影响因素
(1)公众对精神病患者的歧视状况
经两独立样本t检验发现,歧视精神病患者评估量表总分与量表编制者曾庆枝调查结果无显著差异(P=1.000)。隔离维度和能力维度得分显著低于曾庆枝的调查结果(P<0.001),而危险维度得分显著高于曾庆枝的调查结果(P<0.001)。
对不同调查对象(患者家属、护士、学生)歧视精神病患者评估量表的评分进行比较,除能力维度评分外,三组人群在量表总分、隔离维度以及危险维度评分存在显著差异(P<0.001)。进一步多重比较发现：护士和毕业班学生的量表总分、隔离维度、危险维度评分均显著高于患者家属(P<0.001),护士的隔离维度评分显著高于毕业班学生(P<0.001),但护士和毕业班学生在量表总分以及其它维度评分均没有显著差异(P>0.05)。
精神病医院护士与综合医院护士歧视精神病患者评估量表总分和能力维度评分没有显著差异(P值分别为0.391、0.404),精神病医院护士的隔离维度评分显著高于综合医院护士(P<0.001),而危险维度评分则显著低于综合医院护士(P<0.001)。
理科大专生和护理大专生歧视精神病患者评估量表的评分比较,两组在量表总分、隔离维度和危险维度评分均无显著差异(P>0.05),但理科大专生的能力维度评分显著高于护理大专生(P<0.001)。
对护理专业中专、大专、本科生歧视精神病患者评估量表的评分进行比较,发现除能力维度外,不同层次护理专业学生的量表总分、隔离维度以及危险维度评分均存在显著差异(P<0.001),进一步多重比较发现：护理本科学生的量表总分和隔离维度评分显著低于护理中专和大专学生。护理中专生的隔离维度评分显著低于大专生,但危险维度评分显著高于大专生和本科生。
对临床医学专业与护理专业本科生歧视精神病患者评估量表的评分进行比较发现,护理专业本科生在量表总分和隔离维度评分显著高于临床医学专业本科生(P值分别为0.030、0.003),但在危险维度和能力维度,两类学生之间无显著差异(P值分别为0.141,0.828)。
(2)公众对精神病患者歧视状况的影响因素
多元线性回归分析结果显示：影响歧视精神病患者评估量表总分的因素包括调查对象类别、性别、年龄、文化程度、是否参加过精神/心理知识讲座、与精神病患者的接触程度和生活联系程度。护士和学生的量表总分均高于患者家属；男性量表总分低于女性；年龄越大者量表总分越高；文化程度越高、参加过精神/心理知识讲座、与精神病患者接触越多、生活联系越紧密的调查对象的量表总分越低,即对精神病患者的歧视程度越低。
2、精神病患者感知的病耻感及其影响因素
(1)精神病患者感知的病耻感及社会人口学因素、临床因素对病耻感的影响
精神病患者Link病耻感系列量表得分与国外常模(量表中点2.5分)之间存在显著差异(P<0.05)。除了不同/羞耻维度的得分高于国外常模外,其他维度得分均显著低于国外常模(P<0.001)。
精神病患者Link病耻感系列量表中条目6、7、9、11、12、44、46的平均分高于中点分2.5分,条目16、45的平均分等于中点分,其它37个条目的平均分都低于中点分。除了第16、22、25、28、37、45条目之外,其它40个条目得分均与中点分2.5有显著差异(P<0.05)。
精神分裂症与情感障碍患者Link病耻感系列量表的评分比较：精神分裂症患者的贬低一歧视感知、教育、挑战、误解4个维度的评分显著高于情感障碍患者(P<0.05),不同/羞耻维度的评分显著低于情感障碍患者,但两种类型精神病患者的保密、退缩、分离维度评分以及病耻感总分均没有显著差异(P>0.05)。
经方差分析发现,住院时间分别在3个月以下,3-6个月,6个月～1年以及1年以上的精神病患者,其病耻感总分以及退缩维度得分存在显著差异(P值分别为0.049,0.033),而四组患者之间,量表的其它维度得分均无显著差异(P>0.05)。对住院时间3个月以下及住院时间3个月以上的患者进行比较,发现前者的病耻感总分和退缩维度得分显著高于后者(P值分别为0.013,0.021),两组患者量表其它维度得分没有显著差异。
经回归分析发现,对于精神病患者而言,年龄越大、入院前不与家人同住的患者病耻感评分越高；住院时间越长的患者其病耻感评分越低。单独对精神分裂症患者进行分析,发现女性、已婚、入院前不与家人同住的患者病耻感总分更高；对于情感障碍患者而言,没有发现独立的社会人口学危险因素。
(2)精神病患者的社会支持、一般自我效能感、应对方式及其对病耻感的影响
①社会支持：精神病患者社会支持量表总分与国内常模比较,差异有统计学意义(P<0.001),精神病患者社会支持低于全国常模。精神分裂症患者和情感障碍患者的社会支持总分以及各维度评分均存在显著差异(P<0.05),精神分裂症患者的社会支持量表总分、客观支持、主观支持以及社会支持利用度均显著低于情感障碍患者(P<0.05)。
②一般自我效能感：经两独立样本t检验,精神病患者的一般自我效能感评分显著低于全国常模(p<0.001)。精神分裂症和情感障碍患者的一般自我效能感评分没有显著差异(P=0.562)。
③应对方式：精神病患者积极应对维度平均分与全国常模比较,没有显著性差异(P=0.758)。患者消极应对维度平均分与全国常模比较,显著低于全国常模(P<0.001)。精神分裂症患者的积极应对评分显著低于情感障碍患者(P=0.049),但两种类型精神病患者的消极应对评分无显著差异(P=0.408)。
④社会支持、一般自我效能感、应对方式对病耻感的影响：相关分析发现,病耻感与社会支持总分、社会支持利用度、一般自我效能感评分之间存在显著的负相关关系(P<0.05),与消极应对存在显著正相关关系(P<0.01)。多元线性逐步回归分析发现,消极应对为病耻感的显著影响因素(P<0.05),采用消极应对方式越多的患者,则病耻感越严重。
(3)精神病患者的生存质量及其影响因素
精神分裂症患者和情感障碍患者生存质量量表总分及各维度得分均无显著差异(P>0.05)。
逐步线性回归分析发现以下因素对精神病患者生存质量有显著影响：患者年龄、性别、居住地、入院前是否在工作、婚姻状况、入院前是否与家人同住、自知力。年龄偏小、女性、居住在城市、入院前不在工作、与配偶分居、入院前不与家人同住、自知力越差的患者其生存质量量表总分越高,即生存质量越差。不同类型精神病患者生存质量的影响因素有所不同,对于精神分裂症患者而言,女性、与配偶分居的患者其生存质量量表总分较高,即生存质量较差。对于情感障碍患者,年龄越小、家庭人均月收入越低者其生存质量量表总分越高,即生存质量越差。
相关分析发现,生存质量总分与贬低-歧视感知维度评分存在显著正相关关系(P<0.01),与社会支持总分、客观支持、社会支持利用度、一般自我效能感以及积极应对方式评分均存在显著负相关关系(P<0.01)。经逐步回归分析发现,社会支持、一般自我效能感和消极应对均为生存质量的显著影响因素(P<0.05)。一般自我效能感越强、社会支持越多的患者,生存质量量表总分越低,即患者自我评价生存质量越好,而消极应对方式越强的患者,自我评价生存质量越差。
结论：
1、公众对精神病患者的歧视状况及其影响因素的研究
(1)公众(精神病患者家属、护士、学生)对精神病患者存在歧视,不同类别的调查对象对患者的歧视程度、歧视的维度(隔离、危险、能力维度)存在差异。
(2)对精神病患者歧视程度的影响因素为：调查对象类别、性别、年龄、文化程度、是否参加过精神／心理知识讲座、与精神病患者接触程度和生活联系程度。护士和学生对精神病患者的歧视程度比家属严重；男性对患者的歧视程度比女性轻；年龄越大者,对患者歧视越严重；文化程度越高、参加过精神／心理知识讲座、与精神病患者接触越多、生活联系越紧密的调查对象对患者的歧视程度越轻。
(3)公众对精神病患者的歧视现象普遍存在,需引起各级政府的高度重视,应采取有针对性的干预措施,降低或消除对患者的歧视,从而降低或消除患者的病耻感,促进其康复。
2、精神病患者感知的病耻感及其影响因素的研究
(1)406例精神病患者存在病耻感,但比西方国家精神病患者病耻感水平低。精神分裂症患者病耻感水平较情感障碍患者的高。患者的社会支持、一般自我效能感、消极应对方式均显著低于全国常模。精神病患者病耻感的影响因素为：年龄、入院前是否与家人同住、应对方式、住院时间。年龄越大,入院前不与家人同住,采用消极应对方式越多的患者,感知的病耻感越严重；住院时间越长,感知的病耻感越轻。此外,病耻感与社会支持、一般自我效能感存在显著负相关关系。精神分裂症患者病耻感的影响因素为：性别、婚姻状况、入院前是否与家人同住。女性、已婚、入院前不与家人同住的患者病耻感更严重；对于情感障碍患者,没有发现影响其病耻感的独立的社会人口学危险因素。
精神病患者生存质量的影响因素包括患者年龄、性别、入院前是否在工作、居住地、婚姻状况、入院前是否与家人同住、自知力、应对方式、社会支持及一般自我效能感。精神病患者年龄越小、女性、入院前不在工作、居住在城市、离异或丧偶或分居、入院前不与家人同住、自知力越差、采用消极应对方式越多的患者,其生存质量越差；社会支持、一般自我效能感越强的患者,其生存质量越好。
(3)病耻感对生存质量没有显著影响,但两者存在相关关系。Link病耻感系列量表贬低一歧视感知维度得分与生存质量总分存在显著正相关关系,病耻感量表贬低一歧视感知维度得分越高,则生存质量越差。
(4)由于精神病患者存在病耻感,且社会人口学因素,临床因素、社会心理因素对患者病耻感有影响,故应采取有针对性干预措施,降低其病耻感,促进患者生理、心理、社会层面的全面康复。
Stigma among patients with mental disorders is increasingly recognized as a global public health problem. Public discrimination against patients with mental disorder is very common, which leads to the stigma in most psychiatric patients. Stigma has a severe impact on the patient's psychological status, social function, compliance with treatment, and recovery. In Chinese culture, psychiatric patients suffer from social discrimination, so perceived stigma has become an important issue to be studied on.
Objectives:
1. To describe the public (relatives of the psychiatric patients, nurses, students) discrimination against patients with mental disorders, and to explore its influencing factors and strategies of reducing discrimination.
2. To describe the stigma levels perceived by patients with mental disorders, to analyze the influencing factors such as social demographic factors, clinical factors, social support, general self-efficacy, and coping style etc. on the patient's stigma, and to explore the strategies of reducing stigma.
3. To investigate the influence by perceived stigma on quality of life of the patients with mental disorders. To explore the strategies used to improve patients' quality of life.
This study will provide a scientific basis for reducing the public's prejudice and discrimination towards the psychiatric patients, reducing the patients'stigma, improving quality of life of the patients, formulating mental health work policies by the government, in order to promote physiological, psychological, and social aspects of rehabilitation of patients with mental disorders.
Methods:
1. The survey of the public
This study is a descriptive study, used questionnaire method and convenience sample survey. A total of1864public received the survey, including relatives of patients with mental disorders, students (secondary professional school students, associate degree program students, undergraduate), nurses (psychiatric hospital nurses, nurses in comprehensive hospitals). The survey instruments include:general information questionnaire and assessment scale of discrimination against patients with mental disorders. For the latter scale, higher scores may indicate more serious discrimination against the patients.
2. The investigation of the patients with mental disorders
The survey was carried out at psychiatric departments of3hospitals in Guangzhou. By using convenience sampling method, the patients meeting the inclusion criteria were recruited in the survey. Patients'diagnosis was schizophrenia and affective disorder. The instruments used in the survey were:general information questionnaire, Link stigma series scale, social support assessment scale, schizophrenic quality of life scale, general self-efficacy scale, simplified coping style questionnaire. Patients suffering from mental disorders in the survey were given written informed consent after being fully informed about the study procedures. A total of430copies of questionnaires were given to the patients, and effective questionnaires were406, so efficiency was94.42%.
Results:
1. The public discrimination against patients with mental disorders and its influencing factors.
(1) The public discrimination against patients with mental disorders
Two independent sample t test showed no significant difference (P=1.000) between the total scores of the scale of discrimination against patient with mental disorders in this research and that of scale editor Zeng Qingzhi's finding. Scores of isolation dimensions and ability dimension were significantly lower than Zeng Qingzhi's findings (P<0.001), but score of dangerous dimensions was significantly higher than Zeng Qingzhi's survey results (P<0.001).
The scores of the scale of discrimination against patients with mental disorders were compared among the subjects of patients'relatives, nurses and students. In addition to the ability dimension scores, the three groups total scores of the scale, isolation dimension score and risk dimension score had significant difference (P<0.001). Multiple comparison showed that as compare to the patient's relatives, total scores of the scale, isolation dimension scores, dangerous dimension scores were significantly higher in nurses and students (P<0.001). Isolation dimension score of nurses was significantly higher than that of the students (P<0.001). However, there were no significantly differences in total scores of the scale, dangerous dimension scores and ability dimension scores between nurses and students (P>0.05).
There were no significant difference in total scores of the scale and ability dimension scores between nurses in psychiatric hospitals and comprehensive hospitals (P=0.391,0.404). The isolation dimension scores of psychiatric hospital nurses were significantly higher than that of nurses in comprehensive hospitals (P<0.001), but the dangerous dimension scores were significantly lower than that of the nurses in comprehensive hospital (P<0.001).
There was no significant differences in total scores of the scale, isolation dimension scores and dangerous dimension scores between associate degree program students majoring in science and nursing (P>0.05), but ability dimension score of the students majoring in science was significantly higher than that of the students majoring in nursing (P<0.001).
In addition to the ability dimension, there were significant differences in total scores of the scale, isolation dimension scores and dangerous dimension scores among nursing students in certificate program, associate degree program and bachelor's degree program (P<0.001). Multiple comparisons showed that the total scores of the scale, isolation dimension score of nursing students in bachelor's degree program was significantly lower than that of the nursing students in certificate program and associate degree program. The isolation dimension score of the nursing students in certificate program was significantly lower than that of the nursing students in associate degree program; but the dangerous dimension score was significantly higher than that of the nursing students in associate degree program and bachelor's degree program.
The total score of the scale and isolation dimension score of nursing students in bachelor's degree program was significantly higher than that of the students majoring in clinical medicine (P=0.030,0.003), but there was no significant difference in dangerous dimension score and ability dimension score between the two students groups (P=0.141,0.828).
(2) Factors that influence the public discrimination against patient with mental disorders
Multiple regression analysis showed:factors influence the total score of the scale were type of investigation objects, gender, age, educational background, attended psychiatric/psychological lectures or not, contact degree and life connection degree to the patients with mental disorders. Nurses and students' total scores of the scale were higher than those of family members of the patients. Male's total score of the scale was lower than that of females. The older of the age, the higher total score of the scale would be. The public with higher educational background attended psychiatric/psychological lectures, with higher contact degree, and with higher life connection degree would have lower total scores of the scale, which indicate lower degree of discrimination against the patients.
2. Perceived stigma of psychiatric patients and its influencing factors
(1) Perceived stigma of patients with mental disorders, influence of social demographic factors, clinical factors on patient's stigma.
There was significant difference in the scores of Link stigma series scale between the patients with mental disorders and the norm (mid point2.5)(P<0.05). Except different/shame dimension score was significantly higher than the norm, scores of other dimensions were significantly lower than the norm (P<0.01).
As to the Link stigma series scale of the patients with mental disorders, the average scores of item6,7,9,11,12,44,46were higher than midpoint2.5. The average scores of item16and45were equal to the midpoint2.5. Other37items' average scores were lower than the midpoint2.5. In addition to item16,22,25,28,37,45, the average scores of other40items had significant difference as compare to the midpoint2.5(P<0.05).
Comparison of the scores of Link stigma series scale between patients with schizophrenia and affective disorder:scores of perceived devaluation-discrimination, education, challenge and misunderstanding dimensions in the patients with schizophrenia were significantly higher than that of the patients with affective disorders (P<0.05). Score of different/sham dimension of patients with schizophrenia was significantly lower than that of the patients with affective disorders. But scores of confidentiality, withdrawal, separation dimensions showed no significant difference between the two kinds of mental disorders (P>0.05).
Analysis of variance showed:there were significant differences in total scores of the scale and score of withdrawal dimension among patients with mental disorders whose hospitalization time were within3months,3to6months,6months to1year and more than1year respectively (P=0.049,0.033), however scores of other dimensions showed no significant difference among the patients with4different length hospitalization time (P>0.05). Comparing patients whose hospitalization time is within3months and more than3months, we found that the former patients'total score of the scale and score of withdrawal dimension were significantly higher than that of the latter patients (P=0.013,0.021), and there were no significant difference in other dimensions between patients whose length of hospitalization time was within3months and more than3months.
Regression analysis showed, general speaking, to patients with mental disorders, the older age, not living with family members before hospitalization, the higher score of stigma scale the patient would have. The longer of hospitalization time, the lower score of stigma scale the patients would have. Regression analysis of patients with schizophrenia showed, female, married, not living with family members before hospitalization would have higher total scores of stigma scale; as for the patients with affective disorders, regression analysis showed that no independent social demographic risk factors were found.
(2) Patients'social support, general self-efficacy, coping style and its influence on the stigma
①Social support:There was significant difference in the total score of social support scale between the patients with mental disorders and that of the national norm (P<0.001). Patients with mental disorder got lower social support than normal persons. There were significant differences in total score of social support scale and scores of each dimension between patients with schizophrenia and affective disorders (P<0.05). Total scores of social support scale of patients with schizophrenia, scores of objective support, subjective support and utilization of social support were significantly lower than that of patients with affective disorders (P<0.05).
②General self-efficacy:Two independent sample t test showed that the score of general self-efficacy scale in patients with mental disorders was significantly lower than national norm (P<0.001). There was no significant difference in the scores of self-efficacy between patients with schizophrenia and patients with affective disorders (P=0.562).
③Coping style:As compare to the norm, there was no significant difference in the average score of positive coping style dimension in patients with mental disorders (P=0.785), but significantly lower in the average score of negative coping style dimension than the national norm (P<0.001). Average score of positive coping style in patients with schizophrenia was significantly lower than that of patients with affective disorders (P=0.049), but there was no significant difference in negative coping style of the two kinds of mental disorders (P=0.408).
④Influencing of social support, general self-efficacy, coping style on the stigma:Correlation analysis showed that stigma had significant negative correlation with total score of social support, utilization of social support, general self-efficacy (P<0.05), stigma had positive correlation with negative coping style (P<0.01). Multiple linear stepwise regression showed, negative coping style was the significant influence factor to the stigma (P<0.05). The more negative coping style adopted by the patients, the more serious stigma the patient would perceive.
(3) Quality of Life (QOL) and its influencing factors on the patients with mental disorders
There were no significant difference in the total scores of QOL and the scores of each dimension between patients with schizophrenia and affective disorders (P>0.05).
Stepwise linear regression analysis revealed the following factors has significant influence on the QOL of patients with mental disorders:age, gender, place of residence, being work or not before hospitalization, marriage status, living with family or not before hospitalization, insight. Patient with younger age, female, living in city, not at work before hospitalization, separate from spouses, not living with the family before hospitalization, and with poor insight had higher total score of QOL, which means poor QOL. The influencing factors that influence the QOL of the patients with schizophrenia and affective disorders were different. As for the patients with schizophrenia who were female, separated from spouses had higher total score of QOL, namely had poor QOL. As for the patients with affective disorders, those with younger age, lower family income had higher total score of QOL, namely had poor QOL.
Correlation analysis showed:Total score of QOL had significant positive correlation with score of perceived devaluation-discrimination dimension (P<0.01); had significant negative correlation with total score of social support, score of objective support, utilization of social support, general self-efficacy and positive coping style (P<0.01). Stepwise regression revealed that social support, general self-efficacy and negative coping style were significant influencing factors on patients'QOL (P<0.05). Patients with higher general self-efficacy, more social support would have lower total score of QOL, namely better QOL. Patients adopted more negative coping style, would have poor QOL.
Conclusion:
1. Study on public discrimination against patient with mental disorder and its influencing factors
(1) Discrimination against patients with mental disorders by the public (relatives of psychiatric patients, nurses, and students) indeed existed. The degree of discrimination, and discrimination dimensions (isolation, dangerous, ability dimension) were different in different investigation objects.
(2) Factors influence discrimination degree against patients with mental disorders were types of investigation objects, gender, age, educational background, participated in psychiatric/psychological lectures or not, degree of contact and life connection with the patients. The discrimination attitude of nurses and students was more serious than that of the relatives of the patients; male's discrimination against patients with mental illness is less serious than females; the older of the patients'age, the more serious discrimination against the patients. Patients with higher level of education, having attended the psychiatric/psychological lectures, with higher degree of contact, and with close life connection to the patients, would have less discrimination against the patients with mental disorders.
(3) Because the public's discrimination against patients with mental disorders are popular, government should pay more attention to it, and effective intervention should be taken to reduce or eliminate the discrimination toward the patients, in order to reduce or eliminate the patients stigma, as the result to promote recovery of the patients.
2. Study on psychiatric patients'stigma, quality of life and its influencing factors
(1)406patients with mental disorders had perceived stigma, but less serious than psychiatric patients in western countries. Schizophrenic patients'stigma was more serious than that of patients with affective disorders. The patients'social support, general self-efficacy, negative coping style were significantly lower than that of the national norm. Factors influence the psychiatric patients'stigma were age, living with the family or not, coping style, length of hospitalization time. Those with older age, not living with the family before hospitalization, adopted more negative coping styles would perceive more serious stigma; those with longer hospitalization time, would perceive less serious stigma. Further more, patients'stigma had significant negative correlation with social support and general self-efficacy. Factors influence schizophrenic patients'stigma:those who were female, married, not living with the family before hospitalization would have more serious stigma. As for the patients with affective disorder, no independent social demographic risk factors that influence the stigma were found.
(2) Factors influence psychiatric patients'QOL were age, gender, being work or not before hospitalization, place of residence, marriage status, living with the family or not before hospitalization, insight, coping style, social support and general self efficacy. Psychiatric patients who were younger, female, not being work before hospitalization, living in city, divoice or died of the spouse or being separated from the spouses, not living with family before hospitalization, with worse insight, and adopted more negative coping styles would have poor QOL. Psychiatric patients with good social support, general self-efficacy would have better QOL.
(3) Stigma had no significant influence on psychiatric patient's QOL, but there was correlation between them. Score of perceived devaluation-discrimination dimension of the stigma scale had significant positive correlation with QOL of psychiatric patient. The higher score of perceived devaluation-discrimination dimension of stigma scale, the poor QOL the patient would have.
(4) Because psychiatric patient had perceived stigma, and social demographic factors, clinical factors, social and psychological factors could influence patient's perceived stigma, effective intervention should be taken to reduce patients'stigma, in order to promote their physiological, psychological, social aspects of recovery.
引文
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