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Attitudes towards psychiatry of undergraduate medical students at Bayero University, Nigeria.

According to the World Health Organization, 10-18% of Nigerians suffer from mental or psychological disorders, both mild and more disabling (it has been estimated that about a third of patients attending general health services clinics suffer from some form of mental disorders), and psychiatric disorders are among the 10 top causes of global economic burden. (1,2) There is also an increasing trend of drug and alcohol abuse among Nigerian youth. (3)

The provision of mental health services to all citizens of Nigeria by the year 2000 and beyond, a goal highlighted in the National Mental Health Policy, (4) is far from being realised owing to scarcity of both mental health facilities and personnel. It is estimated that 400 psychiatrists are needed to have the minimum required impact on mental health coverage. Nigeria currently has 120 psychiatrists serving a population of over 140 000 000.4

Postgraduate medical training in Nigeria is stressful, spanning 4-6 years, and trainees require good coping skills. (5) Time pressure, frequent examinations, a high workload, poor pay, and physical and emotional problems experienced by trainees are among the reasons that have been given for the stressfulness of residency. (6) Despite these obstacles, a rising proportion of Nigerian doctors seek postgraduate medical education due to the large number of doctors who are qualifying, increased remuneration and prestige for specialists, and an ever more competitive practice environment globally. (7) However, despite an increase in the number of doctors who decide to specialise, a relatively small proportion choose to do so in psychiatry. (3)

Clinical clerkship in psychiatry for undergraduates at Bayero University medical school takes place during the students' 6th academic year, lasting for 4 weeks. During this period, the students receive 6 hours of theoretical lectures per week and do twice-weekly ward rounds and clinic consultations.

Undergraduate students' attitudes towards psychiatry potentially have important implications for their future practice, not only influencing the way they will respond to psychological problems in their patients, but also in terms of recruitment into the field of psychiatry. (8,9) However, having a positive attitude towards psychiatry does not guarantee selection of psychiatry as an area of professional specialisation. (10) Positive experiences during students' clerkship in psychiatry and their personal contact with mental illness increase the likelihood that they will have positive attitudes towards the profession, (11) but because of other deciding factors may well not guarantee an increase in the number wishing to specialise in psychiatry. (11) The competition from other medical departments for curriculum time in medical schools has reduced the duration of medical students' exposure to psychiatry clerkship, (12-14) and this not only negatively affects students' acquisition of knowledge in psychiatry but also undermines their understanding of its importance as a field of medicine. Reintegrating psychiatry, neurology, and other areas of clinical neurosciences in the medical school curriculum, thereby allotting more time to psychiatry, has been the focus of considerable interest in recent years. (15,16)

Medical students tend to take the view that psychiatric patients suffer from chronic illnesses with a poor prognosis, lack adequate social support systems and are difficult to interview, and that psychiatrists practise outside mainstream medicine. (12,17-19) Like the Nigerian public, many of our medical students believe in the influence of supernatural forces (evil spirits) in the causation of mental illness, and that even when they have been treated, psychiatric patients are unpredictable and lacking in intelligence. (20,21) The Nigerian public's stereotypes of psychiatric patients are largely derived from the vagrants wandering the streets of the country. (22,23) Psychiatric illness is therefore often feared, and people avoid relating to mentally ill persons in close social relationships such as marriage. (22-24) Medical students would be expected to be better informed and more accepting of mental illness, (22) but have been found to have negative attitudes similar to those of the general public. (25)

The present study set out to determine medical students' attitudes towards psychiatry as a profession and a choice for future specialisation. The study, which as far as the author is aware is the first in this geographical area, also investigated the effect of clerkship on students' views of psychiatry.


A prospective and comparative study was conducted among 5th-and 6th-year (final-year) medical students at Bayero University, Kano, Nigeria, during February 2008. At that time the final-year students had done their clerkship in psychiatry 2 months previously, and the 5th-year students had yet to start theirs. Data were collected using an abridged form of Balon et al.'s 1999 questionnaire, (25) based on a questionnaire used by Nielsen et al. in 1981. The abridged questionnaire was self-administered, and consisted of 27 questions. The first 4 questions related to socio-demographic factors such as gender, age, academic year and choice of medical specialty. The remaining 23 questions were in five sub-sections and examined the attitudes of the students towards psychiatry with reference to the following aspects: (i) overall merits of psychiatry; (ii) efficacy; (iii) role and functioning of psychiatrists; (iv) possible abuse and social criticism; and (v) career and personal rewards. Respondents had to either agree or disagree with each of the 23 items. The students were informed that the purpose of the research was to elicit their candid opinions about psychiatry as a profession, that participation was voluntary, and that there were no penalties for not participating. The students' informed consent was verbally solicited, as completing the questionnaire implied acceptance of consent. The students were assured that their responses would remain anonymous, since the questionnaire did not include any information by means of which they could be identified. All the students who were present in class on the day of the study and agreed to participate completed the questionnaire before their first morning lecture. Permission and assistance were obtained from the tutoring lecturer present on that day, and approval was obtained from the teaching hospital ethics committee before conducting the study.

The questionnaire was tested for ease of understanding among 20 selected 4th-year clinical medical students, and necessary revisions were made.

Data were analysed with SPSS version 10, simple frequency distribution tables were used, categorical values were summarised in absolute numbers, and percentages were calculated to one decimal place. Tests of association between the final-year and 5th-year students' responses were done using the chi-square test.


The study population of 119 consisted of 35 6th-year and 84 5th-year students.

Socio-demographic characteristics

Sixty-six (78.6%) of the 5th-year students and 25 (71.4%) of the

6th-years completed the questionnaire. The mean ages of the two groups were 24.6 and 24.8 years, respectively. Their sociodemographic characteristics are summarised in Table I.

Preferred field of future specialisation

Ten (15.2%) of the 5th-year students chose internal medicine and 10 surgery as their preferred field of future specialisation, while 6 (24.0%) of the 6th-year students chose internal medicine and 5 (20.0%) surgery. Twelve (18.1%) of the 5th-year students said they would choose obstetrics and gynaecology, 8 (12.1%) family medicine, and 3 each (4.5%) paediatrics, neurology and diagnostic radiology. Only 1 5th-year student (1.5%) wanted to specialise in psychiatry. Sixteen (24.2%) of the 5th-years were undecided, and none chose anaesthesia or emergency medicine. Three 6th-year students (12.0%) selected paediatrics, 4 (16.0%) chose family medicine as their area of future specialisation, and 1 each (4.0%) chose neurology, diagnostic radiology, anaesthesia and emergency medicine. Three (12.0%) of the 6th-year students were undecided about their preferred field of future specialisation, and none wanted to specialise in psychiatry.

Attitudes of the medical students towards psychiatry

Overall merits and efficacy of psychiatry. Nineteen (76.0%) of the 25 6th-year students and 58 (87.9%) of the 66 5th-years agreed with the statement that modern psychiatry was making advances in ways of rendering efficient care to patients with major mental disorders ([chi square] (1, N= 91)=0.051, p>0.05), and 22 (88.0%) of 6th-years and 46 (69.7%) of 5th-years with the statement that psychiatry was a rapidly expanding field of medicine ([chi square] (1, N= 91)=0.608, p>0.05). Three (12.0%) and 8 (12.1%) of 6th- and 5th-year students, respectively, were of the opinion that psychiatry was unscientific and imprecise ([chi square] (1, N=91)=0.686, p>0.05), while 23 (92.0%) 6th-year and 62 (93.9%) 5th-year students would recommend psychiatric consultations to family members suffering from very upsetting and non-resolving emotional problems ([chi square] (1, N=91)=0.296, p>0.05). Most of the 6th- and 5th-year students (23 (92.0%) and 63 (95.5%), respectively) agreed that psychiatry would be helpful in liaison practice ([chi square] (1, N=91)=0.189, p>0.05), and 19 (76.0%) of the 6th-year and 55 (83.3%) of the 5th-year students perceived psychiatric treatment as being helpful ([chi square] (1, N=91)=0.377, p>0.05).

Cross-tabulation analysis of the final-year and 5th-year students' responses with regard to the overall merit and efficacy of psychiatry did not show any significant differences (p>0.05).

Role definition and functioning of a psychiatrist. Twenty-three (92.0%) 6th-year and 55 (83.3%) 5th-year students disagreed with the statement that psychiatry is not a genuine and valid branch of medicine; 12 (48.0%) and 48 (72.7%), respectively, were of the opinion that most psychiatrists were clear, logical thinkers; 15 (60.0%) and 39 (59.1%), respectively, disagreed with the view that clinical psychologists and social workers were as qualified as psychiatrists to diagnose and treat emotionally disturbed persons; 13 (52.0%) and 48 (72.7%), respectively, were of the opinion that psychiatrists had the most authority and influence among mental health professionals; 19 (76.0%) and 40 (60.6%), respectively, did not agree that psychiatrists were frequently apologetic; 20 (80%) and 52 (78.8%), respectively, did not think that psychiatry was too 'biologically minded'; and 14 (56.0%) and 34 (51.5%), respectively, did not agree that psychiatry was too analytical, theoretical and psychodynamic.

As seen in Table II, there were no significant differences between the 6th- and 5th-year students' responses with regard to the role and functioning of a psychiatrist (p>0.05).

Possible abuse and social criticism. Sixteen (64.0%) and 39 (59.1%) of 6th- and 5th-year students, respectively, did not agree that psychiatrists frequently abuse their legal power to hospitalise patients against their will. Thirteen (52.0%) and 44 (66.7%), respectively, did not perceive that psychiatrists make as much money as most other doctors. There were no statistically significant differences between the 6th- and 5th-year students' responses on the above ([chi square] (1, N= 91) =0.341, p>0.05 for abuse of legal power and [chi square] (1, N=91) =0.231, p>0.05 for social criticism).

Career and personal reward. Sixteen (64.0%) 6th-year and 50 (75.8%) 5th-year students were of the opinion that psychiatry had a low prestige among the Nigerian public; 8 (32.0%) and 14 (21.2%), respectively, were of the opinion that psychiatry had a high status among other medical disciplines; 21 (84.0%) and 42 (63.6%), respectively, did not agree that doctors should choose psychiatry as an alternative residency career when unable to secure placement in their area of first choice; 19 (76.0%) and 43 (65.2%), respectively, felt that their families would not discourage them from entering psychiatry if they so wished, but 13 (52.0%) and 34 (51.5%), respectively, were of the opinion that their friends and fellow students would discourage them from specialising in psychiatry; 16 (64.0%) and 16 (24.2%), respectively, did not feel that an expression of interest in psychiatry would make others regard them as being odd, neurotic or behaving peculiarly; and 19 (76.0%) and 41 (62.1%), respectively, would feel uncomfortable with mentally ill persons.

Cross-tabulation analyses of the 6th-year and 5th- year students' opinions about psychiatry as a career showed no statistically significant differences (p>0.05) (Table III).

Discussion and conclusion

The findings of this study indicate that medical students' choice of psychiatry as a field of future medical specialisation probably depends on factors that may not be favourably influenced during clerkship in psychiatry. Despite the fact that the majority would not opt to specialise in psychiatry, the students' attitudes with regard to most of the variables tested were positive. This result is consistent with some earlier studies that found positive changes in students' attitudes towards psychiatry after clerkship, without similar changes in their choice of future area of specialisation. (10,13,25) However, others have claimed that the quality and duration of psychiatry clerkships were very important influences on students' desire to specialise in psychiatry. (12-14) Our students' 4-week duration of clerkship in psychiatry was probably not enough to expose them to a real understanding of the practice of psychiatry, and would therefore not have had a marked influence on their preformed negative attitudes towards the profession.

In previous studies, some of the reasons suggested for the contrast between medical students' positive attitudes towards psychiatry and their failure to choose psychiatry as a future area of specialisation (26) have been that undergraduate teaching of psychiatry was disorganised; that the profession lacked scientific rigour, and was less financially rewarding than other areas of medical practice; that psychiatrists and the profession of psychiatry had less prestige and were less respected than other areas of practice in the eyes of the public; (26-28) and that psychiatric patients were hard to talk to and difficult to understand. (29) Despite our students' acknowledgement of the high intellectual demands of psychiatry, most were of the opinion that although the field was helpful in liaison practice, it had low status, was regarded by the public as having less prestige than other areas of medical practice, and was less financially rewarding. There is widespread stigmatisation of mental illness in Nigeria, (30) resulting in a generally negative perception of mental health issues. Both psychiatric patients and providers of mental health services therefore have an unfavourable image, and psychiatry is rated low as a profession by society. A mere 4 weeks' clerkship in psychiatry was not long enough to change the students' culturally enshrined negative beliefs.

However, in contrast to some negative opinions on the part of medical students on the scientific standard, efficacy of treatment, and biopsychological/ biomedical perception of psychiatric practice described in previous studies, (29-31) our students felt that psychiatry was an advancing scientific field of medical endeavour. This could partly be to their exposure to psychiatric syndromes and observation of patients' responses to effective biological and psychological treatments during their clerkship. The 5th-year students, who had not yet done their clerkship, might have had similar attitudes because they knew of people who had responded well to psychiatric treatment.

In not expecting clinical psychologists and social workers to be as qualified as psychiatrists in diagnosing and treating emotionally disturbed persons, the students were presumably aware that eligibility for a residency career in psychiatry requires successful completion of undergraduate medical education. In addition, the students would probably expect psychiatrists to have more authority and influence than other mental health professionals because doctors are the key figures in determining the plan of care for patients.

There is a high degree of competition for residency positions in postgraduate training facilities in Nigeria. Because of better pay after attaining specialist qualification, many doctors opt for further training rather than to practice as non-specialists, and the number of doctors seeking postgraduate medical education currently outnumbers the spaces available in the postgraduate training facilities. Although our students did not view psychiatry as a popular choice, the number of doctors seeking careers in this field may therefore rise in the near future.

People with psychiatric problems are sometimes not voluntarily admitted to hospital, their next of kin (usually the accompanying relatives) giving informed consent on their behalf. However, involuntary confinement of persons labelled with psychiatric illness for punitive reasons (32) is not a feature of psychiatric practice in Nigeria, which explains why the students did not agree that psychiatrists abuse their power with regard to compulsory admission of patients.

In spite of the 6th-year students' 4 weeks' clerkship in psychiatry, many were of the opinion that psychiatrists were not clear, logical thinkers, and together with the 5th-year students said that they would feel uncomfortable when in contact with psychiatric patients. The short duration of the clerkship was probably not enough to allay their culturally imbibed 'fear of the unknown' with regard to the patients. In addition, the public attitude that 'healers of mentally ill persons are like their patients' could have prejudiced the students' opinion about psychiatrists not being clear and logical in thinking.

Inculcating the biopsychosocial ideology of illness model into the 1st-year and preclinical teaching curricula of medical students might affect doctors' future preference for psychiatry. There is a need to organise goal-orientated public enlightenment campaigns on mental health literacy (knowledge and beliefs about mental disorders that aid their recognition, management, or prevention). Teaching of psychiatry should start from the students' preclinical days, and during this period much of the teaching should focus on the neuroscientific aspects of psychiatric disorders. Psychiatry clerkships should be more practically orientated than theoretical, exposing students to real-life experiences in the field.

Despite the relatively small population of students in the study, not all of them were able to fill in the questionnaire. It is therefore necessary to compare future findings from similar population groups with those of this study before generalisation of its findings. A future study on attitudes of preclinical and clinical medical students towards psychiatry may well reveal more than the findings of the present study.


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N C Aghukwa, MB BCh, FMCPsych (Nig)

Department of Psychiatry, Aminu Kano Teaching Hospital, Kano, Nigeria
Table I. Socio-demographic characteristics of clinical medical
students at Bayero University, Kano, Nigeria (N (%))

                  6th (final) year    5th year
Age (yrs)              (N=25)          (N=66)

  20-24              12 (48.0%)      18 (27.3%)
  25-29              13 (52.0%)      46 (69.7%)
  30-34                  0 (0%)        2 (3.0%)
  Male               12 (48.0%)      51 (77.3%)
  Female             13 (52.0%)      15 (22.7%)
Marital status
  Married             4 (16.0%)        2 (3.0%)
  Single             21 (84.0%)      64 (97.0%)
Ethnic origin
  Hausa              19 (76.0%)      61 (92.4%)
  Igbo                 1 (4.0%)          0 (0%)
  Yoruba                 0 (0%)        2 (3.0%)
  Other                 5 (20%)        3 (4.5%)
  Islam              19 (76.0%)      65 (98.5%)
  Christianity        5 (20.0%)        1 (1.5%)
  Other                1 (4.0%)          0 (0%)

Table II. Responses on the role and functioning of psychiatrists from
clinical medical students at Bayero University, Kano, Nigeria

                                          6th (final) year (N=25)

                                          Agreed      Disagreed
Question   Variable                      (N (%))       (N (%))

1.         Not genuine and valid
           branch of medicine            2 (8.0%)     23 (92.0%)

2.         Most psychiatrists are
           clear, logical thinkers      12 (48.0%)   12 (48.0%) *

3.         Clinical psychologists
           and social workers as
           qualified as psychiatrists
           to diagnose mental
           illness                      10 (40.0%)    15 (60.0%)

4.         Psychiatrists have the
           most authority and
           influence among
           mental health
           professionals                13 (52.0%)   10 (40.0%) *

5.         Psychiatrists are
           frequently apologetic        5 (20.0%)    19 (76.0%) *

6.         Too biologically minded
           and not attentive to
           patient's physiology         5 (20.0%)     20 (80.0%)

7.         Too analytical,
           theoretical and
           psychodynamic                11 (44.0%)    14 (56.0%)

                            5th year (N=66)

Question             Agreed             Disagreed
                    (N (%))              (N (%))

1.                 11 (16.7%)           55 (83.3%)

2.                 48 (72.7%)           17 (25.8%) *

3.                 24 (36.4%)           39 (59.1%) *

4.                 48 (72.7%)           16 (24.2%) *

5.                 26 (39.4%)           40 (60.6%)

6.                 10 (15.2%)           52 (78.8%) *

7.                 27 (40.9%)           34 (51.5%) *

Question          [chi square]              df          p-value

1.                   0.189                  1           0.664

2.                   3.511                  1           0.173

3.                   1.418                  1           0.234

4.                   6.799                  1           0.033

5.                   0.565                  1           0.452

6.                   2.426                  1           0.119

7.                   0.006                  1           0.937

Not all subjects responded.

Table III. Reponses on career and personal rewards of psychiatry from
clinical medical students at Bayero University, Kano, Nigeria

                                            6th (final) year (N=25)

                                               Agreed       Disagreed
No.   Variable                                (N (%))        (N (%))

1.    Low prestige among the public          16 (64.0%)     8 (32.0%) *
2.    High status among other medical        8 (32.0%)     17 (68.0%)
3.    Alternative residency career           2 (8.0%)      21 (84.0%) *
4.    Family's disapproval of                6 (24.0%)     19 (76.0%)
      specializing in psychiatry
5.    Friends/fellow students would          13 (52.0%)    12 (48.0%)
      disapprove of specializing in
6.    Student's expression of interest in    9 (36.0%)     16 (64.0%)
      psychiatry associated with odd,
      peculiar or neurotic behaviours
7.    Uncomfortable with mentally ill        19 (76.0%)     4 (16.0%) *

                        5th year (N=66)

      Agreed                                Disagreed
No.   (N (%))                               (N (%))        [chi square]

1.    50 (75.8%)                             16 (24.2%)       0.329
2.    14 (21.2%)                             52 (78.8%)       1.176
3.    23 (34.8%)                             42 (63.6%) *     1.335
4.    23 (34.8%)                             43 (65.2%)       0.233
5.    34 (51.5%)                             32 (48.5%)       0.000
6.    49 (74.2%)                             16 (24.2%) *     0.612
7.    41 (62.1%)                             24 (36.4%) *     0.672

No.                   df                      p-value

1.                     1                       0.848
2.                     1                       0.278
3.                     1                       0.513
4.                     1                       1.00
5.                     1                       1.00
6.                     1                       0.736
7.                     1                       0.412

Not all subjects responded.
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Author:Aghukwa, N.C.
Publication:South African Journal of Psychiatry
Article Type:Survey
Geographic Code:6NIGR
Date:Dec 1, 2010
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