Journal of Mental Health and Human Behaviour

: 2021  |  Volume : 26  |  Issue : 2  |  Page : 132--138

Gender-based shame-focused attitude of general public toward mental illness: Evidence from Jharkhand, India

Ravi Shankar Kumar1, Abhijit Pathak2,  
1 Regional Cancer Centre, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
2 Department of Humanities and Social Sciences, National Institute of Technology, Rourkela, Odisha, India

Correspondence Address:
Abhijit Pathak
Department of Humanities and Social Sciences, National Institute of Technology, Rourkela, Odisha


Objective: The present study aimed to examine the attitude of the general public toward the mental illness in Jharkhand. Material and Methods: A community-based cross-sectional study with a sample size of 240 consisting of a male (163) and female (77) of the general population was done. The study was conducted in the urban and rural areas of Hazaribagh district based on a simple random sample technique. To collect data, Attitude Toward Mental Health Problem (ATMHP) was used. The sociodemographic profile has been calculated with descriptive statistics, and Mann–Whitney U-test has been used to find the significant differences in attitude score. Results: Males and females are both having positive attitude attitudes toward mental illness. Females are having a more positive attitude than males since the mean score is lower in all the four domains of ATMHP (9.39 ± 7.03 > 7.51 ± 5.87, 13.36 ± 9.87 > 9.67 ± 9.30, 5.52 ± 4.97 > 4.35 ± 4.59, 7.82 ± 6.34 > 5.53 ± 4.83, 6.41 ± 4.96 > 4.57 ± 4.46). However, a significant difference has not been found in two domains of ATMHP at 0.05 significant statistical levels. After controlling the co-variates through multinomial logistic regression, males showed 3.7 times odds of developing shame than female toward family member and statistically significant differences were found at less than P value 0.05 levels. Conclusions: People have started to comprehend and empathize with the patient and the family of the mentally ill, and they do not feel shame in admitting, seeking help, and reaching family to help.

How to cite this article:
Kumar RS, Pathak A. Gender-based shame-focused attitude of general public toward mental illness: Evidence from Jharkhand, India.J Mental Health Hum Behav 2021;26:132-138

How to cite this URL:
Kumar RS, Pathak A. Gender-based shame-focused attitude of general public toward mental illness: Evidence from Jharkhand, India. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Aug 8 ];26:132-138
Available from:

Full Text


Attitude is the projection of our view toward the person or an object. It is a matter of like or dislike. It is built upon the acquired knowledge and shared belief from the immediate environment and culture stereotype. Speaking about the mental illness, attitude will be comprised beliefs on the type of mental illnesses and how people with mental illness look like and the various possibility of cure or treatment.[1],[2],[3],[4],[5] Public attitude toward a person with mental illness is generally determined by the nature of interaction and the level of support they provide. Here, the public comprised community, peers, and co-workers of a person with mental illness.[1],[5] A sense of cooperation, help, and opportunities provided by the public reflects a positive attitude. If the society alienates, discriminates, and becomes noncooperative, it shows a negative attitude. These positive negative shades of public attitude also influence and determines an individual's attitude toward mental illness. The positive experience motivates a person to express his thoughts, symptoms, and willingly seek treatment. On the other hand, negative symptoms make an individual reluctant to consult therapy and compel him/her to deny illness symptoms. Although in the last few decades, awareness and mental health literacy have been grown considerably, society is stigmatized on the belief of mental illness and often discriminates people suffering from it.[6]

The term stigma denotes a strong sense of detachment or disapproval on something, which brings disgrace or shame. The stigma attached to mental illness is due to the burden it gives to the family and harms the family's status.[7] Studies have pointed out that the prevalence of stigma leading to a negative attitude is higher in developing countries than in developed countries.[8],[9],[10] Even studies from urban and rural India reported stigmatized negative attitudes and one study revealed a positive attitude toward mental illness.[11],[12],[13],[14],[15],[16] Researchers posited that stigma in society prevails due to the shame that comes after reputation. The honor of the family is assumed by the family members to have been tarnished by their sibling or any other member having a mental illness.[17],[18],[19]

Shame is an individual's emotional experience when failing to meet the self-set standard and societal standard comprised morality, competence, and responsibility.[20] Studies have established a strong association between stigma and shame.[21],[22],[23] Various literature agreed to the finding that stigma leads to shame.[23] Gilbert et al.,[24] through his study, incorporated different aspects of shame with the stigma of mental illness. They categorized into internal shame (disgraceful of self-having a mental illness), external shame (community and family will consider worthless and inferior), and reflected shame (individual and community thinking and concluding person with mental illness to be unworthy and unfit to stay in the society). Studies on shame-focused attitudes are few and keeping this thing in mind, the present study aimed to examine the male and female attitudes falling in the general population toward mental illness in Jharkhand, India.

 Material and Methods

Study area

It was a community-based cross-sectional study conducted between November 2015 and January 2016 in the rural and urban community of Hazaribagh district of Jharkhand.


Since the population size of the universe was unknown, the sample size has been calculated based on Cochran's sample size formula, i.e. S = Z2 × P (1 − P)/M2


S = Sample size of the infinite population (safe to assume 20000 or more)

Z = Z score, i.e. 1.96 (at 95% confidence interval).

P = Assumed response distribution, in this case, the response rate has been considered at 80%

M = Margin of error = 0.05.

The calculation of sample stood at 243, but three respondents did not complete the questionnaire, so we took 240 respondents with the inclusion and exclusion criteria as follows:

Inclusion criteria

18 years of ageHaving any level of educationRespondents do not have any family member suffering from mental illness.

Exclusion criteria

TransgenderIndividuals suffering any form of mental illnessRespondents have family members suffering from mental illness.


Sociodemographic datasheet – A social demographic datasheet to record the profile of the respondent such as respondent's gender, age, education, occupation, and income.Attitude Toward Mental Health Problem (ATMHP) Scale – ATMHP scale was developed by Gilbert et al.[24] to find out the level of negative attitude among the community, family, and self-based on measuring the level of shame. It is a 35-item scale to measure a different aspect of shame in relationship toward mental health problems. Higher score indicates negative attitude and shame. The 35-item scale is divided into five sections and classification of score is present in [Table 1].{Table 1}


Person's perception of how their community sees mental health problems – 1–4A person's perception of how their family perceives mental health problems – 5–8.


A person's perception of how their community would see them if they had a mental health problem – 9–13A person's perception of how their family would see them if they had a mental health problem – 14–18.


Focuses on internal shame and the negative self-evaluation of having a mental health problem-19–23.


Focuses on reflected shame and beliefs about how one's family would be seen if one had a mental health problem – 24–30.


Looks at fears of reflected shame on self, associated with a close relative having a mental health problem – 31–35.

Note: Maximum score of each section

ATMHP = 24

External shame = 30

Internal shame = 15

Reflected shame to others = 21

Reflected shame to self = 15

The factor analysis of ATMHP scale with 35 questions divided into 5 sections has been reported to have an acceptable Cronbach's alphas score of 0.85 and 0.97 for both the Asian and non-Asian countries' respondents; a study conducted by Gilbert et al.[24] shows its reliability across culture.


The researcher along with the volunteers (students of Dr. Guislain Svastha Education Trust (G-SET) in collaboration with the Tata Institute of Social Sciences (TISS) by using convenient sampling technique chose urban and rural locality of Hazaribagh district. They randomly asked questions from the scale and to comprehend them they explain to the respondents.

Data analysis:

The social demographic characteristics of the respondents were analyzed, calculated, and represented through frequency and percentage. The difference in attitude was only analyzed through gender and described using frequency and percentage. The ATMHP is a 4-point Likert scale divided into five sections. According to the severity level, all responses under these five sections were analyzed and coded from one to four. Aggregate mean and standard deviation scores of each section were taken separately for male and female. To find any significant differences in attitude among gender across five sections, Man–Whitney U-test was done with < 0.05 confidence interval level. Analysis of the entire data was done with SPSS version 16 (SPSS Inc., Chicago (IL), US) for windows.

Ethical issues

All respondents participated in the study were informed, and their consent was obtained through a consent form. Ethical clearance for the study was obtained from Dr Guislain Svastha Educational Trust (G-SET), Ranchi, in collaboration with TISS, Mumbai.


[Table 2] demonstrates the sociodemographic profile of 240 respondents of the male and female groups. Majority of respondents are Hindus in both the groups (86.5% and 85.6%) and mostly live in the rural areas (65.0% and 58.4%). The family composition of the respondents revealed that most of the families are nuclear in nature (56.4% and 63.6%) and majorly are married (57.1 % and 83.1 %). Males have dissent education, i.e. 68% aggregate of matriculation, intermediate, and graduation, whereas female score low in education as 36.4% have not completed their matriculation. In occupation, males are mostly daily wager (32.5%) and women are primarily unemployed (54.6%), the majority of both male and female lie between Rs 25,001 to Rs 100,000 annual income category, i. e. 32.9% and 19.2%, respectively.{Table 2}

[Table 3] talks about the prevalence of shame-based attitude of the general public in the region. It clearly confirms that people of the region have more positive attitude and less shame about the mental illness, as the most maximum number of people scored low in all the domains of the scale.{Table 3}

[Table 4] indicates the positive attitude, external shame, internal shame, reflected shame to the family, and reflected shame to the male and female respondents of the general public group.{Table 4}


The presence of a positive attitude was in both male and female. However, the mean score of the female has been found lower than male, i.e. 9.39 ± 7.03 > 7.51 ± 5.87, respectively. It suggests that females understand the concerns of the family and support in every way to help patient and the family.

External shame

This domain took the respondent's opinion if he or she gets mental illness how community and family will look to him or her. Here, both males and females have less external shame, but the male's score has been found higher than female, i.e. 13.36 ± 9.87 > 9.67 ± 9.30. It shows males need to have a more open mind to accept mental illness like other illnesses.

Internal shame

The presence of internal shame was less in both male and female. However, the mean score of male, i.e. 5.52 ± 4.97, was higher than females, i.e. 4.35 ± 4.59, which shows males though have overcome the shame for any mental illness symptoms, females were better in acceptance and feel less shame for themselves.

Reflected shame on family

Reflected shame on family talks about how the community will perceive a family who is having a person living with mental illness. In this also, the mean score of males is higher than female, i.e. 7.82 ± 6.34 > 5.53 ± 4.83 which shows males bother about the reputation of the family and females are more into finding solutions.

Reflected shame on self

This domain took the respondents' opinion if they become the caregiver or if any of their relative diagnosed with mental illness, they will be ashamed of themselves or not. It has been found that males have slightly scored more than females, i.e. 6.41 ± 4.96 > 4.57 ± 4.46, respectively.

However, the significant difference between the gender was only found in external shame, reflected shame on the family, and reflected shame on self (P < 0.05).

Association between gender and attitude and domains of shame has been found to be significant and positively correlated. However, education has no significant correlation, occupation has significant correlation with all the domains of shame, whereas income has an insignificant negative correlation with internal shame, reflected shame to others, and reflected shame to self.

In [Table 5] the significant differences and associations found among the gender for attitude and on various aspects of shame after performing the nonparametric test and Spearman's correlation compelled to look for the confounders. Therefore, we applied the multinomial logistic regression analysis to control the co-variates and then found the differences. In [Table 6], after controlling for the other variables, no significant statistical differences between the gender have been seen as both the gender showed a positive attitude and moderate and low degree of shame. However, males are more prone to develop shame toward a family member if any member is diagnosed with mental illness than females. The differences are significant at P value less than the 0.05 statisical level, and the odds ratio shows a 3.7 times higher probability of males developing shame toward their family and their members diagnosed with mental illness.{Table 5}{Table 6}


The study aims to describe the general population's attitude from both the gender point of view toward mental health problems. The study took 240 respondents from rural and urban areas of Hazaribagh district of Jharkhand. The findings that came out after recording responses on ATMHP scale reveal that both males and females have a positive ATMHP. However, females are having a more positive attitude toward mental illness which is contrary to the previous studies done in the past.[25],[26] Previous studies stated that women have a more negative attitude toward mental illness due to the high presence of stigma. Most of India's women are “homemaker” and rely on praises on fulfillment of the family role they do. When persistently, they fail to execute the role and unable to live with the family's expectation, she loses support from the family, feels inferior, and develops common mental disorder (CMD). Gradually, having CMD and relating self with the person with a severe form of mental illness, she anticipates alienation, discrimination, criticism, and blame for bringing down the family's reputation. Therefore, she has a negative attitude.[27],[28] Male in this study has shown a more positive attitude toward mental illness but lower than females. It can be the outcome of lower mental health literacy. A handful of studies in India have confirmed the prevalence of low mental health literacy.[29],[30],[31]

Moreover, males feel more pride in continuing practices of their culture; they represent it and even did not probe the logic of their customs. Hence, in India, various studies reported supernatural explanations of mental illness prevalent over biomedical explanation. Due to these explanations, people fear the sufferer and make the social distance, which creates stigma among those who suffer and those who make the distance.[32],[33],[34] Studies reported that despite having high literacy, better occupation, and income, men believe in black magic, ghosts as the cause of mental illness.[35],[36] Hence, the reason for lower positive attitude in men in these cases may be due to too much adherence to supernatural explanation having roots from respected culture. However, the reason is still unclear and needs further inquiry.

In case of different facets of shame, males though exhibited less internal, external, reflected shame to the family, and reflected shame to self, they were more than females. However, in the case of internal shame, no significant differences were found. These are notable findings which are contrary to the previous studies where female used to experience more shame.[37],[38] From ancient times, society has segregated the role of male and female. Although in modern society, roles have crossed the gender binary. But still, orthodox attributes such as masculinity, competence, and achiever can stay firm in adverse emotional situations.[39],[40],[41],[42],[43] Therefore, people with mental illness or any other disabilities are considered as burden, weak, incompetent, naive, and dangerous by society. Male do not want to get labeled, so they distance the sufferers and exhibit more shame. However, most of the findings were from developed countries where people have nuclear families – Asian culture; especially in Indian culture; still, the majority comprise the joint and extended family system. Hence, further shame-focused stigmatized attitude-based study is needed across India to determine whether males or females have more shame, do their reasons corroborate with abroad studies, or come up with new explanations.

Though the following study had created a scope for further investigation on shame-focused attitude, it also has a few limitations, which need to be addressed in future studies. First, the study has been conducted in one district of Jharkhand. Therefore, the findings cannot be generalized. Second, a robust sampling technique with evenly matching sociodemographic variables may lead to different findings. Third, the researcher posited the reason for such differences but unable to capture the causes associated with individual perception.


The study reported the presence of a positive attitude among the general population. There is a need to improve the mental health literacy among the population, including biopsychosocial causes of mental illness and information and the establishment of a treatment facility in proximity. It is appreciable that people are aware of the medical treatment on mental illness and did not shy from going there, but the community needs more awareness since unawareness is still evident due to the sluggish implementation of District Mental Health Program (DMHP). According to Pathak and Biswal,[44] only 27.7% of districts have been covered through DMHP in the last three decades. If the state efficiently runs the DMHP, a considerable amount of stigma can be curbed. Further, improved mental health literacy will promote better health-seeking behavior and reduce psychiatric morbidity in the community.


I would like to acknowledge the support provided by postgraduate students of Dr. Guislain Svastha Educational Trust in collaboration with the Tata Institute of Social Sciences in data collection. I would also like to thank Dr. Paul Gilbert for giving permission to use Attitude Towards Mental Health Problem (ATMHP) scale for the current study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Yuan Q, Abdin E, Picco L, Vaingankar JA, Shahwan S, Jeyagurunathan A, et al. Attitudes to mental illness and its demographic correlates among general population in Singapore. PLoS One 2016;11:e0167297.
2Nunnally JC Jr. Popular Conceptions of Mental Health: Their Development and Change. New York: Holt, Rinehart and Winston; 1961.
3L'Abate L. Mental Illnesses – Understanding, Prediction and Control. Rijeka, Croatia: InTech; 2011.
4Chowdhury A, Gupta K, Patel AK. Attitude, belief, and perception toward mental illness among Indian youth. MAMC J Med Sci 2019;5:83-8.
5Schnittker J. An uncertain revolution: Why the rise of a genetic model of mental illness has not increased tolerance. Soc Sci Med 2008;67:1370-81.
6Schomerus G, Schwahn C, Holzinger A, Corrigan PW, Grabe HJ, Carta MG, et al. Evolution of public attitudes about mental illness: A systematic review and meta-analysis. Acta Psychiatr Scand 2012;125:440-52.
7Venkatesh BT, Andrews T, Mayya SS, Singh MM, Parsekar SS. Perception of stigma toward mental illness in South India. J Family Med Prim Care 2015;4:449-53.
8Alonso J, Buron A, Bruffaerts R, He Y, Posada-Villa J, Lepine JP, et al. Association of perceived stigma and mood and anxiety disorders: Results from the World Mental Health Surveys. Acta Psychiatr Scand 2008;118:305-14.
9Buizza C, Pioli R, Ponteri M, Vittorielli M, Corradi A, Minicuci N, et al. Community attitudes towards mental illness and socio-demographic characteristics: An Italian study. Epidemiol Psichiatr Soc 2005;14:154-62.
10Youssef FF, Bachew R, Bodie D, Leach R, Morris K, Sherma G. Knowledge and attitudes towards mental illness among college students: Insights into the wider English-speaking Caribbean population. Int J Soc Psychiatry 2014;60:47-54.
11Basu R, Sau A, Saha S, Mondal S, Ghoshal PK, Kundu S. A study on knowledge, attitude, and practice regarding mental health illnesses in Amdanga block, West Bengal. Indian J Public Health 2017;61:169-73.
12Sneha CR, Reddy MM, Nongmeikapam M, Narayana JS. Awareness and attitude toward mental illness among a rural population in Kolar. Indian J Soc Psychiatry 2019;35:69-74.
13Ghai S, Sharma N, Sharma S, Kaur H. Shame and stigma of mental illness. Delhi Psychiatry J 2013;16:293-301.
14Salve H, Goswami K, Sagar R, Nongkynrih B, Sreenivas V. Perception and attitude towards mental illness in an urban community in South Delhi – A community based study. Indian J Psychol Med 2013;35:154-8.
15Chandramouleeswaran S, Rajaleelan W, Edwin NC, Koshy I. Stigma and attitudes toward patients with psychiatric illness among postgraduate Indian physicians. Indian J Psychol Med 2017;39:746-9.
16Raguram R, Weiss MG, Channabasavanna SM, Devins GM. Stigma, depression, and somatization in South India. Am J Psychiatry 1996;153:1043-9.
17Gilbert P, Gilbert J, Sanghera J. A focus group exploration of the impact of izzat, shame, subordination, and entrapment on mental health service use in South Asian Women living in Derby. Ment Health Relig Cult 2004;7:109-30.
18Lam CS, Tsang H, Chan F, Corrigan PW. Chinese and American perspectives on stigma. Rehabil Educ 2006;20:269-79.
19Lam CS, Tsang HW, Corrigan PW, Lee Y, Angell B, Shi K, et al. Chinese lay theory and mental illness stigma: Implications for research and practices. J Rehabil 2010;76:28-34.
20Tangney JP, Wagner P, Gramzow R. The test of self-conscious affect (TOSCA) Fairfax. VA: George Mason University; 1989.
21Lewis M. Shame. The Exposed Self. New York: The Free Press; 1992.
22Lewis M. Self-conscious emotions. Am Sci 1995;83:68-78.
23Lewis M. Shame and stigma. In: Gilbert P, Andrews B, editors. Shame: Interpersonal Behaviour, Psychopathology and Culture. New York: Oxford University Press; 1998. p. 126-40.
24Gilbert P, Bhundia R, Mitra R, McEwan K, Irons C, Sanghera J. Cultural differences in shame-focused attitudes towards mental health problems In Asian and non-Asian student women. Ment Health Relig Cult 2007;10:127-41.
25Böge K, Zieger A, Mungee A, Tandon A, Fuchs LM, Schomerus G, et al. Perceived stigmatization and discrimination of people with mental illness: A survey-based study of the general population in five metropolitan cities in India. Indian J Psychiatry 2018;60:24-31.
26Trani JF, Bakhshi P, Kuhlberg J, Narayanan SS, Venkataraman H, Mishra NN, et al. Mental illness, poverty and stigma in India: A case-control study. BMJ Open 2015;5:e006355.
27Soman S, Bhat SM, Latha KS, Praharaj SK. Do life events and social support vary across depressive disorders? Indian J Psychol Med 2017;39:316-22.
28Liu SH, Srikrishnan AK, Zelaya CE, Solomon S, Celentano DD, Sherman SG. Measuring perceived stigma in female sex workers in Chennai, India. AIDS Care 2011;23:619-27.
29Ogorchukwu JM, Sekaran VC, Nair S, Ashok L. Mental health literacy among late adolescents in South India: What they know and what attitudes drive them. Indian J Psychol Med 2016;38:234-41.
30Gaiha SM, Sunil GA, Kumar R, Menon S. Enhancing mental health literacy in India to reduce stigma: The foundation head to improve help-seeking behaviour. J Public Ment Health 2014;13:146-58.
31Kermode M, Bowen K, Arole S, Pathare S, Jorm AF. Attitudes to people with mental disorders: A mental health literacy survey in a rural area of Maharashtra, India. Soc Psychiatry Psychiatr Epidemiol 2009;44:1087-96.
32Nambi SK, Prasad J, Singh D, Abraham V, Kuruvilla A, Jacob KS. Explanatory models and common mental disorders among patients with unexplained somatic symptoms attending a primary care facility in Tamil Nadu. Natl Med J India 2002;15:331-5.
33Campion J, Bhugra D. Experiences of religious healing in psychiatric patients in south India. Soc Psychiatry Psychiatr Epidemiol 1997;32:215-21.
34Jacob JA, Kuruvilla A. Quality of life and explanatory models of illness in patients with schizophrenia. Indian J Psychol Med 2018;40:328-34.
35Grover S, Kumar V, Chakrabarti S, Hollikatti P, Singh P, Tyagi S, et al. Explanatory models in patients with first episode depression: A study from north India. Asian J Psychiatr 2012;5:251-7.
36Viswanathan S, Prasad J, Jacob KS, Kuruvilla A. Sexual function in women in rural Tamil Nadu: Disease, dysfunction, distress and norms. Natl Med J India 2014;27:4-8.
37Thangadurai P, Gopalakrishnan R, Kuruvilla A, Jacob KS, Abraham VJ, Prasad J. Sexual dysfunction among men in secondary care in southern India: Nature, prevalence, clinical features and explanatory models. Natl Med J India 2014;27:198-201.
38Orth U, Robins RW, Soto CJ. Tracking the trajectory of shame, guilt, and pride across the life span. J Pers Soc Psychol 2010;99:1061-71.
39Roberts TA, Goldenberg JL. Wrestling with nature: An existential perspective on the body and gender in self-conscious emotions. In: Tracy JL, Robins RW, Tangney JP, editors. The Self-Conscious Emotions: Theory and Research. New York: Guilford; 2007. p. 389-6.
40Gordon PA, Feldman D, Tantillo JC, Perrone K. Attitudes regarding interpersonal relationships with per-sons with mental illness and mental retardation. J Rehabil 2004;70:50-6.
41Hampton NZ, Zhu Y. Gender, culture, and atti-tudes towards people with psychiatric disabilities. J Appl Rehabil Couns 2011;42:12-9.
42Leong FTL, Zachar P. Gender and opinions about mental illness as predictors of attitudes toward seeking pro-fessional psychological help. Br J Guid Couns 1999;27:123-31.
43Williams B, Pow J. Gender differences and mental health: An exploratory study of knowledge and attitudes to mental health among Scottish teenagers. Child Adolesc Ment Health 2007;12:8-12.
44Pathak A, Biswal R. Comprehensive Status of Mental Health in India. Paper presented at: 28th Convention of Annual Academy of Psychology New Delhi, India 2018.