In this study the findings demonstrate that students from the six different health-related courses have a high regard for the medical conditions of intellectual disability and moderate regard for patients with acute mental illness. Substance abuse, however, received a larger number of negative responses.
Most studies into stigma and attitude use research methodologies tailored specifically for the medical conditions being investigated. As such, the results from most other studies are not directly comparable or generalisable. Furthermore, given that attitudes toward medical conditions are culturally and socially sensitive, caution is required when comparing results as they may not be applicable to the present context in Australia. A good example of how attitudes change is shown in Tierney's review on the knowledge, attitudes, and education of nurses with regard to HIV/AIDS in the United Kingdom (UK). In the mid-1980s Tierney reported that nurses were fearful of AIDS, but that by the time her literature review was conducted in 1995, there had been a 'significant improvement in nurses' knowledge and attitudes' toward HIV/AIDS. The change in attitude towards patients with HIV/AIDS was brought about by factual education programs . In other words, there was a significant shift in attitudes and perceptions of members of the nursing profession towards this medical condition following an education program targeting all health care providers.
An analysis of the MCRS's items show in more detail where the difference lies. Across all the medical conditions, students answered in such a way that was indicative of a desire to act professionally. Items such as 'Patients like this irritate me' and 'Treating patients like this is a waste of medical dollars' were answered favourably across all three medical conditions, showing an intention to be fair and responsible in their conduct. The item 'I feel especially compassionate toward patients like this' differed between the medical conditions and was particularly low for substance abuse (mean = 3.36) compared to intellectual disability (mean = 4.25) or acute mental illness (mean = 4.29). Because items were rated on a 6-point Likert scale scores below 3.5 are indicative of negative attitudes. As such, a mean of 3.36 regarding compassion toward patients who have a history of substance abuse is negative. The other three items that come very close to or actually receive negative means with regard to substance abuse were 'I wouldn't mind getting up on call nights to care for patients like this' (mean = 3.35), 'I can usually find something that helps patients like this feel better' (mean = 3.60) and 'I enjoy giving extra time to patients like this' (mean = 3.31). These items suggest students have a reluctance to go out of their way for such patients and perhaps to a certain extent consider their skills not relevant to the problems faced by patients who have substance abuse problems.
Statistically significant differences were also found between the six health-related courses, specifically related to the intellectual disability condition. These differences may be the result of how students from each of the professions view their role in health care and the vantage their profession provides from which to view patients. As well, the differences between the health discipline groups may be attributed to the affective dimension of attitudes that incorporates feelings and emotions which underline the attitude, such as liking or disliking a particular person or group . For instance, those students enrolled in midwifery reported the lowest regard for the substance abuse medical condition. These students possibly considered the effect substance abuse has on the foetus/baby as well as the substance abusing mother and, as such, were less compassionate toward such patients because of the effect certain substances such as alcohol have on the foetuses/baby's health.
Another example is students enrolled in the health science course. Their regard for patients suffering acute mental illness was consistent with the other professions, however, for the one item 'Patients like this irritate me' they were entirely consistent with the other student groups by reporting a particularly high regard. This result is, to a certain extent, inexplicable unless it is attributed to something from the health science course. Further medical conditions are likely to raise further differences between the student groups, although based on such data alone such inferences cannot be supported with absolute certainty. In any case, the data provides sufficient evidence to show that there is a difference in views between the health professional student groups and, more importantly, that the views these students have impact on their attitude toward different medical conditions.
A study by Abed and Neira-Munoz into general practitioners' attitudes towards patients with substance abuse problems determined that their negative attitudes were due to the fact that they considered such a medical condition to be a heavy burden and largely self-inflicted . The students in this study did not give answers indicating they thought such patients were a heavy burden; however, they did answer as though their problems were self-inflicted and thus not as worthy of compassion or empathy. Considering the results of two other medical conditions included in this study provides further evidence for this point. Students enrolled in the occupational therapy course had a high regard for patients with depression (mean = 53.37, SD = 7.32). This is in stark contrast to patients with substance abuse problems, despite one of the symptoms of depression being a dependence on alcohol or drugs . Furthermore, those students enrolled in the physiotherapy course reported their attitudes toward the medical condition of obesity, the only other condition included in the study that could be perceived to be self-inflicted or a result of personal choices made by individuals, as low as substance abuse (mean = 43.65, SD = 7.42). These findings suggest a marked difference in the regard toward a medical condition based on whether the student perceives the condition to be caused by patients' behaviour or not.
There is a wide variety of substances which can be abused, and they generally all have an associated stigma and negative perception. In addressing this problem, health care professionals play an important role in detection and intervention efforts . However, a study by Abouyanni et al. of general practitioners in Sydney, Australia, found many lacked the confidence and experience necessary to deal with such patients and were worried that these patients would be 'difficult, aggressive and demanding' . Another study of general practitioners almost two decades earlier in the UK found attitudes toward individuals with a history of substance abuse were negative, stemming from views that such patients were a heavy burden and their problems self-inflicted .
A number of investigations have found that such attitudes are unhelpful. A UK study looking into what can be done to help injecting drug users benefit from services highlighted the need to address negative preconceptions among professionals in that such attitudes have a negative impact on the treatment process . In a study of those diagnosed with both having a history of substance abuse and having a mental illness such negative attitudes were found to further complicate the lives of those who have been stigmatised, even well after treatment had been successful . Substance abuse is potentially an end-point, for example, a person with depression may take an overdose of their medication as they are unable to cope. Therefore, students need to understand this point and be prepared to identify the underlying cause, if any, behind the substance abuse and not just see it as "attention seeking" behaviour.
Persons with mental illness face similar issues with the impact that negative attitudes and stigma have on their well-being. A survey of individuals with mental illness in Australia found 74% of respondents had experienced stigma, with 13% having experienced stigma directly from health care service providers . The same survey also found respondents would 'feel better about themselves' and 'manage their illness better' if stigma were reduced . Indeed the consequences of stigma are numerous with a sense of shame and difference to others being two of the more apparent consequences . Research has also found the effects of stigma are not confined to the individual, but extend to patients' family members as well .
What makes stigma and negative stereotyping difficult to combat is that some of the concerns people have about the persons with mental illness often have a partial basis in reality . As Gray points out, such patients are not necessarily easy to 'like or engage with' but with better knowledge of their problems generally comes a less stigmatising approach . An example of this is found in Fisher's study of a group of nursing students' first clinical placement at a mental health clinic . The experiences of these students were predominately negative. It was suggested that the experience challenged the nursing students' image of what being a nurse involves because patients in certain cases were aggressive toward them or harassed them .
People with an intellectual disability may also exhibit behaviours that contribute to stigma, including challenging behaviour and sexualised behaviour. People with an intellectual disability lack the mental capacity to understand that certain behaviours are unacceptable, inappropriate, or unlawful in our society and thus this condition has a history of being linked to crime . It is important that health care professionals understand how such behaviour comes about in people with an intellectual disability. There have been a number of studies which have shown that staff reactions to challenging behaviour in these people can have important implications on the intervention strategies employed to mitigate such behaviour . There are also concerns about the poor healthcare that people with an intellectual disability receive. Such concern prompted one study of general practitioners which uncovered that while general practitioners were willing to treat people with an intellectual disability they were not willing to spend more time or complete additional training necessary to effectively treat this client group . Another study found the attitude toward and comfort with people with an intellectual disability is potentially improved by spending time with this group .
The findings from this study can be extrapolated with some confidence to the broader student body enrolled in any of the courses that participated in this study, even though convenience sampling was used. The study sample included a majority of young, female adults, which is consistent with the actual gender make-up of most health-related courses (see Table 1). These results report students' attitudes toward the various medical conditions, but the findings do not confirm without doubt why students reported such a level of regard. The MCRS's items give direction to why students reported their level of regard, but further exploration is required to understand in detail what it is that makes, for instance, students view depression in a much more positive way compared to substance abuse. Further investigation into why such attitudes are held may also provide further insight into why there are statistical significant differences in attitudes between students in the six health-related courses.
This study is potentially limited by the use of convenience sampling of students from one specific educational institution. While this method facilitates recruitment, it is less likely to recruit a representative sample of students. Consequently, those students who did volunteer to participate may themselves bias the results. We are not able to calculate the distribution of non-respondents because none of the courses collect student attendance at lectures. Therefore we are unable to identify who is missing from the lecture at the time the questionnaire was administered and which students did not attempt the questionnaire. As well, ethically the investigators did not collect personal data from respondents since the questionnaires were completed anonymously. Caution is required when interpreting the results as it needs to be kept in mind that the MCRS is a self-report questionnaire and there is the possibility that respondents answered items in a 'socially desirably' manner. Another issue to consider is that the majority of the respondents were female; however, the gender distribution of the respondent group was representative of the students who are enrolled in health professional programs at Monash University. Therefore results of the students' reported views and perceptions may differ from their actual attitudes either in private or when confronted with a patient presenting with one of these medical conditions.