Poor knowledge about mental illness and negative attitudes toward people with mental illness are widespread [4]. In the present study, the studied caregivers had poor knowledge and negative attitude toward mental illness (16.90 ± 4.22) compared to Omani relatives of mentally ill patients (23.66 ± 4.88) [19]. Similarly in Iran, the majority of the families of schizophrenic patients had a negative attitude towards mental illness (88.90%) [21].
Seeking care from traditional healers for the treatment of mentally ill patients is considered a cultural belief in the Egyptian context [22]. In the current study, about 80% of the studied caregivers sought care first from traditional healers for their mentally ill relatives. Sixty percent of outpatients attending in Ain Shams University psychiatric clinic, 59% of schizophrenic patients in Ismailia, and 46.2% of outpatients in Al Minia University Hospital consulted traditional healers as the first help before coming to psychiatrists [23] [24] [20]. In addition, 40.8% of bipolar disorder patients recruited from three different governmental and private psychiatric hospitals in Cairo sought traditional healers, of that 62.2% were before seeking psychiatric services and 37.8% after [22].
The belief in traditional healing is strongly held in the Arab world and is transmitted through generations. A study in the United Arab Emirates showed that about 60% of bipolar disorder patients attending the psychiatric clinics at Al Rashid Hospital, Dubai had visited faith healers before seeking medical services [25].
The usage of traditional medicine as a tool for the treatment of psychiatric patients is not limited to Arabic or Middle East countries. It has been reported by other studies that were conducted in Asia (e.g., Singapore) and in Europe (e.g., Norway and Germany) [26] [27] [28].
The result of study conducted in Malay stated that about 44% of Singaporean mentally ill patients consulted traditional healers as the first contact [26]. While in Norway, 50% of Sámi and 31% of Norwegian psychiatric patients used traditional and complementary healing modalities for psychological problems. It was attributed to the greater importance of religion and spirituality and dissatisfaction with the public psychiatric services especially in the Sámi community [27].
A German study at a public hospital showed that half of the psychiatric inpatients had used traditional or complementary medicine parallel to psychiatric treatment and that those patients from a migrant background had predominantly used traditional forms of healing in comparison with the German patients who had used complementary treatment forms [28].
Educational level, socioeconomic standard, the residence of the caregivers in addition to patients’ behavior are the factors proved to predict caregivers’ literacy and attitude towards mental illness in several studies [29] [30]. As regards to our study, the increasing age of the caregivers significantly predicted poor knowledge and negative attitude towards mental illness (P = 0.036, ß = −0.045). In a systematic review on public attitudes towards mental illness, out of the 33 studies included in the systematic review, 32 reported positive associations between negative attitudes and age [31].
In the present study, education was a significant predictor of caregivers’ knowledge and attitude towards mental illness, where non-educated (illiterates/can read and write) caregivers had poor knowledge and negative attitude towards mental illness (ß = −1.301, P = 0.009). Similar findings were reported among the public in Nigeria and Greece. In Nigeria, literate respondents were seven times more likely to exhibit a positive attitude towards the mentally ill as compared to non-literate subjects [32]. Grecian respondents with a high level of education had a favorable attitude towards mental illness and believed that the etiology of mental illness is biological and not God’s punishment [33].
Caregivers’ residence had no role in their knowledge and attitude towards mental illness in the current study. The residence of the family caregivers had a mixed relationship with their knowledge and attitude towards mental illness in previous studies. Rural residence was associated with poor knowledge and more negative attitude towards mentally ill persons in India, Nigeria, and Ethiopia [34] [35] [36]. This was attributed to a lower level of literacy and more belief in the spiritual origin of mental illness in rural areas [36].
However, Chinese rural residents had more positive attitudes toward people with mental disorders than urban ones. One possible explanation for this evidence is that rural communities may be more tolerant of unusual behaviors, typical of people with mental disorders.
Knowledge and attitude towards mental illness of the studied subjects were not predicted by the diagnosed type of mental illness of their relatives (P = 0.340, ß = −0.377). This is consistent with a study of knowledge, attitude, perception, and belief (KAPB) of mentally ill patients’ relatives towards mental illness in India. That study found that KAPB of the relatives was not associated with the patient diagnosed illness (P < 0.05) [29]. Controversy with a Sweden study where public negative attitudes and social distance were significantly higher towards psychotic patients than depressed ones [37].
In the present study, aggressive behavior of the mentally ill patient was a predictor of poor knowledge and negative attitude of the studied caregivers towards mental illness (P = 0.002, ß = −1.434). An Indian study compared the literacy and attitude of the family caregivers of mentally ill patients towards mental illness over a 23-year period between 1993 and 2016. The study revealed that the area of abnormal behaviors (non-restrained aggressive behavior, weak cognitive control, and bizarre behavior) showed a worsening of negative attitudes [30].
Among the studied caregivers, seeking psychiatric care from the start was a significant predictor of good knowledge and a positive attitude towards mental illness (ß = 2.073, P = 0.000). In concordance with this finding, a meta-analysis of twenty-seven studies among general population revealed that participants with a negative attitude towards mental health help-seeking and stigmatizing attitudes towards people with a mental illness were associated with less active psychiatric help-seeking [38].