Factors Related To Public Behavior towards Patients with Mental Disorders in Buton Utara District

Background: People with mental disorders often get greater stigma and discrimination from the surrounding community than individuals who suffer from other medical illnesses. This treatment is due to ignorance or misunderstanding of family or community members regarding mental disorders. This study aims to determine the determinants of community behavior towards people with mental disorders. Method: This type of research is an observational analytic using a cross-sectional design which was carried out in North Buton Regency in October 2022 involving 86 respondents who were selected randomly. Results: The results showed that the behavior of the majority was good as many as 47 respondents (54.7%), followed by poor behavior as many as 39 respondents (45.3%). Community behavior towards people with mental disorders in North Buton Regency is related to income (p-value 0.043), knowledge (p-value 0.000), attitude (p-value 0.014) and is not related to education level (p-value 0.489). Knowledge is the factor most related to people's behavior towards people with mental disorders in North Buton Regency. Conclusion: The conclusion of the study is that people's behavior towards people with mental disorders is related to good knowledge, good attitudes, and income.


BACKGROUND
Mental disorders are still a serious problem in the world.According to the World Health Organization (WHO), in the world there are 450 million people with mental disorders, the prevalence of mental disorders according to WHO in 2019 shows that globally it is estimated that 35 million people experience depression, 60 million people suffer from bipolar affective disorder, 21 million people suffer from schizophrenia disorders.and 47.5 million people worldwide experience dementia [1].The 2018 Riskesdas report, the prevalence of schizophrenia or psychosis is 7%, depression is 6.1%, mental emotionality in the Indonesian population is 9.8%.This shows that the problem of emotional mental disorders is still high in Indonesia.The highest prevalence occurred in the age group > 75 years of 15.8% and the lowest was in the age of 25-24 years of 8.5%.Meanwhile, according to gender prevalence in women (12.1%) is higher than men (7.6%) [2].In the Province of Southeast Sulawesi, the prevalence of severe mental disorders was 3,450 people or 1.6 per million and only 58.2% of those who received services were in North Buton Regency compared to other districts [3].In North Buton Regency the number of people with mental disorders according to the North Buton District Health Office in 2021 is 86 and the number of severe mental disorders has increased to 85 people in 2020, with the largest number spread in the working area of the Kulisusu Health Center [4].
Mental disorders pose a double burden for those who suffer from the disease.Physical, psychological, cognitive, emotional, and social functions are often disrupted by the disease process [5].A person diagnosed with a mental illness often has to overcome resistance, avoidance, and even physical violence caused by negative cultural meanings associated with mental disorders [6] In patients with mental disorders, they are declared cured and then returned to their families, but they often relapse because there is a stigma in the community that they think that if they cannot recover, they are often ostracized in their environment, not given a role and social support, then bullied (Hartanto, 2014).Until now, mental health is still a concern because of the lack of public awareness, there is still discrimination and stigma against people with mental disorders and the ignorance of society in maintaining mental health [7].Not only does the family have an important role in the process of healing people with mental disorders, but the community also participates in the process.An attitude of indifference or indifference, contempt and rejection of people with mental disorders is a problem that is difficult to straighten out.It cannot be denied that the attitudes and acceptance of people with mental disorders from society are factors that influence the healing process [8].
According [9] stated that society still gives prejudice and discrimination against people with mental disorders.They are often ridiculed, shunned, ignored, ostracized and considered a disgrace in society.Many people still think badly of people with mental disorders, the community considers people with mental disorders to be terrible, embarrassing, frightening, and disgraceful people who must be hidden.Some residents also still practice discrimination such as social isolation (seclusion), violence and bullying.One of the reasons is the low level of public education and knowledge about mental health.Families with low education tend not to understand how to care for family members who have mental disorders, so they often ignore family functions.Communities need to have knowledge, perceptions and attitudes in increasing awareness and a good response from the community towards people with mental disorders in their surroundings.Good knowledge, perceptions and attitudes need to be owned by the community, by having good knowledge and perceptions it is hoped that the attitude of the community can have a good attitude towards people with mental disorders [10] Preliminary research in North Buton Regency, some people said that they felt afraid when they met people with mental disorders so they tended to avoid and minimize them.Another source said that if there were members of the community who suffered from mental disorders, they would be taken to a traditional healer, because according to them, mental disorders were caused by possession by spirits.If the dukun cannot heal, then people with mental disorders will be put in shackles because it can disturb other residents.Based on the trend of the incidence of people with mental disorders in North Buton Regency compared to other districts in Southeast Sulawesi Province, this prompted the author to conduct a study entitled analysis of factors related to people's behavior towards people with mental disorders in North Buton Regency.This study was to analyze factors related to people's behavior towards people with mental disorders in North Buton Regency.

METHOD
This research is a cross sectional study design.The research was carried out in the working area of the Buton Utara District Health Office, from November to December 2022.The research sample consisted of 86 families with family members suffering from mental disorders.The research instrument is a questionnaire.Chi-Square data analysis and multivariate test using logistic regression.  1 shows that of the 16 respondents who have higher education, there are 7 respondents (43.8%) who have good behavior.Then from 70 respondents who had low education, there were 30 respondents (42.9%) who had poor behavior.The results of the Chi Square test obtained a p-value of 0.480 > 0.05, meaning that there is no relationship between education and the community for people with mental disorders in North Buton Regency.Table 3 shows that of the 53 respondents who have good knowledge, there are 45 respondents (84.9%) who have good behavior.Then from 33 respondents who had less knowledge, there were 31 respondents (93.9%) who had less behavior.The results of the Chi Square test obtained a p-value of 0.000 <0.05, meaning that there is no relationship between knowledge and the community towards people with mental disorders in North Buton Regency.Table 4 shows that of the 53 respondents who had good attitudes, there were 35 respondents (66%) who had good behavior.Then of the 33 respondents who had less attitude, there were 21 respondents (63.6%) who had less behavior.The results of the chi square test obtained a p-value of 0.014 <0.05, meaning that there is no relationship between attitude and society towards people with mental disorders in North Buton Regency.1.5 shows that the Wald value of the knowledge variable is the largest among the other variables, namely 27.091 (Pvalue 0.000), so it can be concluded that the variable most related to people's behavior is knowledge.The R Square value is 70.4%, meaning that the predictor variable can explain the predictive variable (people's behavior) of 70.4% in the sense that 70.4% of people's behavior is related to the variables studied and only 29.7% of people's behavior is related to other variables not examined.

Community behavior
In the results of this study it can be reported that the behavior of the majority is good as many as 47 respondents (54.7%), followed by less behavior as many as 39 respondents (45.3%).The community often offers assistance to families of people with mental disorders (79%), 88% of respondents do not forbid families from shackling people with mental disorders, 79% of respondents do not seek information in the media for the treatment of patients with mental disorders and 100% of respondents have never visited people with mental disorders in his home.According [11], that participants said that the negative behavior given by society towards people with mental disorders was to be ridiculed, kicked out and scolded when they came to people's homes.
Human behavior is essentially an activity of the man himself, behavior is also what the organism does, whether it can be observed directly or indirectly and this means that behavior occurs when something is needed to cause a reaction, which is called stimulation., thus a certain stimulus will produce a certain behavioral reaction.Based on the results of research on people's behavior towards people with mental disorders, it is divided into two, namely positive behavior and negative behavior.The positive behavior of the community can be reflected in the respondents providing motivation to families with mental disorders to treat family members, respondents have concern for people with mental disorders, respondents often remind families to care for patients and other support.This is similar to previous studies but carried out in different places, namely regarding family support in the care of patients with mental disorders using the health promotion model approach, it was found that 47 families provided good support in the care of patients with mental disorders [12].Negative things in this study were still found in people who behaved negatively towards people with mental disorders, namely tending to harass people by making people with mental disorders jokes or ridicule, being beaten, kicked out, and scolded.This is a stigma in the form of discrimination against people with mental disorders.Discrimination is negative behavior perpetrated against people with mental disorders, in the form of demeaning the person [11].The form of negative behavior carried out by the community is avoiding people with mental disorders, people prefer not to approach and run when they accidentally meet people with mental disorders [13].

Education
Education is an institutional stage of activity that is used to perfect individual development in mastering knowledge, habits, attitudes and so on.Meanwhile, according to [14] defines education as a process of developing one's skills in the form of attitudes and behavior that prevail in society.The process by which a person is influenced by a guided environment, especially in the school environment so that he can achieve social skills and develop his personality.
The results showed that the education of the majority was lower education as many as 70 respondents (81.4%), followed by higher education as many as 16 respondents (18.6%).The majority of education was elementary school with 29 respondents (33.7%), followed by high school with 22 respondents (25.6%), junior high school with 19 respondents (22.1%), diploma with 9 respondents (10.5%), and the lowest were Bachelors as many as 7 respondents (8.1%).
Table 1 shows that of the 16 respondents who have higher education, there are 7 respondents (43.8%) who have good behavior.Then from 70 respondents who had low education, there were 30 respondents (42.9%) who had poor behavior.It can be seen that there is a tendency for people who have a low level of education to have bad behavior towards family members who suffer from mental disorders.
The results of the chi square test obtained a p-value of 0.480 > 0.05, meaning that there is no relationship between education and the community for people with mental disorders in North Buton Regency.The results of the study (Widianti, 2018) showed a ρ-value of 0.070 or it could be said that there was no relationship between the educational level factor and the community's stigma about mental patients in Gembongan Village, Ponggok District, Blitar Regency.The level of family education has an effect on poor family support in caring for people with mental disorders.Almost all (72%) of the family education level is elementary school.Low educational level status lacks sufficient information related to knowledge of disease and its treatment in providing family support.
According to [15] that a person's educational level can influence the ability to absorb information, solve problems, and behave well.Low education is at risk of inability to care for their health.According [16], a low level of family education will also affect the incidence of depression so that it will affect poor family support.This is not in line with previous research that there is a relationship between education level and public stigma against people with mental disorders in Demen Hamlet, Pakem District.Education has a significant relationship to the stigma of mental disorders [17] Other research says that people with minimal education can have negative assumptions and prejudices against the family as an attitude that leads to negative evaluations [18].
The results of cross-tabulation of data show that some respondents who have a higher level of education also have poor or bad behavior in responding to people with mental disorders.Caring for patients with mental disorders requires a good understanding of how to care for people with mental disorders.An individual's higher education will tend to generate good motivation in behaving, but of course there are many factors that influence this behavior, so it is not absolute that individuals with higher education will have positive behavior and vice versa.
The researcher's analysis that the level of individual education is one of the aspects involved in a decision making.Whereas in educational institutions, not all educational institutions teach knowledge about stigma, only certain educational institutions teach this.So that the researcher concludes that a person's level of education determines a priority problem as the researcher analyzes, it is necessary to carry out further research regarding the education level factor and the community's stigma about mental patients to find out whether the education level factor does indeed affect the community's stigma towards patients with mental disorders because the results obtained by researchers in the field show that there is no relationship between the level of education and the community's stigma towards patients with mental disorders.

Income
One of the factors that influence family support is the economic factor of families with Javanese disorders.Socio-economic factors here include the level of income or income of the client's family, the higher the family's economic level, the more support and decision making in caring for violent behavior client members.Families with financially superior socio-economic classes will have an adequate level of family support.Family income is one form of instrumental support that will be used in seeking mental health services in caring for family members who suffer from mental disorders.
The results showed that the majority of low incomes were 60 respondents (69.8%), followed by high incomes as many as 26 respondents (30.2%).Low income can be related to the type of work people do in North Buton district, where the majority are farmers and are self-employed, but more respondents have small businesses.
The existence of a family member who suffers from mental disorders will affect the financial ability of the family.The financial needs and burdens in the family will increase, for family members with sufficient economic capacity, the burden that will arise will be less than family members who cannot afford it [19].The assumption of researchers is that patients suffering from mental disorders need support from the family so that the patient is able to meet their needs with the help of the family.
In this study it was reported that of the 26 respondents who had high incomes, there were 19 respondents (73.1%) who had good behavior.Then from 60 respondents who have low income, there are 28 respondents (46.7%) who have less behavior.The results of the chi square test obtained a p-value of 0.043 <0.05, meaning that there is a relationship between income and society for people with mental disorders in North Buton Regency.
Socio-economic factors are one of the causes for the emergence of various psychological stressors in family life and society in general.Apart from being the cause of prolonged stress, socio-economic conditions are also the cause of negative stigma in society.Stigma is completely dependent on socio-economic, political, cultural, and power is needed to stigmatize.The income factor also affects poor family support.A person's economic status will determine the availability of a facility needed for certain activities, so that this socio-economic status will affect a person's support.One of the factors that influence support is socio-economic factors, namely the higher the economic level of a person, usually the more responsive they are to the symptoms of the disease they feel.So that he will immediately seek help when he feels there is a disturbance in his health.The results showed that almost all (75.6%) had an income below the 2022 regional minimum wage standard (UMR) in North Buton Regency.
Socio-economic factors here include the level of income or income of families with mental disorders, the higher the economic level of the family, the more support and decision making in caring for family members with mental disorders.Families with financially superior socio-economic classes will have an adequate level of family support.Family income is one form of instrumental support that will be used in seeking mental health services in caring for family members who experience mental disorders.In addition, with family wages that are below the regional minimum wage (UMR), families will definitely be outside the home more often to work from morning to evening, resulting in a lack of support given to people with mental disorders.
This finding reinforces, which states that almost all (96%) have income <Rp.1,200,000.Regional minimum wage (UMR) in 2015 in Ponorogo Regency is Rp.1,150,000.Poor economic factors will affect family readiness in caring for mental patients with schizophrenia.

Knowledge
Someone who has a mental disorder in society will have deviant behavior and experience emotional distortions [20].Changes in behavior in someone with a severe mental disorder cause rejection in society because of the emergence of a negative stigma perception of someone with a mental disorder [21].Society also considers someone with a severe mental disorder to be very dangerous, aggressive and prone to committing acts of violence, so that society is more alienating and rejects if there is someone with a mental disorder in your environment [22].herefore, it is important for families to understand the concept of good care for people with mental disorders, so that families or communities can provide good treatment for people with mental disorders.Based on the results of the study it was reported that the majority knowledge was good as many as 53 respondents (61.6%), followed by less knowledge as many as 33 respondents (38.4%).Families in North Buton Regency understand better that mental illness is a disease that can be cured, mental illness is not a contagious disease.However, there are still many families who say that people with mental disorders are very dangerous if allowed to roam because they have the potential to cause trouble.
Negative stigma with bad knowledge that is owned by the community because many people still give a negative label to people with mental disorders.This is because many people say people with mental disorders are called crazy people because the nickname has been attached from long ago, are afraid of people with mental disorders, do not want to associate or approach people with mental disorders or their families, people with mental disorders should be put into just a mental hospital so that the surrounding environment is safe from the tantrums of people with sudden mental disorders, and the community also says they have never received counseling about mental disorders so that people do not know about mental disorders.
The low level of public knowledge regarding information about the signs and symptoms of mental disorders should be of concern to health workers so they can provide counseling to the community.Community knowledge is very important in underlying the formation of attitudes in acceptance of people with mental disorders.This knowledge can be obtained naturally or in a planned manner, namely through the educational process.In addition to education, awareness is also needed from the community itself, so that the community has good knowledge in order to create a positive stigma towards people with mental disorders around their environment.Not all people have a negative stigma against people with mental disorders, there are people who have a positive stigma with good knowledge.This is because there is still a sense of community care for people with mental disorders who are around them, society says people with mental disorders have the same rights as us to live and be valued and protected, caring for and caring for people with mental disorders is one of the healing processes for people with mental disorders.mental disorders, some people also say they like to read and seek information about mental disorders because each of us has the potential for mental disorders that we must understand for ourselves and for others.
The results of this study are the same as research conducted by [23] concerning public stigma against people with mental disorders in Kebumen district which states that one of the reasons is the low level of education and knowledge about mental health In this study it was reported that of the 53 respondents who had good knowledge, there were 45 respondents (84.9%) who had good behavior.Then from 33 respondents who had less knowledge, there were 31 respondents (93.9%) who had less behavior.The results of the chi square test obtained a p-value of 0.000 <0.05, meaning that there is no relationship between knowledge and the community towards people with mental disorders in North Buton Regency.Lack of public knowledge about mental disorders makes society form a bad stigma against people with mental disorders.
This finding further reinforces previous findings which reported that there is a relationship between knowledge and people's attitudes towards people with mental disorders in the Colomadu 1 Health Center Work Area with a significance value (p-value) of 0.000 [24].This is also in line with the research of [25].who reported that there was a relationship between the level of education and the level of knowledge about mental health with people's attitudes towards mental patients in RW XX Duwet Village.
Community knowledge about mental disorders still lacks special attention by health workers, especially mental health nurses in the community, so that it can worsen the provision of services in the community.Therefore, the current research will change knowledge about the stigma of mental disorders in society, especially in North Buton Regency, for example by providing psychoeducation for families or the community.

Attitude
Attitudes are views or feelings that are accompanied by a tendency to act according to the attitude of the object.In this study, some respondents had a positive attitude towards patients with mental disorders.This is possible because the respondent has the right understanding regarding mental disorders and this does not interfere with or conflict with his personal values.
Based on the results of the study showed that the attitude of the majority was good as many as 53 respondents (61.6%), followed by a less attitude as many as 33 respondents (38.4%).People with mental disorders often get greater stigma and discrimination from the surrounding community than individuals who suffer from other medical illnesses.Not only causing negative consequences for sufferers but also for family members, including being called a madman, attitudes of rejection, denial, and being set aside as well as negative views.Society's view of people with mental disorders has an impact on people with mental disorders, these views can be either negative or positive views.Negative views can have a negative impact on people with mental disorders which will lead to a long healing process for people with mental disorders.In this condition, society should act as a support system for people with mental disorders.
People with mental disorders have a high risk of human rights violations.They are often referred to as madness (insanity or madness).This treatment is due to ignorance or misunderstanding of family or community members and even nurses or medical personnel regarding mental disorders.Mental disorders can affect a person's life function.Activities, social life, work rhythm, and relationships with family are disrupted due to symptoms of anxiety, depression, and psychosis.Someone with any mental disorder should get treatment immediately.Delay in treatment will further harm the sufferer, family and society.
Based on the results of the study, it was shown that of the 53 respondents who had good attitudes, there were 35 respondents (66%) who had good behavior.Then of the 33 respondents who had less attitude, there were 21 respondents (63.6%) who had less behavior.There is a tendency for people who have a positive attitude towards people with mental disorders to behave well in caring for people with mental disorders.The results of the chi square test obtained a p-value of 0.014 <0.05, meaning that there is no relationship between attitude and society towards people with mental disorders.in North Buton Regency.This is due to poor knowledge that creates a bad attitude towards people with mental disorders.Society says they don't really care about people with mental disorders, people are indifferent because of each other's busyness, and also people see this as a negative, embarrassing and threatening problem, so people stay away from people with mental disorders and their families.The community said they were afraid and did not want to interfere in the affairs of their neighbors who had mental disorders.
The attitude of people who do not care because they are afraid that people with mental disorders will relapse or do things that are harmful to their families.The community also says that people with mental disorders are very disturbing to the community because they like to ask for money or food, people with mental disorders should be taken to a mental hospital and not roaming outside.But not all people in RW 07 have a negative stigma with a bad attitude, there are people who have a positive stigma with a good attitude as much as this is because the community cares about their neighbors and feels sorry for people with mental disorders and their families.The community says if these mental disorders happen to us, do we accept being alienated and hated by other people and mental problems must be considered and handled carefully from the health department or puskesmas as well as from the community environment.Positive stigma will give a good attitude to people with mental disorders and their families.So that there is no longer a negative label attached to people with mental disorders in society.
In line with research conducted by [25]by obtaining a significant value of 0.000, it means that there is a relationship between the level of education and people's attitudes towards patients with mental disorders.Research conducted by Wiharjo (2014) also states that there are other factors that influence attitudes, namely community stigma, with the result (p) = 0.000 (p <0.05), meaning that there is a significant positive relationship between community stigma and people's attitudes towards people with schizophrenia .Differences in social stigma against people with schizophrenia are influenced by several factors, including a lack of information.
Based on the results of this study, the Wald value of the knowledge variable is the largest among the other variables, namely 27.264 (P-value 0.000), so it can be concluded that the variable most related to people's behavior is knowledge.The R Square value is 70.3%, meaning that the predictor variable can explain the predictive variable (people's behavior) of 70.4% in the sense that 70.4% of people's behavior is related to the variables studied and only 29.6% of people's behavior is related to other variables not examined.
In this study it was proven that people's knowledge really dominates changes in people's behavior in responding to or caring for people with mental disorders.So that it can be said that even though people have less income, if they are well-informed then, with this understanding, people will be more likely to take good care of people with mental disorders.

CONCLUSION
There is no relationship between education level and people's behavior towards people with mental disorders in North Buton Regency.There is a relationship between income, knowledge, and attitudes with people's behavior towards people with mental disorders in North Buton Regency.Knowledge is the factor most related to people's behavior towards people with mental disorders in North Buton Regency village community causing people to label, prejudice and discrimination of persons with mental disorders.The existence of public stigma causes people with mental disorders to suffer more, have difficulty recovering and are prone to relapse.

Table 2 .
Analysis of the Relationship between Income and Community Behavior towards People with Mental Disorders in North Buton Regency in 2022

Table 3 .
Analysis of the Relationship between Knowledge and Community Behavior for People with Mental Disorders in North Buton Regency in 2022

Table 5 .
The relationship between the independent variables and the dependent variable