1 Introduction

The prevalence of mental health disorders is rapidly increasing and is now one of the top 10 causes of global burden. A global meta-analysis study conducted in 204 countries from 1990 to 2019 examined 12 mental health disorders, revealing that disability-adjusted life-years increased from 80.8 to 125.3 million people [1]. Psychiatric illnesses affect over 450 million individuals worldwide, with significant adverse consequences [2]. The World Health Organization (WHO) estimates that the ratio of individuals with mental health disorder is 1:8, and as of a consensus reached in 2019, nearly 970 million people globally live with mental disorders [3]. Iraq and Iraqi Kurdistan face significant challenges regarding mental disorders [4,5,6,7,8,9]. A recent national survey showed that the estimated lifetime prevalence of any disorder was 18.8% [10]. According to the same survey, anxiety disorders were found to be the most prevalent in Iraq, with a relatively high percentage of 13.8%, followed by mood disorders (7.5%) and behavioural disorders (1.8%) [10].

Several studies have shown that individuals with mental health disorders face significant stigmatization, which seems to be more prevalent than the stigma faced by individuals with physical illnesses [11, 12]. This stigma is present not only in developing countries but also in developed ones [13]. However, there is more variation in stigmatization across cultures in developing countries, which can be attributed to personal, cultural, and healthcare service barriers that hinder access to treatment [13]. Mental health professionals are particularly concerned about the negative prejudices and stereotyping experienced by individuals with mental health disorder, considering their vulnerability. University students, as members of the community, also hold attitudes toward individuals with mental health disorder that are important in terms of interactions and seeking support [14].

Stigmatization can be defined as adverse attitudes that lead to fear and discrimination against individuals with mental health disorder. It consists of three components: ignorance (related to knowledge), prejudice (related to attitudes), and discrimination (related to behavior) [15]. Many factors contribute to stigmatization, including misinformation or lack of knowledge, avoidance behaviors, and negative attitudes [16]. Stigmatization has social consequences such as limited job opportunities and reduced access to housing. Mentally ill individuals are often treated as having fewer rights than their healthy counterparts [17]. The main barrier for individuals with mental health disorder is the stigma associated with it. Feelings of shame and fear of discrimination make it difficult for them to seek help or manage their conditions [18].

In developed societies, attitudes toward mental health disorder are shaped by factors such as knowledge about mental health disorder, interactions with individuals who have mental health disorder, media influences and narratives, cultural stereotypes, institutional practices, and past experiences [19]. Recent researches suggests that collectivist cultures are more susceptible to stigmatizing attitudes compared to individualist cultures [20, 21]. There is evidence of intercultural differences in attitudes and beliefs, as well as changes over time [22]. A meta-analysis has shown that individuals in early adulthood are more likely to experience mental health disorders [23], particularly first-year university students [24]. This susceptibility can be attributed to lifestyle changes such as living away from home and forming new social connections, as well as academic demands such as handling new subjects, heavy workloads, and adapting to new study styles. The attitudes of college students, specifically towards mental health disorder, have been an area of interest [25]. Since the perspectives and attitudes of college students have a significant impact on the wider community, universities provide an ideal setting for implementing a comprehensive mental health strategy [26, 27].

Given the prevalence of negative attitudes towards individuals with mental health disorder documented in the literature, it is important to understand the attitudes and beliefs of undergraduate students [27, 28]. Assessing student attitudes towards individuals with mental health disorder is valuable for understanding the living conditions of those affected. Negative attitudes displayed by university students towards their mentally ill peers, particularly the associated stigma, act as a barrier to seeking help [29]. Although studies have been conducted on medical students in Iraq [30, 31], there is limited understanding of attitudes among undergraduate students towards mental health disorder [25]. To date, no research has been conducted on undergraduate students in the Kurdistan Region of Iraq. The aim of this study was to assess the attitudes of university students towards individuals with mental health issues. The hypothesis posits that students may hold negative attitudes towards individuals with mental health disorder due to the lack of mental health education in undergraduate curricula.

2 Materials and methods

2.1 Study design, setting, and period

A cross-sectional study was conducted in Ranya city, located in the Kurdistan region of Iraq, from April 2022 to June 2022. The study aimed to assess the attitudes of 294 university students towards individuals with mental health disorders.

2.2 Inclusion and exclusion criteria

Only students in the first, second, third, and fourth years of their academic program were included in the study. Students who had previously taken a mental health course or declined to participate were excluded.

2.3 Sample size

A minimum sample size of 257 students was determined to be necessary to adequately represent a population of 5000 students. This calculation was based on a 90% confidence level, a 50% anticipated response distribution, and a 5% margin of error. However, data were collected from a total of 294 students.

2.4 Study tools and measures

A structured questionnaire was distributed to the study sample using convenience sampling. The questionnaire was translated into Kurdish and then back-translated into English to ensure accuracy. The translation from English to Kurdish was carried out by a university English teacher specialized in English language and linguistics. Another university teacher, also specialized in the same field, reviewed the translated Kurdish text against the original English text. The researchers visited both campuses of the University of Raparin, specifically Ranya campus and Qaladze campus, and distributed the paper questionnaires to the students during and outside of class time. The students independently completed the questionnaire using a self-administered approach. Participation in the study was voluntary, and students from all colleges at the University of Raparin were included.

The questionnaire collected sociodemographic information about the students, including age, year of study, gender, major, and social class. Additionally, it included the Attitude Scale for Mental health disorder (ASMI), which is a reliable and valid self-report tool used to measure attitudes towards individuals with mental health disorder [32, 33]. The ASMI has been utilized in various surveys and research studies conducted in different countries, including studies involving medical students in Iraq [27, 30, 31, 34,35,36,37,38,39,40]. The scale consists of 34 statements that are rated on a Likert scale ranging from 1 (totally disagree) to 5 (totally agree). It is divided into following six subscales, with lower scores indicating more positive attitudes.

  1. (A)

    The separatism subscale, consisted of ten statements (1–9, 24) showing the discriminatory attitude of the students against mental health disorder.

  2. (B)

    The stereotyping subscale consisted of four statements (10–13) designed to assess the degree to which respondents maintain social distance from people who have mental health disorder.

  3. (C)

    Restrictiveness, another subscale that consisted of four statements (14–17), was used to indicate that people who have mental health disorders do not have the same rights as people without these problems.

  4. (D)

    Benevolence (positive questions (reversed), which consisted of eight statements (18–26 except 24), showed sympathetic and kind views toward people who have mental health disorder.

  5. (E)

    The pessimistic prediction subscale, containing four statements (27–30), indicated students’ prejudicial level toward people with mental health disorder.

  6. (F)

    The stigmatization component consisted of five statements (31–34) showing the discriminatory behavior of the students against people with mental health disorder.

Furthermore, since the ASMI scale had not been previously validated in the Kurdish population, a pilot study was conducted to assess the content validity and reliability of the questionnaire. For reliability assessment, the Cronbach’s alpha test was applied to a sample size of 10%, resulting in an acceptable score of 0.8.

2.5 Ethical approval and informed consent

This research study adhered to the guidelines established by the Institutional Research Ethics Board and the Declaration of Helsinki. Ethical permission (dated January 23, 2022, No. 408-29-07) was obtained from the ethics committee of the University of Raparin, College of Nursing. Before participating in the study, all students involved provided informed consent.

2.6 Data analysis

The data were analyzed using SPSS software to calculate descriptive statistics (e.g., mean, standard deviation, frequency, and percentage). The Spearman correlation test was used to determine the relationship between two quantitative variables that were not normally distributed. The Mann–Whitney test was applied to assess the relationship between two grouped categorical variables. In addition, a one-sample t-test was conducted to evaluate students’ attitudes towards individuals with mental health disorder (both positive and negative). A p-value of 0.05 was considered statistically significant.

3 Results

Of the 294 participating students, the mean age was 22.3 ± 2.46, ranging from 17 to 34 years old. Although the study focused on undergraduate students, it also included students over the age of 25. This was because some participants were 2-year diploma holders who wanted to pursue further studies at university. Out of the 294 participants, 157 (53.4%) were male and 137 (46.6%) were female. The majority of students, 256 (87.1%), resided in urban areas. Furthermore, a large majority of students, 271 (92.2%), belonged to the middle class.

In terms of field of study (college), the majority of students were in the basic sciences, with 98 (33.3%) students, followed by human sciences and languages, each with 84 (28.6%) students. A smaller number of students, 21 (7.1%), were majoring in nursing, while an even smaller number, 7 (2.4%), were majoring in pure sciences. When considering the year of study, the sample was distributed as follows: 91 (31%) students were first-year students, followed by 70 (23.8%) second-year students, 70 (23.8%) fourth-year students, and 63 (21.4%) third-year students (Fig. 1).

Fig. 1
figure 1

Demographic characteristics of the students

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Overall, the study found that participants had predominantly negative attitudes towards individuals with mental health disorders. The mean score was 91.03 with a standard deviation of 14.819. The results of a one-sample t test were statistically significant (t = − 16.162, P = 0.001). Out of the participants, 35.7% held negative attitudes, 34.7% had positive attitudes, and 29.6% had neutral attitudes (see Table 1).

Table 1 Students’ attitudes towards people with mental health disorder
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Table 3 presents a comparison of the various subscales. The subscale with the lowest mean score was restrictiveness (9.9 ± 3.78). The pessimistic prediction subscale had a mean score of 10.44 ± 3.75. The stigmatization subscale had a mean score of 11.11 ± 3.87. The stereotyping subscale had a mean score of 13.41 ± 3.49. The benevolence subscale had a mean score of 15.91 ± 6.07. The separatism subscale had a mean score of 30.26 ± 6.44 (see Fig. 2).

Fig. 2
figure 2

The comparison between the attitudinal mental health disorder subscales

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When comparing the students’ attitudinal subscales based on age groups, it was found that younger students exhibited lower mean scores in separatism (29.43), stereotyping (12.86), and stigmatization (10.30) compared to older students. However, these differences were not statistically significant for any of the three attitude subscales (P = 0.336, 0.478, and 0.199, respectively). The 20–25-year-olds had the lowest mean scores in restrictiveness (9.70) and pessimistic prediction (10.37). Again, the differences in restrictiveness (P = 0.226) and pessimistic prediction (P = 0.780) between this age group and the others were not significant. Students aged 25 years and above had the lowest mean score on the benevolence subscale (14.77), but there were no significant differences observed between the benevolence subscale and students’ age groups (P = 0.314) (see Fig. 3).Turning to gender differences in attitudinal subscales among students, it was found that female students generally had lower mean scores in separatism, stereotyping, benevolence, pessimistic prediction, and stigmatization, with the exception of restrictiveness, where males had lower mean scores compared to females. Furthermore, all differences in attitudinal subscales between male and female students were not statistically significant (see Fig. 4).

Fig. 3
figure 3

The comparison of attitudinal subscales according to age groups

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Fig. 4
figure 4

The comparison of the attitudinal subscales according to gender

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The analysis of the attitudinal subscales based on students’ place of residence indicated that urban students had a higher mean score (29.98) in the separatism subscale, compared to rural students (32.16). This difference was statistically significant (P = 0.046). Furthermore, urban students had lower mean scores in the restrictiveness (9.82), benevolence (15.86), and stigmatization (11.01) subscales compared to rural students (10.47, 16.24, and 11.76, respectively). However, these differences were not statistically significant (P = 0.368, 0.437, and 0.232). On the other hand, rural students had lower mean scores in both the stereotyping (13.37) and pessimistic prediction (10.34) subscales compared to urban students (13.41 and 10.45), but these differences were not statistically significant (P = 0.866 and 0.832) (see Fig. 5).

Fig. 5
figure 5

The comparison of student’s attitude subscales based on place of residence

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Regarding social class, students in the upper social class had the lowest mean scores in the stereotyping (12.5) and restrictiveness (8.93) subscales compared to other social classes. However, these differences were not statistically significant. Similarly, students in the middle social class had lower mean scores in benevolence (15.73) and stigmatization (11.03) subscales compared to other social classes, but these differences were not statistically significant. Lower social class students had the lowest mean scores in both the separatism and pessimistic prediction subscales (12.5 and 8.93), and these differences were also not statistically significant for either subscale (see Fig. 6). Table 2 presents the distribution of students’ attitude subscale scores across different years or levels of education. First-year students had the lowest mean scores in the separatism (29.93), stereotyping (12.71), and stigmatization (11.01) subscales compared to higher years, but these differences were not statistically significant (P = 0.918, 0.075, and 0.350, respectively). Second-year students had the lowest mean score only in the pessimistic prediction subscale (10.17) compared to the other years, and this difference was not statistically significant (P = 0.875). Third-year students did not have the lowest mean scores in any of the subscales. Finally, fourth-year students had the lowest mean scores in both the restrictiveness (9.54) and benevolence (15.06) subscales compared to lower years, but these differences were not statistically significant (P = 0.6 and 0.452, respectively). Students in the nursing college had lower mean scores in separatism (29.10), benevolence (14.19), pessimistic prediction (10.19), stigmatization (9), and restrictiveness (7.71) compared to students in other colleges. However, these differences were not statistically significant, as indicated by the non-significant P-values of 0.231, 0.181, 0.867, and 0.704, respectively. The only exception was the restrictiveness subscale, which showed highly significant differences (P = 0.0001). Similarly, the science college had the lowest mean score in stereotyping (12.71) compared to students in other colleges, but the difference was not statistically significant (P = 0.303) (see Table 3).

Fig. 6
figure 6

The comparison of students’ attitudes according to social class

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Table 2 The distribution of attitude subscales across different years of study
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Table 3 The distribution of student’s attitudes based on college
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Regarding the correlation among students’ attitude subscales, the results demonstrated a highly significant and positive relationship (r = + 0.311, P = 0.0001) between separatism and stereotyping. Additionally, a highly significant positive relationship (r = + 0.268, P = 0.0001) was observed between separatism and restrictiveness. In contrast, a non-significant positive relationship (r = + 0.027, P = 0.643) was found between separatism and benevolence. Positive and significant relationships were identified between separatism and pessimistic prediction (r = + 0.153, P = 0.009) and stigmatization (r = + 0.151, P = 0.010). Furthermore, stereotyping demonstrated positive relationships with the other subscales, namely restrictiveness (P = 0.0001, r = + 0.235), pessimistic prediction (P = 0.02, r = + 0.135), and stigmatization (P = 0.029, r = + 0.127), except for benevolence, which exhibited a significant negative correlation (P = 0.002, r = − 0.002).Furthermore, the restrictiveness attitude subscale was significantly positively correlated with benevolence (P = 0.002, r = + 0.182), pessimistic prediction (P = 0.0001, r = + 0.327), and stigmatization (P = 0.0001, r = + 0.239). Additionally, the relationship between benevolence and pessimistic prediction was not significant (P = 0.489, r = + 0.41), but a positive relationship (P = 0.001, r = + 0.253) was found between benevolence and stigmatization. Finally, the relationship between pessimistic prediction and stigmatization was significantly positive (P = 0.0001, r = + 0.253) (see Table 4).

Table 4 The correlation among the attitude subscales themselves
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4 Discussion

The aim of the study was to assess university students’ attitudes towards individuals with mental health disorder and explore how these attitudes vary based on socio-demographic variables. Previous research has examined mental health disorders in Iraq, but specific information about the Kurdistan region is lacking [10, 41]. In Iraq, attitudes towards mental health disorder are complex, with a significant portion of the population holding stigmatising views regarding treatment, work, marriage, and recovery for individuals with mental health disorder [10].

The study’s results indicate that undergraduate students generally hold negative attitudes towards individuals with mental health disorder. Participants primarily displayed negative attitudes characterized by separation, benevolence, and stereotyping, which aligns with the findings of Poreddi et al. [42]. Specifically, university students expressed the belief that support from friends and family is not effective in aiding recovery from mental health disorder. They also indicated a preference for mental health disorder and physical illness to be treated separately in hospitals [43]. However, students were less negative in their stigmatising, pessimistic, and restrictive attitudes. This suggests that although students held negative attitudes overall, they were less negative towards the extreme subscales of stigmatization, pessimistic prediction, and restrictiveness, as evidenced by lower mean scores. Our observation suggests that the negative attitudes described above may be influenced by the tendency of individuals with mental health disorder to conceal their conditions [43]. Additionally, these negative attitudes could be attributed to the perception that mental health disorders are not treated with the same seriousness as physical illnesses, as reflected in the participants’ less extreme attitudes on the respective subscales. These findings are consistent with previous literature [30, 42]. Although the majority of results from this study are negative, there are some positive aspects noted in qualitative studies where participants expressed a range of attitudes, including empathy, indifference, rejection, tolerance, and social acceptance [2]. These findings are consistent with other research conducted by Al-Naggar [44], Poreddi et al. [45], and Desai and Chavda [46], which also found moderate to positive attitudes among medical and health science students. The impact of socio-demographic characteristics on participants’ attitudes showed consistently negative attitudes towards mentally ill individuals across different age groups [41]. This suggests that negative attitudes may be passed down from older adults to younger generations. Another possible explanation is that older students had the lowest mean score on the benevolence subscale, while younger students had the lowest mean on extreme subscales such as separatism and restrictiveness. This may be due to limited life experience among younger students. Older students, having faced life challenges, may be less discriminatory and hostile in their attitudes compared to younger students.

Our results align with recent research by Giralt Palou [47], which showed that older students expressed more negative attitudes. Gender did not have a significant impact, but female respondents generally held more negative attitudes, except for Restrictiveness. Non-significant results suggest that both genders share similar levels of responsibility in their treatment of mentally ill individuals [46]. Previous studies have shown significant gender differences, with women expressing more positive attitudes, particularly on the benevolence subscale [42, 44, 45, 47, 48]. Therefore, contrary to our findings, women are often reported to display benevolence and empathy, whereas men exhibit fear and uncertainty [2]. Place of residence, social class, year of study, and college were not reliable indicators of students’ attitudes towards mentally ill individuals across most subcategories. However, a significant difference was observed between urban and rural students, specifically in relation to stereotyping. Urban students exhibited lower levels of negative attitudes, which may be due to the strong interpersonal relationships and cooperative nature commonly found in rural areas. This aligns with previous research on the influence of place of residence [42]. Rural students may possess greater awareness of appropriate ways to interact with mentally ill individuals. We found a difference in attitudes based on students’ college or field of study. Only nursing students had more negative attitudes compared to students in other disciplines. This may be due to the unique knowledge and experiences gained by nursing students. Poreddi et al. [42] supported these findings in their study, which showed that psychiatric education interventions influenced medical students’ attitudes toward mental health disorder. These findings suggest that familiarity with mental health disorders does not guarantee improvement in students’ attitudes. Regarding the impact of year of study on attitudes, Al-Hemiary’s [30] study of Iraqi medical students found that the attitudes of fourth- and sixth-year students were similar. However, Rodríguez-Riva’s [2] study contradicts our findings, indicating a distinction between first- and fourth-year medical students in terms of their attitudes.

On the topic of social class, no studies were found in our literature review that reported findings related to its impact on attitudes. This study also reported correlations among the components themselves. A positive correlation was found between separatism and variables such as stereotyping, restrictiveness, pessimism, and stigmatization. This means that as separatism scores increased, scores for stereotyping, restrictiveness, pessimistic prediction, and stigmatization also increased. This finding aligns with the participants’ beliefs that individuals with mental health disorder may pose a threat to others, exhibit abnormal behavior, struggle to find employment, face punishment, and be easily recognizable. Consequently, they felt that such individuals should be segregated [26, 39, 45].

A positive association was observed between stereotyping and the variables of restrictiveness, pessimistic prediction, and stigmatization, but a negative association was found with benevolence. As students’ stereotyping attitudes became more negative, their attitudes towards restrictiveness, pessimistic prediction, and stigmatization also became more negative [14, 17]. However, the correlation between stereotyping and benevolence yielded unexpected results. Participants believed that individuals with mental health disorder exhibit low intelligence, abnormal behavior, and are generally disliked by others, leading to stereotyping [2, 24]. The negative correlation between stereotyping and benevolence is plausible since people without benevolent attitudes may be inclined to stereotype individuals with mental health disorder [26, 27, 36].

The study observed a positive but weak relationship between restrictiveness and pessimistic prediction on one hand, and benevolence on the other. This suggests that while some individuals naturally hold benevolent attitudes towards people with mental health disorder [40, 42], their attitude can become ambivalent when influenced by the attitudes of others. Consequently, they may exhibit both benevolence and stigmatising, as well as pessimistically predictive attitudes. It is important to note that although this study established correlations that contribute to the existing literature, most of these correlations were significant but weak.

5 Strengths and limitation

The generalizability of the results is limited for several reasons. Firstly, the participants were exclusively undergraduate students from a single university, so the findings may not be applicable to all universities in the Kurdistan region of Iraq. Secondly, the cross-sectional design of the study makes it difficult to establish causality between variables. Lastly, the results cannot be easily extrapolated as they were obtained using a convenience sample. To achieve greater generalizability, it is necessary to include diverse populations and increase the sample size.

Despite these limitations, we believe that this study presents noteworthy findings that are of interest to both academics and mental health professionals.

6 Conclusion

The attitudes towards individuals who are in good health can affect their lives. Individuals with mental health disorders may be even more affected by these attitudes, as they can have a detrimental impact on their mental health conditions. Our study confirms that individuals with mental health disorders are often singled out and subjected to stereotypes, limitations, stigmatization, pessimistic forecasts, and a lack of benevolence, resulting in a negative perception. These findings align with our observations of the population from which our sample was drawn. Rather than offering support, a majority of our students displayed negative attitudes towards individuals with mental health disorders. Although symposiums are held in the context of this study every year to raise students’ awareness to better perceive people with mental health disorders, the recommendations of such symposiums might have had limited effect on their attitudes. Therefore, our study recommends the establishment of a psychological and guidance counselling centre at the university to raise awareness that mental health disorders, like physical illnesses, are prevalent and can be addressed through guidance and training. Additionally, the study proposes revising the curricula and content of nursing courses to better prepare nursing students for their societal role, as their attitudes were found to be more negative. Our study produced insignificant results regarding the impact of socio-demographic variables on most of the attitude dimensions. Previous studies have shown conflicting outcomes in this regard, so further research is needed to better understand the variability of attitudes based on these variables. Therefore, the present study suggests conducting additional research on the influence of socio-demographic variables on attitudes.