CONCEPTUALIZATION OF NEGATIVE ATTITUDES TOWARDS PEOPLE WITH SCHIZOPHRENIA IN TURKEY

Previous studies have shown that stigmatizing attitudes toward individuals with schizophrenia are common in Turkey, and Turkish society has a tendency to reject such individuals. The purpose of this paper, therefore, is to provide an overview of negative attitudes towards people with schizophrenia in Turkey. A systematic search of the literature in Academic Search Complete, CINAHL, ERIC, MEDLINE, and PsycINFO was performed to review these negative attitudes. Six major themes were identified in 32 studies: (a) health care providers’ negative attitudes, (b) family’s and caregivers’ negative attitudes, (c) the public’s negative attitudes, (d) students’ negative attitudes, (e) perceived and internalized stigma, and (f) stigma reduction. The results supported the hypothesis that health care providers, caregivers and families, the public and students have negative attitudes toward people with schizophrenia, which is consistent with the results of studies conducted worldwide. MEDLINE, , attitude , and


The Conceptualization of Negative Attitudes towards People with Schizophrenia in Turkey
Schizophrenia is a severe and persistent mental illness that affects more than 21 million individuals worldwide, and more than 50% of them do not receive appropriate intervention (World Health Organization 2018). It is commonly linked to stigmatizing public attitudes and is also considered one of the illnesses most negatively discriminated by and excluded from society due to unfamiliarity, perceived dangerousness, fear, and perceived dependency (ALTINDAG et al. 2006;ANGERMEYER et al. 2004;BAG et al. 2006;BOKE et al. 2007;KUKULU & ERGUN, 2007;THOMPSON et al. 2002;UCOK 2007). Stigma starts from the stigmatizing mark (e.g., diagnosis of

Search Outcome
The literature search yielded 100 articles. Abstract reviews were conducted to determine the appropriateness of inclusion in this review, reducing the studies to a collection of 32 studies that were included in this review. Figure 1 represents the flowchart of studies. All studies met the four criteria.

Results
Six major themes were identified in 32 studies: (a) health care providers' negative attitudes, (b) the family's and caregivers' negative attitudes, (c) the public's negative attitudes, (d) students' negative attitudes, (e) perceived and internalized stigma, and (f) stigma reduction techniques for individuals with schizophrenia. Table 1 represents summary of findings.

Health Care Providers' Negative Attitudes toward Schizophrenia
The first theme was the health care providers' negative attitudes toward individuals with schizophrenia (AYDIN et al. 2003;EKER & ARKAR 1991;KUKULU & ERGUN 2007;OZYIGIT et al. 2004;SAVAS et al. 2002;UCOK et al. 2004). Three subthemes were identified under this category. SAVAS and colleagues (2002) explored psychiatrists' attitudes about the patient's right to be informed. Their findings revealed that psychiatrists' decision-making about the right of the patient to be informed depended on the diagnosis itself. Paranoid schizophrenia was found to be the hardest diagnosis for psychiatrists to disclose to patients when compared with obsessive-compulsive personality disorder and antisocial personality disorder (SAVAS et al. 2002). SAVAS and colleagues' argument was supported by a similar research conducted by UCOK and colleagues (2004) showing that more than 42% of psychiatrists never informed their patients about their schizophrenia diagnosis. This number is relatively high when compared with the less than four percent of psychiatrists who never informed patients about a depression diagnosis (UCOK et al. 2004).

Nurses
OZYIGIT and colleagues (2004) examined the attitudes of nurses and nursing school students toward individuals with schizophrenia. Their findings revealed that about 53% of nurses and nursing school students would feel uncomfortable having a neighbor with this mental illness, and about 83% of subjects would not marry someone afflicted by it. KUKULU and ERGUN (2007) recruited nurses from psychiatric wards, university hospitals, training and research hospitals, and psychiatric hospitals to examine nurses' stigmatizing attitudes toward individuals with this illness. About 57% of nurses reported that they would be able to work with someone who has schizo phrenia, but only 6% of them reported that they would marry such an individual (KUKULU & ERGUN 2007).

Miscellaneous
AYDIN and colleagues (2003) recruited 160 hospital staff employees to examine their attitudes toward individuals with schizophrenia and depression. Their study indicated that the frequency of negative attitudes toward individuals with schizophrenia was higher among mental health service providers (e.g., faculty members, resident physicians, and nurses) than hospital staff with no medical training (AYDIN et al. 2003).

Caregivers' Negative Attitudes toward Schizophrenia
Multiple studies have explored caregivers' attitudes toward individuals with schizophrenia (ARKAR & EKER 1992;CETIN et al. 2013;KARANCI 1995;KARANCI & INANDI-LAR 2002;SAĞDUYU et al. 2003;YILDIZ et al. 2010). Similar to health care providers, results indicated that caregivers hold negative attitudes toward such individuals. ARKAR and EKER (1992) recruited 84 subjects to understand caregivers' attitudes toward individuals with psychiatric conditions, including schizophrenia. Their results revealed that having a family member with a severe mental illness did not make any difference in social acceptance, but that the type of psychopathology did make a difference. They reported that paranoid schizophrenia is the least accepted type of psychopathology in terms of social distance among families. KARANCI (1995) recruited 60 family members to examine causal attributions, difficulties, perceived and expected help behavior of health care providers, and hope for the future well-being of caregivers of individuals with schizophrenia. About 50% of participants were optimistic about the future well-being of their afflicted relatives. However, those who were optimistic about their relatives' future well-being were less educated and had relatives whose symptoms were not chronic. KARANCI and INANDILAR (2002) examined the predictors of components of expressed emotion in major caregivers (e.g., mothers, fathers, and spouses) of afflicted individuals. Their results indicated that caregivers were more critical and hostile if these individuals experienced more symptoms and were unable to cope with their symptoms. Similarly, CETIN and colleagues (2013) explored in afflicted in di vidu als the relationship between the independency in their instrumental daily life activities and their family members' care burden and expressed emotions. The caregivers' judgmental, hostile, and overprotective attitudes toward individuals with schizophrenia were found to be negatively correlating with patients' independent living skills (e.g., phone usage) (CETIN et al. 2013).
In an epidemiological investigation, SAĞDUYU and colleagues (2003) examined relatives' beliefs and attitudes toward afflicted individuals. Their findings revealed that more than 72% of subjects held the opinion that individuals with schizophrenia are dangerous, and more than 90% believed that such people failed to take responsibility for their own lives. Additionally, YILDIZ and colleagues (2010) examined relatives' knowledge and opinions about schizophrenia. They recruited 322 family members living with an individual who had this illness. Interestingly, their findings revealed that about 65% of the participants reported beliefs that individuals with schizophrenia are more prone than other individuals to commit crime.

Public's Negative Attitudes towards Schizophrenia
In this review, six studies were found investigating the public's attitudes towards people with schizophrenia (BAG et al. 2006;BOKE et al. 2007;EKER et al. 2010;SAĞDUYU et al. 2001;TASKIN et al. 2002;TASKIN et al. 2003). Three subthemes were identified under this category.

General findings
The majority of studies found that public attitudes toward schizophrenia were negative, and some studies reported that the public was reluctant to have close contact with afflicted individuals (SAĞDUYU et al. 2001;TASKIN et al. 2002;TASKIN et al. 2003). EKER and colleagues (2010) recruited 267 religious officials to examine their attitudes toward individuals with schizophrenia. The results revealed that about 42% of participants stated that they would feel uncomfortable if they had a neighbor with schizophrenia. In addition, about 65% of participants reported that they would not marry someone with this illness. SAĞDUYU and colleagues (2001) reported that 27.3% of the participants believed that individuals with schizophrenia were dangerous and 25.7% believed that that they should not be left 'unattended' in society. TASKIN and colleagues (2002) recruited 208 people living in rural areas to examine public attitudes toward individuals with schizophrenia. More than 60% of subjects reported that they would feel uncomfortable with a neighbor who had schizophrenia, and 61.1% of them did not want to work with someone who had this illness (TASKIN et al. 2002). A similar research by TASKIN and colleagues (2003) revealed that half of the participants reported that such individuals are aggressive and that they should not be free in the society. In addition, more than 85% of subjects reported that they would not marry someone with schizophrenia.

Newspapers
In a retrospective scanning study, BOKE and colleagues (2007) examined the mass media's attitudes toward individuals with schizophrenia. They screened the websites of 12 national newspapers between 2001 and 2006. As opposed to the writing of positive reflections, newspapers in Turkey were instead more likely to negatively describe these individuals. They reported that 'schizophrenia' as a word has a strong negative perception.

Students' Attitudes toward Schizophrenia
In this review, eight studies investigated attitudes of students toward schizophrenia in Turkey (AKDEDE et al. 2004;AKER et al. 2016;AY et al. 2006;DANACI et al. 2016;EKER, 1989;OZMEN et al. 2004;YANIK et al. 2003;YENILMEZ et al. 2010). Two subthemes were identified under this category. (2004) examined attitudes toward individuals with schizophrenia among students. They recruited 159 medical school students and 65 nonmedical students using tutoring services for university entrance exams. Their findings revealed that 63% of medical students and 38% of other students reported that they would change their existing attitudes if a patient with schizophrenia was one of their relatives, meaning that having a family member with this illness would reduce negative attitudes. YANIK and colleagues (2003) recruited 57 students to explore attitudes toward schizophrenia, as well as the influence of psychiatric training among medical students. They found that routine psychiatry training did not increase positive attitudes toward individuals with schizophrenia among medical students. Similarly, Yenilmez and colleagues (2010) recruited 101 first year and 101 fifth year medical school students to compare whether psychiatric training changes students' attitudes toward schizophrenia. They found that a psychiatry internship improves students' positive attitudes toward the illness. AY and colleagues (2006) recruited 452 second and sixth-year medical school students to examine whether the stigma toward mental disorders differs throughout medical education. Their results indicated that sixthyear students had more positive attitudes toward individuals with schizophrenia compared with second year students, although 38.7 % of the sixth-year students still perceived such individuals as being dangerous. Recently, DANACI and colleagues (2016) recruited 106 freshman medical school students who had not received any theoretical or practical training in psychiatry. After five years, students who completed their psychiatry internship were recruited again. Their results revealed that students' attitudes toward individuals with schizophrenia shifted to a positive direction concerning the etiology of schizophrenia, treatment options, approach to such individuals, and social interactions. EKER (1989) recruited 85 undergraduate students to examine attitudes toward mental illness. Results revealed that the most negative ratings were recorded for the paranoid schizophrenia case, and the most positive ratings were recorded for individuals without mental illness (EKER 1989). OZMEN and colleagues (2004) recruited 272 students (e.g., nursing) and examined how labelling affects attitudes toward individuals with schizophrenia using case vignettes. Students reported that such individuals should not be free in the community as they are aggressive, and students would not rent their house to them. (OZMEN et al. 2004). AKER and colleagues (2016) recruited 771 college students to examine whether renaming schizophrenia reduces negative attitudes toward individuals with this illness. Their results suggested that changing the diagnosis 'schizophrenia' to another name did not affect college students' attitudes and stigmatization of the illness.

Self-Stigma
Four studies investigated internalized and self-stigma among individuals with schizophrenia in Turkey (ERTUGRUL & ULUG 2004;GUNER 2014;YILDIZ et al. 2012;YILMAZ & OKANLI 2015). In a qualitative study, GUNER (2014) recruited nine individuals in remission from this illness and conducted an in-depth interview with them to determine their illness perception. She identified five themes from the patients' description of schizophrenia: (a) schizophrenia is a complicated illness, (b) schizophrenia is a mystery, (c) schizophrenia is a lost life, (d) schizophrenia is a dynamic journey towards recovery, and (e) schizophrenia is a developmental process of recovery. This study also revealed that patients felt stigmatized and humiliated due to negative attitudes from society (GUNER 2014). ERTUGRUL and ULUG (2004) indicated that the severity of symptoms is linked to a perception of stigma, meaning that patients with more severe symptoms perceived more stigma than patients with fewer symptoms. YILDIZ and colleagues (2012) recruited 167 individuals with schizophrenia, 45 relatives of such individuals, and 86 individuals with major depressive disorder to examine self-stigma among individuals with schizophrenia, their relatives, and individuals with a major depressive disorder. Individuals with schizophrenia were found to have a higher level of self-stigma than those with major depressive disorder (YILDIZ et al. 2012). YILMAZ and OKANLI (2015) recruited 63 patients with schizophrenia to examine the effect of internalized stigma on the adherence to treatment. Their findings revealed that internalized stigma had a negative effects on the treatment compliance and attitude toward the treatment among individuals with schizophrenia.

Stigma Reduction
In this review, only two studies examined the effects of anti-stigma education and programs (ALTINDAG et al. 2006;UCOK et al. 2006). Two subthemes were identified under this category.

Stigma reduction training for practitioners
UCOK and colleagues (2006) recruited 106 general practitioners from health institutions to examine the impact of anti-stigma education on the attitudes of general practitioners regarding schizophrenia. The health practitioners completed a questionnaire on their views and attitudes towards schizophrenia before participating in the antistigma training session. Then a subsample of 54 general practitioners, which represented the whole sample regarding age, gender, and years in medical practice, completed the questionnaire again three months after their anti-stigma training. Posttest results indicated a significant improvement in the following areas: (a) general practitioners would not like to have a neighbor with schizophrenia, (b) individuals with schizophrenia are untrustworthy, (c) people with schizophrenia could harm child ren, (d) individuals with schizophrenia could be recognized by his/her appearance, (e) schizophrenia could be treated, and (f) individuals with schizophrenia could not comprehend nor utilize suggested treatment.

Stigma reduction training for medical students
ALTINDAG and colleagues (2006) recruited 25 first-year medical school students (intervention group) and 35 first-year medical school students (control group) to examine the effects of an anti-stigma program on medical students' attitudes toward individuals with schizophrenia. Intervention group participants were provided a twohour anti-stigma training. Students in the intervention group showed more positive attitudes toward people with schizophrenia than those who were in control group. Control group participants showed no significant differences in attitudes toward individuals with schizophrenia.

Discussion
The goal of this review was to identify and conceptualize negative attitudes towards individuals with schizophrenia in Turkey. For this purpose, 32 studies were investigated. Common themes identified include negative attitudes toward schizophrenia from health care providers, caregivers and families, public, and students. Self-stigma and stigma reduction were other two themes that emerged from the studies.
Health care providers' attitudes toward individuals with a severe mental illness have been a controversial topic. The findings of this study revealed that health care professionals (e.g., psychiatrists, nurses, physicians) seem to have negative attitudes toward individuals with schizophrenia (SAVAS et al. 2002;UCOK et al. 2004), which is consistent with previous findings (JORM et al. 1999;HUGO 2001;NORDT et al. 2006). Surprisingly, health care professionals show their negative attitudes in different forms, such as psychiatrists' reluctance to inform patients and families of the diagnosis of schizophrenia (SAVAS et al. 2002;UCOK et al. 2004). Another form of negative attitude toward individuals with schizophrenia that is common among health care providers is social distance. For instance, some health care professionals do not want to have a neighbor, co-worker, or partner with schizophrenia (KUKULU et al. 2007;OZYIGIT et al. 2004). This indicates that negative attitudes toward individuals with this illness are still present among medical professionals, which need to be addressed by health care providers who provide services to individuals with schizophrenia in Turkey.
The family burden of care in schizophrenia is extensive in terms of its emotional, psychological, physical, and economic impact on caregivers (AWAD & VORU- GANTI, 2008;YILDIZ et al. 2010). Although family members' attitudes toward the illness may change over time due to living with a person with schizophrenia (YILDIZ et al. 2010), the current findings indicate that caregivers and family members can show judgmental, hostile, and overprotective attitudes towards family members with schizo phrenia (CETIN et al. 2013;KARANCI & INANDILAR 2002;SAĞDUYU et al. 2003). Individuals with schizophrenia are blamed or held responsible for their condition by their family members (VAUGHN & LEFF 1981). Therefore, among relatives, high levels of criticism and negative attitudes are more common, accompanied by higher levels of resignation, coercion, and avoidance of the patient (MAGLIANO et al. 1998). In the current study, findings revealed that family members, caregivers, and relatives hold negative attitudes toward individuals with schizophrenia. Their negative attitudes appear to increase when patients do not show independent living and coping skills (CETIN et al. 2013;KARANCI et al. 2002). Multiple researchers suggested more education and training about schizophrenia for family members, caregivers, and relatives (KARANCI et al. 2002;YILDIZ et al. 2010).
Studies have proven that the public attitudes towards people with mental illnesses are usually negative (ANGERMEYER & DIETRICH 2006;BYRNE 1997;CORRIGAN & WATSON 2002;WOLFF et al. 1996). For example, in their studies, ANGERMEYER and MATSCHINGER (2003) examined similarities and differences of public belief about schizophrenia and depression. They found that the symptoms of both disorders are identified as an sign of a mental illness by the majority of participants; however, individuals with schizophrenia are, by far, more frequently considered unpredictable and dangerous. This study indicates that the society shows a higher level of negative attitudes toward individuals with schizophrenia when compared to those without schizophrenia (SAĞDUYU et al. 2001;TASKIN et al. 2002;TASKIN et al. 2003), which is consistent with previous findings. Some studies indicated that individuals with this illness should not be free in the community, since they are dangerous and unpredictable (BAG et al. 2006;TASKIN et al. 2003). The public does not want to have a neighbor, co-worker, or partner with schizophrenia (EKER et al. 2010;TASKIN et al. 2002). The findings also revealed that Turkish newspapers were found to increase negative attitudes toward individuals with schizophrenia (BOKE et al. 2007), which is important, since mass media may affect society's attitudes toward such individuals.
A growing body of research has been investigating students' attitudes toward mental illness, specifically schizophrenia.  (PINGANI et al. 2015). In the current study, results indicate that students (e.g., medical students and college students) hold negative attitudes toward individuals with schizophrenia, especially paranoid schizophrenia (AKDEDE et al. 2004;EKER 1989;YENILMEZ et al. 2010). Results also revealed that medical students with a psychiatric training hold more positive attitudes than those without psychiatric training (AKDEDE et al. 2004;YANIK et al. 2003), which highlights the importance of psychiatric training and internship experience in changing students' attitudes toward schizophrenia. Consistent with health care providers, caregivers, and the public, students believe that individuals with schizophrenia are dangerous and aggressive (OZMEN et al. 2004).
The self-stigma of people with schizophrenia has not been studied as much as society's negative attitudes toward people with this illness in Turkey. Four studies were found to be investigating internalized and self-stigma among individuals with schizophrenia in Turkey (ERTUGRUL & ULUG 2004;GUNER 2014;YILDIZ et al. 2012;YILMAZ & OKANLI 2015). Patients felt stigmatized and humiliated due to the negative attitudes in the society (GUNER 2014). In addition, ERTUGRUL and ULUG (2004) indicated that the severity of symptoms is positively linked to perceived stigma. Selfstigma may negatively impact treatment adherence and ultimately the recovery of individuals with a severe mental illness (CHAN et al. 2009;CORRIGAN et al. 2006). Therefore, mental health researchers in Turkey may have to further investigate the negative effect of public stigma on individuals with schizophrenia.
Negative attitudes not only affect patients with schizophrenia but also affects their families and societies. Studies suggested that stigma and self-stigma reduction programs can lead to a better psychosocial treatment outcome for such individuals (CHAN et al. 2009;FUNG et al. 2010;FUNG et al. 2011). We found that anti-stigma training programs reduced the negative attitudes of practitioners and medical students (ALTINDAG et al. 2006;UCOK et al. 2006). Therefore, mental health professionals in Turkey should pay more attention to negative attitude reduction programs and training since negative attitudes can be a strong barrier to the psychosocial adjustment, community participation, and overall well-being of individuals with schizophrenia.

Conclusion
In this study, we have provided an overview of negative attitudes evinced by health care providers, caregivers and families, society, and students toward people with schizo phrenia in Turkey. Overall, the results of this study supported the hypothesis that health care providers, caregivers and families, public, and students have negative attitudes toward people with schizophrenia, which is consistent with the results of studies conducted worldwide. Results also suggested that stigma reduction and self-stigma have not been well-documented in Turkey so far, while the few recorded anti-stigma reduction trainings showed improvement in positive attitudes toward individuals with schizophrenia. In future studies, mental health researchers could carry out self-stigma and stigma reduction studies in Turkey in order to examine the effectiveness of interventions aimed at reducing stigma and discrimination. This study has some limitations. First, the studies identified in the literature review only represent negative attitudes in Turkey. Therefore, generalization of findings to other countries may not be accurate. Second, this literature review includes only peer-reviewed journals; however, more studies might be identified through an examination of dissertations and theses.