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'Investigating the Diagnostic Overshadowing Bias in Bangladeshi Health Professionals'

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Title: 'Investigating the Diagnostic Overshadowing Bias in Bangladeshi Health Professionals'
Language: English
Authors: Hinde, Kylie, Mason, Jonathan, Kannis-Dymand, Lee (ORCID 0000-0002-1882-6121), Millear, Prudence, Sultana, Razia
Source: Journal of Mental Health Research in Intellectual Disabilities. 2021 14(1):89-106.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 18
Publication Date: 2021
Document Type: Journal Articles
Reports - Research
Education Level: Secondary Education
Descriptors: Intellectual Disability, Mental Disorders, Comorbidity, Clinical Diagnosis, Health Personnel, Social Bias, Vignettes, Foreign Countries, Intelligence Quotient, Symptoms (Individual Disorders), Special Education, Likert Scales, Secondary Education, Educational Attainment, Schizophrenia, Drug Abuse, Bullying, Comparative Analysis, Physicians, Psychiatry, Folk Culture, Medicine, Psychologists, Allied Health Personnel, Professional Development
Geographic Terms: Bangladesh
DOI: 10.1080/19315864.2020.1856244
ISSN: 1931-5864
Abstract: Introduction: Intellectual disability (ID) and co-morbid mental health problems are more common in developing countries such as Bangladesh. However, little is known about how Bangladeshi health practitioners diagnose mental health disorders in people with an ID. Studies in developed countries have explored the impact of the diagnostic overshadowing bias (DOB): the tendency for health practitioners to misattribute mental health symptomology to a client's ID, rather than a separate mental health disorder. To date, no study has investigated the presence of the DOB in Bangladesh. Method: A range of Bangladeshi health practitioners (N = 243) were randomly assigned a clinical vignette describing a client displaying symptoms of a mental health disorder. Vignette 1 described a client with an IQ of 105 who graduated from secondary school. Vignette 2 described a client with an IQ of 55 who attended special education. All other details were identical. Participants rated the likelihood of seven mental health diagnoses on a 5-point Likert scale. Results: Practitioners were more likely to diagnose schizophrenia, drug problems and being bullied in people with a typical IQ compared to those with an ID. Doctors, psychiatrists, and psychologists appeared to be more affected by the DOB than community health workers, traditional healers, and allied health practitioners. Conclusion: Findings indicate that the bias may be present in Bangladesh healthcare professionals. The development and implementation of specific training programs to meet the differing needs of practitioners, across the health fields are recommended.
Abstractor: As Provided
Entry Date: 2021
Accession Number: EJ1283426
Database: ERIC
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  Value: <anid>AN0148210041;[5ew6]01jan.21;2021Jan22.02:45;v2.2.500</anid> <title id="AN0148210041-1">"Investigating the Diagnostic Overshadowing Bias in Bangladeshi Health Professionals" </title> <p>Introduction: Intellectual disability (ID) and co-morbid mental health problems are more common in developing countries such as Bangladesh. However, little is known about how Bangladeshi health practitioners diagnose mental health disorders in people with an ID. Studies in developed countries have explored the impact of the diagnostic overshadowing bias (DOB): the tendency for health practitioners to misattribute mental health symptomology to a client's ID, rather than a separate mental health disorder. To date, no study has investigated the presence of the DOB in Bangladesh. Method: A range of Bangladeshi health practitioners (N = 243) were randomly assigned a clinical vignette describing a client displaying symptoms of a mental health disorder. Vignette 1 described a client with an IQ of 105 who graduated from secondary school. Vignette 2 described a client with an IQ of 55 who attended special education. All other details were identical. Participants rated the likelihood of seven mental health diagnoses on a 5-point Likert scale. Results: Practitioners were more likely to diagnose schizophrenia, drug problems and being bullied in people with a typical IQ compared to those with an ID. Doctors, psychiatrists, and psychologists appeared to be more affected by the DOB than community health workers, traditional healers, and allied health practitioners. Conclusion: Findings indicate that the bias may be present in Bangladesh healthcare professionals. The development and implementation of specific training programs to meet the differing needs of practitioners, across the health fields are recommended.</p> <p>Keywords: Diagnostic; overshadowing; bias; intellectual; disability; Bangladesh</p> <p>Within developing countries, it is estimated that 1.64% of the population have an intellectual disability (ID), and a further estimated 22.4% of that population present with comorbid mental health disorders (United Nations Development Programme, [<reflink idref="bib29" id="ref1">29</reflink>]). Despite this, in developing countries such as Bangladesh, individuals with an ID and comorbid mental health disorders typically receive limited mental health interventions (World Health Organisation, [<reflink idref="bib33" id="ref2">33</reflink>]). There is limited literature reporting current trends in health practitioner knowledge of ID and comorbid mental health disorders, including mental health diagnostic practices in general in Bangladesh; a densely populated country with a current estimated population of 164+ million (World Bank, [<reflink idref="bib32" id="ref3">32</reflink>]). Existing exploratory research indicates the majority of individuals who seek services for mental health disorders in Bangladesh are often only able to access practitioners who have limited training in mental health care, which tends to result in either no diagnosis and treatment, or misdiagnosis and inappropriate treatment (M. D. Hossain et al., [<reflink idref="bib10" id="ref4">10</reflink>]; Islam, [<reflink idref="bib11" id="ref5">11</reflink>]; Nuri et al., [<reflink idref="bib24" id="ref6">24</reflink>]). For these populations, misdiagnosis may lead to poorer health outcomes, including shorter life expectancy, societal segregation, and subsequent poverty (Nuri et al., [<reflink idref="bib24" id="ref7">24</reflink>]). Inadequate mental health care increases strain on a number of national systems, including public health expenditure, economic costs related to workforce productivity, and social systems (Nuri et al., [<reflink idref="bib24" id="ref8">24</reflink>]).</p> <hd id="AN0148210041-2">BANGLADESHI HEALTH PROFESSIONALS</hd> <p>According to the current hierarchy of health care in Bangladesh, psychiatrists are the most preferred, yet least accessible first point of care for mental health-related issues. The World Health Organization report on health care in Bangladesh ([<reflink idref="bib35" id="ref9">35</reflink>]) indicated that there were 73 psychiatrists servicing a then population of 142+ million people (WHO-AIMS, [<reflink idref="bib35" id="ref10">35</reflink>]). In contrast, traditional healers are identified 90% of the time as a front-line health service in communities due to being most accessible, and often responsible for making referrals to psychiatrists or medical doctors (Giasuddin et al., [<reflink idref="bib5" id="ref11">5</reflink>]; Rawal et al., [<reflink idref="bib26" id="ref12">26</reflink>]). This is despite healers having limited to no formal training in assessment and treatment of mental health-related issues (Abdullah et al., [<reflink idref="bib1" id="ref13">1</reflink>]; WHO, [<reflink idref="bib34" id="ref14">34</reflink>]). Anecdotal research indicated that healers in Bangladesh rely on knowledge of herbal remedies, and use of traditional healing rituals, to bring relief to a person afflicted with mental illness (Giasuddin et al., [<reflink idref="bib5" id="ref15">5</reflink>]). Medical doctors in Bangladeshi vary in level of qualification, with some identified as private practitioners (PPs) with a general medical degree, general physicians (GPs) or medical officers with more specialized practice (Giasuddin et al., [<reflink idref="bib5" id="ref16">5</reflink>]; Karim et al., [<reflink idref="bib15" id="ref17">15</reflink>]). General public access primary, secondary or tertiary level facility-based doctors based on their social standing.</p> <p>Allied health professions such as social workers, occupational therapists and psychologists are the least utilized mental health care services in Bangladesh, and generally provide complementary treatment once diagnosis has been provided by a psychiatrist (Nuri et al., [<reflink idref="bib24" id="ref18">24</reflink>]; WHO AIMS, 2007). This is in contrast to most Western countries where psychologists often play an instrumental role in assessment, diagnosis and treatment of mental health disorders (Man et al., [<reflink idref="bib20" id="ref19">20</reflink>]). Community health workers have recently become an important adjunct to community health care in Bangladesh, and provide health promotion, education, screening and provision of essential care based on training received by government-funded community clinics (Ministry of Health and Family Welfare, [<reflink idref="bib22" id="ref20">22</reflink>]). On the whole, the accessibility of health care practitioners trained in mental health and intellectual disability in Bangladesh is limited.</p> <p>At present medical doctors in Bangladesh receive limited to no university-based training in mental health assessment and/or treatment provision to persons with IDs. Psychiatrists complete 5 academic years plus 1 year of internship training covering basic psychiatry concepts including the diagnosis and management of common psychiatric problems. Psychologists complete 5 years of study which includes 4 years of undergraduate study and one-year master's training before qualifying as a clinical psychologist. As far as known, no Bangladeshi tertiary health care training course explicitly incorporates training on the assessment, diagnosis and/or treatment of mental health problems in persons with an ID.</p> <hd id="AN0148210041-3">THE DIAGNOSTIC OVERSHADOWING BIAS</hd> <p>The term diagnostic overshadowing bias was first identified by Levitan and Reiss in the early 1980s to describe the phenomenon where health practitioners disregard and/or misattribute mental health symptomology as being part of the patient's ID, rather than a separate mental health disorder (Levitan & Reiss, [<reflink idref="bib17" id="ref21">17</reflink>]). The identification of the bias coincided with societal shifts toward the recognition of mental health and ID as two separate conditions, and the need to achieve higher standards of care for these populations (Mason & Scior, [<reflink idref="bib21" id="ref22">21</reflink>]). Research has indicated that if health practitioners hold this bias, there is an increased risk of diagnostic errors, inadequate treatment strategies, and overall poorer outcomes for persons with an ID (Mason & Scior, [<reflink idref="bib21" id="ref23">21</reflink>]; Shefer et al., [<reflink idref="bib27" id="ref24">27</reflink>]; Thornicroft et al., [<reflink idref="bib28" id="ref25">28</reflink>]).</p> <p>Several explanations have been proposed for the diagnostic overshadowing bias. Levitan and Reiss ([<reflink idref="bib17" id="ref26">17</reflink>]) suggested there may be a tendency for practitioners to place higher importance on the observable and "unusual" behavioral symptoms of people with an ID, over the less discernible internal symptoms (such as thoughts and mood states). A recent Australian study conducted by Hinde and Mason ([<reflink idref="bib8" id="ref27">8</reflink>]) indicated that almost 40 years after Levitan and Reiss' study, practitioners working with people with an ID continue to demonstrate a tendency to focus on observable symptoms over internal mental health symptoms. Furthermore, while practitioners were better at identifying external (observable) mental health symptoms, they could recall less than 50% of internal symptoms for depression, anxiety, and psychosis when measured against ICD-10 diagnostic criteria (Hinde & Mason, [<reflink idref="bib8" id="ref28">8</reflink>]). Thornicroft et al. ([<reflink idref="bib28" id="ref29">28</reflink>]) also suggested that health practitioners preferred to triage treatment based on symptoms that are observable, definable, and tangibly manageable. Collectively, this evidence suggests that some complexities in the detection of mental health symptoms when an individual has a comorbid ID are still prevalent.</p> <p>Mason and Scior ([<reflink idref="bib21" id="ref30">21</reflink>]) found that, regardless of a health practitioner's level of prior education, the presence of an ID may impede recognition of several mental health disorders. In addition, UK-based psychologists and psychiatrists were more likely to diagnose schizophrenia and drug problems in people with a typical IQ than in those with an ID and that both professions were no more likely to diagnose affective disorders and anxiety for clients with a typical IQ or a low IQ (Mason & Scior, [<reflink idref="bib21" id="ref31">21</reflink>]). Furthermore, Harris ([<reflink idref="bib6" id="ref32">6</reflink>]), reported that health practitioners tended to under-diagnose anxiety and depressive disorders in persons with an ID. Difficulty in detecting affective disorders and anxiety in persons with an ID may stem from these diagnoses relying heavily on insight and a patient's self-report of internal symptoms, which may be challenging for some individuals with an ID.</p> <hd id="AN0148210041-4">THE DIAGNOSTIC OVERSHADOWING BIAS IN DEVELOPING COUNTRIES</hd> <p>While the diagnostic overshadowing bias has been investigated in numerous developed countries, there are limited studies investigating the bias within developing countries, and even less within the context of ID. Several recently published studies from developing countries such as Uganda (Rasmussen et al., [<reflink idref="bib25" id="ref33">25</reflink>]), China (Li et al., [<reflink idref="bib19" id="ref34">19</reflink>]), Malaysia (Jasraj & Viknesh, [<reflink idref="bib13" id="ref35">13</reflink>]), and Nepal (Kohrt et al., [<reflink idref="bib16" id="ref36">16</reflink>]), briefly mention the bias in the broader context of obstacles for achieving better general mental health service provision. Bangladesh faces similar obstacles to improving the outcomes for persons with mental health disorders, including a dense population, limited governmental policies and support including limited training and assessment regarding mental health diagnosis, stigma surrounding the label of ID, inadequate and limited practitioner and access to evidence-based interventions, and high consumer demand for treatment (Bangladesh Health Watch Report, [<reflink idref="bib2" id="ref37">2</reflink>]; Hasan et al., [<reflink idref="bib7" id="ref38">7</reflink>]; Islam, [<reflink idref="bib11" id="ref39">11</reflink>]). In the context of these obstacles, it is plausible to hypothesize that health practitioners from Bangladesh and other developing countries would demonstrate the bias within the context of ID.</p> <p>In detecting the overshadowing bias in a sample of health practitioners, the vignette approach has traditionally been utilized in research. A number of studies have demonstrated the reliability of this methodology in detecting the bias in samples of health practitioners across developed countries (Jamieson & Mason, [<reflink idref="bib12" id="ref40">12</reflink>]; Mason & Scior, [<reflink idref="bib21" id="ref41">21</reflink>]; Reiss & Levitan, [<reflink idref="bib18" id="ref42">18</reflink>]). This approach involves presenting the participant with one of two possible short clinical vignettes describing a person displaying characteristic symptoms of a recognizable mental health disorder, such as schizophrenia or anxiety. The only difference between the two vignettes is that in one vignette, the person is described as having an IQ within the typical range (90 to 110), and in the second vignette, the person is described as having a low IQ (below 70).</p> <hd id="AN0148210041-5">THE PRESENT STUDY</hd> <p>Up until the early 2000s, the diagnostic overshadowing bias was found in samples of health practitioners from countries with developed health and social care systems such as the UK (Mason & Scior, [<reflink idref="bib21" id="ref43">21</reflink>]) and the USA (Levitan & Reiss, [<reflink idref="bib17" id="ref44">17</reflink>]). Recent studies have found limited evidence that health practitioners from developed countries are still affected by the bias (Geiss et al., [<reflink idref="bib4" id="ref45">4</reflink>]; Jamieson & Mason, [<reflink idref="bib12" id="ref46">12</reflink>]). Jamieson and Mason ([<reflink idref="bib12" id="ref47">12</reflink>]) attributed the absence of bias in their sample of Australian health practitioners to advances in assessment and diagnostic processes, awareness of comorbidity, a growth in evidence-based treatment options, and reductions in negative attitudes toward working with people with IDs and comorbid mental health disorders. Trends in the overshadowing bias research over the past 20 years indicate that identification and awareness of this bias in the USA in the 1980s may have been the first step toward eliminating the bias from practitioners working in developed countries.</p> <p>Recent research from Bangladesh indicates high levels of stigma in health practitioners regarding mental health and ID (A. Hossain et al., [<reflink idref="bib9" id="ref48">9</reflink>]), as well as limited resources to diagnose, treat, and participate in specialized training (Nuri et al., [<reflink idref="bib24" id="ref49">24</reflink>]). In accordance with existing research, the presence of these factors in Bangladesh suggests that Bangladeshi health practitioners may be susceptible to the diagnostic overshadowing bias. Despite this, the overshadowing bias has never been explicitly investigated in Bangladeshi health practitioners.</p> <p>Limited research has explored diagnostic knowledge across such a variety of practitioners in Bangladesh. A variety of health practitioners may be involved in the diagnosis and treatment of persons with an ID and mental health disorders in Bangladesh, involving both community practitioners (community health workers and various allied health professionals) and medical practitioners (such as doctors, psychiatrists, or nurses). Previous studies have indicated that the amount of diagnostic training a practitioner has may make them more or less susceptible to the bias. For example, psychiatrists, psychologists, and doctors are thought to be less affected by the bias due to their diagnostic training background (Jess et al., [<reflink idref="bib14" id="ref50">14</reflink>]; Mason & Scior, [<reflink idref="bib21" id="ref51">21</reflink>]; Shefer et al., [<reflink idref="bib27" id="ref52">27</reflink>]). In addition, literature outlining the most common mental health disorders experienced by people with an ID in Bangladesh is scarce. The Bangladesh Health Watch Report ([<reflink idref="bib2" id="ref53">2</reflink>]) indicated that schizophrenia, affective disorders, and anxiety disorders were the most common presenting mental health disorders in the general Bangladeshi population.</p> <p>Therefore, the present study seeks to establish if the diagnostic overshadowing bias exists in a broad sample of Bangladeshi health practitioners, and secondly, if present, to establish if the bias affects certain types of health professions more than others. It is hypothesized that the bias will be present in a sample of Bangladeshi health professionals. In addition, it is predicted that psychiatrists, psychologists and doctors will be less affected by the bias than community health workers, allied health practitioners, and nurses.</p> <hd id="AN0148210041-6">METHOD</hd> <p></p> <hd id="AN0148210041-7">Procedure</hd> <p>Ethical approval was granted through the Human Research Ethics Committee of a regional Australian university and through the Ethics Committee of a regional hospital in Bangladesh. An e-mail was sent across Bangladesh's eight administrative divisions to administrators of professional associations, hospitals, community organizations, and health facilities inviting members to participate in the survey. Professional bodies were contacted by the professions of psychiatry, psychology, medicine (doctors), social work, occupational therapy, speech therapy, community work, and nursing. A chain-referral sampling technique was used, whereby existing participants forwarded details of the study to their professional colleagues.</p> <p>An e-mail to potential participants included a link to the Research Project Information Sheet (RPIS) and consent, clinical vignette, and survey, which were located on an electronic survey website (SurveyMonkey). All participant materials including the invitation e-mail, RPIS, vignette, and survey questions were first completed in English and then translated to Bengali; the national language of Bangladesh. A Bangladeshi national with a Master in Applied Linguistics and English Language provided all translations. Two independent Bangladeshi health professionals proficient in the English language cross-checked translated documents for consistency in meaning of health terminology.</p> <hd id="AN0148210041-8">Measures</hd> <p>After the participants agreed to participate in the study a questionnaire was provided to participants, with the goal of assessing the existence and influence of the diagnostic overshadowing bias in diagnosis and treatment recommendation decisions by Bangladeshi health professionals. Questions used in the current study were the same as used in the study by Jamieson and Mason ([<reflink idref="bib12" id="ref54">12</reflink>]). To conceal the nature of the study, participants were required to complete the vignette-based questions measuring the DOB, before answering demographic information such as their age, profession type, number of years working with people with an ID, and specialized training undertaken in working with clients with an ID.</p> <p>Following Mason and Scior ([<reflink idref="bib21" id="ref55">21</reflink>]) and Jamieson and Mason ([<reflink idref="bib12" id="ref56">12</reflink>]), participants were randomly assigned to one of two versions of an otherwise identical clinical vignette. Both vignettes described the hypothetical case of "Abdul", a person with mental health symptoms broadly consistent with someone who has schizophrenia. The vignette also suggests the presence of symptoms of anxiety, low mood, and psychosis. Low mood referred to general moodiness and sadness, and did not correspond with the levels of depression. In vignette 1, Abdul had an IQ of 105 and graduated from secondary school (see Figure 1), whereas in vignette 2 Abdul had an IQ of 55 and attended special classes. All other vignette details were the same. 119 participants received vignette 1 (49%), and 124 participants vignette 2 (51%).</p> <p>Graph: Figure 1. Example of vignette</p> <p>After reading the vignette, participants were then asked to complete a questionnaire. The questionnaire was designed to prevent participants from returning to previously answered questions. This function ensured that initial diagnostic questions could not be altered when participants completed later questions that may have revealed the focus of the study. Participants were asked to indicate the likelihood that the person described in the vignette was experiencing seven of the most commonly occurring mental health disorders or conditions on a 5-point Likert scale (1 = <emph>strongly disagree</emph>, 2 = <emph>disagree</emph>, 3 = <emph>neutral</emph>, 4 = <emph>agree</emph>, 5 = <emph>strongly agree</emph>). The issues included: depression, social anxiety disorder (SAD), intellectual disability (ID), drug problems, schizophrenia, being bullied, and generalized anxiety disorder (GAD).</p> <hd id="AN0148210041-9">Participants</hd> <p>Two hundred and seventy-five participants completed the study. Thirty-two participants did not complete the consent process and were excluded from analysis. One-hundred and forty-six males (60.1%), ninety-six females (39.5%), and 1 non-binary person (0.4%) completed the survey. The average age was 33.39 years, with a range from 20 to 73 years. Participants were grouped according to similar role description and current hierarchy in mental health care in Bangladesh as per suggestions from Giasuddin et al. ([<reflink idref="bib5" id="ref57">5</reflink>]), A. Hossain et al. ([<reflink idref="bib9" id="ref58">9</reflink>]), and Islam ([<reflink idref="bib11" id="ref59">11</reflink>]). These were: (<reflink idref="bib1" id="ref60">1</reflink>) psychiatrists (<emph>n</emph> = 35, 14.4%), (<reflink idref="bib2" id="ref61">2</reflink>) traditional healers and community workers (<emph>n</emph> = 30, 12.3%), (<reflink idref="bib3" id="ref62">3</reflink>) medical doctors (<emph>n</emph> =78, 32.1%), (<reflink idref="bib4" id="ref63">4</reflink>) nurses (<emph>n</emph> = 31, 12.8%), (<reflink idref="bib5" id="ref64">5</reflink>) psychologists (<emph>n</emph> = 35, 14.4%), (<reflink idref="bib6" id="ref65">6</reflink>) allied health (speech therapists, occupational therapists, social workers) (<emph>n</emph> = 33, 13.6%), and (<reflink idref="bib7" id="ref66">7</reflink>) "other" (teachers, physiotherapists, administration staff, etc.) (<emph>n</emph> = 22, 9.1%). Teachers, physiotherapists, and administration staff were not directly targeted for inclusion in this study, however, "word of mouth" dissemination of the survey meant that a small group of these professions were incidentally captured in the final sample. Medical doctors generally reported being either private practitioners or general practitioners.</p> <hd id="AN0148210041-10">Data Analysis</hd> <p>Analyses were conducted using SPSS (version 26) statistical software (SPSS Inc., Chicago, IL, USA). Univariate normality was assessed and could be assumed. The assumption of homogenous covariance matrices across professional groups was violated. Pillai's Trace was interpreted <emph>F</emph>(<reflink idref="bib36" id="ref67">36</reflink>, 1374) = 2.13, <emph>p</emph> <.001, partial</p> <p>Graph</p> <p> <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mrow><mi>η</mi></mrow></mrow></math> </ephtml> <sups>2</sups> =.053.</p> <p>To investigate the presence of the diagnostic overshadowing bias, a between-groups MANOVA was used. The between-groups factors were Practitioner type (psychiatrists, traditional healers and community workers, doctors, nurses, psychologists, allied health, other) and Vignette type (ID, IQ-typical). The dependent variables were the likelihood rating of each of the six diagnosis options (depression, social anxiety, drug problems, schizophrenia, being bullied, general anxiety disorder). To account for family-wise error rates as there were seven profession groups, a Bonferroni adjustment was used in the SPSS analyses, although this meant that the level of significance was very strict.</p> <hd id="AN0148210041-11">RESULTS</hd> <p>Table 1 shows the mean scores for the Profession groups, in which the different professions scored the likelihood of the diagnosis of each disorder or condition (depression, social anxiety, drug problems, schizophrenia, being bullied, general anxiety disorder) made by each of the different profession types, regardless of vignette that the participant had read.</p> <p>Table 1. Mean scores for each mental health disorder or condition provided by each profession type</p> <p> <ephtml> <table><thead><tr><td>Diagnosis</td><td>Psychiatrist</td><td>Healers & Community Workers</td><td>Doctor</td><td>Nurse</td><td>Psychologist</td><td>Allied Health</td><td>Other*</td></tr><tr><td>ID <italic>M (SD)</italic></td><td>IQt <italic>M (SD)</italic></td><td>ID <italic>M (SD)</italic></td><td>IQt <italic>M (SD)</italic></td><td>ID <italic>M (SD)</italic></td><td>IQt <italic>M (SD)</italic></td><td>ID <italic>M (SD)</italic></td><td>IQt <italic>M (SD)</italic></td><td>ID <italic>M (SD)</italic></td><td>IQt <italic>M (SD)</italic></td><td>ID <italic>M (SD)</italic></td><td>IQt <italic>M (SD)</italic></td><td>ID <italic>M (SD)</italic></td><td>IQt <italic>M (SD)</italic></td></tr></thead><tbody><tr><td>Depression</td><td>2.75 (1.04)</td><td>2.33 (1.75)</td><td>3.07 (1.94)</td><td>3.65 (1.69)</td><td>3.54 (1.48)</td><td>3.28 (1.65)</td><td>2.64 (1.46)</td><td>3.42 (1.74)</td><td>2.56 (1.46)</td><td>2.65 (1.35)</td><td>3.47 (1.74)</td><td>2.92 (1.49)</td><td>3.11 (1.53)</td><td>3.54 (1.39)</td></tr><tr><td>SAD</td><td>2.38 (1.19)</td><td>2.17 (1.60)</td><td>3.60 (1.59)</td><td>3.65 (1.69)</td><td>3.19 (1.55)</td><td>3.78 (1.58)</td><td>2.53 (1.42)</td><td>3.00 (1.57)</td><td>2.75 (1.44)</td><td>3.20 (1.24)</td><td>2.88 (1.45)</td><td>2.86 (1.46)</td><td>3.67 (1.66)</td><td>4.00 (1.08)</td></tr><tr><td>ID</td><td>4.25 (1.49)</td><td>2.33 (2.07)</td><td>3.00 (2.00)</td><td>2.71 (2.13)</td><td>2.81 (1.42)</td><td>2.06 (1.30)</td><td>3.65 (1.32)</td><td>2.86 (1.61)</td><td>4.50 (1.15)</td><td>2.58 (1.60)</td><td>2.91 (1.02)</td><td>1.93 (1.14)</td><td>3.78 (1.30)</td><td>2.77 (1.83)</td></tr><tr><td>Drug Problems</td><td>2.38 (1.06)</td><td>3.17 (1.47)</td><td>1.67 (0.98)</td><td>2.60 (1.54)</td><td>2.07 (1.28)</td><td>2.13 (1.48)</td><td>2.41 (1.46)</td><td>3.07 (1.14)</td><td>1.87 (1.02)</td><td>2.85 (1.50)</td><td>2.05 (1.30)</td><td>3.00 (1.62)</td><td>1.66 (1.11)</td><td>2.31 (1.32)</td></tr><tr><td>Schizophrenia</td><td>3.38 (1.77)</td><td>4.67 (0.82)</td><td>3.13 (1.55)</td><td>3.95 (1.57)</td><td>4.12 (1.27)</td><td>4.78 (0.55)</td><td>2.76 (1.64)</td><td>4.14 (1.29)</td><td>3.18 (1.38)</td><td>4.50 (0.95)</td><td>3.47 (1.37)</td><td>4.00 (1.30)</td><td>4.44 (0.88)</td><td>3.77 (1.48)</td></tr><tr><td>Being Bullied</td><td>1.88 (0.83)</td><td>2.67 (1.63)</td><td>2.80 (1.46)</td><td>3.20 (1.28)</td><td>2.90 (1.46)</td><td>2.50 (1.41)</td><td>2.47 (1.46)</td><td>3.07 (1.49)</td><td>2.88 (1.59)</td><td>3.20 (1.06)</td><td>2.82 (1.63)</td><td>3.42 (1.16)</td><td>3.33 (1.41)</td><td>3.77 (1.24)</td></tr><tr><td>GAD</td><td>2.50 (1.07)</td><td>3.00 (1.90)</td><td>3.40 (1.68)</td><td>3.80 (1.61)</td><td>3.79 (1.54)</td><td>3.90 (1.38)</td><td>2.88 (1.54)</td><td>4.14 (0.95)</td><td>2.88 (1.45)</td><td>3.15 (1.66)</td><td>3.29 (1.61)</td><td>3.29 (1.49)</td><td>3.88 (1.54)</td><td>4.46 (0.66)</td></tr></tbody></table> </ephtml> </p> <p>1 ID, Intellectual Disability; IQt, IQ-typical group; SAD, Social Anxiety Disorder; GAD, Generalized Anxiety Disorder.</p> <ulist> <item>2 *Other = teachers, physiotherapists, administration staff.</item> <item>3 Scale: 1 = <emph>strongly disagree</emph>, 2 = <emph>disagree</emph>, 3 = <emph>neutral</emph>, 4 = <emph>agree</emph>, 5 = <emph>strongly agree.</emph></item> </ulist> <p>Table 2 shows the means and standard deviations for the Vignette condition, i.e., Vignette 1 (IQ typical) and Vignette 2 (Person with ID), where participants rated the likelihood of diagnosis for each of the six mental health disorders or conditions.</p> <p>Table 2. Effect of vignette type on diagnosis for each mental health disorder or condition</p> <p> <ephtml> <table><thead><tr><td /><td>Vignette Group</td></tr></thead><tbody><tr><td /><td>V1 IQt <italic>M (SD)</italic></td><td>V2 ID <italic>M (SD)</italic></td></tr><tr><td>Diagnosis</td></tr><tr><td>Depression</td><td>3.19 (1.59)</td><td>3.15 (1.57)</td></tr><tr><td>SAD</td><td>3.40 (1.53)</td><td>3.03 (1.51)</td></tr><tr><td>ID</td><td>2.45 (1.62)</td><td>3.40 (1.50)</td></tr><tr><td>Drug Problem</td><td>2.61 (1.47)**</td><td>2.03 (1.21)**</td></tr><tr><td>Schizophrenia</td><td>4.31 (1.18)**</td><td>3.58 (1.47)**</td></tr><tr><td>Being bullied</td><td>3.05 (1.34)*</td><td>2.78 (1.42)*</td></tr><tr><td>GAD</td><td>3.73 (1.45)*</td><td>3.35 (1.55)*</td></tr></tbody></table> </ephtml> </p> <ulist> <item>4 Scale: 1 = <emph>strongly disagree</emph>, 2 = <emph>disagree</emph>, 3 = <emph>neutral</emph>, = agree, 5 = <emph>strongly agree</emph>.</item> <item>5 ID, Intellectual Disability; IQt, IQ-typical group; SAD, Social Anxiety Disorder; GAD, Generalized Anxiety Disorder. *Indicates <emph>p < </emph>0.05. **Indicates <emph>p < </emph>0.01.</item> </ulist> <p>A between-groups 2 × 7 MANOVA was conducted, using the type of Vignette (IQ typical, ID) and the participants' Profession (psychiatrists, traditional healers and community workers, doctors, nurses, psychologists, allied health, other). The outcomes were the likelihood of the six different diagnoses or conditions. First, the results of the MANOVA found a significant main effect for the type of Vignette, as practitioners who received the IQ typical vignette being more likely to diagnose disorders than those receiving vignette with the low IQ vignette (<emph>F(</emph>6, 224) = 5.65, <emph>p < </emph>.001, η<sups>2</sups> =.131). Follow-up ANOVAs found that across the professions, participants were more likely to diagnose the typical IQ person with drug problems (F(<reflink idref="bib1" id="ref68">1</reflink>,<reflink idref="bib229" id="ref69">229</reflink>) = 13.533, <emph>p</emph> <.001, n<sups>2</sups> =.056), schizophrenia (F(<reflink idref="bib1" id="ref70">1</reflink>,<reflink idref="bib226" id="ref71">226</reflink>) = 16.764, <emph>p</emph> <.001, n2 =.068), and GAD (F(<reflink idref="bib1" id="ref72">1</reflink>,<reflink idref="bib229" id="ref73">229</reflink>) = 3.926, <emph>p</emph> =.049) and experiencing bullying (F(<reflink idref="bib1" id="ref74">1</reflink>,<reflink idref="bib229" id="ref75">229</reflink>) = 4.363, <emph>p</emph> =.038, n2 =.019) than a person with an ID.</p> <p>Second, the results of the MANOVA found a significant main effect of the type of Profession in how the professions overall diagnosed the different disorders (<emph>F</emph>(<reflink idref="bib36" id="ref76">36</reflink>, 1374) = 2.13, <emph>p < </emph>.001, η<sups>2</sups> =.053). Specifically, the professions differed significantly in how they diagnosed schizophrenia (<emph>F</emph> (<reflink idref="bib6" id="ref77">6</reflink>, 229) = 3.43; <emph>p</emph> <.016; partial η<sups>2</sups> =.08), SAD (<emph>F</emph> (<reflink idref="bib6" id="ref78">6</reflink>, 229) = 3.24; <emph>p</emph> <.016; partial η<sups>2 </sups>=.08), and GAD (<emph>F</emph> (<reflink idref="bib6" id="ref79">6</reflink>, 229) = 2.75; <emph>p</emph> <.016; partial η<sups>2</sups> =.07). For schizophrenia, doctors were more likely than nurses (<emph>t</emph>(<reflink idref="bib103" id="ref80">103</reflink>) = 3.61, <emph>p</emph> =.008) and healers and community workers (<emph>t</emph>(<reflink idref="bib107" id="ref81">107</reflink>) = 3.41, <emph>p</emph> =.016) to diagnose the disorder or condition. For SAD, the likelihood of diagnosis was only nominally higher for psychiatrists than the other professions (i.e., amongst teachers, physiotherapists, administration staff) (<emph>t</emph>(<reflink idref="bib34" id="ref82">34</reflink>) = 3.02, <emph>p</emph> =.059). Finally, for GAD, psychologists were nominally more likely than the other professions to diagnose GAD (<emph>t</emph>(<reflink idref="bib56" id="ref83">56</reflink>) = 2.87, <emph>p</emph> =.093).</p> <p>Finally, the MANOVA results found that the interaction between Vignette and Profession was non-significant, <emph>F</emph>(<reflink idref="bib36" id="ref84">36</reflink>, 1374) = 0.987, <emph>p</emph> =.492, η<sups>2</sups> =.025. Individual ANOVAs were also non-significant (i.e., range <emph>p</emph>s =.092-.953). As such, none of the interactions were explored to avoid Type I errors.</p> <hd id="AN0148210041-12">DISCUSSION</hd> <p>This study sought to investigate the diagnostic overshadowing bias in a sample of Bangladeshi health practitioners. Consistent with our hypotheses, participants were more likely to diagnose mental health disorders or conditions in IQ typical clients compared to those with an ID, indicating the presence of the bias. In particular, practitioners were more likely to consider diagnoses of schizophrenia, drug problems and being bullied for people with a typical IQ than those with an ID. Our results also demonstrate that diagnoses made differed by profession type. For example, regardless of vignette, psychiatrists were more likely than other practitioners (such as teachers, administration, and team leaders) to diagnose SAD. Doctors were more likely than nurses, traditional healers, and community workers to diagnose schizophrenia (the implied ICD-10 diagnosis described in the vignette). Finally, psychologists were nominally more likely than other practitioners to diagnose GAD. Contrary to our predictions, no profession was more likely than any other to demonstrate diagnostic overshadowing.</p> <p>Our results were similar to those of Mason and Scior ([<reflink idref="bib21" id="ref85">21</reflink>]), in that disorders and conditions such as schizophrenia and drug problems were more likely to be diagnosed for people with an IQ within the typical range, and less likely for those with an ID. This suggests that Bangladeshi practitioners may subscribe to common misconceptions that people with IDs do not use drugs (Chapman & Wu, [<reflink idref="bib3" id="ref86">3</reflink>]) and are not susceptible to more serious mental health disorders such as schizophrenia (Morgan et al., [<reflink idref="bib23" id="ref87">23</reflink>]).</p> <hd id="AN0148210041-13">Bullying and Diagnostic Overshadowing Bias</hd> <p>In addition, our results suggested Bangladeshi practitioners perceived those with an ID as less likely to be bullied compared to people with a typical IQ. This finding was unexpected, and did not reflect existing research indicating that people with disabilities or mental health disorders in Bangladesh tend to experience discrimination, negative attitudes, and hardship from both society and from treating health practitioners (M. D. Hossain et al., [<reflink idref="bib10" id="ref88">10</reflink>]; Giasuddin et al., [<reflink idref="bib5" id="ref89">5</reflink>]; Islam, [<reflink idref="bib11" id="ref90">11</reflink>]). Existing literature has mostly reported on the perceptions of the general Bangladesh public, whereas our findings were based on the perceptions of health practitioners, who may have more day to day professional exposure to this client population. This hints at a discrepancy between societal perceptions of people with an ID and mental health disorders and health practitioners who work with this client population. Our results may indicate that Bangladeshi health practitioners have limited understanding of the difficulties faced in society by people with an ID and mental health problems.</p> <hd id="AN0148210041-14">Depression and Diagnostic Overshadowing Bias</hd> <p>Our results further indicated that participants did not differ in likelihood of diagnosing anxiety disorders (SAD and GAD) or depression. Furthermore, the majority of Bangladeshi health practitioners in the study either disagreed or were neutral about diagnosing depression, regardless of vignette. This suggests that Bangladeshi health practitioners may be less likely to diagnose depression for both people with an ID and IQ typical people. This finding is concerning considering that both depression and anxiety are globally the most prevalent mental health disorders (WHO, [<reflink idref="bib33" id="ref91">33</reflink>]).</p> <p>Previous reports demonstrate the likelihood that health practitioners make a diagnosis of depression for a person with an ID when given the choice between other possible diagnoses. For example, an Australian study used an almost identical vignette format to detect the DOB, and found that out of six possible diagnoses (depression, social anxiety disorder, drug problem, schizophrenia, being bullied, and generalized anxiety disorder), medical professionals were least likely to make a diagnosis of depression for the person with an ID. However, a further similar study from the UK showed that when given a choice between several possible diagnoses psychiatrists and psychologists were more likely to diagnose depression than the other options, in a client with an ID (Mason & Scior, [<reflink idref="bib21" id="ref92">21</reflink>]). This finding was also consistent in a sample of Israeli psychiatrists (Werner et al., [<reflink idref="bib31" id="ref93">31</reflink>]).</p> <p>Harris ([<reflink idref="bib6" id="ref94">6</reflink>]) provided anecdotal evidence that depression was often missed in a number of clients with an ID due to poor screening tools, irregular symptom presentation, and a mismatch between diagnostic criteria between ID populations and that of the general population. Both Harris ([<reflink idref="bib6" id="ref95">6</reflink>]) and Jamieson and Mason ([<reflink idref="bib12" id="ref96">12</reflink>]) attributed their findings to possible lower levels of confidence in detecting internal symptoms, such as a patient's mood and thoughts. In addition to low confidence, Hinde and Mason ([<reflink idref="bib8" id="ref97">8</reflink>]) suggested that limited knowledge of depression and anxiety symptomology may influence the likelihood of diagnosis.</p> <hd id="AN0148210041-15">ID Detection and Diagnostic Overshadowing Bias</hd> <p>With the exception of the psychiatrist and psychologist professions, our results indicated that professions were no more likely to diagnose ID in the ID vignette than in the IQ typical vignette. That Bangladeshi health practitioners do not recognize the symptoms of intellectual disability is concerning and may present further implications to this research. For example, if medical practitioners and community health workers, who are usually the first points of care are unable to recognize symptoms of ID, detection of mental health issues in this client population may be secondary issue.</p> <hd id="AN0148210041-16">Training and Diagnostic Overshadowing Bias</hd> <p>Contrary to our predictions, our results found that participants who were more likely to have a background of diagnostic training (e.g., psychiatrists, doctors, psychologists) were no less affected by the bias than other professions with limited to no diagnostic training (social work, occupational therapy, speech therapy, community work, nursing). This was an unexpected outcome, as existing literature indicates that medical professionals who have background training in diagnostic practice are less likely to make diagnostic errors, compared to practitioners who have not undergone intensive diagnostic training (Man et al., [<reflink idref="bib20" id="ref98">20</reflink>]). There may be several explanations for no difference between professions being detected. Firstly, it may be possible that health care training programs in Bangladesh, introduce or concretize bias. For example, in tertiary training students may learn about intellectual disability and may infer differences in mental health presentation where none exists. Secondly, given the health structure in Bangladesh, community-based practitioners, traditional healers, allied health professionals and nurses are less likely to make use of diagnoses in their practice, possibly due to having less knowledge about ID.</p> <hd id="AN0148210041-17">Traditional Healers</hd> <p>An additional profession category of traditional healer was included in this study. This profession type had not been included in any previous studies investigating the overshadowing bias, suggesting that in developed countries, healers are not commonly associated with health care provision for persons with ID and mental disorders. Our results indicated that although traditional healers were the least likely out of all professionals to make a diagnosis of schizophrenia, they were more likely to diagnose depression and anxiety in both IQ typical and ID populations than other professions. While it is encouraging to note that healers are detecting behavioral and emotional disturbance, our results indicate that they may be less likely to recognize more complex mental health disorders such as schizophrenia, and as a default, may diagnose anxiety and depression. This is concerning in the context of research suggesting that community-based healers act as a front-line health service for people with mental health symptoms up to 90% of the time in Bangladesh due to shortages of, and limited access to trained mental health practitioners (Abdullah et al., [<reflink idref="bib1" id="ref99">1</reflink>]; Rawal et al., [<reflink idref="bib26" id="ref100">26</reflink>]; WHO, [<reflink idref="bib34" id="ref101">34</reflink>]). With healers being largely responsible for the detection of mental health disorders, and access to trained mental health professionals being limited, our results may indicate that complex mental health disorders may currently be largely undetected and untreated in Bangladesh.</p> <hd id="AN0148210041-18">LIMITATIONS</hd> <p>While the presence of the diagnostic overshadowing bias was demonstrated statistically, other authors dispute whether traditional methodology reflects reality, as the bias has yet to be demonstrated outside of vignette approaches (Jamieson & Mason, [<reflink idref="bib12" id="ref102">12</reflink>]; Mason & Scior, [<reflink idref="bib21" id="ref103">21</reflink>]). In addition, our sample size distribution was unbalanced between professional groups. While this aided statistical comparison, it may have reduced the richness of the data for each specific profession.</p> <p>Finally, researchers involved in this study were mostly Australian psychologists, therefore, some cultural differences may have been overlooked. Authors attempted to mitigate cross-cultural differences by including the following measures: the lead researcher had previously lived and worked in Bangladesh; the project was granted ethical approval by an ethics committee in Bangladesh; an in-country Bangladeshi researcher and host organization were recruited; and regular discussion and cross-checking of all documents and translations with in-country health practitioners occurred throughout the project.</p> <hd id="AN0148210041-19">RECOMMENDATIONS</hd> <p>The question now arises of how to utilize these findings to assist Bangladeshi health practitioners, and those living with mental health disorders and comorbid IDs in Bangladesh. Importantly, consideration should be given to improving practitioner knowledge of mental health symptoms and accurate diagnosis and treatment of mental health disorders in persons with an ID. Existing research has suggested that promoting awareness and acknowledgment of the diagnostic overshadowing bias may be the first step to reducing bias (Shefer et al., [<reflink idref="bib27" id="ref104">27</reflink>]).</p> <hd id="AN0148210041-20">Training for Health Practitioners</hd> <p>In addition, existing literature suggests that the development and implementation of ID-specific training may increase knowledge, improve assessment, diagnosis and treatment, and reduce bias in health practitioners toward this client population (Jamieson & Mason, [<reflink idref="bib12" id="ref105">12</reflink>]; Jess et al., [<reflink idref="bib14" id="ref106">14</reflink>]). For example, Shefer et al. ([<reflink idref="bib27" id="ref107">27</reflink>]) attributed improvements in mental health detection in persons with an ID in the USA to the development and availability of ID-specific training and professional development opportunities. Despite these suggestions, there have been no clinical trials conducted to examine the effect of targeted training on the presence of the DOB in health professionals working with people with IDs and co-occurring mental health problems. As our results indicate the presence of the bias in a sample of Bangladeshi health professionals, it is recommended that a clinical trial examining the effects of ID specific training on the presence of the DOB in health professionals be conducted in Bangladesh.</p> <p>Existing literature indicates that Bangladesh has already undergone a successful trial of training community health practitioners in mental health detection and care (WHO, [<reflink idref="bib34" id="ref108">34</reflink>]). This trial did not target traditional healers, other allied health or medical professionals. To the best of our knowledge, this training protocol, or any other ID and/or mental health-specific training, has not been widely implemented for medical and/or allied health professionals (e.g., psychiatrists, doctors, psychologists). Literature reveals that traditional healers and community health workers are largely the first point of care for people presenting with IDs and mental health concerns in the Bangladeshi community. Therefore, if training programs similar to those run previously by the WHO were to be re-introduced, it is recommended they are intentionally designed to address mental health care for the ID population, and are targeted toward both community-based practitioners (traditional healers, community health workers) and medical professionals (psychiatrists, doctors, and allied health professionals).</p> <p>Drawing from countries such as the UK, Australia, and the USA may be useful in gauging the scope of health practitioner training required to eliminate, or reduce, the presence of bias in Bangladeshi health practitioners. In these countries, intentionally designed ID specific training was gradually developed and implemented across tertiary settings, and in both hospital (inpatient and outpatient facilities) and community healthcare settings, in order to encourage widespread awareness of mental health disorders in people with an ID (Jess et al., [<reflink idref="bib14" id="ref109">14</reflink>]; Weise & Trollor, [<reflink idref="bib30" id="ref110">30</reflink>]).</p> <hd id="AN0148210041-21">CONCLUSION</hd> <p>The results of the present study suggest that the diagnostic overshadowing bias was present in a sample of Bangladeshi health practitioners. Of the seven mental health disorders included in this study, practitioners were more likely to consider diagnoses of schizophrenia, drug problems and being bullied for people with a typical IQ than those with an ID. We also found that no profession type was more likely than any other to demonstrate the bias. The development and implementation of training programs to meet the differing needs of practitioners across the health fields are recommended. In particular, the model of training initiated by the WHO in 1995 provides a starting point for moving forward. Facilitating ongoing training will not only enhance the capacity of health practitioners across all levels of care in the diagnosis of mental disorders in people with an ID, but will also improve outcomes for this clinical population within Bangladesh.</p> <hd id="AN0148210041-22">DISCLOSURE STATEMENT</hd> <p>No conflicts of interest are associated with this study.</p> <ref id="AN0148210041-23"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref13" type="bt">1</bibl> <bibtext> This manuscript has not been published elsewhere and has not been submitted simultaneously for publication elsewhere.</bibtext> </blist> </ref> <ref id="AN0148210041-24"> <title> REFERENCES </title> <blist> <bibtext> Abdullah, A. S., Rawal, L. B., Choudhury, S. R., Baral, S., Jiang, L., & Sha, T. (2019). Use of community health workers to manage and prevent noncommunicative diseases: policy options based on findings of the COACH study. World Health Organisatio n. Regional Office for South-East Asia. https://apps.who.int/iris/handle/10665/325733</bibtext> </blist> <blist> <bibl id="bib2" idref="ref37" type="bt">2</bibl> <bibtext> Bangladesh Health Watch Report. (2016). Non-communicable diseases in Bangladesh: Current scenario and future directions. BRAC University, Bangladesh Health Watch Secretariat.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref62" type="bt">3</bibl> <bibtext> Chapman, C. S. L., & Wu, L. T. (2012). Substance abuse among individuals with intellectual disabilities. Research in Developmental Disabilities, 33 (4), 1147 – 1156. https://doi.org/10.1016/j.ridd.2012.02.009</bibtext> </blist> <blist> <bibl id="bib4" idref="ref45" type="bt">4</bibl> <bibtext> Geiss, M., Chamberlain, J., Weaver, T., McCormick, C., Raufer, A., & Scoggins, L. (2017). Diagnostic overshadowing of the psychiatric population in the emergency department: Physiological factors identified for an early warning system. Journal of the American Psychiatric Nurses Association, 24 (4), 327 – 331. https://doi.org/10.1177/1078390317728775</bibtext> </blist> <blist> <bibl id="bib5" idref="ref11" type="bt">5</bibl> <bibtext> Giasuddin, N. A., Chowdhury, N. F., Hashimoto, N., Fujisawa, D., & Waheed, S. (2012). Pathways to psychiatric care in Bangladesh. Social Psychiatry and Psychiatric Epidemiology, 47 (1), 129 – 136. https://doi.org/10.1007/s00127-010-0315-y</bibtext> </blist> <blist> <bibl id="bib6" idref="ref32" type="bt">6</bibl> <bibtext> Harris, J. C. (2006). Intellectual disability: Understanding its development, causes, classification, evaluation, and treatment. Oxford University Press.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref38" type="bt">7</bibl> <bibtext> Hasan, M. T., Sultana, A., Faizah, F., & Hossain, M. M. (2019). New mental health act in Bangladesh: Unfinished agendas. The Lancet, 6 (1). https://doi.org/10.1016/S2215-0366(18)30472-3</bibtext> </blist> <blist> <bibl id="bib8" idref="ref27" type="bt">8</bibl> <bibtext> Hinde, K., & Mason, J. (2020). Health practitioner knowledge and confidence in diagnosis and treatment of mental health issues in people with intellectual disabilities. Journal of Intellectual & Developmental Disability, 45 (3), 269 – 278. https://doi.org/10.3109/13668250.2020.1730075</bibtext> </blist> <blist> <bibl id="bib9" idref="ref48" type="bt">9</bibl> <bibtext> Hossain, A., Rehena, J., & Razia, M. S. (2018). Mental Health Disorders Status in Bangladesh: A Systematic Review. JOJ Nursing & Health Care, 7 (2), 1 – 4. https://doi.org/10/19080/JOJNHC.2018.07.555708</bibtext> </blist> <blist> <bibtext> Hossain, M. D., Ahmed, H. U., Chowdhury, W. A., Niessen, L. W., & Alam, D. S. (2014). Mental disorders in Bangladesh: A systematic review. BMC Psychiatry, 14 (1), 216. https://doi.org/10.1186/s12888-014-0216-9</bibtext> </blist> <blist> <bibtext> Islam, T. (2019). Short-term follow up treatment outcome and referral pattern of mental illness at a psychiatric outpatient clinic of Dhaka city, Bangladesh. Global Scientific Journals, 7 (5), 115 – 127. https://eoi.citefactor.org/10.11216/gsj.2019.05.21120</bibtext> </blist> <blist> <bibtext> Jamieson, D., & Mason, J. (2019). Investigating the existence of the diagnostic overshadowing bias in Australia. Journal of Mental Health Research in Intellectual Disabilities, 12 (1–2), 58 – 70. https://doi.org/10.1080/19315864.2019.1595231</bibtext> </blist> <blist> <bibtext> Jasraj, S., & Viknesh, N. (2017). A better mental health for all. MJP, 26 (1), 52 – 61. https://<ulink href="http://www.mjpsychiatry.org/index.php/mjp/article/view/431/322">www.mjpsychiatry.org/index.php/mjp/article/view/431/322</ulink></bibtext> </blist> <blist> <bibtext> Jess, G., Torr, J., Cooper, S., Lennox, N., Edwards, N., Galea, J., & O'Brien, G. (2008). Specialist versus generic models of psychiatry training and service provision for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 21 (2), 183 – 193. https://doi.org/10.1111/j.1468-3148.2007.00394.x</bibtext> </blist> <blist> <bibtext> Karim, R., Shaheed, F., & Paul, S. (2006). Psychiatry in Bangladesh. International Psychiatry, 3 (3), 16 – 18. https://doi.org/10.1192/S1749367600004835</bibtext> </blist> <blist> <bibtext> Kohrt, B. A., Jordans, M. J. D., Turner, E. L., Sikkema, K. J., Luitel, N. P., & Rai, S. (2018). Reducing stigma among healthcare providers to improve mental health services (RESHAPE): Protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal. Pilot & Feasibility Studies, 4 (36), 1–18. https://doi.org/10.1186/s40814-018-0234-3</bibtext> </blist> <blist> <bibtext> Levitan, G., & Reiss, S. (1983). Generality of diagnostic overshadowing across disciplines. Applied Research in Mental Retardation, 4 (1), 59 – 64. https://doi.org/10.1016/S0270-3092(83)80018-6</bibtext> </blist> <blist> <bibtext> Levitan, G., & Reiss, S. (1983). Generality of diagnostic overshadowing across disciplines. Applied Research in Mental Retardation, 4, 59 – 64. doi: 10.1016/S02703092(83)80018-6 1 4</bibtext> </blist> <blist> <bibtext> Li, J., Fan, Y., Zhong, H., Duan, X., Chen, W., Evans-Lacko, S., & Thornicroft, G. (2019). Effectiveness of an anti-stigma training on improving attitudes and decreasing discrimination towards people with mental disorders among care assistant workers in Guangzhou, China. International Journal of Mental Health Systems, 13 (1), 1–10. https://doi.org/10.1186/s13033-018-0259-2</bibtext> </blist> <blist> <bibtext> Man, J., Kangas, M., Trollor, J., & Sweller, N. (2017). Clinical competencies and training needs of psychologists working with adults with intellectual disabilities and comorbid mental ill health. Clinical Psychologist, 21 (3), 206 – 214. https://doi.org/10.1111/cp.12092</bibtext> </blist> <blist> <bibtext> Mason, J., & Scior, K. (2004). 'Diagnostic overshadowing' amongst clinicians working with people with intellectual disabilities in the UK. Journal of Applied Research in Intellectual Disabilities, 17 (2), 85 – 90. https://doi.org/10.1111/j.1360-2322.2004.00184.x</bibtext> </blist> <blist> <bibtext> Ministry of Health and Family Welfare. (2019). Bangladesh national strategy for community health workers.</bibtext> </blist> <blist> <bibtext> Morgan, V. A., Leonard, H., Bourke, J., & Jablensky, A. (2008). Intellectual disability co- occurring with schizophrenia and other psychiatric illness: Populations-based study. The British Journal of Psychiatry : The Journal of Mental Science, 193 (5), 364 – 372. https://doi.org/10.1192/bjp.bp.107.044461</bibtext> </blist> <blist> <bibtext> Nuri, N. N., Sarker, M., Ahmed, H. U., Hossain, M. D., Beiersmann, C., & Jahn, A. (2018). Pathways to care of patients with mental health problems in Bangladesh. International Journal of Mental Health Systems, 12 (1), 39. https://doi.org/10.1186/s13033-018-0218-y</bibtext> </blist> <blist> <bibtext> Rasmussen, J. D., Kakuhikire, B., Baguma, C., Ashaba, S., Cooper-Vince, C. E., & Perkins, J. M. (2019). Portrayals of mental illness, treatment, and relapse, and their effects on the stigma of mental illness: Population-based, randomised survey experiment in rural Uganda. PLoS Medicine, 16 (9), 2 – 19. https://doi.org/10.1371/journal.pmed.1002908</bibtext> </blist> <blist> <bibtext> Rawal, L. B., Kanda, K., Biswas, T., Tanim, I., Poudel, P., & Renzaho, A. M. N. (2019). Non-communicable disease (NCD) corners in public sector health facilities in Bangladesh: A qualitative study assessing challenges and opportunities for improving NCD services at the primary healthcare level. BMJ, 9, 1–9. https://doi.org/10.1136/bmjopen-2019-029562</bibtext> </blist> <blist> <bibtext> Shefer, G., Henderson, C., Howard, L. M., Murray, J., & Thornicroft, G. (2014). Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms – A qualitative study. PLoS One, 9 (11), e111682. https://doi.org/10.1371/journal.pone.0111682</bibtext> </blist> <blist> <bibtext> Thornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., & Rose, D. (2016). Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet, 387 (10023), 1123 – 1132. https://doi.org/10.1016/S0140-6736(15)00298-6</bibtext> </blist> <blist> <bibtext> United Nations Development Programme. (2015). Human development report. UNPD.</bibtext> </blist> <blist> <bibtext> Weise, J., & Trollor, J. N. (2017). Preparedness and training needs of an Australian public mental health workforce in intellectual disability mental health. Journal of Intellectual & Developmental Disability, 43(4), 431–440. https://doi.org/10.3109/13668250.2017.1310825</bibtext> </blist> <blist> <bibtext> Werner, S., Levav, I., Stawski, M., & Polakiewicz, Y. (2007). Israeli psychiatrists report on their ability to care for individuals with intellectual disability and psychiatric disorders. Isr J Psychiatry Relat Sci, 50 (3), 202 – 9. PMID:24622480</bibtext> </blist> <blist> <bibtext> World Bank, World Development Indicators. (2019). The World Bank Annual Report: Ending Poverty, Investing in Opportunity. Washington, DC: World Bank. https://data.worldbank.org/indicator/IT.NET.USER.ZS</bibtext> </blist> <blist> <bibtext> World Health Organisation. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. World Health Organization.</bibtext> </blist> <blist> <bibtext> World Health Organisation Division of Strengthening of Health Services and the Traditional Medicine Programme. (1995). Traditional practitioners as primary health care workers. World Health Organisation, California.</bibtext> </blist> <blist> <bibtext> World Health Organisation. Regional Office for South-East Asia. (2007). WHO-AIMS report on mental health systems in Bangladesh. WHO Regional Office for South-East Asia. https://apps.who.int/iris/handle/10665/206149</bibtext> </blist> </ref> <aug> <p>By Kylie Hinde; Jonathan Mason; Lee Kannis-Dymand; Prudence Millear and Razia Sultana</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib29" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib33" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib32" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib10" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib11" firstref="ref5"></nolink> <nolink nlid="nl6" bibid="bib24" firstref="ref6"></nolink> <nolink nlid="nl7" bibid="bib35" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib26" firstref="ref12"></nolink> <nolink nlid="nl9" bibid="bib34" firstref="ref14"></nolink> <nolink nlid="nl10" bibid="bib15" firstref="ref17"></nolink> <nolink nlid="nl11" bibid="bib20" firstref="ref19"></nolink> <nolink nlid="nl12" bibid="bib22" firstref="ref20"></nolink> <nolink nlid="nl13" bibid="bib17" firstref="ref21"></nolink> <nolink nlid="nl14" bibid="bib21" firstref="ref22"></nolink> <nolink nlid="nl15" bibid="bib27" firstref="ref24"></nolink> <nolink nlid="nl16" bibid="bib28" firstref="ref25"></nolink> <nolink nlid="nl17" bibid="bib25" firstref="ref33"></nolink> <nolink nlid="nl18" bibid="bib19" firstref="ref34"></nolink> <nolink nlid="nl19" bibid="bib13" firstref="ref35"></nolink> <nolink nlid="nl20" bibid="bib16" firstref="ref36"></nolink> <nolink nlid="nl21" bibid="bib12" firstref="ref40"></nolink> <nolink nlid="nl22" bibid="bib18" firstref="ref42"></nolink> <nolink nlid="nl23" bibid="bib14" firstref="ref50"></nolink> <nolink nlid="nl24" bibid="bib36" firstref="ref67"></nolink> <nolink nlid="nl25" bibid="bib229" firstref="ref69"></nolink> <nolink nlid="nl26" bibid="bib226" firstref="ref71"></nolink> <nolink nlid="nl27" bibid="bib103" firstref="ref80"></nolink> <nolink nlid="nl28" bibid="bib107" firstref="ref81"></nolink> <nolink nlid="nl29" bibid="bib56" firstref="ref83"></nolink> <nolink nlid="nl30" bibid="bib23" firstref="ref87"></nolink> <nolink nlid="nl31" bibid="bib31" firstref="ref93"></nolink> <nolink nlid="nl32" bibid="bib30" firstref="ref110"></nolink>
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  Group: Ti
  Data: 'Investigating the Diagnostic Overshadowing Bias in Bangladeshi Health Professionals'
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  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Hinde%2C+Kylie%22">Hinde, Kylie</searchLink><br /><searchLink fieldCode="AR" term="%22Mason%2C+Jonathan%22">Mason, Jonathan</searchLink><br /><searchLink fieldCode="AR" term="%22Kannis-Dymand%2C+Lee%22">Kannis-Dymand, Lee</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-1882-6121">0000-0002-1882-6121</externalLink>)<br /><searchLink fieldCode="AR" term="%22Millear%2C+Prudence%22">Millear, Prudence</searchLink><br /><searchLink fieldCode="AR" term="%22Sultana%2C+Razia%22">Sultana, Razia</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Mental+Health+Research+in+Intellectual+Disabilities%22"><i>Journal of Mental Health Research in Intellectual Disabilities</i></searchLink>. 2021 14(1):89-106.
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  Label: Availability
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 18
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2021
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Secondary+Education%22">Secondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Intellectual+Disability%22">Intellectual Disability</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Comorbidity%22">Comorbidity</searchLink><br /><searchLink fieldCode="DE" term="%22Clinical+Diagnosis%22">Clinical Diagnosis</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Personnel%22">Health Personnel</searchLink><br /><searchLink fieldCode="DE" term="%22Social+Bias%22">Social Bias</searchLink><br /><searchLink fieldCode="DE" term="%22Vignettes%22">Vignettes</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Intelligence+Quotient%22">Intelligence Quotient</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Special+Education%22">Special Education</searchLink><br /><searchLink fieldCode="DE" term="%22Likert+Scales%22">Likert Scales</searchLink><br /><searchLink fieldCode="DE" term="%22Secondary+Education%22">Secondary Education</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Attainment%22">Educational Attainment</searchLink><br /><searchLink fieldCode="DE" term="%22Schizophrenia%22">Schizophrenia</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Abuse%22">Drug Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Bullying%22">Bullying</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Physicians%22">Physicians</searchLink><br /><searchLink fieldCode="DE" term="%22Psychiatry%22">Psychiatry</searchLink><br /><searchLink fieldCode="DE" term="%22Folk+Culture%22">Folk Culture</searchLink><br /><searchLink fieldCode="DE" term="%22Medicine%22">Medicine</searchLink><br /><searchLink fieldCode="DE" term="%22Psychologists%22">Psychologists</searchLink><br /><searchLink fieldCode="DE" term="%22Allied+Health+Personnel%22">Allied Health Personnel</searchLink><br /><searchLink fieldCode="DE" term="%22Professional+Development%22">Professional Development</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Bangladesh%22">Bangladesh</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/19315864.2020.1856244
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1931-5864
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Introduction: Intellectual disability (ID) and co-morbid mental health problems are more common in developing countries such as Bangladesh. However, little is known about how Bangladeshi health practitioners diagnose mental health disorders in people with an ID. Studies in developed countries have explored the impact of the diagnostic overshadowing bias (DOB): the tendency for health practitioners to misattribute mental health symptomology to a client's ID, rather than a separate mental health disorder. To date, no study has investigated the presence of the DOB in Bangladesh. Method: A range of Bangladeshi health practitioners (N = 243) were randomly assigned a clinical vignette describing a client displaying symptoms of a mental health disorder. Vignette 1 described a client with an IQ of 105 who graduated from secondary school. Vignette 2 described a client with an IQ of 55 who attended special education. All other details were identical. Participants rated the likelihood of seven mental health diagnoses on a 5-point Likert scale. Results: Practitioners were more likely to diagnose schizophrenia, drug problems and being bullied in people with a typical IQ compared to those with an ID. Doctors, psychiatrists, and psychologists appeared to be more affected by the DOB than community health workers, traditional healers, and allied health practitioners. Conclusion: Findings indicate that the bias may be present in Bangladesh healthcare professionals. The development and implementation of specific training programs to meet the differing needs of practitioners, across the health fields are recommended.
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  Data: 2021
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  Data: EJ1283426
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      – SubjectFull: Intellectual Disability
        Type: general
      – SubjectFull: Mental Disorders
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