Target-specific stigma change: a strategy for impacting mental illness stigma

Adolescent boys' experiences of mental health and school health services - an interview study from Norway

BACKGROUND

Mental health problems among adolescents is a global challenge. During the transition to adolescence, physiological, psychological, and social changes occur, leading to increased vulnerability. Thus, adolescent boys are less likely to seek help for mental health problems, which makes them an undetected group. The aim of this study was to gain a deeper understanding of adolescent boys' experiences of mental health and school health service.

METHODS

An inductive, qualitative design was chosen using three focus group interviews and three individual interviews. The study included 18 adolescent boys in 7th grade, in a school located in a medium-sized municipality in Norway. The interviews were analysed with qualitative content analysis. The consolidated criteria for reporting qualitative research (COREQ) were followed in this study.

RESULTS

The overall theme "barriers towards seeking help", and three categories- navigating stigma and privacy concerns; perceptions of self-responsibility; and lacking knowledge of mental health problems and help-seeking-described the adolescent boys experiences. The awareness and willingness to seek help were present, but there are barriers preventing the adolescent boys from acting on that willingness.

CONCLUSIONS

Lack of knowledge and a non-permissive culture for mental health problems among adolescents contributes to decreased help-seeking behaviour among adolescent boys. The school health service is the most related health service for adolescents and should focus on being available and strengthening empowerment and mental health literacy through the development and implementation of interventions to promote mental health.

The Personal Suicide Stigma Questionnaire (PSSQ): Relation to Self-Esteem, Well-Being, and Help-Seeking

Two studies are reported that extend the evidence base for use of the Personal Stigma of Suicide Questionnaire (PSSQ). In the first study (N = 117), the Rosenberg Self-Esteem Scale, the WHO-5 measure of well-being, as well as measures of suicidality were examined in relation to the PSSQ. A self-selected sub-sample (N = 30) completed the PSSQ after an interval of two months. In line with the stigma internalization model, when demographic variables and suicidality were accounted for, the PSSQ self-blame subscale was the most significant predictor of self-esteem. As for well-being, the rejection subscale was involved as well as self-blame. The retest stability of the PSSQ for the sub-sample was 0.85 and coefficient alpha for the total sample was 0.95, indicating both good stability and internal consistency for the scale. In the second study (N = 140), PSSQ was studied in relation to intention to seek help from four sources in the case of suicidal ideation. The strongest relationship with PSSQ was with intention not to seek help from anyone (r = 0.35). When other variables were included in the prediction of help-seeking from a general medical practitioner, family or friends, or from nobody, the only significant PSSQ correlate was minimization. For help-seeking from a psychologist or psychiatrist, the most significant predictor was judged helpfulness of prior contact with them. The results from these studies strengthen previous findings of the construct validity of the PSSQ and point to its utility in understanding barriers to help-seeking among those experiencing suicidality.

Exploring Local Values and Beliefs to Develop School-based Mental Health Anti-Stigma: A Phenomenology Study

BACKGROUND: Students in middle-income countries frequently experience stigma related to mental disorders (MDs). Those with MDs are stereotyped as incompetent, uncontrollable, uncooperative, and dangerous. Stereotypes are predominantly formed and disseminated due to culture and beliefs. Therefore, it is essential to investigate, comprehend, and apply the local values and beliefs to increase the effectiveness of school-based anti-stigma programs. AIM: This study aims to investigate the local values and beliefs related to mental health anti-stigma as early initiation of school-based anti-stigma development. METHODS: This is an exploratory phenomenological study. A total of 30 informants were interviewed personally or participated in focus group discussions. Content analysis was performed to identify related sub-themes and themes. RESULTS: This study identified seven themes and 15 sub-themes. The seventh theme included the importance of school-based anti-stigma, school-based anti-stigma approach, school-based anti-stigma method, media dissemination of school-based anti-stigma information, design of school-based anti-stigma information, the target group of school-based anti-stigma, and collaboration partners of school-based anti-stigma. CONCLUSION: Adolescents in middle school frequently experience stigma regarding their mental health from their peers. Using both Islamic and mental health approaches, integrating internal and external stakeholders, dispelling unfavorable misconceptions and stereotypes, encouraging students to understand and empathize with others, and reducing the harmful effects of mental health stigma were found to help reduce the stigma of mental illness.

Photovoice as a Method to Reduce the Stigma of Mental Illness Among Health Care Students

Photovoice is theorized to influence those who interact with the photos and captions, and so it is important to examine and further understand this mechanism. This article seeks to further our understanding of this critical process—that is, what is the impact of the Photovoice Artist’s stories on the viewing audience? Herein we demonstrate how an incarnation of photovoice, digital storytelling, and photo elicitation impacted mental illness stigma among health sciences students. By focusing on application beyond the original exhibition, this article highlights how photovoice methods and aims overlap with best practices in stigma reduction, and its fit with multimodal anti-stigma interventions. Overall, this study contributes to addressing the question of how photovoice can be applied to achieve action for social change.

Strategies to Reduce Mental Illness Stigma: Perspectives of People with Lived Experience and Caregivers

BACKGROUND

Reducing the stigma surrounding mental illness is a global public health priority. Traditionally, anti-stigma campaigns were led by mental health professionals/organisations and had an emphasis on increasing mental health literacy. More recently, it has been argued that people with lived experience have much to contribute in terms of extending and strengthening these efforts. The purpose of this paper was to elicit views and suggestions from people with lived experience (PWLE) as well as from informal caregivers of people with mental health conditions, on effective strategies to combat the stigma surrounding mental illness.

METHODS

Six focus group discussions (FGDs) were carried out with PWLE recruited at outpatient services at the Institute of Mental Health, Singapore, and five FGDs were carried out with informal caregivers who responded to advertisements for the study between March and November 2018. In all, the sample comprised 42 PWLE and 31 caregivers. All the FGDs were transcribed verbatim and were analysed using thematic analysis. A pragmatic approach was adopted for the study, and the researchers did not assume any particular philosophical orientation.

RESULTS

Four overarching themes depicting strategies to combat stigma were identified through thematic analysis. They were (1) raising mental health awareness, (2) social contact, (3) advocacy by influential figures or groups, and (4) the legislation of anti-discriminatory laws.

CONCLUSIONS

These strategies were in line with approaches that have been used internationally to disrupt the process of stigma. Our study has further identified nuanced details on how these strategies can be carried out as well as possible areas of priority in the Singapore landscape.

Stigma toward Wuhan people during the COVID-19 epidemic: an exploratory study based on social media

Background

Stigma associated with infectious diseases is common and causes various negative effects on stigmatized people. With Wuhan as the center of the COVID-19 outbreak in China, its people were likely to be the target of stigmatization. To evaluate the severity of stigmatization toward Wuhan people and provide necessary information for stigma mitigation, this study aimed to identify the stigmatizing attitudes toward Wuhan people and trace their changes as COVID-19 progresses in China by analyzing related posts on social media.

Methods

We collected 19,780 Weibo posts containing the keyword ‘Wuhan people’ and performed a content analysis to identify stigmatizing attitudes in the posts. Then, we divided our observation time into three periods and performed repeated-measures ANOVA to compare the differences in attitudes during the three periods.

Results

The results showed that stigma was mild, with 2.46% of related posts being stigmatizing. The percentages of stigmatizing posts differed significantly during the three periods. The percentages of ‘Infectious’ posts and ‘Stupid’ posts were significantly different for the three periods. The percentage of ‘Irresponsible’ posts was not significantly different for the three periods. After government interventions, stigma did not decrease significantly, and stigma with the ‘Infectious’ attitude even increased. It was not until the government interventions took effect that stigma significantly reduced.

Conclusions

This study found that stigma toward Wuhan people included diverse attitudes and changed at different periods. After government interventions but before they took effect, stigma with the ‘Infectious’ attitude increased. After government interventions took effect, general stigma and stigmas with ‘Infectious’ and ‘Stupid’ attitudes decreased. This study constituted an important endeavor to understand the stigma toward Wuhan people in China during the COVID-19 epidemic. Implications for stigma reduction and improvement of the public’s perception during different periods of epidemic control are discussed.

Sociodemographic correlates of public stigma about mental illness: a population study on Hong Kong's Chinese population

BACKGROUND

Individuals with psychiatric disorders are often unwilling to seek help or often follow treatment regimens, fearing public stigma. This study identified the sociodemographic correlates of public stigma while accounting for mental health literacy and life satisfaction.

METHODS

This study analysed data for 1514 individuals who participated in a population-based random telephone survey conducted in 2018. Sociodemographic characteristics included gender, age, education level, and occupation. Data on public stigma, mental health literacy, and life satisfaction were also collected. Multiple linear regression was conducted to examine the effects of sociodemographic characteristics on public stigma. A moderation analysis was performed to investigate the role of age and education in the relationship between mental health literacy and public stigma.

RESULTS

Sociodemographic characteristics, such as female gender, older age, lower education, and occupation (particularly retired and homemakers), were associated with a higher public stigma. The association between public stigma and mental health literacy was the most significant among individuals aged 50 years and above with lower education levels.

CONCLUSIONS

This study showed that certain population subgroups, based on their sociodemographic profile, have a higher stigma about mental illnesses. Understanding the differential effects of sociodemographic factors on public stigma is imperative to developing effective anti-stigma campaigns.

A Call to Action. A Critical Review of Mental Health Related Anti-stigma Campaigns

Using a knowledge-attitudes-behavior practice (KABP) paradigm, professionals have focused on educating the public in biomedical explanations of mental illness. Especially in high-income countries, it is now common for education-based campaigns to also include some form of social contact and to be tailored to key groups. However, and despite over 20 years of high-profile national campaigns (e.g., Time to Change in England; Beyond Blue in Australia), examinations suggest that the public continue to Other those with experiences of mental ill-health. Furthermore, evaluations of anti-stigma programs are found to have weak- to no significant long-term effects, and serious concerns have been raised over their possible unintended consequences. Accordingly, this article critically re-engages with the literature. We evidence that there have been systematic issues in problem conceptualization. Namely, the KABP paradigm does not respond to the multiple forms of knowledge embodied in every life, often outside conscious awareness. Furthermore, we highlight how a singular focus on addressing the public's perceived deficits in professionalized forms of knowledge has sustained public practices which divide between "us" and "them." In addition, we show that practitioners have not fully appreciated the social processes which Other individuals with experiences of mental illness, nor how these processes motivate the public to maintain distance from those perceived to embody this devalued form of social identity. Lastly, we suggest methodological tools which would allow public health professionals to fully explore these identity-related social processes. Whilst some readers may be frustrated by the lack of clear solutions provided in this paper, given the serious unintended consequences of anti-stigma campaigns, we caution against making simplified statements on how to correct public health campaigns. Instead, this review should be seen as a call to action. We hope that by fully exploring these processes, we can develop new interventions rooted in the ways the public make sense of mental health and illness.

Self-Destigmatization Process? Experiences of Persons Living with Bipolar Disorder: A Qualitative Study

This qualitative study investigated subjective experiences of self-stigmatization and self-destigmatization among people living with bipolar disorder (BD). We conducted in-depth interviews focusing on self-stigmatization and self-destigmatization with 22 individuals living with BD. The interview transcripts were thematically analyzed using a mixed inductive and deductive approach. Thirty-six codes were extracted and organized into six themes: language, behaviors, relationships, personal experience, identity, and healthcare. Each theme was characterized by an evolution process, and the codes were distributed in a step-by-step order as landmarks. The process begins with the experience of self-stigmatization, and develops toward self-destigmatization. This study presents a new six-dimension process called the "self-destigmatization process" (SDP), a personal and interrelational process that deconstructs self-stigmatization. Clinicians can use the landmarks of the process for clinical assessment and therapeutic interventions to increase recovery orientation.

Help-Seeking by Parental Caregivers of Individuals with Intellectual Disabilities and Dual Diagnosis

This study examined the roles of stigma and of enabling factors in help-seeking by parental caregivers of individuals with intellectual disabilities and dual diagnosis. Questionnaires were completed by 195 family caregivers. Lower family stigma was related to higher personal enabling factors (e.g. knowledge about services and previous experience in seeking help), which in turn was related to higher help-seeking behaviors. Higher professional enabling factors (e.g. attitude of the professional, services in the vicinity) were related to higher intentions to seek help, which were related to higher help-seeking behaviors. Professionals can help families achieve a greater sense of self-efficacy in their own help-seeking process by providing them with knowledge about services and facilitating a more positive experience in the process.

Paediatricians' attitudes and beliefs towards transgender people: a cross-sectional survey in Israel

OBJECTIVE

The number of transgender and gender non-conforming children is on the rise. For these children, the timing of medical intervention is crucial, yet transgender children report poorer overall physical and mental health outcomes compared with their cisgender peers. We aim to describe how paediatricians perceive transgender people.

SETTING

The 'Transgender Attitudes and Beliefs Scale', which consists of 29 items in three domains-human value, interpersonal comfort and sex/gender beliefs-was administered to 391 senior and resident paediatricians in Israel. The responses on a 7-point Likert scale were collapsed into two categories: a mean score of ≥6 for each domain was a 'Favourable' perception and <6 'Unfavourable'.

RESULTS

Of 355 respondents (91% response rate), 221 (62%) were females, 132 (37%) were males and 2 identified as 'other'; 290 (82%) were born in 'trans-respect countries', 274 (77%) identified as secular, 223 (63%) were senior physicians and 132 (27%) were residents. Overall, 90% of the cohort scored favourably on the 'Human value' domain, 68% on 'Interpersonal comfort' and 40% on 'Sex/gender beliefs'. In the 'Interpersonal comfort' domain, being a man, birthplace in a transphobic country, identification as religious and being a senior physician were all associated with increased ORs for an unfavourable score: 2.1 (95% CI 1.3 to 3.4), 3.4 (95% CI 1.9 to 6.3), 2.4 (95% CI 1.4 to 4.2) and 1.8 (95% CI 1.1 to 3.0), respectively. In the 'Sex/gender beliefs' domain, being a man and identifying as religious had significantly increased ORs for unfavourable scores: 2.2 (95% CI 1.3 to 3.5) and 10.6 (95% CI 4.7 to 24.1), respectively.

CONCLUSIONS

Negative attitudes towards transgender people are still widespread among paediatricians. Interventions are warranted to positively impact these attitudes.

Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma

Persons with mental illness frequently encounter public stigma and may suffer from self-stigma. This review aims to clarify the concept of mental illness stigma and discuss consequences for individuals with mental illness. After a conceptual overview of stigma we discuss two leading concepts of mental illness stigma and consequences of stigma, focussing on self-stigma/empowerment and fear of stigma as a barrier to using health services. Finally, we discuss three main strategies to reduce stigma - protest, education, and contact – and give examples of current anti-stigma campaigns. Well-designed anti-stigma initiatives will help to diminish negative consequences of mental illness stigma.

Prevalence and factors associated with higher levels of perceived stigma among people with schizophrenia Addis Ababa, Ethiopia

Background

Schizophrenia is a severe and disabling chronic mental disorder and accompanied by different levels of a perceived stigma that affects almost all age groups. This perceived stigma negatively impacts the quality of life, physical, and mental well-being of people with schizophrenia. It is also linked with a poor level of functioning, poor adherence to drugs, and increased dropout rate. However, research into perceived stigma and associated factors among people with schizophrenia in low- and middle-income countries are limited. Therefore, this study aimed to explore the perceived stigma and correlates among people with schizophrenia in Ethiopia.

Methods

An institution based cross-sectional study was conducted from May to June 2018. A structured, pre-tested, and interviewer-administered questionnaire was used to collect data. The standardized perceived devaluation and discrimination questionnaire was used to assess perceived stigma. The systematic random sampling technique was used to select study participants. Binary logistic regression analysis was used to identify factors associated with perceived stigma. An odds ratio (OR) with a 95% confidence interval (CI) was computed to assess the strength of the association.

Results

The prevalence of high perceived stigma was found to be 62.6% [95% CI 58.3, 67.4]. In the multivariate logistic regression, female sex [AOR = 2.30, 95% CI 1.42, 3.71], age of onset of schizophrenia [AOR = 1.85, 95% CI 1.19, 2.89], multiple hospitalizations [AOR = 1.7, 95% CI 1.16, 3.27], and duration of illness 1–5 years [AOR = 2, 95% CI 1.01, 3.27], 6–10 years [AOR = 2.48, 95% CI 1.29, 4.74], and ˃10 years [AOR = 2.85, 95% CI 1.40, 5.79] were factors significantly associated with higher perceived stigma.

Conclusion

In the present study, the prevalence of high perceived stigma among people with schizophrenia was found to be 62.6%. Female sex, age of onset of schizophrenia, multiple hospitalizations, and duration of illness were factors significantly associated with higher perceived stigma. Measures to enhance the awareness of the patients, their families and their social networks about perceived stigma and associated factors, by the leading government and healthcare institutions are warranted.

Associative stigma experienced by mental health professionals in China and the United States

PURPOSE

"Associative stigma" is the negative stereotyping of mental health service providers who treat people with serious mental illness. The Clinician Associative Stigma Scale (CASS) has been validated in a US sample but not in other nations, e.g., in China which has been found to have substantially higher levels of stigma towards people with mental illness than the US.

METHODS

The 19-item CASS was translated into Chinese and administrated to 665 mental health professionals working in psychiatric hospitals in Southern China. Confirmatory factor analysis (CFA) was used to compare the factor structure with that found in the US sample. Socio-demographic correlates of CASS scores and comparison with US data were conducted using regression models and t test.

RESULTS

CFA showed a good model fit (GFI = 0.911 and RMSEA = 0.068) for the four factors found in the US study: (1) discomfort with disclosing about working with serious mental illness, (2) stereotypes about professionals' own poor mental health, (3) stereotypes about unpleasantness of working with people with serious mental illness, and (4) stereotypes about lack of treatment effectiveness. Total CASS score and subscales concerning stereotypes about providers' mental health and about unpleasantness of working with such patients were significantly lower in China than in the US (both P < 0.001), but stereotypes concerning professional ineffectiveness were higher in China.

CONCLUSION

Associative stigma was lower in China than in the US, possibly reflecting the cultural dominance of respect for educated professionals over stigma towards people with serious mental illness.

A cross-sectional comparative study of perceived stigma between patients with epilepsy and patients living with HIV/AIDS in Accra, Ghana

BACKGROUND

Health-related stigma is a great challenge to the treatment of diseases. In epilepsy like other conditions, it causes affected individuals to conceal their illness. In this study, we described stigma perceived by patients with epilepsy at the Korle Bu Teaching Hospital (KBTH), a tertiary referral facility, and the Accra Psychiatry Hospital in Ghana (APH). We then compared the perception of stigma in patients with epilepsy to stigma perceived by persons living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (PLWHA), a chronic communicable disease stigmatized in Ghana.

METHODS

A total of 351 patients with epilepsy were recruited from both sites by systematic random sampling and interviewed. The Kilifi Stigma Scale for Epilepsy was used to determine individual patient's stigma score. Statistical analysis was done using multiple logistic regression analysis to control for the effect of measured independent variables that were significant on univariate analysis: age, gender, marital status, income, type of epilepsy, and the frequency of seizures, on the outcome variable. Comparative analysis of the mean stigma score in patients with epilepsy and persons living with HIV/AIDS was done using the Student's t-test and Mann-Whitney U test (Wilcoxon rank sum test).

RESULTS

The presence of perceived stigma using the Kilifi Stigma Score Estimation was 32.02% (62), 33.33% (49), and 28.88% (54) among respondents from KBTH, APH, and PLWHA respectively. Results from Wilcoxon rank sum test showed that the median stigma score between the three groups was significant; KBTH and APH (p-value; 0.0258), KBTH and PLWHA (p-value; 0.00001), and APH and PLWHA (p-value; 0.0000). Age (<40 years), seizure frequency, ethnic group (Ewe and Guan), and being divorced showed high odds for perceived stigma among KBTH patients with epilepsy. Having tertiary education led to lower odds for perceived stigma in epilepsy for APH patients with epilepsy.

CONCLUSION

This study showed that epilepsy is associated with a high stigma perception. The perceived stigma was greater than stigma in PLWHAs in Accra. Stigma was affected by unemployment, ethnicity (Ewe and Guan), and uncontrolled seizures. Increasing age reduced perceived stigma and the management of patients with epilepsy in a psychiatric facility might have impacted negatively on the perceived stigma.

Mental Health Related Stigma as a 'Wicked Problem': The Need to Address Stigma and Consider the Consequences

Recent reviews on the evidence base for mental health related stigma reduction show that under certain conditions interpersonal contact is effective in promoting more positive attitudes, reduced desire for social distance, and increased stigma related knowledge (knowledge which disconfirms beliefs based on stereotypes). Short-term interventions may have effects that are attenuated over time; longer term programmes may support sustained improvements, but research following up long-term interventions is scarce. However, the effectiveness of these interventions should not obscure the nature of stigma as a social problem. In this article we describe stigma as a 'wicked problem' to highlight some implications for intervening against stigma and evaluating these efforts. These include the risks of unintended consequences and the need to continually reformulate the concept of stigma, to ensure that tackling stigma at the structural, interpersonal, and intrapersonal levels become part of the core business of stakeholder organisations. We compare the main targets of anti-stigma programmes with what is known about the sources of stigma and discrimination and their impacts to identify targets for future intervention. In some cases, interventions have been directed at the interpersonal level when structural level intervention is also needed; in others, systematic reviews have not so far identified any interventions.

Clear Skies Ahead: The Way Out of Identity Confusion

This article argues that the mental health nursing role suffers from a lack of coherence which creates problems both inside and outside of the profession. It looks at evolutionary and other reasons for the development of this identity confusion and highlights the consequences for the profession. A potential way forward is then considered, which incorporates reflective practice and greater promotion of the role, building on the unique strengths of the profession. The article concludes by suggesting that mental health nurses have reason to be proud of the work they do, and also that the profession has grounds for optimism.

Self-Stigma in Relatives of people with Mental Illness scale: development and validation

BACKGROUND

Serious mental illness (SMI) is profoundly stigmatised, such that there is even an impact on relatives of people with SMI. Aims To develop and validate a scale to comprehensively measure self-stigma among first-degree relatives of individuals with SMI.

METHOD

We conducted group interviews focusing on self-stigma with first-degree relatives (n = 20) of people with SMI, from which 74 representative quotations were reframed as Likert-type items. Cognitive interviews with relatives (n = 11) identified 30 items for the Self-Stigma in Relatives of people with Mental Illness (SSRMI) scale. Relatives (n = 195) completed the scale twice, a month apart, together with four external correlate scales.

RESULTS

The 30-item SSRMI was reliable, with scores stable over time. Its single-factor structure allowed generation of a 10-item version. Construct validity of 30- and 10-item versions was supported by expected relationships with external correlates.

CONCLUSIONS

Both versions of the SSRMI scale are valid and reliable instruments appropriate for use in clinical and research contexts. Declaration of interest None.

Predictors of treatment utilization and barriers to treatment utilization among individuals with lifetime cannabis use disorder in the United States

OBJECTIVE

To present information on predictors of treatment utilization and barriers to treatment utilization among individuals with lifetime DSM-5 cannabis use disorder (CUD).

METHOD

Face-to-face survey of a representative sample of the adult US general population (n=36,309).

RESULTS

Treatment rates for CUD were low in this general population survey (13.7%). Severity of CUD and comorbidity of other lifetime drug use disorders were significant predictors of lifetime treatment utilization for CUD. Preference for self-reliance, minimizing problems, fear of stigma, and financial and structural issues were among the most frequently endorsed reasons for respondents not seeking treatment when they perceived the need for treatment among individuals with lifetime CUD, regardless of whether they eventually utilized treatment at some time in their lives.

CONCLUSIONS

Given the rising prevalence of CUD in the US over the past decade and currently low treatment rates for CUD, increased provision for services for CUD appears critically needed, especially those that screen for and treat, when present, other drug use disorders. Programs to reduce stigma and financial barriers are needed, as well as programs to increase awareness among the general public, health care professionals about the nature and seriousness of CUD, and the availability and effectiveness of treatment for this disorder.

Can interpersonal contact help improve attitudes toward soldiers with intellectual disability? An Israeli study

BACKGROUND

It has been argued that interpersonal contact is the best intervention for reducing negative attitudes and discrimination toward individuals with intellectual disabilities (ID). In Israel, the Equal in Uniform project makes it possible for individuals with ID to serve alongside soldiers without ID in ordinary military units in the Israeli Defense Forces. The project provided the opportunity to examine the effect of contact on the attitudes of soldiers without ID.

METHODS

Data analyses are based on data collected from 220 soldiers without ID via a self-administered questionnaire based on the Multidimensional Attitudes Scale. Of these, 138 were in contact with soldiers with ID as part of the project.

RESULTS

A mediation model showed that the impact of contact with a soldier with ID on withdrawal behaviour was mediated by cognitive attributions and negative affect. Contact was directly associated with prosocial behaviour.

DISCUSSION

Results support the importance of contact between soldiers with and without ID to bring about improved attitudes toward the former.

Survey on Tuberculosis Patients in Rural Areas in China: Tracing the Role of Stigma in Psychological Distress

Depressed patients had risks of non-adherence to medication, which brought a big challenge for the control of tuberculosis (TB). The stigma associated with TB may be the reason for distress. This study aimed to assess the psychological distress among TB patients living in rural areas in China and to further explore the relation of experienced stigma to distress. This study was a cross-sectional study with multi-stage randomized sampling for recruiting TB patients. Data was collected by the use of interviewer-led questionnaires. A total of 342 eligible and accessible TB patients being treated at home were included in the survey. Psychological distress was measured using the Kessler Psychological Distress Scale (K10). Experienced stigma was measured using a developed nine-item stigma questionnaire. Univariate analysis and multiple logistic regression were used to analyze the variables related to distress, respectively. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to present the strength of the associations. Finally, the prediction of logistic model was assessed in form of the Receiver Operating Characteristic (ROC) curve and the area under the ROC curve (AUC). According to the referred cut-off point from K10, this study revealed that 65.2% (223/342) of the participants were categorized as having psychological distress. Both the stigma questionnaire and the K10 were proven to be reliable and valid in measurement. Further analysis found that experienced stigma and illness severity were significant variables to psychological distress in the model of logistic regression. The model was assessed well in predicting distress by use of experienced stigma and illness severity in form of ROC and AUC. Rural TB patients had a high prevalence of psychological distress. Experience of stigma played a significant role in psychological distress. To move the barrier of stigma from the surroundings could be a good strategy in reducing distress for the patients and TB controlling for public health management.

The Missing Thread - How Fiction Cheats Mental Health Nursing

Mental health nursing occupies an important place in mental health care, and nurses perform valuable work, yet fiction writers tend to rely on outdated imagery to portray the profession. This imagery reinforces negative stereotypes of mental health nursing. This article examines the problem and explores the implications for the profession, particularly in relation to stigma and public confidence. It outlines a significant gap in narrative literature, specifically in relation to the therapeutic relationship, and asks what can be done to encourage more realistic portrayals of the role.

Interventions to reduce discrimination and stigma: the state of the art

BACKGROUND

There is a rich literature on the nature of mental health-related stigma and the processes by which it severely affects the life chances of people with mental health problems. However, applying this knowledge to deliver and evaluate interventions to reduce discrimination and stigma in a lasting way is a complex and long-term challenge.

METHODS

We conducted a narrative synthesis of systematic reviews published since 2012, and supplemented this with papers published subsequently as examples of more recent work.

RESULTS

There is evidence for small to moderate positive impacts of both mass media campaigns and interventions for target groups in terms of stigma-related knowledge, attitudes, and intended behaviour in terms of desire for contact. However, the limited evidence from longer follow-up times suggests that it is not clear whether short-term contact interventions have a lasting impact.

CONCLUSIONS

The risk that short-term interventions may only have a short-term impact suggests a need to study longer term interventions and to use interim process and outcome data to improve interventions along the way. There is scope for more thorough application of intergroup contact theory whenever contact is used and of evidence-based teaching and assessment methods when skills training is used for target groups.

Stigma in the Area of Intellectual Disabilities: Examining a Conceptual Model of Public Stigma

Studies in the area of intellectual disability (ID) stigma are few and atheoretical. This study examined the adequacy of the conceptual framework of stigma from the mental illness field regarding ID. Telephone interviews were conducted with a nationally representative sample of 304 adults in Israel. Participants were read a vignette describing a man with ID and answered items related to cognitive, emotional, and behavioral reactions. Behavioral dimensions included: Withdrawal, Social distance, and Helping behaviors. The stigma process leading to Withdrawal was drawn through Negative affect, whereas the process to Social distance was drawn through Calm affect. One unique aspect of the stigma process in ID is the importance of Calm affect, which helped reduce Social distance.

Health behaviour change of people living with HIV after a comprehensive community-based HIV stigma reduction intervention in North-West Province in South Africa

All over the world, health behaviour is considered a complex, far reaching and powerful phenomenon. People's lives are influenced by their own or others' health behaviour on a daily basis. Whether it has to do with smoking, drinking, pollution, global warming or HIV management, it touches lives and it challenges personal and community responses. Health behaviour, and health behaviour change, probably holds the key to many a person's immediate or prolonged life or death outcomes. The same can be said about communities, culture groups and nations. This SANPAD-funded study focused on research questions relating to health behaviour change for people living with HIV (PLWH) in the North-West Province in South Africa. It investigated whether a comprehensive community-based HIV stigma reduction intervention caused health behaviour change in PLWH. An quantitative single system research design with one pre- and four repetitive post-tests utilizing purposive sampling was used to test change-over-time in the health behaviour of 18 PLWH. The results of the study indicated statistical and/or practical significant change-over-time. The intervention not only addressed the health behaviour of PLWH, but also their HIV stigma experiences, HIV signs and symptoms and their quality of life in the context of being HIV positive. The recommendations include popularization of the comprehensive community-based HIV stigma reduction intervention and extending it to include a second intervention to strengthen health behaviour and quality of life for PLWH in the community at large.

Relationship between the public's belief in recovery, level of mental illness stigma, and previous contact

Disbelief exits that individuals who have a mental health condition are able to recover and fully function in life. This study analyzed 1,437 adults from the 2006 General Social Survey. Structural equation modeling (1) examined the relationship between respondents' level of prejudicial attitudes and social distance (i.e., stigma) toward individuals who have a mental health condition and their belief in the potential of recovery (2) tested whether previous contact with an individual who received treatment was a mediator. Findings indicated that the belief in recovery led to lower levels of social distance. Prejudicial attitudes were found to be a predictor of one's level of social distance. Previous contact was not a mediator however; males, minorities and those with less education were less likely to have had previous contact. Results indicated a need to emphasize the probability of recovering from a mental health condition when developing target-specific stigma reducing strategies.

Stigma From Professional Helpers Toward Survivors of Intimate Partner Violence

The authors explored experiences of stigma from professional helpers toward survivors of intimate partner violence in two related studies with a combined sample of 231 participants. Qualitative interview and quantitative survey data were analyzed with content analysis procedures using an a priori coding strategy. Results suggest that survivors felt stigmatized by mental health professionals, attorneys and judges, health care professionals, law enforcement, professionals in the employment or education systems, parenting-related professionals, as well as friends and family. The most frequently occurring stigma categories were feeling dismissed, denied, and blamed. Participants cited the most common sources of stigma occurred from interactions with professionals in the court system and law enforcement officers. Implications for future research and practice are discussed.

Suck It Up: Opinions and Attitudes about Mental Illness Stigma and Help-Seeking Behaviour of Male Varsity Football Players

The purpose of this qualitative study was to understand the attitudes and opinions of varsity football players toward mental health and help-seeking. The insights gained from this study may contribute to a greater understanding of how stigma functions in a competitive, elite-level football team. The authors concluded that the competitive edge required for success in elite athletics conflicts with mental health issues and illnesses. Components of the stigma process (labelling, stereotyping, separation, status loss, and discrimination), along with the impact of gender on stigma toward mental illness and help-seeking behaviours, are explored. Recommendations are made to broaden the scope of mental health initiatives for student athletes.

Public stigma towards mental illness in the Greek culture

Mental illness stigma negatively affects the lives of individuals with mental health disorders. Studies have indicated that the type and degree of stigma significantly varies across cultures. This study aimed to add to this body of knowledge by examining the prevalence and the type of mental illness stigma among individuals who identified themselves as Greek. It also examined the influence of a range of potential within-culture stigma moderating factors, including levels of previous experience with mental illness and mental illness knowledge. A cross-sectional quantitative design was employed, and 111 participants living in England and Greece were sampled through the snowball sampling technique. Stigma prevalence was measured using the 'Community Attitudes to Mental Illness' questionnaire. The findings revealed that participants showed a high degree of sympathy for people with mental illness but also considered them to be inferior and of a lower social class, and needing strict societal control. Higher stigma was significantly associated with being educated in England (instead of Greece), higher religiosity, lower knowledge levels and lower levels personal experience of mental illness. Targeted antistigma campaigns specifically tailored for the Greek culture are required in order to help reduce stigmatizing attitudes.

Self-stigma among caregivers of people with mental illness: toward caregivers' empowerment

BACKGROUND

In addition to economic and material burdens, caregivers of people with mental illness are exposed to psychosocial challenges. Self-stigma is among the psychological challenges that can be exacerbated by intrinsic and/or extrinsic factors. Caregivers' self-stigma can negatively influence the patients' treatment and rehabilitation process. The objective of this study was to measure the level and correlates of self-stigma among caregivers of people with mental illness.

METHODS

An interviewer-administered cross-sectional study was conducted in the Jimma University Specialized Hospital Psychiatry Clinic in Ethiopia on a sample of 422 caregivers. Data were collected by trained nurses working in the clinic using a pretested questionnaire. Multivariate linear regression was performed to identify the correlates of self-stigma among caregivers of people with mental illness.

RESULTS

The majority (70.38%) of the caregivers were male. On a scale of 0 to 15, with 0 being low and 15 being high, the average self-stigmatizing attitude score was 4.68 (±4.11). A statistically significant difference in mean self-stigma score was found between urban and rural respondents (t=3.95, P<0.05). Self-stigma of caregivers showed significant positive correlation with perceived signs of mental illness (r=0.18, P<0.001), perceived supernatural explanations of mental illness (r=0.26, P<0.001), and perceived psychosocial and biological explanations of mental illness (r=0.12, P<0.01). The only independent predictor of caregivers' self-stigma was perceived supernatural explanation of mental illness (standardized β=0.22, P<0.001).

CONCLUSION

The tendency of caregivers to avoid being identified with the patients was observed. Low exposure to mental health information was also reported. Caregivers' self-stigma in this study was significantly correlated with perceived supernatural explanation of mental illness. Since caregivers' self-stigma may negatively influence patients' treatment-seeking, adherence, and rehabilitation processes, programs that enhance coping strategies by strengthening self-esteem and empowerment by health care providers and establish family support groups may be helpful to tackle self-stigma among caregivers of people with mental illness.

Judicial Perceptions of Media Portrayals of Offenders with High Functioning Autistic Spectrum Disorders

In recent years, sensational media reporting focusing on crimes committed by those diagnosed with or thought to have High Functioning Autistic Spectrum Disorders (hfASDs) has caused societal speculation that there is a link between the disorder and violent criminality. No research exists on how and if the judiciary understands and is affected by this coverage. Therefore this study aims to examine how judges perceive and are influenced by media attention surrounding hfASDs and criminality. Semi-structured interviews were conducted with 21 California Superior Court Judges, including questions on media portrayal. Judges perceived general media portrayals of hfASDs in both positive and negative ways. However, almost all judges who had experienced media coverage surrounding hfASDs and criminality identified it as misleading and harmful to public perceptions of the disorder. These findings suggest judges are not exempt from media attention surrounding violence and hfASDs, and they recognize the potential adverse effects of this negative coverage. Although judges’ report their opinions are not affected, the results demonstrate that judges are worried that the public and potentially other criminal justice actors are adversely affected and will continue to be moving forward.

Shame-Focused Attitudes Toward Mental Health Problems

The purpose of this study was to examine the effects of gender and culture on shame-focused attitudes toward mental health problems. Two hundred and ninety-three university students from Asian, Latino, and Caucasian American cultural backgrounds participated in the study. The Attitudes Toward Mental Health Problems Scale was used to measure shame-focused attitudes. A 2 (gender) × 3 (culture) multivariate analyses of variance was performed. Results indicated that there was no significant gender difference in shame-focused attitudes toward mental health problems. Of the three ethnic cultural groups, Latino American students had the highest mean score on how shameful they would feel if they had mental health problems. Asian American students had the lowest mean score on how negative their families would view themselves if they had mental health problems. Implications of the results for rehabilitation research and practice are discussed.

California's historic effort to reduce the stigma of mental illness: the Mental Health Services Act

In a historic effort to reduce the stigma of mental illness, California voters approved the Mental Health Services Act in 2004. The law funds a comprehensive statewide prevention initiative that places stigma and discrimination reduction at its center, with 25 projects providing interventions at the institutional, societal, and individual levels. Stakeholders selected specific strategies from the research-based California Strategic Plan on Reducing Stigma and Discrimination. Strategies range from social marketing to increase public knowledge to capacity building at the local level, including training that emphasizes participation by consumers of mental health services and cultural competence. Collectively, these strategies aim to foster permanent change in the public perception of mental illness and in the individual experience of stigma. We examined the context, planning, programming, and evaluation of this effort.

Strategies to fight stigma toward people with mental disorders: perspectives from different stakeholders

This study aims to provide a more complete and exhaustive perspective on the whole range of potential strategies to fight stigma by considering the perspectives of different stakeholders. Delegates to a Canadian conference were invited to participate in a survey that focused on stigma, from which the responses to the following question were analyzed: tell us briefly what you do to reduce prejudice and stigma toward people with a diagnosis of mental disorder? From 253 participants, 15 categories of strategies to fight stigma were identified from the verbatim (e.g., sharing/encouraging disclosure). These categories fell under six main themes: education, contact, protestation, person centered, working on recovery and social inclusion, and reflexive consciousness. The occurrence of these themes was different among stakeholders (clinical, organizational, and experiential knowledge). For example, people with mental disorders (experiential knowledge) often mentioned contact and person centered strategies, while mental health professionals (clinical knowledge) preferred education and working on recovery and social inclusion strategies. The results from this study highlight the need to pay more attention to the concept of disclosure of mental disorders in the process for de-stigmatization. Future studies are needed to assess the impact of the emerging strategies to fight stigma in the community.

Fighting psychiatric stigma in the classroom: the impact of an educational intervention on secondary school students' attitudes to schizophrenia

BACKGROUND

Adolescents constitute an appealing target group for fighting stigma and discrimination surrounding mental illness, since it is during this developmental period that adult attitudes about mental illness are formed and consolidated.

AIM

The aim of the present study was twofold, to explore adolescents' beliefs and attitudes to schizophrenia and to evaluate the effectiveness of an anti-stigma intervention in altering them.

METHODS

A total of 616 high school students participated in the study, divided into a control condition and an anti-stigma intervention group. Data were collected at three time points: before the intervention, upon its completion and at a 12-month follow-up.

RESULTS

Baseline measurements indicated that students espoused certain stereotypical beliefs about patients with schizophrenia and were reluctant to interact with them on some occasions. Upon completion of the intervention, positive changes were recorded in students' beliefs, attitudes and desired social distance; however, only the changes in beliefs and attitudes were maintained after one year.

CONCLUSION

For anti-stigma interventions to be effective, they should be continuously delivered to students throughout the school years and allow for an interaction between students and patients. Health promotion programmes might be an appropriate context for incorporating such interventions.

The parental attitudes toward psychological services inventory: adaptation and development of an attitude scale

The purpose of this paper is to provide psychometric data on the Parental Attitudes Toward Psychological Services Inventory (PATPSI), which is a revised measure to assess parents' attitudes toward outpatient mental health services. Using a sample of adults (N = 250), Study 1 supported a 3-factor structure (RMSEA = .05, NNFI = .94, and CFI = .94), adequate internal consistency (ranging from .72 to .92), and test-retest reliability (ranging from .66 to .84). Additionally, results indicated that individuals with previous use of mental health services reported more positive views toward child mental health services. Study 2 provided confirming evidence of the 3-factor structure (NNFI = .94, RMSEA = .08, and the CFI = .95) and adequate reliability (ranging from .70 to .90) using a parent-sample (N = 260). Additionally, discriminate validity of the PATPSI was supported. Implications for research and clinical practice are discussed.

Stereotypes of mental disorders differ in competence and warmth

Theoretical models of public stigma toward mental illness have focused on factors that perpetuate stigma toward the general label of "mental illness" or toward a handful of specific illnesses, used more or less interchangeably. The current work used the Stereotype Content Model (Fiske, Cuddy, Glick, & Xu, 2002) to examine how one facet of public stigma--stereotype content--differs as a function of specific mental illnesses. Participants were recruited online from across the U.S. Study 1 demonstrated that the overarching category of people with mental illness was perceived as relatively incompetent, but not very hostile (i.e., relatively warm). Study 2 found that when the general label of mental illness was separated into thirteen individual disorders, distinct stereotype content toward four clusters of illnesses emerged. One cluster, typified by illnesses with psychotic features (e.g., schizophrenia), was perceived to be hostile and incompetent. A second cluster, comprised of mood and anxiety disorders, was perceived as average on both competence and warmth. A third cluster of illnesses with neuro-cognitive deficits was thought to be warm but incompetent. The fourth cluster included groups with sociopathic tendencies and was viewed as hostile but relatively competent. The results clearly demonstrate that the stereotype content that underlies public stigma toward individual mental illnesses is not the same for all disorders. Harnessing knowledge of differing stereotype content toward clusters of mental illnesses may improve the efficacy of interventions to counteract public stigma.

Improving medical student attitudes towards people with schizophrenia

OBJECTIVE

To develop and evaluate an intervention for final year medical students to reduce stigma against people with schizophrenia.

METHOD

A total of 87 students participated in a 3-h workshop that included both a contact component (a DVD of a young man with schizophrenia) and an experience of simulated auditory hallucinations. Attitudes to schizophrenia were evaluated using the Attitudes to Mental Illness Questionnaire (AMIQ), completed at the beginning and end of the workshop.

RESULTS

There was a significant improvement in mean AMIQ scores after participating in the workshop. Students with more negative attitudes before the workshop showed the most significant improvement, whilst there was little change for students who held more positive attitudes.

CONCLUSION

A workshop combining a DVD narrative by a young person with schizophrenia and simulated auditory hallucinations is an effective teaching tool to improve medical students' attitudes to people with schizophrenia.

Social Marketing’s Unique Contribution to Mental Health Stigma Reduction and HIV Testing: Two Case Studies

Since its inception in 2005, articles in Health Promotion Practice’s social marketing department have focused on describing social marketing’s unique contributions and the application of each to the practice of health promotion. This article provides a brief review of six unique features (marketing mix, consumer orientation, segmentation, exchange, competition, and continuous monitoring) and then presents two case studies—one on reducing stigma related to mental health and the other a large-scale campaign focused on increasing HIV testing among African American youth. The two successful case studies show that social marketing principles can be applied to a wide variety of topics among various population groups.

Stigma and treatment for alcohol disorders in the United States

Among a nationally representative sample of adults with an alcohol use disorder, the authors tested whether perceived stigmatization of alcoholism was associated with a lower likelihood of receiving alcohol-related services. Data were drawn from a face-to-face epidemiologic survey of 34,653 adults interviewed in 2004-2005 who were aged 20 years or older and residing in households and group quarters in the United States. Alcohol abuse/dependence was diagnosed by using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, version (AUDADIS-IV). The stigma measure used was the Perceived Devaluation-Discrimination Scale. The main outcome was lifetime intervention including professional services and 12-step groups for alcohol disorders. Individuals with a lifetime diagnosis of an alcohol use disorder were less likely to utilize alcohol services if they perceived higher stigma toward individuals with alcohol disorders (odds ratio = 0.37, 95% confidence interval: 0.18, 0.76). Higher perceived stigma was associated with male gender (β = -0.75; P < 0.01), nonwhite compared with non-Hispanic white race/ethnicity, lower income (β = 1.0; P < 0.01), education (β = 1.48; P < 0.01), and being previously married (β = 0.47; P = 0.02). Individuals reporting close contact with an alcohol-disordered individual (e.g., relative with an alcohol problem) reported lower perceived stigma (β = -1.70; P < 0.01). A link between highly stigmatized views of alcoholism and lack of services suggests that stigma reduction should be integrated into public health efforts to promote alcohol treatment.

Measuring the impact of programs that challenge the public stigma of mental illness

Public stigma robs people with mental illnesses from rightful opportunities related to work and other important life goals. Advocates have developed anti-stigma programs meant to address the prejudice and discrimination associated with these conditions. Evidence is now needed to make sense of program impact; this paper looks at measurement issues related to stigma change. Community-based participatory research is central to this research and includes the involvement of a diverse collection of stakeholders in all phases of evaluation. Investigators should be cautious about measures vis-à-vis social desirability effects and should directed by social validity of targeted audiences. Conceptual domains with some research support that correspond with assessments include behavior, penetration, psychological perspective, knowledge, and physiological/information processes. These issues are summarized as ten recommendations for evaluation of anti-stigma programs.