Cultural variation in the stigmatisation of mental illness

Cultural adaptation of INDIGO mental health stigma reduction interventions using an ecological validity model in north India

Background

The International Study of Discrimination and Stigma Outcomes (INDIGO) Partnership is a multi-country international research program in seven sites across five low- and middle-income countries (LMICs) in Africa and Asia to develop, contextually adapt mental health stigma reduction interventions and pilot these among a variety of target populations. The aim of this paper is to report on the process of culturally adapting these interventions in India using an established framework.

Methods

As part of this larger program, we have contextualized and implemented these interventions from March 2022 to August 2023 in a site in north India. The Ecological Validity Model (EVM) was used to guide the adaptation and contextualization process comprising eight dimensions.

Findings

Six dimensions of the Ecological Validity Model were adapted, namely language, persons, metaphors, content, methods, and context; and two dimensions, namely concepts and goals, were retained.

Conclusion

Stigma reduction strategies with varied target groups, based on culturally appropriate adaptations, are more likely to be acceptable to the stakeholders involved in the intervention, and to be effective in terms of the program impact.

Discrimination reported by people with schizophrenia: cross-national variations in relation to the Human Development Index

AIMS

Mental health related stigma and discrimination is a universal phenomenon and a contributor to the adversity experienced by people with schizophrenia. Research has produced inconsistent findings on how discrimination differs across settings and the contextual factors that underpin these differences. This study investigates the association between country-level Human Development Index (HDI) and experienced and anticipated discrimination reported by people with schizophrenia.

METHODS

This study is a secondary data analysis of a global cross-sectional survey completed by people living with schizophrenia across 29 countries, between 2005 and 2008. Experienced and anticipated discrimination were assessed using the Discrimination and Stigma Scale (DISC-10). Countries were classified according to their 2006 HDI. Negative binomial and Poisson regression analyses with a robust standard errors approach were conducted to investigate associations between country-level HDI and discrimination.

RESULTS

In the regression analyses, no evidence was found for a linear association between HDI and experienced or anticipated discrimination. Further exploratory analyses showed a significant non-linear association between HDI ratings and experienced discrimination. Participants in "high" and "very high" HDI countries reported more experienced discrimination compared to those in "medium" HDI countries.

CONCLUSIONS

HDI does, to some extent, appear to be associated with how far discrimination is experienced across different contexts. More high-quality cross-national research, including research focused on "medium" and "low" countries, is needed to substantiate these findings and identify underlying factors that may explain the pattern observed for experienced discrimination, including generating new datasets that would enable for these analyses to be repeated and contrasted with more recent data. An in-depth understanding of these factors will further aid the adaptation of cross-cultural and context specific anti-stigma interventions in future.

The clinical and psychosocial correlates of self-stigma among people with schizophrenia spectrum disorders across cultures: A systematic review and meta-analysis

BACKGROUND

Individuals with schizophrenia spectrum disorders (SSD) are at heightened risk of experiencing self-stigma, and some cultures are more stigmatizing towards SSD than others. The first purpose of this review is to provide an estimate of the relationship between self-stigma and clinical and psychosocial outcomes. The second purpose is to examine how these relationships vary across cultures.

METHOD

Studies reporting correlations between self-stigma and outcome variable(s) were identified through electronic database searches from June 1, 2021, to January 2, 2022. Mean effect sizes were calculated using Fisher's r-to-Z-transformation.

RESULTS

Sixty-three articles (N = 8925, 22 countries) were included in the systematic review and fifty-three articles (N = 7756) were included in the meta-analysis. For the most studied clinical correlates, self-stigma had a moderate, positive correlation with depressive symptoms (r = 0.49, p < .001), a moderate, negative correlation with functioning (r = -0.39, p < .001), and a positive, small correlation with severity of psychotic symptoms (r = 0.29, p < .001), negative symptoms (r = 0.18, p < .001) and positive symptoms (r = 0.13, p = .01). For the most studied psychosocial correlates, self-stigma had a strong, negative correlation with quality of life (r = -0.52, p < .001) and self-esteem (r = -0.55, p < .001). The correlates of self-stigma were similar across cultures.

DISCUSSION

Self-stigma shows strong to small correlations with clinical and psychosocial variables similarly across cultures. More research is needed to examine underlying mechanisms to develop effective interventions.

Perceived stigmatization and discrimination of people with mental illness: A survey-based study of the general population in five metropolitan cities in India

BACKGROUND

India faces a significant gap between the prevalence of mental illness among the population and the availability and effectiveness of mental health care in providing adequate treatment. This discrepancy results in structural stigma toward mental illness which in turn is one of the main reasons for a persistence of the treatment gap, whereas societal factors such as religion, education, and family structures play critical roles. This survey-based study investigates perceived stigma toward mental illness in five metropolitan cities in India and explores the roles of relevant sociodemographic factors.

MATERIALS AND METHODS

Samples were collected in five metropolitan cities in India including Chennai (n = 166), Kolkata (n = 158), Hyderabad (n = 139), Lucknow (n = 183), and Mumbai (n = 278). Stratified quota sampling was used to match the general population concerning age, gender, and religion. Further, sociodemographic variables such as educational attainment and strength of religious beliefs were included in the statistical analysis.

RESULTS

Participants displayed overall high levels of perceived stigma. Multiple linear regression analysis found a significant effect of gender (P < 0.01), with female participants showing higher levels of perceived stigma compared to male counterparts.

CONCLUSION

Gender differences in cultural and societal roles and expectations could account for higher levels of perceived stigma among female participants. A higher level of perceived stigma among female participants is attributed to cultural norms and female roles within a family or broader social system. This study underlines that while India as a country in transition, societal and gender rules still impact perceived stigma and discrimination of people with mental illness.

Stigma related to bipolar disorder in the perception of psychiatrists from Belo Horizonte, Minas Gerais State, Brazil

This research sought to understand meanings and implications of the stigma related to bipolar disorder in relation to social processes and local cultural value systems. Seven semidirected individual interviews were performed with psychiatrists (from Belo Horizonte city, Minas Gerais State, Brazil) and analyzed with referential from the Medical Anthropology. Some potential stigmatizing views about bipolar disorder patients were endorsed by respondents related to biomedical model of bipolar disorder. They claimed about the extreme trivialization of this diagnosis nowadays and observed that, in spite of the mitigation of stigma related to bipolar disorder over time, it remains an important issue, especially at labor fields and as a cause of refusal of treatment.

Culture, Cultural Competency and Psychosocial Occupational Therapy: A Middle Eastern Perspective

A Western occupational therapist appointed to mental health services for Emirati nationals in Al Ain in the United Arab Emirates is faced with many questions regarding competent practice in what is, to the therapist, a largely alien culture. In an effort to develop a culturally sensitive approach to a new service development, an extensive review was undertaken of the cultural competency and related occupational therapy literature and a framework for culturally competent practice was proposed (Awaad 2003a).

One of the key themes identified was the importance of attaining, and the skilful use in therapy, of specific cultural knowledge. This paper attempts to apply this principle through an exploration of the literature concerned with social, occupational and mental health practices in Middle Eastern Islamic societies and their relationship to psychosocial occupational therapy.

Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan

Background

Afghanistan lacks suitable specialized mental healthcare services despite high prevalence of severe mental health disorders which are aggravated by the conflict and numerous daily stressors. Recent studies have shown that Afghans with mental illness are not only deprived of care but are vulnerable in many other ways. Innovative participatory approaches to the design of mental healthcare policies and programs are needed in such challenging context.

Methods

We employed community based system dynamics to examine interactions between multiple factors and actors to examine the problem of persistently low service utilization for people with mental illness. Group model building sessions, designed based on a series of scripts and led by three facilitators, took place with NGO staff members in Mazar-I-Sharif in July 2014 and in Kabul in February 2015.

Results

We identified major feedback loops that constitute a hypothesis of how system components interact to generate a persistently low rate of service utilization by people with mental illness. In particular, we found that the interaction of the combined burdens of poverty and cost of treatment interact with cultural and social stigmatizing beliefs, in the context of limited clinical or other treatment support, to perpetuate low access to care for people with mental disorders. These findings indicate that the introduction of mental healthcare services alone will not be sufficient to meaningfully improve the condition of individuals with mental illness if community stigma and poverty are not addressed concurrently.

Conclusions

Our model highlights important factors that prevent persons with mental illness from accessing services. Our study demonstrates that group model building methods using community based system dynamics can provide an effective tool to elicit a common vision on a complex problem and identify shared potential strategies for intervention in a development and global health context. Its strength and originality is the leadership role played by the actors embedded within the system in describing the complex problem and suggesting interventions.

Attitude towards psychiatrists: A comparison between two metropolitan cities in India

BACKGROUND

Few patients in need of mental health care have access to psychiatric care in low and middle income countries. Public attitudes towards psychiatrists have not been adequately studied in most developing countries and especially in India, where on average one trained psychiatrist is available for 300,000 people. The aim of our study was to explore attitudes towards psychiatrists in the general population in two Indian metropolitan cities (Chennai and Kolkata) and to identify factors that could influence these attitudes.

SUBJECTS AND METHODS

Explorative surveys in the context of public attitudes towards psychiatrists were conducted in a convenience sample from the general population in Chennai (n=166) and Kolkata (n=158). Sampling was balanced for age, gender and school education.

RESULTS

Comparing the two samples using a multivariate analysis, we found more negative attitudes towards psychiatrists in Chennai compared to Kolkata (p<0.0001). Negative attitudes correlated with lower education levels (p<0.001) and stronger religious beliefs (p<0.05) in both cities.

CONCLUSION

Attitudes towards psychiatrists differed widely between two large metropolitan cities in India. In line with previous studies, negative attitudes correlated with lower level of education and stronger religious beliefs across both cities. Future studies may identify finer cultural and social factors that play an important role in attitudes towards psychiatrists in a diverse country like India.

Stigma and discrimination related to mental illness in low- and middle-income countries

AIMS

This paper aims to provide an overview of evidence from low- and middle-income countries (LAMICs) worldwide to address: the nature of stigma and discrimination, relevant context-specific factors, global patterns of these phenomena and their measurement and quantitative and qualitative evidence of interventions intended to reduce their occurrence and impact. The background to this study is that the large majority of studies concerned with identifying effective interventions to reduce stigma and discrimination originate in high-income countries (HICs). This paper therefore presents such evidence from, and relevant to, LAMICs.

METHODS

Conceptual overview of the relevant peer-reviewed and grey literature on stigma and discrimination related to mental illness in LAMICs are available in English, Spanish, French and Russian.

RESULTS

Few intervention studies were identified related to stigma re-education in LAMICs. None of these addressed behaviour change/discrimination, and there were no long-term follow-up studies. There is therefore insufficient evidence at present to know which overall types of intervention may be effective and feasible and in LAMICs, how best to target key groups such as healthcare staff, and how far they may need to be locally customised to be acceptable for large-scale use in these settings. In particular, forms of social contacts, which have been shown to be the most effective intervention to reduce stigma among adults in HICs, have not yet been assessed sufficiently to know whether these methods are also effective in LAMICs.

CONCLUSION

Generating information about effective interventions to reduce stigma and discrimination in LAMICs is now an important mental health priority worldwide.

Psychiatric stigma and discrimination in South Africa: perspectives from key stakeholders

BACKGROUND

Stigma and discrimination against people with mental illness remain barriers to help seeking and full recovery for people in need of mental health services. Yet there is scarce research investigating the experiences of psychiatric stigma on mental health service users in low- and middle-income countries (LMICs). The aim of this study was therefore to explore the experiences of psychiatric stigma by service users in order to inform interventions to reduce such stigma and discrimination in one LMIC, namely South Africa.

METHODS

Participants comprised a total of 77 adults aged above 18 years, made up of service providers including professional nurses (10), lay counsellors (20), auxiliary social workers (2); and service users (45).

RESULTS

Psychiatric stigma was found to be perpetuated by family members, friends, employers, community members and health care providers. Causes of psychiatric stigma identified included misconceptions about mental illness often leading to delays in help-seeking. Experiencing psychiatric stigma was reported to worsen the health of service users and impede their capacity to lead and recover a normal life.

CONCLUSION

Media campaigns and interventions to reduce stigma should be designed to address specific stigmatizing behaviours among specific segments of the population. Counselling of families, caregivers and service users should include how to deal with experienced and internalized stigma.

Internalized stigma among patients with schizophrenia in Ethiopia: a cross-sectional facility-based study

BACKGROUND

Despite the potential impact on treatment adherence and recovery, there is a dearth of data on the extent and correlates of internalized stigma in patients with schizophrenia in low income countries. We conducted a study to determine the extent, domains and correlates of internalized stigma amongst outpatients with schizophrenia in Ethiopia.

METHODS

The study was a cross-sectional facility-based survey conducted at a specialist psychiatric hospital in Addis Ababa, Ethiopia. Consecutive consenting individuals with a diagnosis of schizophrenia were recruited and assessed using an Amharic version of the Internalized Stigma of Mental Illness (ISMI) scale.

RESULTS

Data were collected from 212 individuals, who were mostly single (71.2%), unemployed (70.3%) and male (65.1%). Nearly all participants (97.4%) expressed agreement to at least one stigma item contained in the ISMI; 46.7% had a moderate to high mean stigma score. Rural residence (OR = 5.67; 95% CI = 2.30, 13.00; p < 0.001), single marital status (OR = 3.39; 95% CI = 1.40, 8.22; p = 0.019) and having prominent psychotic symptoms (OR = 2.33; 95% CI = 1.17, 4.61; p = 0.016) were associated independently with a higher stigma score. Almost half of those who discontinued their treatment reported that they had done so because of perceived stigma. Those who had attempted suicide (45.3%) were more likely to have a high stigma score (OR = 2.29; 95% CI = 1.27, 4.11; p = 0.006). Over 60% of the variation in the experience of stigma was explained by four factors: social withdrawal (16.7%), perceived discrimination (14.1%), alienation (13.9%) and stereotype endorsement (12.7%).

CONCLUSION

Internalized stigma is a major problem among persons with schizophrenia in this outpatient setting in Ethiopia. Internalized stigma has the potential to substantially affect adherence to medication and is likely to affect the recovery process.

Cultural aspects of schizophrenia

Over the past 50 years, schizophrenia as a disorder has been widely studied across cultures throughout the world. There are differences not only in the symptoms and presentation but also in outcome and prognosis. Various authors have tried to explore and explain such variation but the reasons for this are not always clear. In this paper, we review some of the cultural aspects of schizophrenia.

Talking about stigma towards mental health professionals with psychiatry trainees: a movie club approach

Psychiatry as a discipline is often perceived as 'different' by other medical professionals as much as by a common man. This perception of 'difference' may give rise to stigma both towards mental illness and to mental health professionals. Mental health professionals are thus both recipients of stigma and agents who can de-stigmatize psychiatry. A psychiatry movie club approach can be a very useful learning experience to understand various aspects of this stigmatization process. This paper presents a brief account of such an endeavour in which the film Gothika (2003) was used to help psychiatry trainees talk about their experiences with stigma towards mental illness as well as their profession.

Experiences of stigma and discrimination among users of mental health services in Poland

Stigmatization is commonly recognized as one of the main barriers to recovery and to social inclusion of people with mental illnesses. This exploratory study investigated the frequency, type, and sources of actual stigma and discrimination experiences among Polish psychiatric patients. A total of 442 people, treated in various psychiatric health care facilities in Warsaw, were interviewed with the use of the Consumer Experiences of Stigma Questionnaire (CESQ). Qualitative data regarding sources of experienced stigma were also obtained. The respondents reported relatively frequent experiences of stigmatization in everyday situations and interpersonal relations, but they seldom complained of any specific instances of discrimination. The most frequently reported source of stigma was employers and supervisors at work, followed by family, and general community members. Implications of the findings for clinical practice and policy are discussed.

A survey into student nurses' attitudes towards mental illness: implications for nurse training

This paper reports on a survey of attitudes to mental illness that was completed with a cohort of pre-registration nurses in 2007 in a large university in Essex. The background literature highlights the effects of attitudes on stigma, disadvantage and discrimination and presents a brief review of the literature on cultural variations in attitudes. It also briefly reviews the attitudes of health professionals to mental illness. A survey using the Community Attitudes to Mental Illness questionnaire was completed and ethnicity proved to be an important factor in accounting for variations in attitudes to mental illness. The Black and Black British group displayed less positive attitudes across all nursing branches when compared to the white group. The differences raised questions about how best nurse training can prepare nurses to practice in culturally sensitive ways that acknowledge the beliefs of patients whilst avoiding stereotyping and discrimination. Personal contact with someone with mental illness was also found to be a significant factor and the importance of user involvement in training is discussed. The paper concludes with some recommendations for nurse training that include greater use of teaching strategies that challenge beliefs and assumptions and promote a commitment to multicultural mental health practice.

Service user perspectives on the impact of a mental illness diagnosis

Aim – to provide a conceptual and practical analysis of the impacts of mental health diagnoses on consumers and to consider how service users might contribute to the new psychiatric classifications currently being drawn up. Methods – A search was carried out revealing a very sparse literature on this topic. Consultations with service users were conducted and the views of experts sought. Results – Diagnosis is important as it marks the formal status of psychiatric patient being conferred. Consumers react differently, and often, negatively to this. Stigma can follow from a diagnosis. The process of giving a diagnosis can range from one of negotiation and taking the person's strengths into account to the blunt allocation of an unwanted label. Consumers can be reduced to their diagnosis so it becomes their whole personhood and this can have an effect on their sense of self. However, consumers are not passive victims and have their own strategies for dealing with these issues. Conclusion – Consumers can use these experiences to make contributions to the new diagnostic classification systems and to future research.

Structural forces and the production of TB-related stigma among Haitians in two contexts

In recent years renewed interest in health-related stigma has underscored the importance of better understanding the structural underpinnings of stigma processes. This study investigated the influence of sociocultural context on perceived components of tuberculosis-related stigma in non-affected persons by comparing Haitians living in South Florida, USA, with Haitians residing in Léogane Commune, Haiti. Using the methods of cultural epidemiology, a two-phase study based on fieldwork between 2004 and 2007 collected ethnographic data on the cultural context and components of tuberculosis (TB) stigma, and administered a stigma scale developed specifically for these populations. Thematic analysis of stigma components expressed in interviews, focus groups and observation revealed commonalities as well as distinctive emphases of TB stigma in the two comparison groups. Factor analyses of stigma scale scores confirmed the thematic differences revealed in ethnographic findings and highlight the influence of political and economic factors in shaping the meaning and experience of illness. Perceived components of TB stigma among Haitians in South Florida incorporated aspects of Haitian identity as a negatively stereotyped minority community within the larger society, while in Haiti, stigma was associated primarily with poverty, malnutrition, and HIV co-infection. Discussion of findings focuses on the social production of perceived and anticipated stigma as it is influenced by structural forces including the influences of politics, economics, institutional policies, and health service delivery structures. The findings also demonstrate the value of a transnational framework encompassing both sending and receiving countries for understanding TB-related stigma in immigrant communities.

Sri Lankan doctors' and medical undergraduates' attitudes towards mental illness

BACKGROUND

Stigmatizing attitudes towards mental illness can impede help-seeking and adversely affect treatment outcomes, especially if such attitudes are endorsed by medical personnel. In order to help identify targets for anti-stigma interventions, we comprehensively examined negative attitudes towards mental illness displayed by Sri Lankan doctors and medical students and compared these with equivalent UK and other international data.

METHOD

A self-report questionnaire originally developed in the UK was completed by medical students (n = 574) and doctors (n = 74) from a teaching hospital in Colombo. The questions assessed the presence and intensity of stigmatizing attitudes towards patients with schizophrenia, depression, panic disorder, dementia and drug and alcohol addiction.

RESULTS

The study revealed higher levels of stigma towards patients with depression, alcohol and drug addiction in this Sri Lankan sample compared to UK data but attitudes towards schizophrenia were less stigmatized in Sri Lanka. Blaming attitudes were consistently high across diagnoses in the Sri Lankan sample. Sri Lankan medical students displayed more negative attitudes than doctors (P < 0.001). Overall stigma was greatest towards patients with drug addiction, followed by, alcohol addiction, schizophrenia, depression, panic disorder and dementia.

CONCLUSIONS

Sri Lankan doctors and undergraduates endorse stigmatizing attitudes towards mental illnesses and are especially prone to see patients as blameworthy. As such attitudes are likely to affect the engagement of patients in treatment and specific interventions that modify negative attitudes towards people with mental illnesses are needed. Ensuring that medical students have contact with recovered patients in community psychiatry settings may be one way of decreasing stigmatizing attitudes.

Barriers to medication counselling for people with mental health disorders: a six country study

Provision of medication information may improve adherence and prevent medication related problems. People with mental health disorders commonly receive less medication counselling from pharmacists than people with other common long term and persistent disorders.

Determinants of mental health stigma among pharmacy students in Australia, Belgium, Estonia, Finland, India and Latvia

BACKGROUND

Healthcare professionals commonly exhibit negative attitudes toward people with mental disorders. Few international studies have sought to investigate the determinants of stigma.

OBJECTIVE

To conduct an international comparison of pharmacy students' stigma towards people with schizophrenia, and to determine whether stigma is consistently associated with stereotypical attributes of people with schizophrenia.

METHOD

Students (n = 649) at eight universities in Australia, Belgium, India, Finland, Estonia and Latvia completed a seven-item Social Distance Scale (SDS) and six items related to stereotypical attributes of people with schizophrenia.

RESULTS

Mean SDS scores were 19.65 (+/- 3.97) in Australia, 19.61 (+/- 2.92) in Belgium, 18.75 (+/- 3.57) in India, 18.05 (+/- 3.12) in Finland, and 20.90 (+/- 4.04) in Estonia and Latvia. Unpredictability was most strongly associated with having a high social distance in Australia (beta = -1.285), the perception that people will never recover in India (beta = - 0.881), dangerousness in Finland (beta = -1.473) and the perception of being difficult to talk to in Estonia and Latvia (beta = -2.076). Unpredictability was associated with lower social distance in Belgium (beta = 0.839).

CONCLUSION

The extent to which students held stigmatizing attitudes was similar in each country, however, the determinants of stigma were different. Pharmacy education may need to be tailored to address the determinants of stigma in each country.

Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey

BACKGROUND

Many people with schizophrenia experience stigma caused by other people's knowledge, attitudes, and behaviour; this can lead to impoverishment, social marginalisation, and low quality of life. We aimed to describe the nature, direction, and severity of anticipated and experienced discrimination reported by people with schizophrenia.

METHODS

We did a cross-sectional survey in 27 countries, in centres affiliated to the INDIGO Research Network, by use of face-to-face interviews with 732 participants with schizophrenia. Discrimination was measured with the newly validated discrimination and stigma scale (DISC), which produces three subscores: positive experienced discrimination; negative experienced discrimination; and anticipated discrimination.

FINDINGS

Negative discrimination was experienced by 344 (47%) of 729 participants in making or keeping friends, by 315 (43%) of 728 from family members, by 209 (29%) of 724 in finding a job, 215 (29%) of 730 in keeping a job, and by 196 (27%) of 724 in intimate or sexual relationships. Positive experienced discrimination was rare. Anticipated discrimination affected 469 (64%) in applying for work, training, or education and 402 (55%) looking for a close relationship; 526 (72%) felt the need to conceal their diagnosis. Over a third of participants anticipated discrimination for job seeking and close personal relationships when no discrimination was experienced.

INTERPRETATION

Rates of both anticipated and experienced discrimination are consistently high across countries among people with mental illness. Measures such as disability discrimination laws might, therefore, not be effective without interventions to improve self-esteem of people with mental illness.

Stigma and discrimination limit access to mental health care

This editorial provides an overview of how far access to mental health care is limited by perceptions of stigma and anticipated discrimination. Globally over 70% of young people and adults with mental illness receive no treatment from healthcare staff. The rates of non-treatment are far higher in low income countries. Evidence from some descriptive studies and epidemiological surveys suggest that potent factors increasing the likelihood of treatment avoidance, or long delays before presenting for care include: (i) lack of knowledge about the features and treatability of mental illnesses; (ii) ignorance about how to access assessment and treatment; (iii) prejudice against people who have mental illness, and (iv) expectations of discrimination against people who have a diagnosis of mental illness. The associations between low rates of help seeking, and stigma and discrimination are as yet poorly understood and require more careful characterisation and analysis, providing the platform for more effective action to ensure that a greater proportion of people with mental illness are effectively treated in future.

Resources for mental health: scarcity, inequity, and inefficiency

Resources for mental health include policy and infrastructure within countries, mental health services, community resources, human resources, and funding. We discuss here the general availability of these resources, especially in low-income and middle-income countries. Government spending on mental health in most of the relevant countries is far lower than is needed, based on the proportionate burden of mental disorders and the availability of cost-effective and affordable interventions. The poorest countries spend the lowest percentages of their overall health budgets on mental health. Most care is now institutionally based, and the transition to community care would require additional funds that have not been made available in most countries. Human resources available for mental health care in most low-income and middle-income countries are very limited, and shortages are likely to persist. Not only are resources for mental health scarce, they are also inequitably distributed-between countries, between regions, and within communities. Populations with high rates of socioeconomic deprivation have the highest need for mental health care, but the lowest access to it. Stigma about mental disorders also constrains use of available resources. People with mental illnesses are also vulnerable to abuse of their human rights. Inefficiencies in the use of available resources for mental health care include allocative and technical inefficiencies in financing mechanisms and interventions, and an overconcentration of resources in large institutions. Scarcity of available resources, inequities in their distribution, and inefficiencies in their use pose the three main obstacles to better mental health, especially in low-income and middle-income countries.

Perception of the public towards the mentally ill in developed Asian country

OBJECTIVE

This study assessed public perceptions and attitudes towards and causal beliefs about mental health problems in Singapore - a multi-racial country in South-East Asia.

METHOD

A nation-wide survey using a structured questionnaire was conducted on those aged between 15 and 69 years.

RESULTS

The overall response rate was 68.1% with a total of 2,632 respondents. About 38.3% (95% CI, 36.4-40.2) believed that people with mental health problems were dangerous and 49.6% (95% CI, 47.7-51.5) felt that the public should be protected from them. A negative attitude towards mental health problems correlated with greater age and less education. The Chinese were more likely to want to hide their illness should they become mentally unwell while the Malays seemed to have a more tolerant attitude (P = 0.032).

CONCLUSION

Public awareness and anti-stigma campaigns should focus on those commonly held misconceptions and target specific populations.

Stigmatization of severe mental illness in India: Against the simple industrialization hypothesis

BACKGROUND

Major international studies on course and outcome of schizophrenia suggest a better prognosis in the rural world and in low-income nations. Industrialization is thought to result in increased stigma for mental illness, which in turn is thought to worsen prognosis. The lack of an ethnographically derived and cross-culturally valid measure of stigma has hampered investigation. The present study deploys such a scale and examines stigmatizing attitudes towards the severely mentally ill among rural and urban community dwellers in India.

AIM

To test the hypothesis that there are fewer stigmatizing attitudes towards the mentally ill amongst rural compared to urban community dwellers in India.

MATERIALS AND METHODS

An ethnographically derived and vignette-based stigmatization scale was administered to a general community sample comprising two rural and one urban site in India. Responses were analyzed using univariate and multivariate statistical methods.

RESULT

Rural Indians showed significantly higher stigma scores, especially those with a manual occupation. The overall pattern of differences between rural and urban samples suggests that the former deploy a punitive model towards the severely mentally ill, while the urban group expressed a liberal view of severe mental illness. Urban Indians showed a strong link between stigma and not wishing to work with a mentally ill individual, whereas no such link existed for rural Indians.

CONCLUSION

This is the first study, using an ethnographically derived stigmatization scale, to report increased stigma amongst a rural Indian population. Findings from this study do not fully support the industrialization hypothesis to explain better outcome of severe mental illness in low-income nations. The lack of a link between stigma and work attitudes may partly explain this phenomenon.

A cross-national study of the stigmatization of severe psychiatric illness: historical review, methodological considerations and development of the questionnaire

Despite their potential significance for public policy and health provision in different societies, popular conceptualizations of and social responses to severe psychiatric illness remain relatively unexamined. Two general research procedures may be identified: (1) the anthropological approach uses ethnographic methods to look at explicit categorizations, and (2) the sociological approach employs quantitative survey methods to examine the public ;stigma' of psychiatric illness. This article reviews methodological and conceptual approaches to the study of stigma and describes the development of an ethnographically grounded questionnaire to examine ;stigmatization' from data in different cultures. The difficulties of achieving cross-cultural comparability of meaning are discussed and the psychometric properties of the instrument are presented.

Selfhood and social distance: toward a cultural understanding of psychiatric stigma in Egypt

Psychiatric stigma is a concept that is often used uncritically by policy-makers to explain the underutilization of professional psychiatric services in non-Western societies. Stigma, however, is a multi-determined process manifestations and effects of which cannot be viewed separately from the larger social and cultural context. The present paper presents the results of a qualitative study of psychiatric stigma in Egypt from the perspective of lay respondents. A vignette method was used to elicit judgments of social distance and qualitative responses to stories depicting psychosis, depression, alcohol abuse and a 'possession state' from 208 respondents recruited through their places of work. The results indicated that while stigma does exist in Egypt, the form that it takes must be understood with reference to Egyptian notions of selfhood that locate behavioral disturbances in the intersubjective rather than intrapsychic realm. On the one hand, individual blame is diffused as responsibility for the illness and its cure is placed in the social, not personal (or biological) realm. On the other, behavioral disorders that threaten the social fabric of society are particularly stigmatized and often met with social rejection.

Perception of and attitude towards mental illness in Oman

BACKGROUND

As conceptions of mental illness are often dictated by prevailing socio-cultural factors and the philosophy of the time, there is little research to substantiate how mental illness is perceived in the Arab world in the light of both traditional and more recent modernization and acculturation processes.

AIMS

To examine whether social factors exert an influence on a person's attitude towards people with mental illness (PWMI) in the rapidly changing country of Oman.

METHODS

This study compares the response elicited from medical students, relatives of psychiatric patients and the general Omani public on the causes of mental illness, attitudes toward PWMI and the care and management of people with mental illness.

RESULTS

This study found no relationship between attitudes towards PWMI, and demographic variables such as age, educational level, marital status, sex and personal exposure to people with mental illness. Both medical students and the public rejected a genetic factor as the cause of mental illness; instead they favoured the role of spirits as the aetiological factor for mental illness. There were favourable responses on statements regarding value of life, family life, decision-making ability, and the management and care of mental illness. However, both medical students and the public thought that PWMI tend to have peculiar and stereotypical appearances and the majority preferred that facilities for psychiatric care should be located away from the community. Although the relatives of psychiatric patients were concerned about the welfare of mental patients, their responses varied and were often contingent upon their expectations.

CONCLUSIONS

The data suggest that neither socio-demographic factors nor previous exposure to PWMI was related to attitudes towards PWMI. Although the attitudes of Omanis toward PWMI appear to fluctuate in complex ways, traditional beliefs on mental illness have yet to be eroded by exposure to a biomedical model of mental illness. This study largely supports the view that the extent of stigma varies according to the cultural and sociological backgrounds of each society.

Gender and the stigma of onchocercal skin disease in Africa

This paper reports results from a multicenter study of gender differences in the stigma associated with onchocercal skin disease (OSD) in five African sites: Cameroon, Ghana, Nigeria (Awka and Ibadan) and Uganda. The studies used a common protocol to compare affected and unaffected respondents, that is, men and women with onchodermatitis in highly endemic areas and respondents from communities with low endemicity or no onchocerciasis. The methods were both quantitative and qualitative, allowing for the comparison of stigma scores and people's verbal descriptions of their experiences and attitudes. Questions to the unaffected were asked after providing them with photographs and short descriptions (vignettes) depicting typical cases. We found that stigma was expressed more openly by the unaffected, who perceived OSD as something foreign or removed from themselves, whereas the affected tended to deny that they experienced stigma as a result of the condition. Gender differences in stigma scores were not significantly different for men and women, but qualitative data revealed that stigma was experienced differently by men and women, and that men and women were affected by it in distinctive ways. Men were more concerned about the impact of the disease on sexual performance and economic prospects, whereas women expressed more concern about physical appearance and life chances, especially marriage. Similar trends were found in the different sites in the responses of affected and unaffected respondents, and differences between them, despite geographical and cultural variations.