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1.  Barriers to treatment and culturally endorsed coping strategies among depressed African-American older adults 
Aging & mental health  2010;14(8):971-983.
Objective
Older adults are particularly vulnerable to the effects of depression, however, they are less likely to seek and engage in mental health treatment. African-American older adults are even less likely than their White counterparts to seek and engage in mental health treatment. This qualitative study examined the experience of being depressed among African-American elders and their perceptions of barriers confronted when contemplating seeking mental health services. In addition, we examined how coping strategies are utilized by African-American elders who choose not to seek professional mental health services.
Method
A total of 37 interviews were conducted with African-American elders endorsing at least mild symptoms of depression. Interviews were audiotaped and subsequently transcribed. Content analysis was utilized to analyze the qualitative data.
Results
Thematic analysis of the interviews with African-American older adults is presented within three areas: (1) Beliefs about Depression Among Older African-Americans: (2) Barriers to Seeking Treatment for Older African-Americans: and (3) Cultural Coping Strategies for Depressed African-American Older Adults.
Conclusion
Older African-Americans in this study identified a number of experiences living in the Black community that impacted their treatment seeking attitudes and behaviors. which led to identification and utilization of more culturally endorsed coping strategies to deal with their depression. Findings from this study provide a greater understanding of the stigma associated with having a mental illness and its influence on attitudes toward mental health services.
doi:10.1080/13607863.2010.501061
PMCID: PMC3060025  PMID: 21069603
depression; beliefs/attitudes; health service use; stigma; aging
2.  Perspectives on perceived stigma and self-stigma in adult male patients with depression 
There are two principal types of stigma in mental illness, ie, “public stigma” and “self-stigma”. Public stigma is the perception held by others that the mentally ill individual is socially undesirable. Stigmatized persons may internalize perceived prejudices and develop negative feelings about themselves. The result of this process is “self-stigma”. Stigma has emerged as an important barrier to the treatment of depression and other mental illnesses. Gender and race are related to stigma. Among depressed patients, males and African-Americans have higher levels of self-stigma than females and Caucasians. Perceived stigma and self-stigma affect willingness to seek help in both genders and races. African-Americans demonstrate a less positive attitude towards mental health treatments than Caucasians. Religious beliefs play a role in their coping with mental illness. Certain prejudicial beliefs about mental illness are shared globally. Structural modeling indicates that conformity to dominant masculine gender norms (“boys don’t cry”) leads to self-stigmatization in depressed men who feel that they should be able to cope with their illness without professional help. These findings suggest that targeting men’s feelings about their depression and other mental health problems could be a more successful approach to change help-seeking attitudes than trying to change those attitudes directly. Further, the inhibitory effect of traditional masculine gender norms on help-seeking can be overcome if depressed men feel that a genuine connection leading to mutual understanding has been established with a health care professional.
doi:10.2147/NDT.S54081
PMCID: PMC4122562  PMID: 25114531
stigma; self-stigma; depression; male gender
3.  Stigmatizing Attitudes towards Mental Illness among Racial/Ethnic Older Adults in Primary Care 
Objective
The current study applies the perceived stigma framework to identify differences in attitudes toward mental health and mental health treatment among various racial/ethnic minority older adults with common mental health problems including depression, anxiety disorders, or at-risk alcohol use. Specifically, this study examines to what extent race/ethnicity is associated with differences in: (1) perceived stigma of mental illness; and (2) perceived stigma for different mental health treatment options.
Methods
Analyses were conducted using baseline data collected from participants who completed the SAMHSA Mental Health and Alcohol Abuse Stigma Assessment, developed for the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) study, a multi-site randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1247 non-Latino Whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos.
Results
African-Americans and Latinos expressed greater comfort in speaking to primary care physicians or mental health professionals concerning mental illness compared to non-Latino Whites. Asian-Americans and Latinos expressed greater shame and embarrassment about having a mental illness than non-Latino Whites. Asian-Americans expressed greater difficulty in seeking or engaging in mental health treatment.
Conclusions
Racial/ethnic differences exist among older adults with mental illness with respect to stigmatizing attitudes towards mental illness and mental health treatment. Results of this study could help researchers and clinicians educate racial/ethnic minority older adults about mental illness and engage them in much needed mental health services.
doi:10.1002/gps.3928
PMCID: PMC3672370  PMID: 23361866
race/ethnicity; stigma; older adults
4.  HIV, Gender, Race, Sexual Orientation, and Sex Work: A Qualitative Study of Intersectional Stigma Experienced by HIV-Positive Women in Ontario, Canada 
PLoS Medicine  2011;8(11):e1001124.
Mona Loutfy and colleagues used focus groups to examine experiences of stigma and coping strategies among HIV-positive women in Ontario, Canada.
Background
HIV infection rates are increasing among marginalized women in Ontario, Canada. HIV-related stigma, a principal factor contributing to the global HIV epidemic, interacts with structural inequities such as racism, sexism, and homophobia. The study objective was to explore experiences of stigma and coping strategies among HIV-positive women in Ontario, Canada.
Methods and Findings
We conducted a community-based qualitative investigation using focus groups to understand experiences of stigma and discrimination and coping methods among HIV-positive women from marginalized communities. We conducted 15 focus groups with HIV-positive women in five cities across Ontario, Canada. Data were analyzed using thematic analysis to enhance understanding of the lived experiences of diverse HIV-positive women. Focus group participants (n = 104; mean age = 38 years; 69% ethnic minority; 23% lesbian/bisexual; 22% transgender) described stigma/discrimination and coping across micro (intra/interpersonal), meso (social/community), and macro (organizational/political) realms. Participants across focus groups attributed experiences of stigma and discrimination to: HIV-related stigma, sexism and gender discrimination, racism, homophobia and transphobia, and involvement in sex work. Coping strategies included resilience (micro), social networks and support groups (meso), and challenging stigma (macro).
Conclusions
HIV-positive women described interdependent and mutually constitutive relationships between marginalized social identities and inequities such as HIV-related stigma, sexism, racism, and homo/transphobia. These overlapping, multilevel forms of stigma and discrimination are representative of an intersectional model of stigma and discrimination. The present findings also suggest that micro, meso, and macro level factors simultaneously present barriers to health and well being—as well as opportunities for coping—in HIV-positive women's lives. Understanding the deleterious effects of stigma and discrimination on HIV risk, mental health, and access to care among HIV-positive women can inform health care provision, stigma reduction interventions, and public health policy.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
HIV-related stigma and discrimination—prejudice, negative attitudes, abuse, and maltreatment directed at people living with HIV—is a major factor contributing to the global HIV epidemic. HIV-related stigma, which devalues and stereotypes people living with HIV, increases vulnerability to HIV infection by reducing access to HIV prevention, testing, treatment, and support. At the personal (micro) level, HIV-related stigma can make it hard for people to take tests to determine their HIV status or to tell other people that they are HIV positive. At the social/community (meso) level, it can mean that HIV-positive people are ostracized from their communities. At the organizational/political (macro) level, it can mean that health-care workers treat HIV-positive people differently and that governments are deterred from taking fast, effective action against the HIV epidemic. In addition, HIV-related stigma is negatively associated with well-being among people living with HIV. Thus, among HIV-positive people, those who have experienced HIV-related stigma have higher levels of mental and physical illness.
Why Was This Study Done?
Racism (oppression and inequity founded on ethno-racial differences), sexism and gender discrimination (oppression and inequity based on gender bias in attitudes), and homophobia and transphobia (discrimination, fear, hostility, and violence towards nonheterosexual and transgender people, respectively) can also affect access to HIV services. However, little is known about how these different forms of stigma and discrimination interact (intersect). A better understanding of the effect of intersecting stigmas on people living with HIV could help in the development of stigma reduction interventions and HIV prevention, treatment and care programs, and could help to control global HIV infection rates. In this qualitative study (an analysis of people's attitudes and experiences rather than numerical data), the researchers investigate the intersection of HIV-related stigma, racism, sexism and gender discrimination, homophobia and transphobia among marginalized HIV-positive women in Ontario, Canada. As elsewhere in the world, HIV infection rates are increasing among women in Canada. Nearly 25% of people living with HIV in Canada are women and about a quarter of all new infections are in women. Moreover, there is a disproportionately high infection rate among marginalized women in Canada such as sex workers and lesbian, bisexual, and queer women.
What Did the Researchers Do and Find?
The researchers held 15 focus groups with 104 marginalized HIV-positive women who were recruited by word-of-mouth and through flyers circulated in community agencies serving women of diverse ethno-cultural origins. Each focus group explored topics that included challenges in daily life, medical issues and needs, and issues that were silenced within the participants' communities. The researchers analyzed the data from these focus groups using thematic analysis, an approach that identifies, analyzes, and reports themes in qualitative data. They found that women living with HIV in Ontario experienced multiple types of stigma at different levels. So, for example, women experienced HIV-related stigma at the micro (“If you're HIV-positive, you feel shameful”), meso (“The thing I hate most for people that test positive for HIV is that society ostracizes them”), and macro (“A lot of women are not getting employed because they have to disclose their status”) levels. The women also attributed their experiences of stigma and discrimination to sexism and gender discrimination, racism, homophobia and transphobia, and involvement in sex work at all three levels and described coping strategies at the micro (resilience; “I always live with hope”), meso (participation in social networks), and macro (challenging stigma) levels.
What Do These Findings Mean?
These findings indicate that marginalized HIV-positive women living in Ontario experience overlapping forms of stigma and discrimination and that these forms of stigma operate over micro, meso, and macro levels, as do the coping strategies adopted by the women. Together, these results support an intersectional model of stigma and discrimination that should help to inform discussions about the complexity of stigma and coping strategies. However, because only a small sample of nonrandomly selected women was involved in this study, these findings need to be confirmed in other groups of HIV-positive women. If confirmed, the complex system of interplay of different forms of stigma revealed here should help to inform health-care provision, stigma reduction interventions, and public-health policy, and could, ultimately, help to bring the global HIV epidemic under control.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001124.
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment; its publication HIV and stigma deals with HIV-related stigma in the UK
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on women, HIV, and AIDS, on HIV and AIDS stigma and discrimination, and on HIV/AIDS statistics for Canada (in English and Spanish)
The People Living with Stigma Index to address stigma relating to HIV and advocate on key barriers and issues perpetuating stigma; it has recently published Piecing it together for women and girls, the gender dimensions of HIV-related stigma; its website will soon include a selection of individual stories about HIV-related stigma
Patient stories about living with HIV/AIDS are available through Avert and through the charity website Healthtalkonline
doi:10.1371/journal.pmed.1001124
PMCID: PMC3222645  PMID: 22131907
5.  DEPRESSION STIGMA, RACE, AND TREATMENT SEEKING BEHAVIOR AND ATTITUDES 
Journal of community psychology  2010;38(3):350-368.
This study examined the relationship between internalized and public stigma on treatment-related attitudes and behaviors in a community sample of 449 African American and white adults aged 18 years and older. Telephone surveys were administered to assess level of depressive symptoms, demographic characteristics, stigma, and treatment-related attitudes and behaviors. Multiple regression analysis indicated that internalized stigma mediated the relationship between public stigma and attitudes toward mental health treatment. Within group analyses indicated that the mediating effect of internalized stigma was significant for whites only. Among African Americans, internalized stigma did not mediate public stigma; it was directly related to attitudes toward mental health treatment. The internalization of stigma is key in the development of negative attitudes toward mental health treatment, and future research should focus on this aspect of stigma in both individual and community-based efforts to reduce stigma.
doi:10.1002/jcop.20368
PMCID: PMC3026177  PMID: 21274407
6.  Attitudes and beliefs about mental health among African American older adults suffering from depression 
Journal of aging studies  2010;24(4):266-277.
Depression among older adults is a major public health concern leading to increased disability and mortality. Less than 3% of older adults utilize professional mental health services for the treatment of depression, less than any other adult age group. And despite similar rates of depression, African Americans are significantly less likely to seek, engage and be retained in professional mental health services than their white counterparts. Cultural differences in the way depression symptoms are manifested, defined, interpreted and labeled may in part explain some of these racial differences in help-seeking behaviors. Focus group methodology was utilized to identify and explore attitudes and beliefs about depression and mental health treatment utilization among 42 older African Americans who had recently suffered a major depressive episode. Thematic analysis of identified six overarching themes: (a) perceptions of depression, (b) the African American experience, (c) seeking treatment as a last resort, (d) myths about treatment, (e) stigma associated with seeking treatment and (f) culturally appropriate coping strategies. We discuss implications for practice, education and research.
doi:10.1016/j.jaging.2010.05.007
PMCID: PMC3060786  PMID: 21423819
Aging; Depression; Stigma; Treatment
7.  Descriptive epidemiology of stigma against depression in a general population sample in Alberta 
BMC Psychiatry  2010;10:29.
Background
Mental health illnesses, such as depression, are responsible for a growing disease burden worldwide. Unfortunately, effective treatment is often impeded by stigmatizing attitudes of other individuals, which have been found to lead to a number of negative consequences including reduced help-seeking behavior and increased social distance. Despite the high prevalence of depression in Canada, little research has been conducted to examine stigma against depression in the Canadian general population. Such information is crucial to understanding the current state of stigmatizing attitudes in the Canadian communities, and framing future stigma reduction initiatives. The objectives of this study were to estimate the percentages of various stigmatizing attitudes toward depression in a general population sample and to compare the percentages by demographics and socioeconomic characteristics.
Methods
We conducted a cross-sectional telephone survey in Alberta, Canada, between February and June 2006. Random digit dialing was used to recruit participants who were aged 18-74 years old (n = 3047). Participants were presented a case vignette describing a depressed individual, and responded to a 9-item Personal Stigma questionnaire. The percentages of stigmatizing attitudes were estimated and compared by demographic and socioeconomic variables.
Results
Among the participants, 45.9% endorsed that depressed individuals were unpredictable and 21.9% held the view that people with depression were dangerous. Significant differences in stigmatizing attitudes were found by gender, age, education, and immigration status. A greater proportion of men than women held stigmatizing views on each stigma item. No consistent trend emerged by age in stigma against depression. Participants with higher levels of education reported less stigmatizing attitudes than those with less education. Participants who were not born in Canada were more likely to hold stigmatizing attitudes than those who were born in Canada.
Conclusion
In the general population, stigmatizing attitudes towards depression differ by demographic characteristics. Men, those with less education and immigrants should be the targets of stigma reduction campaigns.
doi:10.1186/1471-244X-10-29
PMCID: PMC2873467  PMID: 20398429
8.  Attitudes toward mental health services: Age-group differences in Korean American adults 
Aging & mental health  2009;13(1):127-134.
The present study examined the attitudes toward mental health services held by younger (aged 20–45, n = 209) and older (aged 60 and older, n = 462) groups of Korean Americans. Following Andersen’s (1968; A behavioral model of families’ use of health service, Center for Health Administration Studies) behavioral health model, predisposing (age, gender, marital status and education), need (anxiety and depressive symptoms) and enabling (acculturation, health insurance coverage and personal experience and beliefs) variables were considered. In the mean-level assessment, younger and older adults were found to hold a similar level of positive attitudes toward mental health services. In the multivariate analysis, culture-influenced beliefs were shown to have a substantial contribution to the model of attitudes toward mental health services in both age groups. The belief that depression is a medical condition was found to be a common predictor of positive attitudes across the groups. In the older adult sample, more negative attitudes were observed among those who believed that depression is a sign of personal weakness and that having a mentally ill family member brings shame to the whole family. Our findings show that older adults are not only more subject to cultural misconceptions and stigma related to mental disorders, but also their attitudes toward service use are negatively influenced by the cultural stigma. The findings provide important implications for interventions targeted to improve access to mental health care among minority populations. Based on the similarities and differences found between young and old, both general and age-specific strategies need to be developed in order to increase effectiveness of these programs.
doi:10.1080/13607860802591070
PMCID: PMC2737391  PMID: 19197698
mental health; service utilization; Korean American adults
9.  Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach 
PLoS Medicine  2006;3(10):e452.
Background
Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.
Methods and Findings
We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its “War on Drugs.” African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off “dopesickness” rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.
Conclusions
Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.
Bourgois and colleagues found that the African American and white men in their study had a different pattern of drug use and risk behaviors, adopted different strategies for survival, and had different personal histories.
Editors' Summary
Background.
There are stark differences in the health of different ethnic groups in America. For example, the life expectancy for white men is 75.4 years, but it is only 69.2 years for African-American men. The reasons behind these disparities are unclear, though there are several possible explanations. Perhaps, for example, different ethnic groups are treated differently by health professionals (with some groups receiving poorer quality health care). Or maybe the health disparities are due to differences across ethnic groups in income level (we know that richer people are healthier). These disparities are likely to persist unless we gain a better understanding of how they arise.
Why Was This Study Done?
The researchers wanted to study the health of a very vulnerable community of people: heroin users living on the streets in the San Francisco Bay Area. The health status of this community is extremely poor, and its members are highly stigmatized—including by health professionals themselves. The researchers wanted to know whether African American men and white men who live on the streets have a different pattern of drug use, whether they adopt varying strategies for survival, and whether they have different personal histories. Knowledge of such differences would help the health community to provide more tailored and culturally appropriate interventions. Physicians, nurses, and social workers often treat street-based drug users, especially in emergency rooms and free clinics. These health professionals regularly report that their interactions with street-based drug users are frustrating and confrontational. The researchers hoped that their study would help these professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients.
What Did the Researchers Do and Find?
Over the course of six years, the researchers directly observed about 70 men living on the streets who injected heroin as they went about their usual lives (this type of research is called “participant observation”). The researchers specifically looked to see whether there were differences between the white and African American men. All the men gave their consent to be studied in this way and to be photographed. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men. The researchers found that the white men were more likely to supplement their heroin use with inexpensive fortified wine, while African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime, and these men tended to consider themselves as destitute outcasts. African American men had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families, and these men tended to consider themselves as professional outlaws. The white men persevered less in attempting to find a vein in which to inject heroin, and so were more likely to inject the drug directly under the skin—this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most of their income through petty crime and/or through offering services such as washing car windows at gas stations.
What Do These Findings Mean?
Among street-based heroin users, there are important differences between white men and African American men in the type of drugs used, the method of drug use, their social backgrounds, the way in which they identify themselves, and the health risks that they take. By understanding these differences, health professionals should be better placed to provide tailored and appropriate care when these men present to clinics and emergency rooms. As the researchers say, “understanding of different ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care.” One limitation of this study is that the researchers studied one specific community in one particular area of the US—so we should not assume that their findings would apply to street-based heroin users elsewhere.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030452.
The US Centers for Disease Control (CDC) has a web page on HIV prevention among injection drug users
The World Health Organization has collected documents on reducing the risk of HIV in injection drug users and on harm reduction approaches
The International Harm Reduction Association has information relevant to a global audience on reducing drug-related harm among individuals and communities
US-focused information on harm reduction is available via the websites of the Harm Reduction Coalition and the Chicago Recovery Alliance
Canada-focused information can be found at the Street Works Web site
The Harm Reduction Journal publishes open-access articles
The CDC has a web page on eliminating racial and ethnic health disparities
The Drug Policy Alliance has a web page on drug policy in the United States
doi:10.1371/journal.pmed.0030452
PMCID: PMC1621100  PMID: 17076569
10.  Internet-Based Interventions to Promote Mental Health Help-Seeking in Elite Athletes: An Exploratory Randomized Controlled Trial 
Background
Mental disorders are more common in young adults than at any other life stage. Despite this, young people have low rates of seeking professional help for mental health problems. Young elite athletes have less positive attitudes toward seeking help than nonathletes and thus may be particularly unlikely to seek help. Interventions aimed at increasing help-seeking in young elite athletes are warranted.
Objective
To test the feasibility and efficacy of three Internet-based interventions designed to increase mental health help-seeking attitudes, intentions, and behavior in young elite athletes compared with a control condition.
Methods
We conducted a randomized controlled trial (RCT) of three brief fully automated Internet-based mental health help-seeking interventions with 59 young elite athletes recruited online in a closed trial in Australia. The interventions consisted of a mental health literacy and destigmatization condition, a feedback condition providing symptom levels, and a minimal content condition comprising a list of help-seeking resources, compared with a control condition (no intervention). We measured help-seeking attitudes, intentions and behavior using self-assessed surveys. Participation was open to elite athletes regardless of their mental health status or risk of mental illness.
Results
Of 120 athletes initially agreeing to participate, 59 (49%) submitted a preintervention or postintervention survey, or both, and were included in the present study. Adherence was satisfactory, with 48 (81%) participants visiting both weeks of assigned intervention material. None of the interventions yielded a significant increase in help-seeking attitudes, intentions, or behavior relative to control. However, at postintervention, there was a trend toward a greater increase in help-seeking behavior from formal sources for the mental health literacy/destigmatization condition compared with control (P = .06). This intervention was also associated with increased depression literacy (P = .003, P = .005) and anxiety literacy (P = .002, P = .001) relative to control at postintervention and 3-month follow-up, respectively, and a reduction in depression stigma relative to control at postintervention (P = .01, P = .12) and anxiety stigma at 3-month follow-up (P = .18, P = .02). The feedback and help-seeking list interventions did not improve depression or anxiety literacy or decrease stigmatizing attitudes to these conditions. However, the study findings should be treated with caution. Due to recruitment challenges, the achieved sample size fell significantly short of the target size and the study was underpowered. Accordingly, the results should be considered as providing preliminary pilot data only.
Conclusions
This is the first RCT of an Internet-based mental health help-seeking intervention for young elite athletes. The results suggest that brief mental health literacy and destigmatization improves knowledge and may decrease stigma but does not increase help-seeking. However, since the trial was underpowered, a larger trial is warranted.
Trial Registration
2009/373 (www.clinicaltrials.gov ID: NCT00940732), cited at http://www.webcitation.org/5ymsRLy9r.
doi:10.2196/jmir.1864
PMCID: PMC3414855  PMID: 22743352
Mental health; help-seeking; elite athletes
11.  Public stigma against family members of people with mental illness: findings from the Gilgel Gibe Field Research Center (GGFRC), Southwest Ethiopia 
Background
Public stigma against family members of people with mental illness is a negative attitude by the public which blame family members for the mental illness of their relatives. Family stigma can result in self social restrictions, delay in treatment seeking and poor quality of life. This study aimed at investigating the degree and correlates of family stigma.
Methods
A quantitative cross-sectional house to house survey was conducted among 845 randomly selected urban and rural community members in the Gilgel Gibe Field Research Center, Southwest Ethiopia. An interviewer administered and pre-tested questionnaire adapted from other studies was used to measure the degree of family stigma and to determine its correlates. Data entry was done by using EPI-DATA and the analysis was performed using STATA software. Unadjusted and adjusted linear regression analysis was done to identify the correlates of family stigma.
Results
Among the total 845 respondents, 81.18% were female. On a range of 1 to 5 score, the mean family stigma score was 2.16 (±0.49). In a multivariate analysis, rural residents had significantly higher stigma scores (std. β = 0.43, P < 0.001) than urban residents. As the number of perceived signs (std. β = -0.07, P < 0.05), perceived supernatural (std. β = -0.12, P < 0.01) and psychosocial and biological (std. β = -0.11, P < 0.01) explanations of mental illness increased, the stigma scores decreased significantly. High supernatural explanation of mental illness was significantly correlated with lower stigma among individuals with lower level of exposure to people with mental illness (PWMI). On the other hand, high exposure to PWMI was significantly associated with lower stigma among respondents who had high education. Stigma scores increased with increasing income among respondents who had lower educational status.
Conclusions
Our findings revealed moderate level of family stigma. Place of residence, perceived signs and explanations of mental illness were independent correlates of public stigma against family members of people with mental illness. Therefore, mental health communication programs to inform explanations and signs of mental illness need to be implemented.
doi:10.1186/1472-698X-14-2
PMCID: PMC3933511  PMID: 24555444
Stigma; Mental illness; Family stigma; Psublic stigma
12.  Stigma in response to mental disorders: a comparison of Australia and Japan 
BMC Psychiatry  2006;6:21.
Background
There are few national or cross-cultural studies of the stigma associated with mental disorders. Australia and Japan have different systems of psychiatric health care, and distinct differences in cultural values, but enjoy similar standards of living. This study seeks to compare the nature and extent of stigma among the public in the two countries.
Methods
A household survey of the public was conducted in each country using similar methodologies. The Australian study comprised a national survey of 3998 adults aged over 18 years. The Japanese survey involved 2000 adults aged 20 to 69 from 25 regional sites distributed across the country. Interviewees reported their personal attitudes (personal stigma, social distance) and perceptions of the attitudes of others (perceived stigma, perceived discrimination) in the community with respect to four case vignettes. These vignettes described a person with: depression; depression with suicidal ideation; early schizophrenia; and chronic schizophrenia.
Results
Personal stigma and social distance were typically greater among the Japanese than the Australian public whereas the reverse was true with respect to the perception of the attitudes and discriminatory behaviour of others. In both countries, personal stigma was significantly greater than perceived stigma. The public in both countries showed evidence of greater social distance, greater personal stigma and greater perceived stigma for schizophrenia (particularly in its chronic form) than for depression. There was little evidence of a difference in stigma for depression with and without suicide for either country. However, social distance was greater for chronic compared to early schizophrenia for the Australian public.
Conclusion
Stigmatising attitudes were common in both countries, but negative attitudes were greater among the Japanese than the Australian public. The results suggest that there is a need to implement national public awareness interventions tailored to the needs of each country. The current results provide a baseline for future tracking of national stigma levels in each country.
doi:10.1186/1471-244X-6-21
PMCID: PMC1525161  PMID: 16716231
13.  African American Men and Women's Attitude Toward Mental Illness, Perceptions of Stigma, and Preferred Coping Behaviors 
Nursing research  2013;62(3):185-194.
Background
Although research focused on African Americans with mental illness has been increasing, few researchers have addressed gender and age differences in beliefs, attitudes, and coping.
Objective
To examine African Americans' beliefs about mental illness, attitudes toward seeking mental health services, preferred coping behaviors, and whether these variables differ by gender and age.
Method
An exploratory, cross-sectional survey design was used. Participants were 272 community-dwelling African Americans aged 25-72 years. Data analysis included descriptive statistics and general linear regression models.
Results
Depression was the most common mental illness and there were no gender differences in prevalence. Both men and women believed they knew some of the symptoms and causal factors of mental illness. Their attitudes suggested they are not very open to acknowledging psychological problems, are very concerned about stigma associated with mental illness, and are somewhat open to seeking mental health services, but they prefer religious coping. Significant gender and age differences were evident in attitudes and preferred coping.
Discussion
Our findings have implications for gender and age-specific psychoeducation interventions and future research. For instance, psychoeducation or community awareness programs designed to increase openness to psychological problems and reducing stigma are needed. Also, exploration of partnerships between faith-based organizations and mental health services could be helpful to African Americans.
doi:10.1097/NNR.0b013e31827bf533
PMCID: PMC4279858  PMID: 23328705
African Americans; mental illness; beliefs; coping behaviors
14.  The stigma of childhood mental disorders: A conceptual framework 
Objective
To describe the state of the literature on stigma associated with children’s mental disorders and highlight gaps in empirical work.
Method
We reviewed child mental illness stigma articles in (English only) peer-reviewed journals available through Medline and PsychInfo. We augmented these with adult-oriented stigma articles that focus on theory and measurement. 145 articles in PsychInfo and 77 articles in MEDLINE met search criteria. The review process involved identifying and appraising literature convergence on the definition of critical dimensions of stigma, antecedents, and outcomes reported in empirical studies.
Results
We found concurrence on three dimensions of stigma (negative stereotypes, devaluation and discrimination), two contexts of stigma (self, general public), and two targets of stigma (self/individual, family). Theory and empirics on institutional and self stigma in child populations were sparse. Literature reports few theoretic frameworks and conceptualizations of child mental illness stigma. One model of help-seeking (the FINIS) explicitly acknowledges the role of stigma in children’s access and utilization of mental health services.
Conclusions
Compared to adults, children are subject to unique stigmatizing contexts that have not been adequately studied. The field needs conceptual frameworks that get closer to stigma experiences that are causally linked to how parents/caregivers cope with children’s emotional and behavioral problems such as seeking professional help. To further research in child mental illness, we suggest an approach to adapting current theoretical frameworks and operationalizing stigma highlighting three dimensions of stigma, three contexts of stigma (including institutions), and three targets of stigma (self/child, family and services).
PMCID: PMC2904965  PMID: 20215931
Stigma; Child mental disorders; Conceptual framework; Caregiver help-seeking
15.  Reducing stigma toward seeking mental health treatment among adolescents 
Stigma research and action  2011;1(2):9-21.
Purpose
This study examined the effectiveness of an intervention to reduce explicit and implicit stigma-relevant attitudes toward mental illness and treatment-seeking and behavioural indicators of willingness to seek treatment.
Methods
Adolescents were randomly assigned to the experimental (education about mental illness and treatment involving psychoeducation and contact (via DVD) with an affected individual) or control intervention (education about tobacco).
Results
Findings suggest the stigma intervention was effective at reducing explicit but not implicit stigma-relevant attitudes. As hypothesized, participants receiving the experimental intervention reported less explicit stigma toward treatment and greater openness to personally seek treatment if they had also reported prior mental health treatment.
Conclusions and Implications
These findings support the potential for a brief educational intervention among adolescents to reduce negative attitudes toward mental health treatment, but raise questions about how to effectively address implicit stigma as well as the importance of translating stigma reduction into behavior changes.
PMCID: PMC3839682  PMID: 24286023
stigma; mental illness; treatment-seeking; implicit and explicit attitudes
16.  Identification of and Beliefs about Depressive Symptoms and Preferred Treatment Approaches Among Community-living Older African Americans 
Objective
To examine older African American’s recognition of and beliefs about depressive symptoms, preferred symptom management strategies, and factors associated with willingness to use mental health treatments. Differences between depressed and non-depressed and men and women were examined.
Design
Cross-sectional survey.
Setting
Home, senior center.
Participants
153 senior center members (56=males, 97=females) ≥55 years.
Measurements
Using a depression vignette, participants indicated if the person was depressed and their endorsement of items reflecting beliefs, stigma, symptom management, and willingness to use treatments (yes/no). PHQ-9 assessed current symptomatology.
Results
Overall, 24.2% reported depressive symptoms (≥5); 88.2% correctly identified the person in the vignette as depressed. Most (≥75%) endorsed active symptom management strategies, preference for treatment in physician and therapist offices, and willingness to take medications, seek therapy, see doctor and attend support groups; <33% viewed depression as stigmatizing whereas 48% viewed depression as normal aging. Logistic regressions revealed lower education, higher physical function and feeling okay if community knew of depression diagnosis were associated with willingness to see physician if feeling depressed; being married and believing anti-depressant medications are beneficial were related to willingness to use medications. Different associations emerged for depressed/non-depressed and men and women.
Conclusions
Overall, this older African American sample had positive attitudes and beliefs and endorsed traditional treatment modalities suggesting that beliefs alone are unlikely barriers to underutilization of mental health services. As different factors were associated with willingness to seek physician help and use medications and factors differed for depressed/non-depressed and by sex, interventions should be tailored.
doi:10.1097/JGP.0b013e31825463ce
PMCID: PMC4030409  PMID: 22643600
Depression; health disparities; depression beliefs
17.  The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya: A Prospective Mixed-Methods Study 
PLoS Medicine  2012;9(8):e1001295.
Janet Turan and colleagues examined the role of the perception of women in rural Kenya of HIV-related stigma during pregnancy on their subsequent utilization of maternity services.
Background
Childbirth with a skilled attendant is crucial for preventing maternal mortality and is an important opportunity for prevention of mother-to-child transmission of HIV. The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which we examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilization of maternity services.
Methods and Findings
From 2007–2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up (all women who tested HIV-positive or were not tested for HIV, and a random sample of HIV-negative women, n = 598); 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews with community health workers, childbearing women, and family members (n = 48) aided our interpretation of the quantitative findings and highlighted ways in which HIV-related stigma may influence birth decisions. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Our quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery (adjusted odds ratio = 0.44, 95% CI 0.22–0.88).
Conclusions
Our findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families.
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Every year, nearly 350,000 women die from pregnancy- or childbirth-related complications. Almost all these “maternal” deaths occur in developing countries. In sub-Saharan Africa, for example, the maternal mortality ratio (the number of maternal deaths per 100,000 live births) is 500 whereas in industrialized countries it is only 12. Most maternal deaths are caused by hemorrhage (severe bleeding after childbirth), post-delivery infections, obstructed (difficult) labor, and blood pressure disorders during pregnancy. All these conditions can be prevented if women have access to adequate reproductive health services and if trained health care workers are present during delivery. Notably, in sub-Saharan Africa, infection with HIV (the virus that causes AIDS) is an increasingly important contributor to maternal mortality. HIV infection causes maternal mortality directly by increasing the occurrence of pregnancy complications and indirectly by increasing the susceptibility of pregnant women to malaria, tuberculosis, and other “opportunistic” infections—HIV-positive individuals are highly susceptible to other infections because HIV destroys the immune system.
Why Was This Study Done?
Although skilled delivery attendants reduce maternal mortality, there are many barriers to their use in developing countries including cost and the need to travel long distances to health facilities. Fears and experiences of HIV-related stigma and discrimination (prejudice, negative attitudes, abuse, and maltreatment directed at people living with HIV) may also be a barrier to the use of skilled childbirth service. Maternity services are prime locations for HIV testing and for the provision of interventions for the prevention of mother-to-child transmission (PMTCT) of HIV, so pregnant women know that they will have to “deal with” the issue of HIV when visiting these services. In this prospective mixed-methods study, the researchers examine the role of pregnant women's perceptions of HIV-related stigma in their subsequent use of maternity services in Nyanza Province, Kenya, a region where 16% women aged 15–49 are HIV-positive and where only 44.2% of mothers give birth in a health facility. A mixed-methods study combines qualitative data—how people feel about an issue—with quantitative data—numerical data about outcomes.
What Did the Researchers Do and Find?
In the Maternity in Migori and AIDS Stigma (MAMAS) study, pregnant women with unknown HIV status living in rural regions of Nyanza Province answered questions about their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal clinic visit. After delivery, the researchers asked the women who tested HIV positive or were not tested for HIV and a sample of HIV-negative women where they had delivered their baby. They also gathered qualitative information about barriers to maternity and HIV service use by interviewing childbearing women, family members, and community health workers. The qualitative data indicate that labor in a health facility is commonly viewed as being most appropriate for women with pregnancy complications such as HIV infection. Thus, women delivering at health facilities risk being labeled as HIV positive, a label that the community associates with promiscuity. The quantitative data indicate that women with more negative attitudes about HIV-positive people (higher perceptions of HIV-related stigma) at baseline were about half as likely to deliver in a health facility with a skilled attendant as women with more positive attitudes about people living with HIV.
What Do These Findings Mean?
These findings suggest that HIV-related stigma is associated with the low rate of delivery by skilled attendants in rural areas of Nyanza Province and possibly in other rural regions of sub-Saharan Africa. Community mobilization efforts aimed at increasing the use of PMTCT services may be partly responsible for the strong perception that delivery in a health facility is most appropriate for women with HIV and other pregnancy complications and may have inadvertently strengthened the perception that women who give birth in such facilities are likely to be HIV positive. The researchers suggest, therefore, that health messages should stress that delivery in a health facility is recommended for all women, not just HIV-positive women or those with pregnancy complications, and that interventions should be introduced to reduce HIV-related stigma. This combined strategy has the potential to increase the use of maternity services by all women and the use of HIV and PMTCT services, thereby reducing some of the most pressing health problems facing women and their children in sub-Saharan Africa.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001295.
The United Nations Children's Fund (UNICEF) provides information on maternal mortality, including the WHO/UNICEF/UNFPA/World Bank 2008 country estimates of maternal mortality; a UNICEF special report tells the stories of seven mothers living with HIV in Lesotho
The World Health Organization provides information on maternal health, including information about Millennium Development Goal 5, which aims to reduce maternal mortality (in several languages); the Millennium Development Goals, which were agreed by world leaders in 2000, are designed to eradicate extreme poverty worldwide by 2015
Immpact is a global research initiative for the evaluation of safe motherhood intervention strategies
Maternal Death: The Avoidable Crisis is a briefing paper published by the independent humanitarian medical aid organization Médecins Sans Frontières (MSF) in March 2012
Information is available from Avert, an international AIDS charity on all aspects of HIV/AIDS, including information on women, HIV and AIDS, on HIV and pregnancy, on HIV and AIDS stigma and discrimination, and on HIV in Kenya (in English and Spanish); Avert also has personal stories from women living with HIV
The Stigma Action Network (SAN) is a collaborative endeavor that aims to comprehensively coordinate efforts to develop and expand program, research, and advocacy strategies for reducing HIV stigma worldwide, including mobilizing stakeholders, delivering program and policy solutions, and maximizing investments in HIV programs and services globally
The People Living with Stigma Index aims to address stigma relating to HIV and advocate on key barriers and issues perpetuating stigma; it has recently published Piecing it together for women and girls, the gender dimensions of HIV-related stigma
The Health Policy Project http://www.healthpolicyproject.com has prepared a review of the academic and programmatic literature on stigma and discrimination as barriers to achievement of global goals for maternal health and the elimination of new child HIV infections (see under Resources)
More information on the MAMAS study is available from the UCSF Center for AIDS Prevention Studies
doi:10.1371/journal.pmed.1001295
PMCID: PMC3424253  PMID: 22927800
18.  Facility based cross-sectional study of self stigma among people with mental illness: towards patient empowerment approach 
Background
Self stigma among people with mental illness results from multiple cognitive and environmental factors and processes. It can negatively affect adherence to psychiatric services, self esteem, hope, social integration and quality of life of people with mental illness. The purpose of this study was to measure the level of self stigma and its correlates among people with mental illness at Jimma University Specialized Hospital, Psychiatry clinic in southwest Ethiopia.
Methods
Facility based cross-sectional study was conducted on 422 consecutive samples of people with mental illness using interviewer administered and pretested internalized stigma of mental illness (ISMI) scale. Data was entered using EPI-DATA and analysis was done using STATA software. Bivariate and multivariate linear regressions were done to identify correlates of self stigma.
Results
On a scale ranging from 1 to 4, the mean self stigma score was 2.32 (SD = 0.30). Females had higher self stigma (std. β = 0.11, P < 0.05) than males. Patients with a history of traditional treatment had higher self stigma (std. β = 0.11, P < 0.05). There was an inverse relationship between level of education and self-stigma (std. β = −0.17, P < 0.01). Perceived signs (std. β = 0.13, P < 0.05) and supernatural causes of mental illness (std. β = 0.16, P < 0.01) were positively correlated with self stigma. Higher number of drug side effects were positively correlated (std. β = 0.15, P < 0.05) while higher self esteem was negatively correlated (std. β = −0.14, P < 0.01) with self stigma.
Conclusions
High feeling of inferiority (alienation) but less agreement with common stereotypes (stereotype endorsement) was found. Female showed higher self stigma than male. History of traditional treatment and higher perceived supernatural explanation of mental illness were associated with higher self stigma. Drug side effects and perceived signs of mental illness were correlated with increased self stigma while education and self esteem decreased self stigma among people with mental illness. Patient empowerment psychosocial interventions and strategies to reduce drug side effects can be helpful in reducing self stigma among people with mental illnesses.
doi:10.1186/1752-4458-7-21
PMCID: PMC3848304  PMID: 24004512
Self stigma; Internalized stigma; Stigma; Mental illness; People with mental illness
19.  Effects of labeling and interpersonal contact upon attitudes towards schizophrenia: implications for reducing mental illness stigma in urban China 
Purpose
As mental illness stigma contributes to poor outcomes for schizophrenia in China, locating strategies to reduce public stigma is imperative. It is currently unknown whether diagnostic labeling and contact with different help-seeking sources increase or decrease public stigma in China. Further, it remains unresolved whether prior personal contact acts to reduce stigma in this context. Advancing understanding of these processes may facilitate stigma-reduction strategies.
Methods
We administered an experimental vignette randomly assigning one of four labeling conditions to respondents to assess social distance towards a psychotic vignette individual in a sample of 160 Northern, urban Chinese community respondents.
Results
As expected, respondents given a “non-psychiatric, indigenous label” + “lay help-seeking” condition endorsed the least social distance. Unexpectedly, the labeling condition with a “psychiatric diagnostic label” + “lay help-seeking” condition elicited the greatest social distance. Unlike Western studies, personal contact did not independently decrease community stigma. However, prior contact reduced social distance to a greater extent in the labeling condition with a “non-psychiatric, indigenous label” + “lay help-seeking” condition when compared with all other labeling conditions.
Conclusion
The results indicate that cultural idioms do provide some protection from stigma, but only among respondents who are already familiar with what mental illness is. Our finding that the condition that depicted untreated psychosis elicited the greatest amount of stigma, while the “treated psychosis” condition was viewed relatively benignly in China, suggests that improved access to mental health services in urban China has the potential to decrease public stigma via labeling mechanisms.
doi:10.1007/s00127-011-0452-y
PMCID: PMC3697873  PMID: 22075964
Stigma; Culture; China; Schizophrenia; Attitudes
20.  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.
doi:10.2147/JMDH.S57259
PMCID: PMC3896287  PMID: 24470760
self-stigma; internalized stigma; caregivers; mental illness
21.  Cultural Beliefs and Mental Health Treatment Preferences of Ethnically Diverse Older Adult Consumers in Primary Care 
Background
Beliefs concerning the causes of mental illness may help explain why there are significant disparities in the rates of formal mental health service use among racial/ethnic minority elderly as compared with their Caucasian counterparts. This study applies the Cultural Influences on Mental Health framework to identify the relationship between race/ethnicity and differences in: (1) beliefs on the cause of mental illness; (2) preferences for type of treatment; and (3) provider characteristics.
Method
Analyses were conducted using baseline data collected from participants who completed the Cultural Attitudes toward Healthcare and Mental Illness Questionnaire, developed for the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) study, a multi-site randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1257 non-Latino Whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos.
Results
African-Americans, Asian-Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared to Non-Latino Whites. Race/ethnicity was also associated with determining who makes healthcare decisions, treatment preferences, and preferred characteristics of healthcare providers.
Conclusions
This study highlights the association between race/ethnicity and health beliefs, treatment preferences, healthcare decisions, and consumers' preferred characteristics of healthcare providers. Accommodating the values and preferences of individuals can be helpful in engaging racial/ethnic minority patients in mental health services.
doi:10.1097/JGP.0b013e318227f876
PMCID: PMC3258470  PMID: 21992942
race/ethnicity; health beliefs; older adults
22.  Stigma and the Acceptability of Depression Treatments Among African Americans and Whites 
Journal of General Internal Medicine  2007;22(9):1292-1297.
BACKGROUND
Stigma is associated with depression treatment, however, whether stigma differs between depression treatment modalities is not known, nor have racial differences in depression treatment stigma been fully explored.
OBJECTIVE
To measure stigma for four depression treatments and estimate its association with treatment acceptability for African Americans and whites.
DESIGN
Cross-sectional, anonymous mailed survey.
PARTICIPANTS
Four hundred and ninety African-American and white primary care patients.
MEASUREMENTS
The acceptability of four depression treatments (prescription medication, mental health counseling, herbal remedy, and spiritual counseling) was assessed using a vignette. Treatment-specific stigma was evaluated by asking whether participants would: (1) feel ashamed; (2) feel comfortable telling friends and family; (3) feel okay if people in their community knew; and (4) not want people at work to know about each depression treatment. Sociodemographics, depression history, and current depressive symptoms were measured.
RESULTS
Treatment-specific stigma was lower for herbal remedy than prescription medication or mental health counseling (p < .01). Whites had higher stigma than African Americans for all treatment modalities. In adjusted analyses, stigma relating to self [AOR 0.43 (0.20–0.95)] and friends and family [AOR 0.42 (0.21–0.88)] was associated with lower acceptability of mental health counseling. Stigma did not account for the lower acceptability of prescription medication among African Americans.
CONCLUSIONS
Treatment associated stigma significantly affects the acceptability of mental health counseling but not prescription medication. Efforts to improve depression treatment utilization might benefit from addressing concerns about stigma of mental health counseling.
doi:10.1007/s11606-007-0276-3
PMCID: PMC2219769  PMID: 17610120
stigma; depression treatment; patient preferences; ethnicity
23.  Cultural Variation in Implicit Mental Illness Stigma 
Journal of cross-cultural psychology  2012;43(7):10.1177/0022022112455457.
Culture shapes how individuals perceive and respond to others with mental illness. Prior studies have suggested that Asians and Asian Americans typically endorse greater stigma of mental illness compared to Westerners (White Europeans and Americans). However, whether these differences in stigma arise from cultural variations in automatic affective reactions or deliberative concerns of the appropriateness of one’s reactions to mental illness remains unknown. Here we compared implicit and explicit attitudes toward mental illness among Asian and Caucasian Americans. Asian Americans showed stronger negative implicit attitudes toward mental illness relative to Caucasian Americans, suggesting that cultural variation in stigma of mental illness can be observed even when concerns regarding the validity and appropriateness of one’s attitudes toward mental illness are minimized. Asian Americans also explicitly endorsed greater desire for social distance from mental illness relative to Caucasian Americans. These findings suggest that cultural variations in mental illness stigma may arise from cultural differences in automatic reactions to mental illness, though cultural variations in deliberative processing may further shape differences in these immediate reactions to mental illness.
doi:10.1177/0022022112455457
PMCID: PMC3848905  PMID: 24311820
stigma; culture; mental illness; attitudes; implicit processes; social cognition
24.  Older adults’ help-seeking attitudes and treatment beliefs concerning mental health problems 
Objectives
Older adults with mental health problems are especially unlikely to seek professional mental health services. It is not clear, however, whether their help-seeking attitudes and treatment beliefs contribute to this problem. The objectives of this study were to compare older adults’ attitudes and beliefs to younger adults’ and to examine the influence of age on these variables after controlling for other demographic variables, prior help-seeking, and mental disorders.
Methods
We analyzed cross-sectional data from Part II of the National Comorbidity Survey Replication. This dataset includes 5,692 community-dwelling adults, including 1,341 who were 55 years of age and older. Participants responded to three questions assessing attitudes toward seeking professional mental health services and one question examining beliefs about the percentage of people with serious mental health concerns who benefit from professional help. We used logistic regression to predict positive versus negative attitudes and beliefs from age, gender, education, and race/ethnicity, as well as prior help-seeking and mood and/or anxiety disorder diagnosis.
Results
Overall, more than 80% of participants exhibited positive help-seeking attitudes and more than 70% reported positive treatment beliefs. In contrast to the modest effect of age on beliefs, adults 55 to 74 years of age were approximately two to three times more likely to report positive help-seeking attitudes than younger adults.
Conclusions
Older adults’ positive attitudes and treatment beliefs are unlikely barriers to their use of mental health services. This finding, which is consistent with recent positive views of aging, suggests that enabling resources and need factors are more likely explanations for older adults’ low rates of mental health service use.
doi:10.1097/JGP.0b013e31818cd3be
PMCID: PMC2735824  PMID: 19038900
help-seeking attitudes; treatment beliefs; mental health service utilization
25.  Automatic stereotyping against people with schizophrenia, schizoaffective and affective disorders 
Psychiatry research  2010;186(1):34-39.
Similar to members of the public, people with mental illness may exhibit general negative automatic prejudice against their own group. However, it is unclear whether more specific negative stereotypes are automatically activated among diagnosed individuals and how such automatic stereotyping may be related to self-reported attitudes and emotional reactions. We therefore studied automatically activated reactions toward mental illness among 85 people with schizophrenia, schizoaffective or affective disorders as well as among 50 members of the general public, using a Lexical Decision Task to measure automatic stereotyping. Deliberately endorsed attitudes and emotional reactions were assessed by self-report. Independent of diagnosis, people with mental illness showed less negative automatic stereotyping than did members of the public. Among members of the public, stronger automatic stereotyping was associated with more self-reported shame about a potential mental illness and more anger toward stigmatized individuals. Reduced automatic stereotyping in the diagnosed group suggests that people with mental illness might not entirely internalize societal stigma. Among members of the public, automatic stereotyping predicted negative emotional reactions to people with mental illness. Initiatives to reduce the impact of public stigma and internalized stigma should take automatic stereotyping and related emotional aspects of stigma into account.
doi:10.1016/j.psychres.2010.08.024
PMCID: PMC3005008  PMID: 20843560
stigma; prejudice; shame; anger; semantic priming

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