Transcript Template

The Stigma of Mental Illness
in Global Context: First
Findings from the SGC-MHS
Bernice A. Pescosolido
Indiana University
The Fourth International Stigma Conference
London, UK
January 21-23, 2009
Goal
● To provide a brief background of the
impetus and methods of the Stigma in
Global Context – Mental Health Study
● To move quickly to offer an overview of
preliminary findings from the SGC-MHS
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The SGC-MHS Team – Wave 1
Principal Investigators
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Investigators
• Sigrun Olafsdottir, Boston University
• Tait Medina, Indiana University
Consultants
• Kim Hopper, Nathan Kline Institute for Psychiatric Research
• Aleksandar Janca, University of Western Australia
International Collaborators
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Bernice Pescosolido, Indiana University
Jack K. Martin, Indiana University
J. Scott Long, Indiana University
Tom W. Smith, NORC
Centro de Estudios de Opinión Pública, Argentina
Bangladesh Unnayan Parishad (BUP), Bangladesh
Fundacao Getulio Vargas (FGV) Opiniao, Brazil
Agency for Social Analyses (ASA), Bulgaria
Center of Applied Research, Cyprus College, Cyprus
Centre for Survey Research and Methodology (ZUMA), Germany
National Centre for Social Research, Great Britain
TARKI Social Research Centre, Hungary
Department of Sociology, University of Iceland, Iceland
Korea Institute for Health & Social Affairs, South Korea
Department of Marketing, Massey University, New Zealand
Social Weather Stations, Philippines
Markinor Ltd, South Africa
Análisis Sociológicos Económicos y Políticos (ASEP), Spain
National Opinion Research Center (NORC), United States
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The SGC-MHS – Other Partners
Special Case Collaborators
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Department of Health Sociology, University of Tokyo, Japan
Mark Tausig & Janardan Subedi, University of Akron (Nepal study)
Piet Bracke & Mieke Verhaeghe, Ghent University, Belgium
Ethan Michelson, Indiana University (China study)
Advisors
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Rodney Elgie, Gamian-Europe
Howard Goldman, University of Maryland School of Medicine
Jibum Kim, NORC, University of Chicago
Xingzhu Liu, Fogarty International Center
John Monahan, University of Virginia School of Law
Emeline Otey, National Institute of Mental Health
Anne Rogers, University of Manchester
Norman Sartorius, University of Geneva, Switzerland
Susan Solomon, Office of Behavioral & Social Science Research
Violet Yebei, Indiana University
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Project Funding & Institutional
Support
● National Institutes of Health (R01 TW006374)
● Fogarty International Center
● National Institute of Mental Health
● Office of Behavioral & Social Science Research
● Icelandic Centre for Research and The
University of Iceland
● Rockefeller Foundation
● Indiana University College of Arts & Sciences
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Original and Changing Impetus
● Resurgence in research and policy efforts on public stigma
● Recovery puzzle – WHO International Study of
Schizophrenia (ISoS)
● 1989: Kleinman – single most important finding of mental health
services research
● Individuals with schizophrenia have better outcomes in
“developing” rather than “developed” countries
● FIC/NIH 2001 International Conference on Stigma:
“Stigma and Global Health: Developing a Research
Agenda” and following RFA
● Lancet 2006: particularly Weiss and Ramakrishna call for
understanding stigma in different settings – because
context reflects differences in social and cultural values,
health programs, and behavior of health care personnel
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Limitations
● No overarching theoretical framework
● No or limited comparative studies of
public stigma
SGC-MHS:
● Theoretically-based
● Methodologically coordinated
● Multi-country
● Reliable global program
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Etiology and Effects
of Stigma Model (EES) Expanded
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Participating Countries
• 15 nations across a range of developmental
levels
o Includes Argentina, Bangladesh, Brazil, Bulgaria,
Cyprus, Germany, Great Britain, Hungary,
Iceland, Korea, New Zealand, Philippines, South
Africa, Spain, and the USA
• Additional countries to be included as
special cases
o Japan, Nepal
• Other possible additions
o China, Belgium
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Sampling
• 15 national probability cross-sections
(plus other special cases) fielded to date
• Non-institutionalized adults (18+)
• Multi-stage probability selection
• N = 804 – 1,550 in each nation
• Total N = 18,342 for combined dataset
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Procedures
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Face-to-Face Personal Interviews
Two Part Interview Schedule
75-item substantive core
Standard ISSP measures of socio-demographic
attributes
● Fielded in 4 waves
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3
7
3
2
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countries
countries
countries
countries
in
in
in
in
2004
2005
2006
2007
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Instrumentation
● Vignette-Based
● Modeled after the MacArthur Mental Health Module of
the 1996 GSS (March 12-13, 2004 meeting in Madrid)
● Primary instrument drafted in English, translated into
other languages with translation review
● Culturally tailored on vignettes, idioms, & common
sources of MH care
Pescosolido, B.A. and S. Olafsdottir. “The Logistics of Survey Implementation in a
Comparative Study of Mental Illness: Issues and Resolutions in Translation Across
Cultural Boundaries.” Paper presented at the International Conference on Survey
Methods in Multinational, Multiregional, and Multicultural Contexts, Berlin, Germany,
June 27, 2008.
C. Boyer, B.A. Pescosolido, and T. Medina. “Issues in Understanding Mental Illness and Its
Measurement: Global Problems, Local Manifestations and the Issue of Labeling.” Paper
presented at the International Conference on Survey Methods in Multinational,
Multiregional, and Multicultural Contexts, Berlin, Germany, June 27, 2008.
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Stigma Dimensions
Thirty items tapping eight more-or-less distinct variants
or dimensions of stigmatizing attitudes toward, and
intolerance of, persons with mental health problems.
1.
2.
3.
4.
Social Distance
5. Treatment-based
Stigma
Traditional Prejudice
6. “Outsider” Stigma
Exclusion
7. Threat/Danger
Negative Affect
8. Coercion
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Focus for Today
● Country variation: proportions of
stigmatizing responses by stigma items
for each country
● Additional analyses examining whether
overall proportions are grossly/
systematically affected by “obvious”
within-country factors
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Finding 1
● With the exception of coercion into Tx, the
hierarchy of stigma is clear – schizophrenia,
depression and asthma
.5
0
0
.5
1
People like X are unpredictable
1
Unwilling to work with X on a job
Usa Arg Bra Bgr Cyp Deu Esp Gbr Hun Isl Bgd Kor Phl Nzl Zaf
Schizophrenia
Depression
Usa Arg Bra Bgr Cyp Deu Esp Gbr Hun Isl Bgd Kor Phl Nzl Zaf
Asthma
Schizophrenia
num: 1005
num: 1008
s gc BAR02a02_behavi or-1005_s dworkBD
s gc BAR02a02_behavi or-1008_s tunpredB
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Depression
Asthma
Pescosolido, Page 15
Finding 2
● Stigma is not stigma: ranges from low to quite high
● Significant variation across dimensions
Lowest Levels
High (over 50%)
Treatment – Outsider; Secrecy;
Less Intimacy
Rejection; Affect; Inclusion
Schizophrenia Vignette
Outsider
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Lose Friends
Limits Opps
0
.5
Proportion Stigmatizing
0
.5
Proportion Stigmatizing
.5
0
1
Global Levels of Social Distance
Schizophrenia Vignette
1
Global Levels of Community Stigma
Schizophrenia Vignette
1
Global Levels of Treatment Stigma
Not accepted
Keep secret
Embarrassed
Afraid to tell
Neighbor
Socialize
Childcare
Friend
Work
Marry
Pescosolido, Page 16
See: Pescosolido, B.A., S. Olafsdottir, J.K. Martin,
and J.S. Long. 2008. "Cross-Cultural Issues on the
Stigma of Mental Illness," Pp. 19-35 in J. ArboledaFlorez and N. Sartorius (eds.), Understanding the
Stigma of Mental Illness: Theory and Interventions.
London: John Wiley & Sons, Ltd.
Finding 3
● There is a good deal of cross-national variation in the culture of stigma
● Tends to be consistently high/low (but important exceptions)
Exclusion Items
1
Schizophrenia Vignette
Social Distance: Unwilling to have X as neighbor
Cyp
Schizophrenia Vignette
Bgd
.75
Usa Hun
KorDeu
Esp
Zaf
ArgBra
Phl
Isl Nzl
Gbr
.25
.5
__
0
South _
America_
_Europe _
_ Asia_
0
.5
__
X should not be allowed to teach children
1
Bgr
Usa Arg Bra Bgr Cyp Deu Esp Gbr Hun Isl Bgd Kor Phl Nzl Zaf
Countries Arranged by Continent
0
.25
.5
.75
1
X should not be allowed to supervise others at work
Correlation = 0.97
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Finding 4
.75
1
Schizophrenia Vignette
Bgd
.5
Phl
Cyp
Esp
Zaf
Bgr
Bra
Hun
Arg
Kor
Nzl
Deu
Gbr
Usa
Isl
0
● There is little
relationship with
level of development; and where
it does exist, it is
in the direction
opposite from
the initial
suggestions of
the ISoS
.25
X should not be hired for a job, even if qualified
Exclusion and Level of Development
0
10000
20000
30000
40000
Real Gross Domestic Product per Capita (2003).
Correlation = -0.63
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Finding 5
● Tolerance, Health Funding (not number of psychiatrists/
physicians) are the most closely associated with lower
levels of community-based stigma
Social Distance and Social Capital
Schizophrenia Vignette
1
.5
Gbr
Usa
Phl
Cyp
Isl
Zaf
Deu
.25
0
0
.75
Usa
.25
.5
.75
1
Isl
Esp
Deu
Hun
Bra
Deu
NzlUsa
Gbr
Isl
2.5
5
7.5
Public health expenditures as percentage of gross domestic product (2004).
0
Hun
0
Arg
Esp
Bgr
Bra
Arg
Nzl Gbr
Bgr
Kor
Cyp
Zaf
Kor
.5
Bgd
Phl
.25
.75
Kor
X should be forced by law to take RX meds
Bgd
0
.25
.5
Hun
X should not be hired for a job, even if qualified
Zaf
Bra
Bgr
Arg
.75
Coercion and Health Care
1
1
Exclusion and Health Care
Bgd
Correlation = -0.81
10
0
2.5
5
7.5
Public health expenditures as percentage of gross domestic product (2004).
Correlation = -0.89
Most people can be trusted
Correlation = -0.67
SD_sgcLON04a-CtrustBBYclawdocB
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10
Finding 6
● Personal contact and perceptions of the efficacy of Tx matter
Traditional Prejudice and Contact
Community Stigma and Treatment
Schizophrenia Vignette
Schizophrenia Vignette
Deu
Usa
Isl
Zaf
Bra
Arg
Nzl
Gbr
Phl
.75
Bgd
Esp
Usa
BgrZaf
Kor
Arg
Bra
Hun
Gbr
.5
Esp
Bgr
Cyp
Nzl
Cyp
Phl
Bra
Deu Arg
Esp
Bgr
Hun
Kor
Gbr
ZafUsa
.25
Hun
X's family better off if X's situation was kept secret
.75
Kor
.5
Phl
Cyp
.25
Deu
Isl
0
0
Isl
Nzl
Bgd
0
X would do something violent or harmful toward others
.75
.5
.25
Bgd
1
Threat/Danger and Contact
1
1
Schizophrenia Vignette
0
0
.25
.5
.75
Known someone who recieved treatment for a MH situation
1
.25
.5
.75
1
0
Known someone who recieved treatment for a MH situation
Correlation = -0.66
.25
.5
.75
X's situation will improve with treatment
Correlation = -0.85
Correlation = -0.68
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1
Finding 7
Coercion and Knowledge
1
Bgd
.75
Phl
Cyp
Zaf Bgr
Bra
Esp
.5
Kor
Gbr
Isl
Usa
Nzl
Arg
Hun
Deu
0
.25
The context of
care matters for
endorsements
X should be forced by law to go to a mental hospital
●
Schizophrenia Vignette
0
.25
.5
.75
1
Cause is brain disease or disorder
Correlation = 0.50
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Finding 8
● The Knowledge Solution (proper attributions) is
not promising for stigma reduction
Schizophrenia Vignette
.75
Cyp
.5
Cyp
Phl Bgd
Bgr
Usa
Esp
Hun
Kor
GbrIsl
Kor Deu
Bra Esp
Zaf
ZafNzl
.25
Deu
Bra
Arg
Hun
Bgr
Gbr Isl
PhlNzl
Usa
0
Bgd
Arg
0
.25
.5
.75
If X let people know in TX, X would lose some friends
1
Treatment Stigma and Knowledge
Schizophrenia Vignette
1
Social Distance and Knowledge
0
.25
.5
.75
1
0
Cause is brain disease or disorder
Correlation = 0.55
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.25
.5
.75
1
Cause is genetic or inherited problem
Correlation = 0.78
Pescosolido, Page 22
Finding 9
● However, perceptions of competence are
promising for stigma reduction
Schizophrenia Vignette
1
Threat/Danger and Competence
Schizophrenia Vignette
1
Negative Affect and Competence
Schizophrenia Vignette
1
Traditional Prejudice and Competence
.25
.5
.75
X is able to make decisions about managing own money
Correlation = -0.68
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1
.75
Isl
Bgd
Bgr Hun Phl
Usa
Zaf
Esp
Bra
Gbr
Isl
Nzl
Bgr
Zaf
Esp
Bra
Hun Arg
Phl
.5
Deu
Kor Arg
Deu
0
.25
.75
.5
.5
0
Usa
GbrNzlKor
Bgd
0
.25
Deu
0
.25
Cyp
Cyp
Usa
Gbr
BgrNzlKor
Bra Hun Phl
Arg
Zaf
Isl
Esp
People like X are hard to talk to
.75
Bgd
X would do something violent or harmful toward self
Cyp
0
.25
.5
.75
X is able to make decisions about managing own money
Correlation = -0.73
1
0
.25
.5
.75
X is able to make decisions about managing own money
Correlation = -0.60
Pescosolido, Page 23
1
Finding 10
● Bangladesh (and sometimes Cyprus, Philippines)
stand as outliers and call for additional
investigation
Schizophrenia Vignette
1
Coercion and Competence
Schizophrenia Vignette
1
Negative Affect and Contact
Schizophrenia Vignette
1
Traditional Prejudice and Contact
.5
Deu
Bgr
Usa
Isl Zaf
Bra
Nzl Arg
0
.25
.5
.75
Often see someone with serious MH problem in public
Correlation = -0.20
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1
EspBra
Gbr Kor
.75
Isl
Usa
Nzl
Bgd
Arg
Esp Hun
BgrUsa Bra
Zaf
Kor
Gbr
Deu
Nzl
Deu
Arg
0
Isl
Hun
0
Gbr
Cyp
Phl
Zaf
Bgr
.5
Hun
Esp
Phl
Cyp
.25
X should be forced by law to go to a mental hospital
.75
Kor
0
.25
.5
Phl
Cyp
Bgd
.25
.75
Being around X would make me feel uncomfortable
Bgd
0
.25
.5
.75
Often see someone with serious MH problem in public
Correlation = -0.53
1
0
.25
.5
.75
X is able to make decisions about managing own money
Correlation = -0.58
Pescosolido, Page 24
1
Finding 11
● In-group/out-group differences are not
consistently important. Only fairly consistent in
3 countries: Germany, Great Britain and Hungary
Schizophrenia & Depression Vignettes
Usa Arg Bra Bgr Cyp Deu Esp Gbr Hun Isl Bgd Kor Phl Nzl Zaf
Outgroup
.5
0
.5
0
0
.5
1
People like X are unpredictable
Schizophrenia & Depression Vignettes
1
Unwilling to work with X on a job
Schizophrenia & Depression Vignettes
1
Unwilling to have X care for children
Usa Arg Bra Bgr Cyp Deu Esp Gbr Hun Isl Bgd Kor Phl Nzl Zaf
Ingroup
Outgroup
Usa Arg Bra Bgr Cyp Deu Esp Gbr Hun Isl Bgd Kor Phl Nzl Zaf
Ingroup
Outgroup
num: 1003
num: 1005
num: 1008
s gc BAR03ab02_behavi or-1003_s dc hil dBD
s gc BAR03ab02_behavi or-1005_s dworkBD
s gc BAR03ab02_behavi or-1008_s tunpredB
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Ingroup
Pescosolido, Page 25
Finding 12
● Public responses for different groups tend to
cluster by country
1
Schizophrenia & Depression Vignettes
1
Schizophrenia & Depression Vignettes
gbr
gbr
hun
bgr
hun
bgr
.75
isl
bgd
bgd
cyp
kor
kor
hun
hun
bgr
bgr
phl
phl
deu
esp
esp
gbr
argisl deu
zaf argisl
zaf
gbr
nzl
nzl
bra
bra
usa
usa
0
0
.25
deu
deu
usa
arg
.5
.5
phl
phlzaf
cyp
cyp
kor
bra
kor bra nzl
nzl
esp
esp
.25
.75
bgd
0
.5
1
People like X are unpredictable
Schizophrenia & Depression Vignettes
Unwilling to make friends with X
People like X are unpredictable
Usa Arg Bra Bgr Cyp Deu Esp Gbr Hun Isl Bgd Kor Phl Nzl Zaf
Low Ed
num: 1008
High Ed
0
5
10
15
20
Number of Psychiatrists per 100,000 (2005).
Grey=Female Vignette
Black=Male Vignette
25
0
5
10
Grey=Female Respondent
Black=Male Respondent
s gc BAR03ab02_ed-1008_s tunpredB
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15
Total expenditure on health as percentage of gross domestic product (2004).
Correlation: Female=-0.41 Male=-0.44
Correlation: Female=-0.61 Male=-0.48
sgcSCATTER01a02V2_MI-FB-1118_psychi05BYstunpredB
sgcSCATTER01b02_MI-GY-1224_hgdp04BYsdfriendBD
Pescosolido, Page 26
Next Steps
● Effects of individual level characteristics
● Multi-level analysis
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Stepping Back: Limitations?
Policy Directions?
● How much of a global look? Africa?
China?
● Are attitudes behavior? Does it matter?
● Community-based stigma versus
treatment-based stigma
● Where should our focus be?
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