Research reportWorld survey of mental illness stigma
Introduction
Culture, tradition, as well as access to education and to health services, all shape the perception of mental illness (Cheon and Chiao, 2012). Earlier studies have suggested that developing countries exhibit greater fear, shame, and stigma directed towards mental illness than do developed countries. Shame and fear lead to social distance, which, in turn, results in social isolation, self-stigma, lack of employment opportunity and self-determination, avoidance of help-seeking, poor adherence to treatment and overall poor health in the stigmatized (Cheon and Chiao, 2012, Linz and Sturm, 2013, Rüsch et al., 2014). For these reasons. the National Institute of Mental Health (1996) considers stigma to be the most debilitating aspect of a mental illness.
Stigma leads to mental distress, which then leads to more stigma, and is, thus, a seemingly implacable force. Unpredictable behavior, social skill deficits, and unkempt appearance are often attributed to mental illness (Corrigan, 2000), whereas they could all be the result of stigmatizing attitudes (Hengartner et al., 2013). Such confounding and such consequences make it mandatory to assess mental health stigma not only in developing countries where surveys are habitually conducted, but across the world, in order to institute culturally appropriate interventions (Stuart, 2008).
Many methods have been used to assess stigma, including the use of stigma scales (Pawar et al., 2014), random sampling by postal questionnaire (Mirnezami et al., 2015), telephone surveys (Eurobarometer, 2014), and random questioning of conference attendees (World Health Organization, 2004). Such methods, however, yield relatively small sample sizes. Moreover, they are laborious and, therefore, are unlikely to be replicated by other researchers or repeated over time in order to examine changes in public attitudes in response to intervention or media exposure. In 2012, Schomerus et al. (Schomerus et al., 2012) conducted a systematic review of 16 studies on general population beliefs and attitudes about mental illness that included a minimum of two-year follow-ups. The authors hypothesized that increasing knowledge about the biological correlates of mental illnesses would result in greater social acceptance over time. They did find a trend toward greater mental health literacy, greater endorsement of a biological model of mental illness, and greater acceptance of professional help for mental health problems. Public attitudes towards people with mental illness, however, did not change; if anything, they worsened with time. The authors concluded that social rejection of persons with mental illness has remained disturbingly stable over the last 20 years. Pertinent to our study, they stressed that time-trend analyses of mental illness–related public attitudes have only been conducted in industrialized, first-world countries, and that developments in other parts of the world remain unknown. The 16 studies they reviewed were from the US, the UK, the Netherlands, Australia and New Zealand, Germany, Austria and Poland. No other countries had done stigma follow ups. The following year, Angermeyer et al. (2013) reported that, over twenty years, the German public's attitudes towards people with schizophrenia had worsened, whereas attitudes towards people with depression or alcohol dependence had remained essentially unchanged. That same year, Evans-Lacko et al. (2013) conducted a survey to determine whether an anti-stigma program instituted in England in 2009 had changed public knowledge, attitudes or behavior in relation to people suffering from mental health challenges. They found improvements over the 4 years in intended behavior but no significant improvement in knowledge or reported behavior of respondents. They were encouraged that there was no deterioration of attitudes over the interval.
In 2015, Mirnezami et al. (Mirnezami et al., 2015) reported results of a survey of opinions about mental illness stigma in a single community in Sweden in 1976 and again in 2014. This group found that a quarter of the 500 adults studied still thought in 2014, as they had in 1976, that “people with mental illness commit violent acts more than others,” indicating that that, despite modern advances in education and treatment, the community continued to hold prejudicial views about persons diagnosed with a mental disorder.
Repeat surveys are few and limited to wealthier countries because such surveys are costly and time intensive. Two major international survey mechanisms are the Eurobarometer (2014) and the World Health Organization World Mental Health Survey Initiative (World Health Organization, 2004). However, they focus on the prevalence of mental illness and access to mental health resources. The respondents are sometimes rewarded for participating, depending on the country, and the survey takes on average two hours to complete. The Eurobarometer covers only 27 European Union countries. The WHO initiative only includes 26 countries; it excludes Canada, for example. There are more comprehensive databases of publicly available indicators, notably the global WHO Mental Health Atlas, yet this is comprised of governance, resource, process and management indicators (e.g., the timeliness of the collection of mental health data sets, the presence of stand-alone mental health laws, number of facilities, number of nurses) that are provided to the WHO by state member agencies. For the 2014 Report, only 171 out of the WHO's then-194 members completed even part of the questionnaire.
The present work uses a relatively new survey data collection method to gather global randomized opinion data on stigma from all countries in the world simultaneously, and permits frequent repeats of the survey, whether to confirm reproducibility or to measure change over time in public attitudes. Countries not covered in previous surveys but enjoying over 80% Internet penetration and, thus, exposed to our survey, include Bahrain, Qatar, South Korea, and India. The online survey method was used in this study (a) to examine attitudes around the world towards persons with mental illness and (b) to ascertain the reproducibility of these determinations.
Section snippets
Methods
The survey method used in this study is based on Random Domain Intercept Technology or RDITTM (RIWI Corp., 2015), a method invented and patented by RIWI Corp. (2015). To summarize the survey method: Web users often make mistakes when navigating the Web by incorrectly typing a non-trademarked Internet domain name, whether it is a generic top-level domain (TLD) (e.g. www.anyURLtyped.org), a TLD of any kind (e.g. www.anyURLtyped.xyz), a country code TLD (ccTLD) (e.g. www.anyURLtyped.co), or an
Sample size and response rate
Responses were obtained from 229 countries and protectorates around the globe from September 23, 2013 to May 23, 2015. While the smaller countries only provided between 300 (Mauritania) to 500 (Angola) responses, the larger countries provided between 10,000 and 267,005 (India) replies each. A sample of the total number of replies for 22 major countries is given in Fig. 2, where the total number of replies ranged from 9785 (Germany) to 267,005 (India). 596,712 respondents completed the full
Reproducibility
It was important to test whether the data were reproducible over time. Table 1 indicates that this is the case. India was selected for the reproducibility test because of its strong English language proficiency (English being the mode of the survey language), its very large population, its high Web usage across different sub-geographies and social classes and among urban and rural regions across India, and, most importantly, its status as the country with the highest rates of major depression
Discussion
The data indicate that a high proportion (up to 57%) of individuals in many countries around the world are in daily contact with a person who they think suffers from mental illness, defined for them as including psychosis, depression, addiction, and autism. (Fig. 2). Though different respondents may give different meaning to these terms, the replication analyses indicate that there is apparent stability over time in the understanding of the terms.
Despite reports that mental illness is kept
Limitations
A drawback of this study is that it is limited to English speakers and that Web-based technology generally engages respondents who are relatively young, with a preponderance of males of higher income and educational attainment than the population at large (Norris, 2001). This explains the reason for selecting India to examine the reproducibility of our data, since India has a relatively young population who all speak English. It means, however, that the opinions of the older generation and of
Conclusion
In the last 15 years, there has been increasing recognition of the importance of mental illness stigma, in its prevalence, its measures, its consequences, and its eradication. Despite much work, many challenges remain (Pescosolido, 2013). The literature indicates that there are important differences among various geographic and cultural groups with respect to who is stigmatized and why (Abdullah and Brown, 2011). The global survey method reported here is able to sample a large and diverse
Conflict of interest
The authors state that they have no conflicts of interest.
Acknowledgments
We thank Professor Diane Finegood (Michael Smith Foundation for Health Research) for helpful discussions. This project was supported by RIWI Corp. and partly by the Schizophrenia Fund at Massey College, University of Toronto, Toronto, Ontario, Canada.
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