The Stigma of Mental Illness in Global Context: First Findings from the SGC-MHS

1. 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

2. 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

3. The SGC-MHS Team – Wave 1

4. The SGC-MHS – Other Partners

5. 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

6. 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

7. Limitations • No overarching theoretical framework • No or limited comparative studies of public stigma SGC-MHS: • Theoretically-based • Methodologically coordinated • Multi-country • Reliable global program

8. Etiology and Effects of Stigma Model (EES) Expanded Pescosolido, Page 8

9. Participating Countries • 15 nations across a range of developmental levels • 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 • Japan, Nepal • Other possible additions • China, Belgium

10. 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

11. Procedures • Face-to-Face Personal Interviews • Two Part Interview Schedule • 75-item substantive core • Standard ISSP measures of socio-demographic attributes • Fielded in 4 waves • 3 countries in 2004 • 7 countries in 2005 • 3 countries in 2006 • 2 countries in 2007

12. 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.

13. 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. Social Distance Traditional Prejudice Exclusion Negative Affect Treatment-based Stigma “Outsider” Stigma Threat/Danger Coercion

14. 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

15. Finding 1 • With the exception of coercion into Tx, the hierarchy of stigma is clear – schizophrenia, depression and asthma

16. Finding 2 • Stigma is not stigma: ranges from low to quite high • Significant variation across dimensions

17. Finding 3 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. Arboleda-Florez and N. Sartorius (eds.), Understanding the Stigma of Mental Illness: Theory and Interventions. London: John Wiley & Sons, Ltd. • There is a good deal of cross-national variation in the culture of stigma • Tends to be consistently high/low (but important exceptions) _ Asia_ __ _Europe _ __ South _ America_

18. Finding 4 • There is little relationship with level of develop-ment; and where it does exist, it is in the direction opposite from the initial suggestions of the ISoS

19. Finding 5 Social Capital (trust) • Tolerance, Health Funding (not number of psychiatrists/ physicians) are the most closely associated with lower levels of community-based stigma Public Health Expenditures

20. Finding 6 • Personal contact and perceptions of the efficacy of Tx matter Contact Perceived Tx Efficacy

21. Finding 7 • The context of care matters for endorsements

22. Finding 8 • The Knowledge Solution (proper attributions) is not promising for stigma reduction

23. Finding 9 • However, perceptions of competence are promising for stigma reduction

24. Finding 10 • Bangladesh (and sometimes Cyprus, Philippines) stand as outliers and call for additional investigation

25. Finding 11 • In-group/out-group differences are not consistently important. Only fairly consistent in 3 countries: Germany, Great Britain and Hungary

26. Finding 12 • Public responses for different groups tend to cluster by country

27. Next Steps • Effects of individual level characteristics • Multi-level analysis

28. 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?