Academic literature on the topic 'Stigma equity mental health'

SummaryThere is excess morbidity and mortality from physical illness in people with mental disorders. Problems of somatic care in this patient group comprise difficulties of access to care, problems of equity and adequate use of diagnostic procedures and interventions. There are deficits in routine screening and monitoring, e.g. of metabolic and cardiovascular risks. Measures to ensure adequate physical health care include practical steps to increase service uptake and screening, service-level change such as integrated care models, preventive health interventions and optimisation of psychotropic drug treatment to reduce risk profiles. Issues of stigma and discrimination are important, and the level of staff training and quality of professionals are likely to be pivotal in bringing about change.

Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as possible after diagnosis, has recently been recommended by global and national clinical care guidelines for patients newly diagnosed with human immunodeficiency virus (HIV). Based on San Francisco’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) model, most iART programs in the US condense ART initiation, insurance acquisition, housing assessment, and mental health and substance use evaluation into an initial visit. However, the RAPID model does not explicitly address structural racism and homophobia, HIV-related stigma, medical mistrust, and other important factors at the time of diagnosis experienced more poignantly by African American, Latinx, men who have sex with men (MSM), and transgender patient populations. These factors negatively impact initial and subsequent HIV care engagement and exacerbate significant health disparities along the HIV care continuum. While iART has improved time to viral suppression and linkage to care rates, its association with retention in care and viral suppression, particularly in vulnerable populations, remains controversial. Considering that in the US the HIV epidemic is sharply defined by healthcare disparities, we argue that incorporating an explicit health equity approach into the RAPID model is vital to ensure those who disproportionately bear the burden of HIV are not left behind.

Syria has been the main country of citizenship of refugees in Germany since 2013. Syrians face numerous human rights violations in their country that can be accompanied by the experience of potentially traumatic events, loss and displacement. Along the migration process, refugees are exposed to various factors that can have an impact on mental health. The aim of this study is to investigate sociodemographic, war- and flight-related as well as post-migration factors as predictors of posttraumatic stress, depression, somatization and anxiety in Syrian refugees with posttraumatic stress symptoms based in Germany. Data were based on the baseline sample of the “Sanadak” randomized-controlled trial. A total of 133 adult Syrian refugees participated in the study. A questionnaire covered sociodemographic and flight-related questions as well as standardized instruments for symptoms of PTSD (PDS-5), depression (PHQ-9), somatization (PHQ-15), anxiety (GAD-7), generalized self-efficacy (GSE), religiousness (Z-Scale), social support (ESSI) and mental health stigma (SSMIS-SF). Linear regression models were executed to predict mental health outcomes. Sociodemographic predictors (i.e., female sex, higher education) and flight-related predicting factors (i.e., variability of traumatic events) have a negative impact on mental health in Syrian refugees with posttraumatic stress symptoms in Germany. Mental health stigma predicts worse mental health outcomes. Post-migration factors have a major impact on mental health, such as low income, lack of social support, low life satisfaction or a strongly felt connection to Syria. Somatization is an important manifestation of mental distress in Syrian refugees with posttraumatic stress symptoms. Our study showed a range of factors predicting the mental health of Syrian refugees with posttraumatic stress symptoms. Measures to foster mental health could be securing financial security, promoting gender equality and tailored psychosocial programs addressing mental health stigma, loss and social support networks.

OBJECTIVES/SPECIFIC AIMS: Stigma has been recognized as a major impediment to accessing mental health care among Vietnamese and Asian Americans (Leong and Lau, 2001; Sadavoy et al., 2004; Wynaden et al., 2005; Fong and Tsuang, 2007). The underutilization of mental health care, and disparities in both access and outcomes have been attributed to a large extent to stigma and cultural characteristics of this population (Wynaden et al., 2005; Jang et al., 2009; Leung et al., 2010; Spencer et al., 2010; Jimenez et al., 2013; Augsberger et al., 2015). People with neurotic or behavioral disorders may be considered “bad” as many Vietnamese people believe it is a consequence of one’s improper behavior in a previous life, for which the person is now being punished (Nguyen, 2003). Mental disorders can also been seen as a sign of weakness, which contributes to ambivalence and avoidance of help-seeking (Fong and Tsuang, 2007). Equally important is the need to protect family reputation; having emotional problems often implies that the person has “bad blood” or is being punished for the sins of his/her ancestors (Herrick and Brown, 1998; Leong and Lau, 2001), which disgraces the entire family (Wynaden et al., 2005). In these cases, public stigma (as opposed to internal stigma) is the primary reason for delays in seeking help (Leong and Lau, 2001). Other research has also highlighted the influences of culture on how a disorder may be labeled in different settings, although the presentation of symptoms might be identical (see Angel and Thoits, 1987). In Vietnamese culture, mental disorders are often labeled điên (literally translated as “madness”). A điên person and his or her family are often severely disgraced; consequently the individuals and their family become reluctant to disclose and seek help for mental health problems for fear of rejection (Sadavoy et al., 2004). Despite the critical role of stigma in accessing mental health care, there has been little work in trying to understand how stigmatizing attitudes towards mental illness among Vietnamese Americans manifest themselves and the influences of acculturation on these attitudes. Some previous work indicated a significant level of mental illness stigma among Vietnamese Americans, and experiences of living in the United States might interact with the way stigma manifests among this population (Do et al., 2014). Stigma is a complex construct that warrants a deeper and more nuanced understanding (Castro et al., 2005). Much of the development of stigma-related concepts was based on the classic work by Goffman (1963); he defined stigma as a process by which an individual internalizes stigmatizing characteristics and develops fears and anxiety about being treated differently from others. Public stigma (defined by Corrigan, 2004) includes the general public’s negative beliefs about specific groups, in this case individuals and families with mental illness concerns, that contribute to discrimination. Public stigma toward mental illness acts not only as a major barrier to care, but can also exacerbate anxiety, depression, and adherence to treatment (Link et al., 1999; Sirey et al., 2001; Britt et al., 2008; Keyes et al., 2010). Link and Phelan (2001) conceptualized public stigma through four major components. The first component, labeling, occurs when people distinguish and label human differences that are socially relevant, for example, skin color. In the second component, stereotyping, cultural beliefs link the labeled persons to undesirable characteristics either in the mind or the body of such persons, for example people who are mentally ill are violent. The third component is separating “us” (the normal people) from “them” (the mentally ill) by the public. Finally, labeled persons experience status loss and discrimination, where they are devalued, rejected and excluded. Link and Phelan (2001) emphasized that stigmatization also depends on access to social, economic, and political power that allows these components to unfold. This study aims to answer the following research questions: (1) how does public stigma related to mental illness manifest among Vietnamese Americans? and (2) in what ways does acculturation influence stigma among this population? We investigate how the 4 components of stigma according to Link and Phelan (2001) operationalized and how they depend on the level of acculturation to the host society. Vietnamese Americans is the key ethnic minority group for this study for several reasons. Vietnamese immigration, which did not start in large numbers until the 1970s, has features that allow for a natural laboratory for comparisons of degree of acculturation. Previous research has shown significant intergenerational differences in the level of acculturation and mental health outcomes (e.g., Shapiro et al., 1999; Chung et al., 2000; Ying and Han, 2007). In this study, we used age group as a proxy indicator of acculturation, assuming that those who were born and raised in the United States (the 18–35 year olds) would be more Americanized than those who were born in Vietnam but spent a significant part of their younger years in the United States (the 36–55 year olds), and those who were born and grew up in Vietnam (the 56–75 year olds) would be most traditional Vietnamese. The language used in focus group discussions (FGDs) reflected some of the acculturation, where all FGDs with the youngest groups were done in English, and all FGDs with the oldest groups were done in Vietnamese. METHODS/STUDY POPULATION: Data were collected through a set of FGDs and key informant interviews (KIIs) with experts to explore the conceptualization and manifestation of mental illness public stigma among Vietnamese Americans in New Orleans. Six FGDs with a total of 51 participants were conducted. Participants were Vietnamese American men and women ages 18–75. Stratification was used to ensure representation in the following age/immigration pattern categories: (1) individuals age 56–75 who were born and grew up in Vietnam and immigrated to the United States after age 35; (2) individuals age 36–55 who were born in Vietnam but spent a significant part of their youth in the United States; and (3) individuals age 18–35 who were born and grew up in the United States. These groups likely represent different levels of acculturation, assuming that people who migrate at a younger age are more likely to assimilate to the host society than those who do at a later age. Separate FGDs were conducted with men and women. Eleven KIIS were conducted with 6 service providers and 5 community and religious leaders. In this analysis, we focused on mental illness public stigma from the FGD participants’ perspectives. FGDs were conducted in either English or Vietnamese, whichever participants felt more comfortable with, using semistructured interview guides. All interviews were audio recorded, transcribed and translated into English if conducted in Vietnamese. Data coding and analysis was done using NVivo version 11 (QSR International, 2015). The analysis process utilized a Consensual Qualitative Research (CQR) approach, a validated and well-established approach to collecting and analyzing qualitative data. CQR involves gathering textual data through semistructured interviews or focus groups, utilizing a data analysis process that fosters multiple perspectives, a consensus process to arrive at judgments about the meaning of data, an auditor to check the work of the research team, and the development of domains, core-ideas, and cross-analysis (Hill et al., 2005). The study was reviewed and approved by Tulane University’s Internal Review Board. RESULTS/ANTICIPATED RESULTS: Components of public stigma related to mental illness. The 4 components of public stigma manifest to different extents within the Vietnamese Americans in New Orleans. Labeling was among the strongest stigma components, while the evidence of the other components was mixed. Across groups of participants, Vietnamese Americans agreed that it was a common belief that people with mental disorders were “crazy,” “acting crazy,” or “madness.” “Not normal,” “sad,” and “depressed” were among other words used to describe the mentally ill. However, there were clear differences between younger and older Vietnamese on how they viewed these conditions. The youngest groups of participants tended to recognize the “craziness” and “madness” as a health condition that one would need to seek help for, whereas the oldest groups often stated that these conditions were short term and likely caused by family or economic problems, such as a divorce, or a bankruptcy. The middle-aged groups were somewhere in between. The evidence supporting the second component, stereotyping, was not strong among Vietnamese Americans. Most FGD participants agreed that although those with mental disorders may act differently, they were not distinguishable. In a few extreme cases, mentally ill individuals were described as petty thefts or being violent towards their family members. Similarly to the lack of strong evidence of stereotyping, there was also no evidence of the public separating the mentally ill (“them”) from “us”. It was nearly uniformly reported that they felt sympathetic to those with mental disorders and their family, and that they all recognized that they needed help, although the type of help was perceived differently across groups. The older participants often saw that emotional and financial support was needed to help individuals and families to pass through a temporary phase, whereas younger participants often reported that professional help was necessary. The last component, status loss and discrimination, had mixed evidence. While nearly no participants reported any explicit discriminatory behaviors observed and practiced towards individuals with mental disorders and their families, words like “discrimination” and “stigma” were used in all FGDs to describe direct social consequences of having a mental disorder. Social exclusion was common. Our older participants said: “They see less of you, when they see a flaw in you they don’t talk to you or care about you. That’s one thing the Vietnamese people are bad at, spreading false rumors and discrimination” (Older women FGD). One’s loss of status seemed certain if their or their loved one’s mental health status was disclosed. Shame, embarrassment, and being “frowned upon” were direct consequences of one’s mental health status disclosure and subsequently gossiped about. Anyone with mental disorders was certain to experience this, and virtually everyone in the community would reportedly do this to such a family. “You get frowned upon. In the Vietnamese culture, that’s [a family identified as one with mental health problems] the big no-no right there. When everybody frowns upon your family and your family name, that’s when it becomes a problem” (Young men FGD). This is tied directly to what our participants described as Vietnamese culture, where pride and family reputation were such a high priority that those with mental disorders needed to go to a great extent to protect—“We all know what saving face means” as reported by our young participants. Even among young participants, despite their awareness of mental illness and the need for professional help, the desire to avoid embarrassment and save face was so strong that one would think twice about seeking help. “No, you just don’t want to get embarrassed. I don’t want to go to the damn doctor and be like ‘Oh yeah, my brother got an issue. You can help him?’ Why would I do that? That’s embarrassing to myself…” (Young men FGD). Our middle-aged participants also reported: “If I go to that clinic [mental health or counseling clinic], I am hoping and praying that I won’t bump into somebody that I know from the community” (Middle-aged women FGD). Vietnamese people were also described as being very competitive among themselves, which led to the fact that if a family was known for having any problem, gossips would start and spread quickly wherever they go, and pretty soon, the family would be looked down by the entire community. “I think for Vietnamese people, they don’t help those that are in need. They know of your situation and laugh about it, see less of you, and distant themselves from you” (Older women FGD). Culture and mental illness stigma, much of the described stigma and discrimination expressed, and consequently the reluctance to seek help, was attributed to the lack of awareness of mental health and of mental health disorders. Many study participants across groups also emphasized a belief that Vietnamese Americans were often known for their perseverance and resilience, overcoming wars and natural disasters on their own. Mental disorders were reportedly seen as conditions that individuals and families needed to overcome on their own, rather than asking for help from outsiders. This aspect of Vietnamese culture is intertwined with the need to protect one’s family’s reputation, being passed on from one generation to the next, reinforcing the beliefs that help for mental disorders should come from within oneself and one’s family only. Consequently persons with mental health problems would be “Keeping it to themselves. Holding it in and believing in the power of their friends” (Middle-aged FGD) instead of seeking help. Another dimension of culture that was apparent from FGDs (as well as KIIs) was the mistrust in Western medicine. Not understanding how counseling or medicines work made one worry about approaching service providers or staying in treatment. The habit of Vietnamese people to only go see a doctor if they are sick with physical symptoms was also a hindrance to acknowledging mental illness and seeking care for it. Challenges, including the lack of vocabulary to express mental illness and symptoms, in the Vietnamese language, exaggerated the problem, even among those who had some understanding of mental disorders. It was said in the young men FGD that: “when you classify depression as an illness, no one wants to be sick,… if you call it an illness, no one wants to have that sort of illness, and it’s not an illness that you can physically see…” (Young men FGD). Another young man summarized so well the influence of culture on mental illness stigma: “Us Southeast Asian, like, from my parents specifically has Vietnam War refugees. I think the reason why they don’t talk about it is because it’s a barrier that they have to overcome themselves, right? As refugees, as people who have been through the war… [omitted]They don’t want to believe that they need help, and so the trauma that they carry when they give birth to us is carried on us as well. But due to the language barrier and also the, like, they say with the whole health care, in Vietnam I know that they don’t really believe in Western and Eurocentric medicine. So, from their understanding of how, like from their experience with colonization or French people, and how medicine works, they don’t believe in it” (Young men FGD). One characteristic of the Vietnamese culture that was also often mentioned by our FGD participants (as well as KIIs) was the lack of sharing and openness between generations, even within a family. Grandparents, parents, and children do not usually share and discuss each other’s problems. Parents and grandparents do not talk about problems because they need to appear strong and good in front of their children; children do not talk about problems because they are supposed to do well in all aspects, particularly in school. The competitiveness of Vietnamese and high expectations of younger generations again come into play here and create a vicious cycle. Young people are expected to do well in school, which put pressure on them and may result in mental health problems, yet, they cannot talk about it with their parents because they are not supposed to feel bad about school, and sharing is not encouraged. The Asian model minority myth and the expectations of parents that their children would do well in school and become doctors and lawyers were cited by many as a cause of mental health problems among young people. “Our parents are refugees, they had nothing and our parents want us to achieve this American Dream…. [omitted] It set expectations and images for us…. It was expected for all the Asians to be in the top 10, and for, like a little quick minute I thought I wasn’t going to make it, I was crying” (Yong men FGD). As a result, the mental health problems get worse. “If you’re feeling bad about something, you don’t feel like you can talk about it with anyone else, especially your family, because it is not something that is encouraged to be talked about anyway, so if you are feeling poorly and you don’t feel like you could talk to anybody, I think that just perpetuates the bad feelings” (Middle-aged women FGD). Acculturation and mental illness stigma Acculturation, the degree of assimilation to the host society, has changed some of the understanding of mental illness and stigmatizing attitudes. Differences across generations expressed in different FGDs indicated differences in perceptions towards mental illness that could be attributed to acculturation. For example, the young generation understood that mental illness was a health problem that was prevalent but less recognized in the Vietnamese community, whereas a prominent theme among the older participants was that mental illness was a temporary condition due to psychological stress, that it was a condition that only Caucasians had. Some of the components of public stigma related to mental illness seemed to vary between generations, for example the youngest participants were less likely to put a label on a person with mental health problems, or to stereotype them, compared to the oldest and middle-aged participants. This was attributed to their education, exposure to the media and information, and to them “being more Americanized.” However, there was no evidence that acculturation played an important role in changing the other components of public stigma, including stereotyping, separating, and status loss and discrimination. For example, the need to protect the family reputation was so important that our young participants shared: “If you damage their image, they will disown you before you damage that image” (Young men FGD). Young people, more likely to recognize mental health problems, were also more likely to share within the family and to seek help, but no more likely than their older counterparts to share outside of the family—“maybe you would go to counseling or go to therapy, but you wouldn’t tell people you’re doing that” (Young women FGD). The youngest participants in our study were facing a dilemma, in which they recognized mental health problems and the need for care, yet were still reluctant to seek care or talk about it publicly because of fears of damaging the family reputation and not living up to the parents’ expectations. Many young participants reported that it actually made it very difficult for them to navigate mental health issues between the 2 cultures, despite the awareness of the resources available. “I think it actually makes it harder. Only because you know to your parents and the culture, and your own people, it’s taboo, and it’s something that you don’t talk about. Just knowing that you have the resources to go seek it… You want advice from your family also, but you can’t connect the appointment to your family because you’re afraid to express that to your parents, you know? So I think that plays a big part, and knowing that you are up and coming, but you don’t want to do something to disappoint your family because they are so traditional” (Young men FGD). Some participants felt more comfortable talking about mental health problems, like depression, if it was their friend who experienced it and confided in them, but they would not necessarily felt open if it was their problem. Subtle cultural differences like this are likely overlooked by Western service providers. One older participant summarized it well “They [the young generation] are more Americanized. They are more open to other things [but] I think that mental health is still a barrier.” DISCUSSION/SIGNIFICANCE OF IMPACT: This study investigated how different components of public stigma related to mental illness manifest among Vietnamese Americans, a major ethnic group in the United States, and how acculturation may influence such stigma. The findings highlighted important components of public stigma, including labeling and status loss, but did not provide strong evidence of the other components within our study population. Strong cultural beliefs underlined the understanding of mental health and mental illness in general, and how people viewed people with mental illness. Several findings have been highlighted in previous studies with Asian immigrants elsewhere; for example, a study from the perspectives of health care providers in Canada found that the unfamiliarity with Western biomedicine and spiritual beliefs and practices of immigrant women interacted with social stigma in preventing immigrants from accessing care (O’Mahony and Donnelly, 2007). Fancher et al. (2010) reported similar findings regarding stigma, traditional beliefs about medicine, and culture among Vietnamese Americans. Acculturation played a role in changing stigmatizing attitudes as evidenced in intergenerational differences. However, being more Americanized did not equate to being more open, having less stigmatizing attitudes, or being more willing to seek care for mental health issues. Consistent with previous studies (Pedersen and Paves, 2014), we still found some level of stigma among young people aged 18–35, although some components were lessened with an increased level of acculturation. There was also a conflict among the younger generation, in which the need for mental health care was recognized but accessing care was no easier for them than for their parent and grandparent generations. The study’s findings are useful to adapt existing instruments to measure stigma to this population. The findings also have important program implications. One, they can be directly translated into basic supports for local primary and behavioral health care providers. Two, they can also be used to guide and inform the development and evaluation of an intervention and an additional study to validate the findings in other immigrant ethnic groups in the United States. Finally, based on results of the study, we can develop a conceptual framework that describes pathways through which social, cultural, and ecological factors can influence stigma and the ways in which stigma acts as a barrier to accessing mental health care among Vietnamese Americans. The guiding framework then can be validated and applied in future programs aimed to improve mental health care utilization among ethnic minorities.

Recognition of the effects of social, economic, political and cultural conditions on mental health and the personal, social and economic costs of a growing global mental health crisis (WHO, 2001; EC, 2005) mean that mental health and well-being are a current feature of social policy agendas at UK, European and world levels, with debate increasingly becoming framed in human rights terms. In the UK, policy drives to address social exclusion and health inequalities as key social and economic rights issues have encompassed attention to mental health and distress (DoH, 2003; Social Exclusion Unit, 2004) and mental health has been identified as a priority area for the new Equality and Human Rights Commission (Diamond, 2007; DRC, 2007). At the European level too, rights-based social policy approaches to promoting social cohesion (European Committee for Social Cohesion, 2004) and policy directives on the ‘right to health’ (Commission of the European Communities, 2007) have been centrally concerned with mental health and well-being, and have been accompanied by a European strategy on mental health for the EU (EC, 2005). At a global level, the World Health Organisation has declared enjoyment of the highest attainable standard of health to be a fundamental human right (WHO, 2006). It has launched a new appeal on mental health which draws attention to the impact of human rights violations and cites social isolation, poor quality of life, stigma and discrimination as central issues for those with mental health needs (Dhanda and Narayan, 2007; Horton, 2007; WHO, 2007).

The place of clinical, medical, or health professional interventions in addressing violent radicalization is a topic of ongoing debate. Although violent radicalization is primarily a social phenomenon with significant psychological dimensions, the high prevalence of mental health “issues” and past psychiatric diagnosis in lone actors suggests that it may be useful to distinguish socialized actors who have strong ties to structured extremist organizations from relatively socially isolated actors who claim, and even boast about, virtual affiliation to extremist groups. For the latter, the potential efficacy of mental health interventions should be considered. However, because of the risk of profiling, stigmatization of minorities, pathologizing social dissent, and resistance, clinical intervention may cause harm and should be carefully evaluated. Until the effectiveness of clinical interventions in reducing radical violence is improved through evaluative research, exchanges about existing clinical models can be useful to support practitioners in the field and provide initial insights about good and potentially harmful practices. The Quebec model of clinical services to mitigate violent radicalization (secondary and tertiary prevention) is structured around three pillars: multiple access points to facilitate outreach and decrease stigma; specialized teams to assess and formulate treatment plans based on existing best evidence in forensic, social, and cultural psychiatry; and collaborative involvement with primary care services, such as community mental health, education, and youth protection institutions, which are in charge of social integration and long-term management. Beyond the initial assessment, the program offers psychotherapy and/or psychiatric interventions services, including mentorship to foster clients’ social integration and life-skill development. Artistic programs offering a semi-structured, nonjudgmental environment, thus fostering self-expression and creativity, are very well received by youth. A multimedia pilot program involving young artists has been shown to provide them with alternative means of expressing their dissent. Three years on from its inception, the preliminary evaluation of the Quebec clinical model by its partners and clinicians suggests that it could be considered a promising approach to address the specific challenges of individuals who present as potential lone actors at high risk of violent radicalization. The model does not, however, appear to reach many members of extremist groups who do not present individual vulnerabilities. While initial signs are positive, a rigorous evaluation is warranted to establish the short, medium, and long-term efficacy of the model, and to eventually identify the key elements which may be transferable to other clinical settings. In 2020, a five-year evaluative research project began to examine these questions. It is important to consider that any intervention can be harmful if due attention is not paid to structural discrimination and violence stemming from associated marginalization and exclusion. Clinical care can in no way replace social justice, equity, and human rights—all key pillars in primary prevention against violent radicalization. In the meantime, however, providing empathy and care in the face of despair and rage may prove most beneficial in decreasing the risk of violent acts.

BackgroundStudies have shown that beliefs, attitudes and knowledge towards bipolar disorder are influenced by country-specific social and cultural factors. Our study aims to improve and assess public beliefs, knowledge and attitude towards bipolar disorder in Pakistan.MethodsWe targeted 500 population. A questionnaire was organized into four sections in order to investigate knowledge about bipolar disorder, attitudes and beliefs, treatment options and fighting stigma and help seeking attitudes.ResultsOf the 500 participants, 28% people were aware of exact definition of bipolar disorder. A widespread belief (85%) was that people suffering from bipolar disorder should avoid talking and telling about their illness. According to 50% respondents people experiencing bipolar disorder “are dangerous to others”, 68% population viewed it as a result of black magic. Sixty-five per cent thought that the best way to recover from bipolar disorder consisted in seeking help from Psychiatrist. Twenty per cent thought to take help from religious people and shrines. Most of people seemed convinced that drugs are addictive (70%) and may cause serious side effects (80%).ConclusionsMental health illness including bipolar disorder can be improved by the positive influence of education, employment availability, respect, social support, rehabilitative services, justice and equity. Lack of education, stigmatization, and cultural norms are the leading barriers towards.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

IntroductionLondon Borough of Waltham Forest is composed of an ethnically diverse population. In some ethnic groups, mental illness may prevent access, or influence non-attendance when referred to Mental Health Services.ObjectivesTo examine referrals received by our service and first appointment attendance with respect to gender and ethnicity.AimsTo assess the characteristics of referrals and first appointment attendance when accessing mental health services during August 2009 and compare with ethnic demographics of the borough.MethodsWe retrospectively analysed psychiatric referrals received. Data was collected from electronic patient record.ResultsOf the 159 referrals evaluated, 39% referrals were White, 13% Asian, 13% Black, 3% mixed and 4% other. Majority of referrals were from general practitioners. In 28%, ethnicity was not recorded. 60% were female and 38% male. 52% were referred for mood symptoms. 24% Whites attended their first appointment as opposed to 9% of Asians and 8% Blacks. While referrals reflected the wider population, there was a higher rate of non attendance amongst ethnic minority groups than Whites. Interestingly a higher number of females attended their first appointment compared to males. This may explain for lower number of female admissions compared to males.ConclusionWe found several possible explanations for the above findings from literature which highlighted stigma as a major determining factor. Our trust has an Equality and Diversity Work plan to promote engagement of minority ethnic groups. However there seems to be a relative poverty in accessing services in our Borough.

IntroductionDiscrimination towards people with schizophrenia (PWS) by healthcare professionals is responsible of underdiagnosis and undertreatment of these patients. Negative attitudes toward PSW in health care professionals tend to be present since their university studies and are related to their knowledge and experience about the disease.Objectives and aimsTo assess opinion towards PSW in medical, nursing and psychology students and to investigate the relation with their knowledge of schizophrenia and its causes.MethodsThe study involved 133 medical, 200 nursing and 296 psychology undergraduate students. The opinion on mental illness questionnaire, the Devaluation Consumers Scale, and the Devaluation of Consumer Families Scale were administered to the sample. ANOVA and ANCOVA were used to test differences between groups and the relation between causal explanation of schizophrenia and discrimination towards PWS.ResultsPsychology students were more aware than the other student of public stigma towards PWS and their families (F 12.57, P < 0.001; F 32.69, P < 0.001) and expressed a more positive view on treatments’ effectiveness (F 30.74, P < 0.001). Psychology (OR 0.48, 95% CI 0.26–0.88) and nursing (OR 0.29, 95% CI 0.15–0.55) students were more likely to identify psychological and social risk factors as more frequent causes of schizophrenia (vs. biogenetics) and these, in turn, were related to a better opinion towards social equality of PWS.ConclusionsThese preliminary findings underline the relevance of biopsychosocial model of schizophrenia within stigma-reduction programs for health science students.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The mental health impacts of LGBTQ discrimination during the Covid 19pandemic have been severe. "We find that LGBT adults have experienced thepandemic differently than non-LGBT people in some key domains including withrespect to their risk of COVID-19, mental health, employment loss, vaccine attitudes,and willingness to engage in risk-reduction behavior such as social distancing(Dawson).” Additional help is necessary to manage resources for this group at a timewhen their voice isn’t as strong. Another example of a historical pandemic is the influenza pandemic thatoccurred after World War 1. These pandemics changed history, and the way that wethink and operate as a society. The COVID19 virus especially has changed the world.Some examples of how COVID has changed the world include school closures andlimitations on access to healthcare. The LGBTQIA community especially has struggled with access to equitablehealthcare. "In 31 states there is still no employment discrimination protection fortransgender people. private businesses and individuals continue to discriminateagainst same-sex couples. In Colorado, 41% of LGBQ people and 75% of transgenderpeople report needing to educate their health care providers on LGBTQ-specifichealth needs(McAfee).” The mental healthcare system has oppressed LGBTQIApeople. I wish to provide a contribution to a community where marginalizedcommunities are encouraged to gain social justice. By social justice I meanopportunities and privileges distributed equally within a society. They will gainsocial justice by disrupting systems that abuse oppressed marginalized folks. Thisincludes systems like systemic racism, ableism, sexism, and heterosexism andhomophobia. Institutions such as government, culture, and education reinforce thisoppression. These systems are hurtful and repeated by the mental health system.

This paper, written in journalistic style, discusses the disclosure of mental illness and its relation to stigma and discrimination. It consists of two magazine length articles. The first article (designated as Chapter I) is about the personal disclosure of mental illness by mental health professionals, including psychiatrists, psychologists, social workers, and others who have experienced mental illness themselves. This article discusses the extent of mental illness among professionals, the reasons professionals often remain silent, the risks and benefits of disclosing, and the complexity involved in revealing mental illness. The second article (designated as Chapter I) discusses disclosure as it pertains to all people who have mental illness. This article discusses disclosure and its relationship to stigma and discrimination, why stigma exists and persists, the disclosure of mental illness on the job, and the role of work in stigma reduction and recovery.

Mental health stigma is an important topic as it has an influence on the care clients receive, as well as resources allocated by society. Previous research has primarily investigated the topic of stigma associated with schizophrenia and various factors that may influence the endorsement of stigmatizing beliefs. Few studies have investigated whether the type of mental disorder has an influence on the level of stigma. The current study evaluated the difference in the level of stereotypes endorsed across three conditions: schizophrenia, major depressive disorder, and a typical person. Additionally, this study evaluated the reliability of using a global stereotype score obtained from summing the responses of the Attribution Questionnaire (AQ-27). The results of this study showed that there is a significant difference in the level of global stereotype scores across the three conditions and that a global stereotype score from the AQ-27 is reliable.

This dissertation examines the stigmatization of two health conditions: mental disability and physical disability in the context of China. In particular, it addresses two main themes: the processes and impacts of stigma, and the variables that moderate the association of stigma with social attributes. The first paper applied a qualitative approach to identify the sources of burdens of raising a child with cerebral palsy in China and how stigma and “face” as a cultural factor affect children with cerebral palsy and their families. The findings showed that families with children of cerebral palsy report tremendous financial burdens, insufficient educational and medical services, as well as discrimination among family members and communities. An overwhelming majority of caregivers reported to have had the feeling of “loss of face,” while family members considered the child with cerebral palsy as “useless” and “burdensome.” Their common remarks o “send away the child to orphanage” and “give another birth to a normal child”, reinforced caregivers’ feeling of helplessness, and put many family relationships to an end. The second and third papers on stigma and mental illness studied the underlying social determinants of public stigma and the variations in the general public’s attitudes and reactions toward people with mental illness. Using a population-based stratified sample of 3703 adults from the Stigma in Global Context-Mental Health Study, paper II investigated social attributes, stigma, and the links between them. Paper III assessed how demographics and geographical location structured public perceptions and reactions towards people with mental illness. Findings from paper II indicated that Chinese are less willing to interact with people with depression and schizophrenia than those with a physical illness. Depressive disorders had more rejections than schizophrenia in this study. Age, education, and place of residence among respondents had significant association with public stigma. The label of “mental illness” and perception of dangerousness had significant negative association on social stigma. Findings from paper III indicated that social distance had a significant association with regional context, which suggests that public stigma exists at larger cultural levels. Our findings help inform specific factors in the pursuit of tackling structural discrimination.

Over half of all lifetime mental disorders have their origin in childhood and adolescence, yet many adolescents fail to receive adequate mental health support. Two factors which present barriers to seeking help for mental illness are stigma and a lack of knowledge. Within adult literature, contact with individuals who experience living with a mental illness (intergroup contact) has been successful in improving these. 1109 adolescents took part in a survey which investigated stigma, knowledge, and mental health. Group interviews were conducted to develop an understanding of how adolescents conceptualise mental health. Results from these studies informed the development of a school-based intervention for 11-13 year olds evaluating the use of contact combined with education in a randomised controlled trial. Results were conflicting regarding the use of contact as a means to reduce stigma and promote knowledge and mental health. Contact occurring in naturalistic settings was related to lower stigma and higher knowledge levels. In contrast, the structured contact which took place as part of the intervention was found to significantly reduce impact. Intervention in adolescent populations aiming to reduce stigma, increase knowledge, and promote mental health is needed. Caution is needed regarding the use of contact in adolescent populations.

Class of 2017 Abstract
Objectives: To explore whether rural pharmacists express more stigmatized attitudes towards patients with psychiatric disorders, compared to their urban counterparts. Methods: Data was collected from participants attending the AzPA Southwestern Clinical Pharmacy Seminar during a weekend in February, 2015, using a questionnaire adapted from the Mental Illness: Clinicians’ Attitudes (MICA) Scale v4. The questionnaire consisted of demographic and attitude assessment questions regarding patients suffering from psychiatric disorders across different domains (quality of life, fear of patients, admitting to having a psychiatric disorder, and more). Participants were also asked if they would be interested in taking a continuing education course on mental health. Results: The majority of participants that completed the study were women (75%) and identified racially as white (89%). Pharmacists practice settings were as follows: 79% of pharmacists worked in urban areas and 21% in rural areas. Rural pharmacists displayed significantly higher rates of stigmatized attitudes compared to their urban peers (mean scale score 37.65 vs. 40.15, p=0.049). Conclusions: Pharmacists that practice in rural settings expressed more stigmatized attitudes, compared to their urban counterparts, towards patients diagnosed with psychiatric disorders.

This thesis explores equity issues in the mental health field in Britain by initially developing a conceptual structure to define equity in mental health and then analysing data from three national psychiatric morbidity surveys to measure inequalities and inequities in both mental health and in the use of services. Standard methods are used for measuring income-related and social class-related inequalities with reference to many indicators of mental health which represent 'normative' or 'felt' needs for services. Inequity in the use of mental health services is also examined by relating use of services to needs. Analyses of income-related inequalities and equity are carried out with reference to the general population using data from the Psychiatric Morbidity Survey 2000 and with reference to the minority ethnic groups in Britain using data from the survey of Ethnic Minority Psychiatric Illness Rates in the Community 2000. Changes in social class-related inequalities and equity for the general population between 1993 and 2000 are examined using data from the Psychiatric Morbidity Surveys for those two years, in order to see if the policy and practice changes that took place since the beginning of the 1990s in the health and social care sectors had exerted any impact on equity in mental health. The three mental health surveys being cross-sectional do not permit the study of causal pathways between income and mental health. Therefore, in order to understand the links between living standards, health and health care utilisation patterns further, data from a longitudinal study, the British Household Panel Survey on general health are examined using robust theoretical and empirical models. The assumption is that many of the factors associated with general health are also associated with mental health and much of the model that links income, health and health care utilisation behaviour is likely to be relevant for mental health as well.

Research Aim: The primary purpose of this Saudi-based study is to identify the stigma surrounding mental health problems, as well as to identify the existing and latent views of mental health professionals holding a stigma towards people living with mental health problems in Riyadh, Saudi Arabia. It will focus on mental health experts involved in health care in Riyadh, Saudi Arabia. Methods: A methodological strategy was devised, via the use of a mixed-method approach, which uses quantitative (phase 1) and qualitative (phase 2) data collection approaches and analytical techniques. In Phase 1 (50 participants), two tools were used to assess stigma; the Emotional Reaction on People with mental health problems Scale, and the Attitude Scale. In Phase 2 (5 participants), a one-hour focus group discussion was the method of data collection. The reliability of the two scales for Phase 1 evaluated by measuring internal consistency using SPSS. In Phase 2, Nvivo, version 10 was used for an analysis of the data. The group discussion was thematically analyzed. Principal Findings: The findings confirm that many mental health care providers hold a professional stigma against those with mental health problems of varying degrees. And how the existence and extent of these views might impact on the services provided by mental health professionals and the recovery of people with mental health problems. Phase 1 findings indicate factors that lead to professional stigma, wherein ‘exclusion’, ‘rejection and caution’ and ‘risk and fear’ lead to high levels of professional stigma against people with mental health problems. Phase 2 findings, fit into four main themes influence the issue of professional stigma in mental health services: ‘experiences of professional stigma’; ‘causes of professional stigma’; ‘impact of professional stigma on mental health services’ and ‘recommended minimizing stigma’. The findings of the present study point to the significant convergent between emotional reactions with negative attitudes exhibited regarding people with mental health problems. It was also found that interactions with individuals with mental health concerns contributed to an increase in incidences of stigma by professional mental health staff. Also, it has been shown that insufficient knowledge and undesirable perceptions of people with mental health problems remain apparent, both in Saudi Arabian society and in the mental health profession. Conclusion: It is necessary to focus on reducing professional stigma against people with mental health problems. This can be accomplished through appropriate practices, mental health training, education, and research, as well as professional and social awareness through the media in S.A.; publicize ethical guidelines for mental health care professionals; enhance the provision of mental health practitioners in mental health care services; enact legislation by the Ministry of Health in S.A. Keywords: Stigma, mental health problems, and mental health professional perspective, Saudi Arabia.

"The present study was conducted to explore the perception and views of primary care staff about Depression related Stigma and Discrimination. The Basic Qualitative Research Design was employed and an In-Depth Semi-Structured Discussion Guide consisted of 7 question was developed on the domains of Pryor and Reeder Model of Stigma and Discrimination such as Self-Stigma, Stigma by Association, Structural Stigma and Institutional Stigma, to investigate the phenomenon. Initially, Field Test and Pilot study were conducted to evaluate the relevance and effectiveness of Focus Group Discussion Guide in relation to phenomena under investigation. The suggestions were incorporated in the final Discussion Guide and Focus Group was employed as a data collection measure for the conduction of the main study. A purposive sampling was employed to selected a sample of Primary Care Staff (Psychiatrists, Medical Officers, Clinical Psychologists and Psychiatric Nurses) to elicit the meaningful information. The participants were recruited from the Department of Psychiatry of Pakistan Medical and Dental Council (PMDC) recognized Private and Public Sector hospitals of Lahore, having experience of 3 years or more in dealing with patients diagnosed with Depression. However, for Medical Officers, the experience was restricted to less than one year based on their rotation. To maintain equal voices in the Focus Group, 12 participants were approached (3 Psychiatrist, 3 Clinical Psychologists, 3 Medical Officers and 3 Psychiatric Nurses) but total 8 participants (2 Psychiatrists, 2 Medical Officers, 3 Clinical Psychologists And 1 Psychiatric Nurse) participated in the Focus Group. The Focus Group was conducted with the help of Assistant Moderator, for an approximate duration of 90 minutes at the setting according to the ease of the participants. Further, it was audio recorded and transcribed for the analysis. The Braun and Clarke Reflexive Thematic Analysis was diligently followed through a series of six steps such as Familiarization with the Data, Coding, Generating Initial Themes, Reviewing Themes, Defining and Naming Themes. The findings highlighted two main themes i.e., Determining Factors of Mental Health Disparity and Improving Treatment Regimen: Making Consultancy Meaningful. The first theme was centered upon three subthemes such as Lack of Mental Health Literacy, Detached Attachment and Components of Stigma and Discrimination. The second theme included Establishing Contact and Providing Psychoeducation as a subtheme. The results manifested the need for awareness-based Stigma reduction intervention for Primary Care Staff aims to provide training in Psychoeducation and normalization to reduce Depression related Stigma and Discrimination among patients diagnosed with Depression."

Background: Persons with disability are every person who experiences physical, intellectual, mental, and/ or sensory limitations for a long period of time. These people may experience obstacles and difficulties to participate fully and effectively with other citizens based on equal rights. This study aimed to review the disability perception in sexuality and reproductive health needs. Subjects and Method: This was a scoping review study using the Arksey and O’Malley framework. The framework used to manage research questions was Population, Exposure, Outcome dan Study Design (PEOS). A total of 3 databases, namely Science Direct, PubMed, and Whiley were selected for this study. The data were collected by identifying relevant articles according to inclusion and exclusion criteria. Result: People with disability were human beings who can feel biological needs. Negative stigma from family, health workers, and parents were a very perceived barrier for people with disabilities. These people need to receive special attention regarding information and application of health sexual and reproductive health. Access to information can be applied in communities that gather a large number of people with disability so that it is easy for them to get information on their reproductive needs and rights. Conclusion: People with disability need special attention regarding information and application of sexuality and safe reproductive health. Keywords: persons with disability, sexuality and reproductive health Correspondence: Youlenta Ernesontha. Universitas ‘Aisyiyah Yogyakarta. Email: Youlenta0110@gmail.com. Mobile: 085245639293 DOI: https://doi.org/10.26911/the7thicph.01.07

Cancer stigma may lead to delayed diagnosis and treatment, especially in low- and middle-income countries. This exploratory, pilot study was conducted in India to explore the degree to which cancer stigma is perceived, experienced, and internalized among adults living with cancer and their primary caregivers. We conducted a survey of cancer patients and their caregivers in two Indian cities. The survey assessed perceived, experienced, and internalized stigma; demographic characteristics; patient cancer history; mental health; and social support. A purposive sample of 20 cancer survivor and caregiver dyads was drawn from an ongoing population-based cohort study. Overall, 85 percent of patients and 75 percent of caregivers reported experiencing some level (i.e., yes response to at least one of the items) of perceived, experienced, or internalized stigma. Both patients (85 percent) and caregivers (65 percent) perceived that community members hold at least one stigmatizing belief or attitude toward people with cancer. About 60 percent of patients reported experiencing stigma, and over one-third of patients and caregivers had internalized stigma. The findings indicate that fatalistic beliefs about cancer are prevalent, and basic education about cancer for the general public, patients, and caregivers is required. Cancer-related stigma in India should continue to be studied to determine and address its prevalence, root causes, and influence on achieving physical and mental health-related outcomes.