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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


Stigma In Global Context: Mental Health Study

Research Plan

Specific Aims.  As noted in Healthy People 2010 (2000, Volume 2: 2), a striking finding of the landmark Global Burden of Disease Study (Murray and Lopez 1996) lies in the world-wide impact of MI on overall health and productivity. Profoundly under-recognized, mental illness (MI) constitutes 11% of the global burden of disease, with major depression alone currently ranking fourth and expected to rise to second by 2020. In some regions of the world (e.g., Western Pacific), mental disorders already represent the largest contributor to the total disease burden, and there is great concern with the “mortality crisis” related to mental illness in Eastern Europe (Rutz 2001). However, the WHO’s International Pilot Study of Schizophrenia, the International Study of Schizophrenia (ISoS) and the Study of the Determinants of Outcomes of Severe Mental Disorders (DOSMD) have all documented that there is an enormous heterogeneity in the outcomes of MI within and across countries (e.g., Hopper & Wanderling 2000, Kulhara & Chakrabarti 2001; Sartorius et al. 1996; Sartorius et al. 1978).  While it is generally agreed that the reasons for these differences are “far from clear” (Kuhara and Chakrabarti 2001), explanations revolve around culturally defined processes as playing a role, and specifically call for the study of stigma within and across social and cultural contexts in order to understand its origins, meanings and consequences (Caracci and Mezzich; Hopper and Wanderling 2000; Ng 1997; Rutz 2001; Slu 1989).  In fact, across the scientific and policy literatures, stigma is referred to as the “silent disease” (Corker 2001) or the “second illness” (Meiset et al. 2001), taking a central place in explanations of low service use, inadequate funding of research and treatment infrastructures, and hindered progress toward recovery from MI (Estroff 1981; Markowitz 2001; Okazaki 2000; Sartorius 1998; Wahl 1999).  Indeed, Hinshaw and Cicchetti (2000) contend that “the continued stigmatization of MI may well be the central issue facing the field.”

Despite findings of the pervasive existence and impact of stigma within and across countries (Crisp, Gelder, Rix, Meltzer, Rowlands & Owlen 2000; Fabrega 1991; Pescosolido, Martin, Link, Kikuzawa, Burgos, Swindle & Phelan 2000; Stuart & Aboleda-Florez  2000; Wahl 1999), we know relatively little about the cross-cultural distribution of stigma.  Many researchers across the globe have collected data on stigma, but differences in samples (often student or provider samples) and instrumentation make it difficult, if not impossible, to understand how the social reaction to MI varies across countries, whether the underlying operative processes are similar, whether it maps onto the distribution of outcome heterogeneity, and therefore, whether these differences can offer a wedge into finding bases for decreasing stigma’s negative impacts.  In sum, while the influence of cultural context on health and well-being is widely acknowledged, the empirical literature remains underdeveloped. Moreover, while the basic explanation of cross-cultural variations in outcomes is compelling, the database is thin and the imperative for extensive additional research is clear (Shonkoff and Phillips 2000).  While the World Psychiatric Association’s recent Global Campaign to Fight Stigma and Discrimination Because of Schizophrenia (Sartorius 1997) has encouraged the development of a comparative catalogue of information, to date there have been only a few large-scale studies (e.g., in Canada, the U.K., the U.S. and Germany).  Moreover, there has rarely, if ever, been a coordinated attempt to understand the extent to which MI is understood and stigmatized across countries (e.g., as an exception, see Townsend’s 1975 comparison of the attitudes of German and U.S. high school students and mental health staff).  But even recent cross-national efforts have not been collaborative, making inference about comparative influences difficult. This application proposes a theoretically-based and methodologically coordinated attempt to understand the extent to which MI is understood and stigmatized across countries.  Using a multi-disciplinary and multi-level theoretical framework and a subset of International Social Survey Program (ISSP) member countries, this application proposes a 15-nation collaborative study of the levels and correlates of the stigma of major depression, schizophrenia and bi-polar disorder.  Specifically, we propose to:

  • Aim I.  Derive a comprehensive theoretical model of the etiology of the stigma of MI that is informed by an interdisciplinary synthesis of existing research on the causes and correlates of stigmatizing responses to persons with MI;
  • Aim II.  Develop and pre-test an instrument based on this framework in collaboration with an international set of mental health and survey research experts, and collect data in face-to-face interviews with a nationally representative sample of adults in each country to provide national and international descriptive profiles of the public’s knowledge of, familiarity with, beliefs about, and stigmatizing responses toward MI and persons with MI.
  • Aim III.  Using these data, empirically examine hypotheses proposed under the theoretical model, both nationally and cross-nationally.

The public health ramifications of not knowing the underlying workings of stigma are costly.  According to the Surgeon General of the U.S., stigma is the “most formidable obstacle to future progress in the arena of mental illness and health” (1999:3).  Similarly, the WHO and the World Psychiatric Association mark public stigma and discrimination as the critical barrier to the appropriate care and inclusion of persons with MI in society, and as the “chief nemesis” to improving and assuring the quality of life for persons with severe mental illness (Sartorius 1998; WHO Regional Strategy Volume).  Not surprisingly, a series of reports from the Institute of Medicine (e.g., Singer & Ryff 2001:9) and the NIH (OBSSR 2001:11) as well as the sponsoring PAR identify understanding health disparities following from stigmatization as a key research priority (also Healthy People 2000, Volume 2: 9; and the U.S. Surgeon General’s Report on Mental Health 1999). Existing gaps in scientific knowledge leave little room to estimate the malleability of stigma by marking its cross-national variation and to offer science-based approaches that attempt to change the larger culture and climate of communities. This application focuses on developing a comparative theoretical framework of the etiology of stigma; developing and mounting an empirical study of representative public samples in 15 countries, and examining the causes, consequences and effects of stigma. The proposed study will address the important goal of understanding the etiology of stigma to assist in the development of “evidence-based interventions to prevent or mitigate stigma’s negative effect on the health of individuals, families and societies worldwide” (Keusch 2001  Toward these ends, we draw from and synthesize ideas and expertise of interdisciplinary and international collaborators. Such research on both the individual and collective properties associated with health communities is expected to provide opportunities for prevention and/or intervention at lower cost than traditional individual level strategies (Singer & Ryff 2001:91).

B1. Theoretical Framework.  Aim I proposes to derive a comprehensive theoretical model of the etiology of the stigma of MI that is informed by an interdisciplinary synthesis of existing research on the causes and correlates of stigmatizing responses to persons with MI. As pointed out in a recent Institute of Medicine Report (Pellmar & Eisenberg 2000: 22) the role of theory is to provide a framework for organizing what is known and guiding further investigation.  A core set of concepts frames understanding and lays a foundation for research questions. From Goffman’s original treatise (1963), to Scheff’s (1966) elaboration, to current social psychological and cognitive research, theorists have specified and compiled a solid research base “to understand how persons construct categories and link these categories to stereotyped beliefs” (Link & Phelan 2001: 364; see also Heatherton, Kleck, Hebl & Hull 2000). Researchers have tried to locate critical ingredients that may exacerbate or moderate stigmatizing reactions; however, they have tended to do so in smaller parts (e.g., addressing the potential contribution of Weiner’s 1995 attribution theory on both enacted or received stigma, e.g., Corrigan et al. 2000).  Figure 1, on the following page, attempts to synthesize the theoretical and research contributions on stigma from the social and clinical sciences.  It considers and organizes both the process on the individual level, where most of the research has been done, and embeds this within a contextual framework that translates existing social science research on cross-national influences that may be useful in pursuing the observation that the heterogeneity across countries observed in the ISoS and other studies (Section A) reflects important structural and cultural differences in society.  As Berkman (2002) contends, since the experience of being devalued is highly dependent on social context, theories focused on the individual level should be complemented by the study of systematic patterning across social contexts (see also Crocker et al. 1998). 


Figure 1. Multi-Disciplinary and Multi-level Theoretical Framework of the Etiology & Effects of Stigma

In sum, the theoretical framework suggests that social location (socio-demographic characteristics of both the person with MI and those in a position to support for reject them) influences the knowledge and past experiences that individuals have regarding MI. In turn, these shape the attributions and assessments that individuals make regarding persons with MI.  Together, these factors affect both prejudice and discrimination. This process occurs within a larger social, cultural, economic, human and institutional context which sets the parameters for individuals’ responses. Thus, while the definition of stigma itself has been contested, referring to a wide range of phenomena (see Clausen 1981; Link & Phelan 2001), we limit the concept to the absence or presence of negative attitudes, behavioral predispositions, and behaviors toward persons with MI. While attributions reflect individuals’ beliefs about the underlying causes of MI, assessments target what MI and persons with MI are like. The stigmatizing responses that comprise prejudice include stereotypes and the public’s endorsement of them, while discrimination marks suggestions and enacts behavioral responses including coercion and avoidance. 

The basis for each of the components in Figure 1 and the hypotheses that are suggested as a result are summarized below.   

B.1.a. The Role of Socio-Demographic & Illness Background Characteristics.  Both what individuals with MI “bring” to social interaction and with whom they interact have been seen as important dimensions across different approaches to understanding stigma.  As Link and Phelan (2001:367) point out, stigmatization is contingent upon access to social, economic and political power that allows individuals to be identified as different and to have negative reactions and sanctions applied as a result. While the empirical findings are not consistent at this point in research, the socio-demographic characteristics of both “senders” and “receivers” continue to be important.  Briefly, the characteristics of the illness condition and social characteristics (e.g., race, sex) combine to shape the person’s behavior (both positive and negative) as well as the probability that the person can be easily identified by a stranger as a person with mental health problems (e.g. mark).  This suggests the following general hypothesis:

H1: The socio-demographic attributes of both the person with MI and the person in a position to respond shape knowledge, contact, attributions, assessments, stigmatizing responses and individual and social behaviors.

Specifically, a long tradition of social science research on prejudice as well as Labeling theories have argued that members of disadvantaged groups are disproportionately likely to have negative labels attached to them and encounter rejection (on racial prejudice and discrimination, see Tuch and Martin 1997 for a summary; on MI, see Scheff 1966, NIMH 2002). In particular, past research has highlighted the importance of both gender and race/ethnicity of the person with MI in shaping public reactions (NIMH 2002:29).  For example, in the U.S. Schnittker (2000) found that vignette persons described as female were evaluated as less dangerous than males.  More consistently, non-white males are more likely to have police contact when experiencing mental health problems and to be hospitalized involuntarily in the U.S. (Rosenfield 1984) and the U.K. (African-Caribbeans; Owens et al 1991; Rwegellera 1980; Moodley and Perkins 1991; McGovern et al. 1994).  In cross-cultural context, the task is to locate the outgroup rather than focus on any particular constellation of racial categories since it is power and disadvantage that are key (e.g., the Maoiri in New Zealand , the Turks in Germany ). This suggests:

H1a: Gender and racial or ethnic outgroup status of the target person will be associated with increased prejudice and discrimination and may have an interactive effect.

There is also a long tradition in social science examining the role of asymmetry in responding to individuals with mental health problems.  As Scheff (1966) originally theorized in Labeling Theory, social distance between individuals being assessed and those doing the assessment is likely to produce more negative evaluations and responses.  In studies of providers’ diagnoses of cases and family members’ responses to relatives with MI, both gender and racial “matches” affected how individuals gave meaning to and responded to the situation (e.g., Loring and Powell 1988, Artis 1997). This matching hypothesis is:

H1c: The greater the social distance between the individual with MI and the person reacting, the greater the likelihood of negative attributions, assessment, prejudice and discrimination.

The influence of other socio-demographic characteristics of the responding person presents a complex picture of significant and non-significant effects.  What the studies do provide, however, is a list of character-istics that appear to be central to theoretical considerations within and across countries.  For example, in the U.S. , Ghana , and the U.K. , some mix of race and/or ethnicity influenced how people responded to MI (Alvidrez & Azocar 1999; Cinnirella & Loewenthal 1999; Cooper-Patrick et al 1997; Fosu 1995; Whaley 1997).  Here, unlike the hypothesis above, it is the full constellation of race and ethnic groups that matter. In the U.S., studies find that Latinas, Asian-Americans and African Americans all report different concerns about MI, persons with MI, and the appropriate response to mental health problems. In addition, education (Bhugra 1989; Chou & Mak 1998; Rahav et al. 1984), gender (Schnittker 2000; Thara & Srinivasan 2000), age (Chou & Mak 1998; Fosu 1995; Rahav et al. 1984; Thara & Srinivasan 2000), religion (Cinnirella & Loewenthal 1999; Rahav et al. 1984; Weller & Grunes 1988), rural residence (Rost et al. 1993) have been significantly associated.  On the other hand, studies have found one or more of these influences to be nonsignificant (e.g., Chou & Mak 1998 did not find that gender mattered; the 1996 GSS studies showed a remarkable lack of socio-demographic influences, Pescosolido et al. 2000).  In general, the research literature at this point in time does not allow a definitive list of social and cultural characteristics of persons responding to MI that are or are not important.  Rather, we return to Dowhrenwend & Chin-Song’s (1967) suggestion that lower status groups tend to be less tolerant of MI and that issues such as the religion of “senders” may matter and should be examined within and across countries. Thus, we hypothesize:

H1d: Gender, race/ethnicity, education, income and religion are associated with differential knowledge, contact, attributions, assessments, stigma and individual/social responses.

Finally, to the extent that the profile of the disease influences the perception of, for example, severity or what causes the person to behave in ways outside of social norms (e.g., “inappropriate” verbal remarks, affect, physical manifestations), the probability of prejudice and discrimination increases.  In addition, these factors affect whether and how the person acquires a label for their behavior.  With regard to the person with MI, past research has documented the importance of the nature of the problem that individuals have.  For example, Link et al. (1987) and Phelan et al (1998) found that public reaction to individuals with psychotic symptoms was distinct. In national studies in the U.S. and the U.K. , individuals responded differently to individuals who were described as having different disorders, with a much more positive and accepting response to individuals with depression as opposed to those with schizophrenia (Pescosolido et al. 2000, Crisp et al. 2000).  This suggests the following hypothesis:

H1e: The illness profile (e.g., symptoms, “diagnoses”) will influence attributions, assessments, stigma and individual/social responses.

The Role of Knowledge, Meaning and Information Sources.  An underlying premise of many government and advocacy initiatives is that increasing individuals’ knowledge, or perhaps more importantly, decreasing their misperceptions, will reduce stigma (e.g., the work of the U.S. ’s National Alliance for the Mentally Ill; the Surgeon General’s Report on Mental Health 1999). While this suggests that ignorance and fear are positively related, other studies reveal a set of opposite findings.  For example, in the U.S. , knowledge of the symptoms associated with the acute phase of schizophrenia actually increased negative reactions (Penn et al. 1994).  Further, knowing or accurately assessing a person’s situation as “mental illness” actually resulted in greater levels of desired social distance (Martin et al. 2000; Piner & Kahle 1984).  Despite discrepant findings, the issue here is that the role of knowledge, given its expected role in decreasing stigma, will be important to examine within and across countries.  Therefore, we suggest:

H2a. An individual’s knowledge of MI will be associated with attributions, assessments, stigma and individual/social responses.

In Labeling Theory’s original formulation, the role of social and cultural meaning of symptoms played a central role.  To the extent that the disease profile increases attributes and behaviors deemed socially desirable in that cultural setting (e.g., insight, “visions”), the likelihood of prejudice and discrimination is decreased directly. To the extent that the symptoms associated with MI are in accordance with expectations for individuals and groups or go against them, the reaction is likely to be affected.  For example, Rosenfield (1984) found in the U.S. that individuals who acted in ways that violated expected gender norms were more likely to be diagnosed as having mental problems. Thus, it is not just the nature of the behaviors as described above but the socio-cultural meaning attached to them that influences reactions.  As a result:

H2b:  The meaning attached to behavioral symptoms associated with MI will influence attributions, assessments, stigma and individual/social response.

Finally, both information and meaning may be influenced by the source of the information.  Studies report that primary information sources include experiences with family members or close friends with diagnosable MI (see the contact hypothesis below), the print media and visual media (e.g., movies, television; Granelllo & Pauley 1999).  In studies done primarily outside the U.S., Stout and Villegas (2000) reported to the NIMH Stigma Working Group that existing research on television does, indeed, show predominant negative images of MI in the media, and this research has focused on general issues of MI rather than specific disorders.  More surprisingly, perhaps, Andrade and Rao (1996) found that mass media contributed most to medical students’ understandings of and reaction to persons with MI in India .  In Germany , Angermeyer and Matchinger (1995) documented that violent attacks on public figures by persons identified as “mentally ill” in 1990 pushed population rates of social distance higher, and did not return to initial levels two years later. In the U.S.-based Cultural Indicators Project, Gerbner (1998) reported that characters with MI are depicted as the most dangerous of any kind of identifiable group (racial, ethnic, immigrant). Of almost 7,000 characters identified as being involved in violence or crime in the media, 60% were somehow labeled with a MI. More specifically, characters identified as having MI were 4.5 times more likely to be portrayed as criminals and 3 times more likely to be engaged in violent acts than characters portrayed without such a disability (see also Deifenbach  1997; Signorelli 1990; Wilson et al. 1999).  In fact, news reports of MI, compared to accurate, scientific medical information, systematically misinform the public about MI (Berlin & Malin 1991; Steadman & Cocozza 1977-78).  These studies have been conducted predominately, though not exclusively, in Western societies, and the role of the sources of media and information, while expected to be important are not really known in other parts of the world.  Thus we suggest the following exploratory hypothesis:

H2c.  The type of sources from which individuals receive information about MI will affect attributions, assessments, stigma and individual/social responses. 

The Role of Previous Contact.  Following from the discussion above, one of the most potent sources of information may lie in personal experiences that individuals have with individuals with MI.  As Biernat and Dovodio (2000: 110) point out, intergroup contact has long been psychology and sociology’s prescription for changing attitudes and stereotypes (e.g., Allport 1954, Williams 1947; Kolodziej & Johnson 1966; Mayville & Penn 1998; Penn & Nowlin -Drummond 2001).  From early studies on workplaces, organizations, neighborhoods and schools, there was wide support for the notion that increases in interaction between persons of different groups, those “marked” and “unmarked”, is accompanied by an increase in sentiments of “liking” (Homans 1951; Caplow 1964). The parallel expectation, demonstrated in a number of studies, is that those who had some experience with persons with MI appeared to have less negative reactions, display fewer discriminating behaviors, and hold more tolerant attitudes (Adams & Partee 1998; Jones et al. 1984; Penn et al. 1994).  Studies in Turkey , New Zealand , Nigeria , Hong Kong , and the U.K. have all demonstrated that contact reduced social distance and led to more positive attitudes (Arikan & Uysai 1999; Chou & Mak 1998; Ingamells et al. 1996; Ogedengbe 1993; Read & Law 1999).


However, these findings are, at best, mixed.  Among Chinese nurses in Hong King, Callaghan et al. (1997) found that contact had little effect and that nurses were only “tolerant at a distance”.  In Scotland , Brunton (1997) found that increased community contact had no or even a “hardening” effect on local public attitudes.  In U.K. , Gatherer and Reid (1963) documented that attitudes became more negative with more personal contact.  Overall, some contend in reviews of the contact hypothesis that even demonstrated, significant effects are small in magnitude (e.g., Kolodziej & Johnson 1996) while others contend that the contact hypothesis has not received great empirical support (Desforges et al. 1991).

Yet, the most sophisticated research on this hypothesis has demonstrated that the effects of contact appear to be conditioned on a number of factors which may explain inconsistent findings. Originally, Allport (1954) suggested that contact will reduce prejudice under conditions of equal status, high degree of collaboration, motivation, repeated contact over time, personal rather than formal interaction, and institutional support.  Studies demonstrated that only where contact is voluntary, where it is equal, intensive and/or rewarding, where there is prolonged contact, or where there are a number of people involved did the hypothesis hold (Jackman & Crane 1986; Noel & Pinkney 1974; Weller & Grunes 1988). Under these conditions, the “group” becomes more variable and less monolithic, making it difficult to uphold “global” stereotypes. In sociology, Simmel (1955) argues that it is the configuration of linkages and content in social groups have consequences for individuals both inside and those outside of them.  Social interactions can be positive or negative, or helpful or harmful (Estroff 1981; Rook 1984; Pagel & Becker 1987; Umberson 1987). The simple presence of “contact” cannot be assumed to increase “liking” and decrease stigma. For example, the effect of having contact (i.e., someone in the social network with a MI) can only be considered when the valence (positive or negative) of routine interactions are considered. Even in situations where contact in the relatively impersonal public sphere takes place, both the type of contact and valence can be considered (Phelan and Link 2002).  If the overall impact of social interactions is troubling, harmful or otherwise disturbing, then contact will likely increase stigmatizing attitudes.  If, on balance, interactions are rewarding and enriching, the effect of contact will be to reduce stigma.  These theoretical elaborations set the following hypothesis:

H3a.  The structure (e.g., frequency, closeness) and content (e.g., positive or negative experiences) of social contact interact to influence attributions, assessments, stigma and individual/social responses. 

Further, research from telecommunications, sociology of culture and cognitive science suggest a more complex interplay of how media and interpersonal contact factors work (e.g., Hawkins & Pingree 1982).  That is, while real-life exposure to MI and media exposure to images of MI is expected to have direct effects on both attributions about persons with MI, emotional and cognitive reactions, and stigma, there is also a mediating process at work. When real-life exposure is low or carries a message congruent with the media message, information about MI gleaned from the media is likely to be influential. When real experience with MI illness exists, and that experience disconfirms media messages, the influence of media can be ignored.  Thus, we propose the following mediating hypothesis:

H3b.  Positive personal contacts will dampen the negative effects of media exposure on attributions, assessments, stigma and individual/social responses.

Considering the additional factors in the theoretical framework to this point, an additional mediating hypothesis can be proposed:

H3c: Greater positive level experiences with persons with MI will attenuate the effect of socio-demographic and matching factors on attributions, assessments, stigma and individual/social responses.

The Role of Attributions.  Attributions generally involve explanations about underlying causes, actions or conditions (Dovidio et al. 2000: 19). Corrigan (2000) sees attribution as a cognitive mediator that leads to affective response and behavioral reactions. Sociological literature focusing on race attitudes suggests that one of the most important factors shaping individuals’ attitudes are attributions about the causes of the outgroup’s behavior. Simply stated, this research has documented, in the U.S. for example, the highest levels of anti-black affect among whites who attribute the causes of racial disadvantage to individual-level faults of blacks - e.g., lack of motivation, lack of effort, weak attachment to a work ethic, and so on (Kluegel 1990; Kluegel & Smith 1986; Schuman, Steeh, Bobo & Krysan 1997; Tuch & Hughes 1996). This model, along with Weiner’s (1995) psychological theory of the influence of attributions, has been translated for its utility in understanding the stigma of MI.  For example, the Surgeon General (1999:9) links attributions to “dissipating” stigma.  That is, when people understand that MI is not the result of moral failing or limited will power, but legitimate illnesses that are responsive to specific treatment, stigma will be lessened. In other words, attributing the sources of mental health problems to genetic, biological, or supernatural causes, or to stressful life circumstances, will be negatively related to social distance. On the other hand, attributing mental health problems to bad character or the way an individual was raised will be associated with a desire for greater social distance.  Moreover, more recent research has shown that individuals who see MI scenarios as the result of genetic factors or stress, are less likely to state a preference to avoid social interactions (Martin et al. 2000; also see Al-Krenani et al 2000; Crocker et al. 1988; Deaux et al. 1995; Fosu 1995; Frabel 1993). In fact, Mechanic et al. (1994) found that mental health clients, themselves, who attribute their problems to physical, medical or biological causes report more positive social relationships and higher quality of life.  Thus, adapting these conceptual insights to the examination of public attitudes toward persons with MI, we expect:

H4a.  Individuals who attribute the cause of MI to factors outside of the control of individuals will report fewer negative assessments, stigma and individual/social responses. However, if the cause(s) of MI is located on the shoulders of individuals and their imputed character flaws, the public will report more stigmatizing attitudes and behaviors. 

The Role of Assessment and Labels. Martin, Pescosolido and Tuch (2000) found among a representative sample of Americans, that individuals who attach the label of “mental illness” to a vignette describing a person are less willing to express a preference for interacting with that individual.  Recent research links this type of rejection to the assessment of stigmatizing responses such as dangerousness (e.g., Jones et al 1984; Link et al. 1999; Link et al. 1987; Phelan & Bromet 1998; Phelan et al. 2000; Pescosolido et al. 1999; see Rogers & Pilgrim 2001 on the paradox of stigma and dangerousness statements in government statements in the U.K.).  Further, as stated in the sponsoring PAR, stigma often affects both the perceived and actual ability of individual to fulfill necessary cultural and economic roles in society. Thus, an additional key assessment of individuals with MI is their competence, for example, the ability to make treatment decisions and to manage money (see Pescosolido et al 1999).  Finally, a central assumption in research and policy statements is that awareness of treatment “efficacy” and awareness on the part of the public will reduce stigmatizing responses (DHHS 1999; Arikan 1999?).  Drawing from this, we hypothesize:

H5:  The public’s assessments of individuals with MI regarding such issues as severity, competence, treatment awareness, evaluations of curability, and the willingness to assign a label of MI will influence stigma and individual/social responses.

The Role of Stigma.  To this point, the conceptual model has laid out how socio-demographic attributes, knowledge, contact, attributions and assessments produce both prejudice and discrimination.  The final link in the model is the most expected and understood. That is, stigma produces negative responses in terms of the ability of individuals with MI to enjoy full participation in society.  This well-documented relationship, described throughout this application, and stated in the PAR, is the major motivating force of research and policy initiatives.  Thus, the final individual-level hypothesis simply expresses this:

H6:  Stigmatizing responses that constitute prejudice toward persons with MI shape negative individual and social responses that constitute discrimination.

The Role of Context: Cross-National Exploratory Questions.  While stigma is seen as “cross culturally ubiquitous” (Dovidio et al 2000: 31; Neuberg et al. 2000), the earliest work (Goffman 1963) to the most recent (e.g., Dovidio et al. 2000; Fabrega 1991), conceptualizes stigma as a phenomenon shaped by cultural and historical forces.   Early on, anthropologists described the different ways that cultures shape how individuals with MI are viewed and treated (e.g., Benedict 1934; Townsend 1975).  More recently, Lefley (1990) contends that chronicity, itself, is a cultural artifact based, at least in part on differing worldviews, religious traditions, the role of alternative healing systems, and differences in the culture value of interdependence.  As described in Section A, studies that have documented differences in outcomes for persons with MI across countries point to and call for investigations of stigma across cultural contexts (also see Dovidio et al. 2000; Ng 1997).  They suggest that future research must identify the collective properties of social, cultural, economic and physical environments that influence health and disease outcomes.  However, even with 15 collaborating countries, the ability to determine which characteristics are in operation is limited.  As a result, we suggest two strategies.  The first will examine how the effects expected in Hypotheses 1 through 6 vary across countries (see Analysis Section on testing for level and slope differences across the individual country models).  This suggests the following hypothesis:

H7:  The effects of the relationships between and among concepts that influence stigmatizing response and individual/social responses will vary across nations.

The second strategy lays out a series of sensitizing concepts that can be explored to examine macro-level influences.  Following from Figure 1, the theoretical framework points to the potential influence of four different kinds of “capital” or societal level resources that may influence the social response to persons with MI.  Human and organizational capital targets the organizational policies, incentive structures and resources in health and mental health organizations available to persons with MI.  These differences can be enormous.  Sartorius (1998) reports that the ratio of psychiatrists to the population ranges from 1:1,000-5,00 l in the more developed societies (e.g., Europe) to 1: 50,000- 100,000 in the developing world to only 1:5,000,000 in some African countries.  Not surprisingly, this is not independent of the availability of economic capital in a society which needs to be considered as well. For example, the WHO reports (Regional Strategies Volume : 121) that  countries in the Western Pacific Region devote less than 5% of their small health budgets to mental health and neurological disorders. 

However, more than economic, human and institutional resources are at issue.  In contemporary social science, this focus on community and society level relationships and values are part of a society’s social and cultural capital (e.g., see Lin 1999; Portes 1998; Putnam 1995).  In recent years the notion of social capital has emerged as one of the more promising frameworks in social scientific and popular analyses of the quality of life in contemporary society. While definitions of social capital vary depending on the perspective of the analyst, the consensus in the social and behavioral science literature suggests that “…social capital stands for the ability of actors to secure benefits by virtue of their membership in social networks or other social structures” (Portes 1998: 6). Social capital references issues of social and citizenship rights and emanates from and shapes social relationships.  Cultural capital references the “cultural toolbox” of values and belief systems within a society.  As in micro-level social network theory (see the Contact Hypothesis), these two aspects of the structure of social relationships and their cultural content operate hand-in-hand.  For example, Sampson’s (2002) notion of the “collective efficacy” of “place” which is strongly related to macro-level outcomes (e.g., health outcomes in urban areas of the U.S. ) suggests that two features of geographical units are important -- informal social control and working trust. 

This work further suggests that old theoretical bifurcations need to be rethought.  For example, modernization theorists contend that economic development brings pervasive cultural change while others from traditionalists to postmodernists suggest that cultural values are an enduring and autonomous influence on society (Ingelhart and Baker 2000).  In fact, empirical research suggests that both may be operating within and across societies.  In a study of 65 countries, economic development appears to produce a shift to values that are increasingly tolerant, trusting and participatory.  However, broad cultural heritage (Protestant, Roman Catholic, Confucian and Communist) leaves an imprint on values that endure despite modernization (Inglehart and Baker 1997).  Thus while the world view of people in rich societies differs systematically from those of low income societies, they start from different points shaped by their cultural tradition (Inglehart 1997). Economic capital and cultural capital should be considered as complementary, rather than competing macro-level influences.

In sum, there are four dimensions of cross-national difference that may be useful in exploring if, where and how societal level differences affect stigma.  These considerations lead to two sets of questions.  The first is descriptive and the second is exploratory:

Q1: How do the profiles/levels of knowledge, contact, attributions, assessments, stigmatizing responses and individual and social behaviors differ across countries?

Q2: Do countries with higher levels of social, economic, cultural and human/organizational capital vary systematically in public attitudes toward MI and persons with MI (i.e., higher or lower levels of knowledge, contact, assessments, attributions, stigmatizing responses, and individual/social behavior?