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Introduction: Acute bloody diarrhea obligates rapid and accurate diagnostic evaluation; few studies have described such cohorts of children. Methods: We conducted a planned secondary analysis employing the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) acute gastroenteritis study cohort to describe the characteristics of children with acute bloody diarrhea, compared to a cohort of children without hematochezia. Children <18 years of age presenting to 2 pediatric tertiary care emergency departments (EDs) in Alberta, with ≥3 episodes of diarrhea and/or vomiting in the preceding 24 hours and <7 days of symptoms were consecutively recruited. Stools were tested for 17 viruses, bacteria and parasites. Primary outcomes were clinical characteristics and pathogens identified. Secondary outcomes included interventions and resource utilization. Results: Of 2257 children enrolled between October 2015 and August 2018, hematochezia before or at the index ED visit was reported in 122 (5.4%). Compared to children with nonbloody diarrhea, children with hematochezia had longer illness duration [59.5 vs. 41.5 hrs, difference 10.6, 95% CI 3.5, 19.9], more diarrheal episodes in a 24-hour period [8 vs. 5, difference 3, 95% CI 2, 4], and less vomiting [55.7% vs. 91.1%; difference -35.3%; 95% CI -44.7, -26.3]. They received more intravenous fluids [32.0% vs. 18.3%; difference 13.7%, 95% CI 5.5, 23.0], underwent non-study stool testing [53.7% vs. 4.8%; difference 49.0%, 95% CI 39.6, 58.0], experienced longer ED visits [4.1 vs. 3.3 hours, difference 0.9, 95% CI 0.3, 1.0] and were more likely to have repeat healthcare visits within 14 days [54.8% vs. 34.2%; difference 20.6%, 95% CI 10.8, 30.1]. A bacterial enteric pathogen was found in 31.9% of children with hematochezia versus 6.6% without bloody diarrhea (difference 25.4%, 95% CI 17.2, 34.7). In children with hematochezia, the most commonly detected bacteria were Salmonella spp. (N = 15), Shiga toxin-producing E. coli (N = 9), Campylobacter spp. (N = 7), and Shigella spp. (N = 5). Viruses were detected in 32.8% of children with bloody diarrhea, most commonly adenovirus (N = 15), norovirus (N = 14), sapovirus (N = 8) and rotavirus (N = 7). Conclusion: Children with hematochezia differed clinically from those without hematochezia and required more healthcare resources. While bacterial etiologies are common, several viruses were also detected.
Mental health stigma is a multidimensional concept that encompasses many different themes and definitions. Public stigma is defined as the degree to which the general public holds negative views and discriminates against a specific group.
To understand the context and correlates of stigma in multi-ethnic Singapore.
The current study aimed to (i) explore the factor structure of the Depression Stigma Scale and the Social Distance Scale using an exploratory structural equation modelling approach and (ii) examine the correlates of the identified dimensions of stigma in the general population of Singapore.
Data for the current study came from a larger nation-wide cross-sectional study of mental health literacy conducted in Singapore. All respondents were administered the Personal and Perceived scales of the Depression Stigma Scale and the Social Distance scale to measure personal stigma and social distance respectively.
The findings from the factor analysis revealed that personal stigma formed two distinct dimensions comprising “Weak-not-Sick” and “Dangerous/Unpredictable” components while social distance stigma items loaded strongly into a single factor. Those of Malay and Indian ethnicity, lower education, lower income status and those who were administered the depression and alcohol abuse vignette were significantly associated with higher weak-not-sick scores. Those of Indian ethnicity, 6 years of education and below, lower income status and those who were administered the alcohol abuse vignette were significantly associated with higher dangerous/unpredictable scores.
There is a need for well-planned and culturally relevant anti-stigma campaigns in this population.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Various socio-demographic variables have been shown to influence attitudes towards seeking professional psychological help (ATSPPH), while negative ATSPPH can act as a barrier to mental healthcare, resulting in under-utilization of psychological services.
Aims and objectives
To explore the factor structure of the ATSPPH scale and determine whether any significant socio-demographic differences exist in relation to ATSPPH among a nationally representative sample.
Data was extracted from a population-based, cross-sectional survey conducted between March 2014 and March 2015 among Singapore Residents aged 18-65 years (n = 3006). Respondents completed the 10-item ATSPPH scale and also provided socio-demographic information. Exploratory factor analysis (EFA) was performed to establish the factor structure of the ATSPPH scale. Multivariable linear regression analyses were conducted to examine socio-demographic factors associated with ATSPPH.
EFA revealed that the ATSPPH scale formed three distinct dimensions comprising “Openness to seeking professional help”, “Value in seeking professional help” and “Preference to cope on your own”. Higher “Openness to seeking professional help” scores were significantly associated with 18-34-year-olds and unmarried respondents, whilst Malay ethnicity and lower education were significantly associated with lower openness scores. Malays, Indians and lower education were significantly associated with lower “Value in seeking professional help” scores, whereas higher “Preference to cope on your own” scores were significantly associated with lower education.
Population subgroups including those with lower educational levels and different ethnic groups have more negative ATSPPH. Tailored, culturally appropriate educational interventions which reduce negative ATSPPH are needed, which effectively target these populations.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Given the emphasis on inclusion of well-being interventions in the treatment and rehabilitation of individuals with mental disorders, it is important to understand the level and determinants of positive mental health (PMH) among them.
To conduct a cross-sectional study among patients with schizophrenia, depression and anxiety spectrum disorders to estimate PMH.
(i) To estimate the level of PMH among patients with mental disorders and compare these with the established general population estimates; (ii) to identify socio-demographic and clinical determinants of PMH.
Following ethics approval, 353 patients aged 21-65 years, receiving treatment at a psychiatric hospital in Singapore for schizophrenia, depression or anxiety spectrum disorders were included. Patients provided socio-demographic information and completed the multidimensional PMH instrument that provides total and domain-specific scores ranging from 1 to 6; higher scores indicate better PMH. Functioning was assessed with the Global Assessment of Functioning (GAF) scale and clinical data were obtained from administrative databases.
Sample comprised 142, 139 and 72 patients with schizophrenia, depression and anxiety spectrum disorders respectively, with a mean age of 39.2 years. Mean total PMH scores among them were 4.2, 3.7 and 3.8 respectively which were significantly lower than the general population mean of 4.5 (P < 0.001). Patients of Chinese ethnicity, with lower education, depression or anxiety, and lower GAF scores were more likely to have lower PMH.
This study identified patient subgroups that are likely to have poorer PMH. Interventions facilitating PMH among these patient groups would be beneficial and are needed.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
This paper explores dependencies between operational risks and between operational risks and other risks such as market, credit and insurance risk. The paper starts by setting the regulatory context and then goes into practical aspects of operational risk dependencies. Next, methods of modelling operational risk dependencies are considered with a simulation study exploring the sensitivity of diversification benefits arising from dependency models. The following two sections consider how correlation assumptions may be set, highlighting some generic dependencies between operational risks and with non-operational risks to assist in the assessment of dependencies and correlation assumptions. Supplementary appendices provide further detail on generic dependencies as well as a case study of how business models can lead to operational risks interacting with other risks. Finally, the paper finishes with a literature review of operational risk dependency papers including correlation studies and benchmark reports.
This study investigated the effect of forage type (grass or red clover) and harvesting time (primary growth or regrowth) of silage on energy and N utilisation by sheep fed at maintenance level. Specifically, the assumption of constant loss of energy of digestible organic matter from energy losses in urine and CH4 applied in evaluation of silage metabolisable energy (ME) was investigated. Urinary excretion of high-energy phenolic compounds related to solubilisation of lignin was assumed to affect urinary energy (UE) losses from sheep fed highly digestible grass silage (GS). A total of 25 primary growth and regrowth silages of timothy (Phleum pratense) and meadow fescue (Festuca pratensis) grass mixtures and red clover (Trifolium pratense) samples collected in digestibility trials with sheep, including faecal and urine samples, were used for energy and N determinations. Urinary concentration of monophenolic compounds and CH4 emissions in vitro were also analysed. Daily faecal N output, CH4 yield (MJ/kg DM intake), proportion of CH4 energy in digestible energy (DE) and proportion of UE in DE were greater (P ≤ 0.03) in sheep fed red clover silage (RCS) than GS. Furthermore, less (P = 0.01) energy was lost as UE of DE in sheep fed primary growth GS compared with the other treatments. The relationship between UE and silage N intake or urinary N output for both silage types (i.e. grass v. red clover) was strong, but the fit of the regressions was better for GS than RCS. The CH4/DE ratio decreased (P < 0.05) and the UE/DE ratio increased (P < 0.05) with increasing organic matter digestibility in RCS. These relationships were not significant (P < 0.05) for the GS diets. The regression coefficient was higher (P < 0.05) for GS than RCS when regressing ME concentration on digestible organic matter. The results of this study imply that ME/DE ratio is not constant across first-cut GS of different maturities. The ME production response may be smaller from highly digestible first-cut GS but could not be clearly related to urinary excretion of monophenols derived from solubilisation of lignin. Furthermore, energy lost in urine was not clearly defined for RCS and was much more predictable for GS from silage N concentration.
We present some results from the DRAGON simulations, a set of four direct N-body simulations of globular clusters (GCs) with a million stars and five percent initial (primordial) binaries. These simulations were undertaken with the NBODY6++GPU code, which allowed us to follow dynamical and stellar evolution of individual stars and binaries, formation and evolution of white dwarfs, neutron stars, and black holes, and the effect of a galactic tidal field. The simulations are the largest existing models of a realistic globular cluster over its full lifetime of 12 billion years. In particular we will show here an investigation of the population of binaries including compact objects (such as white dwarfs - cataclysmic variables and merging black hole binaries in the model as counterparts of LIGO/Virgo sources); their distribution in the cluster and evolution with time.
The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural–geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.
Hand-foot-mouth disease (HFMD) is an acute infectious disease caused by serotypes of the enterovirus (EV) family. HFMD reinfection occurs commonly in lack of cross-protection between different EV serotypes. In this study, we investigated the hazards of HFMD reinfection using Cox-proportional hazard model. Retrospective data of 95 209 HFMD cases in Wuhan during 2008–2015 was used. Kaplan–Meier survival methods and Cox-proportional hazard model were used to estimate the hazard probabilities. Of the all HFMD cases, about 2% experienced reinfection (1842/95 209). Kaplan–Meier curves revealed the reinfection risk sharply increased before 40 months from first infection. Higher hazards of reinfection were detected among those who were males, aged 3 years and below, scattered children, belonging to urban areas and first infected with coxsackievirus (CV)-A16 compared with their respective counterparts. Cox-proportional hazard model suggested that gender, age, group, living area and serotypes of first infection had significant effect on reinfection even after adjusting for potential confounding effects of other selected factors considered in the study. These results indicate that boys aged 3 years and below, especially those living in urban areas and first infected with CV-A16 are more prone to reinfection. Interventions should be imposed on these high-risk populations.
Introduction: Gastroenteritis accounts for 1.7 million emergency department visits by children annually in the United States. We conducted a double-blind trial to determine whether twice daily probiotic administration for 5 days, improves outcomes. Methods: 886 children aged 348 months with gastroenteritis were enrolled in six Canadian pediatric emergency departments. Participants were randomly assigned to twice daily Lactobacillus rhamnosus R0011 and Lactobacillus helveticus R0052, 4.0 x 109 CFU, in a 95:5 ratio or placebo. Primary outcome was development of moderate-severe disease within 14 days of randomization defined by a Modified Vesikari Scale score 9. Secondary outcomes included duration of diarrhea and vomiting, subsequent physician visits and adverse events. Results: Moderate-severe disease occurred in 108 (26.1%) participants administered probiotics and 102 (24.7%) participants allocated to placebo (OR 1.06; 95%CI: 0.77, 1.46; P=0.72). After adjustment for site, age, and frequency of vomiting and diarrhea, treatment assignment did not predict moderate-severe disease (OR, 1.11, 95%CI, 0.80 to 1.56; P=0.53). In the probiotic versus placebo groups, there were no differences in the median duration of diarrhea [52.5 (18.3, 95.8) vs. 55.5 (20.2, 102.3) hours; P=0.31], vomiting [17.7 (0, 58.6) vs. 18.7 (0, 51.6) hours; P=0.18], physician visits (30.2% vs. 26.6%; OR 1.19; 95% CI0.87. 1.62; P=0.27), or adverse events (32.9% vs. 36.8%; OR 0.83; 95%CI 0.62. 1.11; P=0.21). Conclusion: In children presenting to an emergency department with gastroenteritis, twice daily administration of 4.0 x 109 CFU of a Lactobacillus rhamnosus/helveticus probiotic does not prevent development of moderate-severe disease or improvements in other outcomes measured.
Piglets are characteristically cold intolerant and thus susceptible to high mortality. However, browning of white adipose tissue (WAT) can induce non-shivering thermogenesis as a potential strategy to facilitate the animal’s response to cold. Whether cold exposure can induce browning of subcutaneous WAT (sWAT) in piglets in a similar manner as it can in humans remains largely unknown. In this study, piglets were exposed to acute cold (4°C, 10 h) or chronic cold exposure (8°C, 15 days), and the genes and proteins of uncoupling protein 1 (UCP1)-dependent and independent thermogenesis, mitochondrial biogenesis, lipogenic and lipolytic processes were analysed. Interestingly, acute cold exposure induced browning of porcine sWAT, smaller adipocytes and the upregulated expression of UCP1, PGC1α, PGC1β, C/EBPβ, Cidea, UCP3, CKMT1 and PM20D1. Conversely, chronic cold exposure impaired the browning process, reduced mitochondrial numbers and the expression of browning markers, including UCP1, PGC1α and PRDM16. The present study demonstrated that acute cold exposure (but not chronic cold exposure) induces porcine sWAT browning. Thus, browning of porcine sWAT could be a novel strategy to balance the body temperature of piglets, and thus could be protective against cold exposure.
Galeruca daurica (Joannis) is a new outbreak pest in the Inner Mongolia grasslands in northern China. Heat shock protein 10 and 60 (Hsp10 and Hsp60) genes of G. daurica, designated as GdHsp10 and GdHsp60, were cloned by rapid amplification of cDNA ends techniques. Sequence analysis showed that GdHsp10 and GdHsp60 encoded polypeptides of 104 and 573 amino acids, respectively. Sequence alignment and phylogenetic analysis clearly revealed that the amino acids of GdHsp10 and GdHsp60 had high homology and were clustered with other Hsp10 and Hsp60 genes in insects which are highly relative with G. daurica based on morphologic taxonomy. The mRNA expression analysis by real-time PCR revealed that GdHsp10 and GdHsp60 were expressed at all development stages and in all tissues examined, but expressed highest in eggs and in adults’ abdomen; both heat and cold stresses could induce mRNA expression of GdHsp10 and GdHsp60 in the 2nd instar larvae; the two Hsp genes were expressed from high to low with the extension of treatment time in G. daurica eggs exposed to freezing point. Overall, our study provides useful information to understand temperature stress responses of Hsp60 and Hsp10 in G. daurica, and provides a basis to further study functions of Hsp60/Hsp10 relative to thermotolerance and cold hardiness mechanism.
Whether monozygotic (MZ) and dizygotic (DZ) twins differ from each other in a variety of phenotypes is important for genetic twin modeling and for inferences made from twin studies in general. We analyzed whether there were differences in individual, maternal and paternal education between MZ and DZ twins in a large pooled dataset. Information was gathered on individual education for 218,362 adult twins from 27 twin cohorts (53% females; 39% MZ twins), and on maternal and paternal education for 147,315 and 143,056 twins respectively, from 28 twin cohorts (52% females; 38% MZ twins). Together, we had information on individual or parental education from 42 twin cohorts representing 19 countries. The original education classifications were transformed to education years and analyzed using linear regression models. Overall, MZ males had 0.26 (95% CI [0.21, 0.31]) years and MZ females 0.17 (95% CI [0.12, 0.21]) years longer education than DZ twins. The zygosity difference became smaller in more recent birth cohorts for both males and females. Parental education was somewhat longer for fathers of DZ twins in cohorts born in 1990–1999 (0.16 years, 95% CI [0.08, 0.25]) and 2000 or later (0.11 years, 95% CI [0.00, 0.22]), compared with fathers of MZ twins. The results show that the years of both individual and parental education are largely similar in MZ and DZ twins. We suggest that the socio-economic differences between MZ and DZ twins are so small that inferences based upon genetic modeling of twin data are not affected.
Studies from high-income countries report moderate-to-strong positive associations between alcohol use disorder (AUD) and other mental disorders, but there is little evidence about the comorbidity of AUD from low-and-middle-income countries.
A sample of 74 752 adults from five provinces that account for >12% of China's adult population was screened using the General Health Questionnaire, and the Structured Clinical Interview for DSM-IV was administered by psychiatrists to a subsample of 9619 males. The associations between AUD and other mental disorders at each site and the characteristics of men with AUD with and without comorbid mental disorders were estimated using logistic regression and summarized across sites using meta-analysis. Generalized estimation equations estimated the associations between the clinical features of alcohol dependence and comorbidity.
Robust inverse associations were found between current AUD and any mood disorder (adjusted OR = 0.6, 95% CI = 0.4–0.8) and any anxiety disorder (OR = 0.5, 95% CI = 0.3–1.0). Compared with men without AUD, men with AUD without comorbid disorders were more likely to be middle-aged, to be currently married, and to have higher family incomes. Men with comorbid AUD and other disorders were more likely to have the clinical features of alcohol dependence than men with AUD without comorbid disorders.
Inverse associations between AUD and other mental disorders and the higher social status of men with AUD than men without AUD found in this large, representative sample of community-dwelling Chinese males highlight the importance of considering the local substance-use culture when designing clinical or preventive interventions for addictive conditions.
To identify the common causal beliefs of mental illness in a multi-ethnic Southeast Asian community and describe the sociodemographic associations to said beliefs. The factor structure to the causal beliefs scale is explored. The causal beliefs relating to five different mental illnesses (alcohol abuse, depression, obsessive-compulsive disorder (OCD), dementia and schizophrenia) and desire for social distance are also investigated.
Data from 3006 participants from a nationwide vignette-based study on mental health literacy were analysed using factor analysis and multiple logistic regression to address the aims. Participants answered questions related to sociodemographic information, causal beliefs of mental illness and their desire for social distance towards those with mental illness.
Physical causes, psychosocial causes and personality causes were endorsed by the sample. Sociodemographic differences including ethnic, gender and age differences in causal beliefs were found in the sample. Differences in causal beliefs were shown across different mental illness vignettes though psychosocial causes was the most highly attributed cause across vignettes (endorsed by 97.9% of respondents), followed by personality causes (83.5%) and last, physical causes (37%). Physical causes were more likely to be endorsed for OCD, depression and schizophrenia. Psychosocial causes were less often endorsed for OCD. Personality causes were less endorsed for dementia but more associated with depression.
The factor structure of the causal beliefs scale is not entirely the same as that found in previous research. Further research on the causal beliefs endorsed by Southeast Asian communities should be conducted to investigate other potential causes such as biogenetic factors and spiritual/supernatural causes. Mental health awareness campaigns should address causes of mental illness as a topic. Lay beliefs in the different causes must be acknowledged and it would be beneficial for the public to be informed of the causes of some of the most common mental illnesses in order to encourage help-seeking and treatment compliance.
The ability to recognise a mental illness has important implications as it can aid in timely and appropriate help-seeking, and ultimately improve outcomes for people with mental illness. This study aims to explore the association between recognition and help-seeking preferences and stigmatising attitudes, for alcohol abuse, dementia, depression, obsessive-compulsive disorder (OCD) and schizophrenia, using a vignette-based approach.
This was a population-based, cross-sectional survey conducted among Singapore Residents (n = 3006) aged 18–65 years. All respondents were asked what they think is wrong with the person in the vignette and who they should seek help from. Respondents were also administered the Personal and Perceived sub scales of the Depression Stigma Scale and the Social Distance Scale. Weighted frequencies and percentages were calculated for categorical variables. A series of multiple logistic and linear regression models were performed separately by vignette to generate odd ratios and 95% confidence intervals for the relationship between help-seeking preference, and recognition and beta coefficients and 95% confidence intervals for the relationship between stigma and recognition.
Correct recognition was associated with less preference to seek help from family and friends for depression and schizophrenia. Recognition was also associated with increased odds of endorsing seeking help from a psychiatric hospital for dementia, depression and schizophrenia, while there was also an increased preference to seek help from a psychologist and psychiatrist for depression. Recognition was associated with less personal and perceived stigma for OCD and less personal stigma for schizophrenia, however, increased odds of social distancing for dementia.
The ability to correctly recognise a mental illness was associated with less preference to seek help from informal sources, whilst increased preference to seek help from mental health professionals and services and less personal and perceived stigma. These findings re-emphasise the need to improve mental health literacy and reinforce the potential benefits recognition can have to individuals and the wider community in Singapore.
An outbreak of gastroenteritis affected 453 attendees (attack rate 28·5%) of six separate events held at a hotel in Singapore. Active case detection, case-control studies, hygiene inspections and microbial analysis of food, environmental and stool samples were conducted to determine the aetiology of the outbreak and the modes of transmission. The only commonality was the food, crockery and cutlery provided and/or handled by the hotel's Chinese banquet kitchen. Stool specimens from 34 cases and 15 food handlers were positive for norovirus genogroup II. The putative index case was one of eight norovirus-positive food handlers who had worked while they were symptomatic. Several food samples and remnants tested positive for Escherichia coli or high faecal coliforms, aerobic plate counts and/or total coliforms, indicating poor food hygiene. This large common-source outbreak of norovirus gastroenteritis was caused by the consumption of contaminated food and/or contact with contaminated crockery or cutlery provided or handled by the hotel's Chinese banquet kitchen.
The current study aimed to: (i) describe the extent of overall stigma as well as the differences in stigma towards people with alcohol abuse, dementia, depression, schizophrenia and obsessive compulsive disorder, as well as (ii) establish the dimensions of stigma and examine its correlates, in the general population of Singapore, using a vignette approach.
Data for the current study came from a larger nation-wide cross-sectional study of mental health literacy conducted in Singapore. The study population comprised Singapore Residents (Singapore Citizens and Permanent Residents) aged 18–65 years who were living in Singapore at the time of the survey. All respondents were administered the Personal and Perceived scales of the Depression Stigma scale and the Social Distance scale to measure personal stigma and social distance, respectively. Weighted mean and standard error of the mean were calculated for continuous variables, and frequencies and percentages for categorical variables. Exploratory structural equation modelling and confirmatory factor analysis were used to establish the dimensions of stigma. Multivariable linear regressions were conducted to examine factors associated with each of the stigma scale scores.
The mean age of the respondents was 40.9 years and gender was equally represented (50.9% were males). The findings from the factor analysis revealed that personal stigma formed two distinct dimensions comprising ‘weak-not-sick’ and ‘dangerous/unpredictable’ while social distance stigma items loaded strongly into a single factor. Those of Malay and Indian ethnicity, lower education, lower income status and those who were administered the depression and alcohol abuse vignette were significantly associated with higher weak-not-sick scores. Those of Indian ethnicity, 6 years of education and below, lower income status and those who were administered the alcohol abuse vignette were significantly associated with higher dangerous/unpredictable scores. Those administered the alcohol abuse vignette were associated with higher social distance scores.
This population-wide study found significant stigma towards people with mental illness and identified specific groups who have more stigmatising attitudes. The study also found that having a friend or family member with similar problems was associated with having lower personal as well as social distance stigma. There is a need for well-planned and culturally relevant anti-stigma campaigns in this population that take into consideration the findings of this study.