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Chapter 2 examines how and why the United States chose to deliver the EITC in one annual payment as a tax refund, and how this is a stark contrast to how other social benefits are administered. One reason is administrative cost – it is relatively inexpensive to allow taxpayers to self-declare eligibility and receive benefits as a tax refund. Because other social benefit programs have direct contact with their recipients prior to payment, those programs have far higher administrative costs and far smaller overpayment rates. Delivery of social benefits through the tax system also avoids the stigma associated with applying for benefits through social welfare workers. This chapter cites empirical studies about taxpayer preferences as to delivery method and timing of refund and evidence as to how EITC recipients spend their refund. It also describes experiments with periodic payment, including the Advance Earned Income Tax Credit.
Previous research has shown that psychoeducation for bipolar disorder (BD) improves symptoms and reduces relapse risk, but there is little research on how this impacts stigma, perceived recovery and views about diagnosis. The aim of this study was to explore whether a cognitive behaviour therapy (CBT)-based 12-week BD psychoeducation group conducted in a community mental health team for adults impacted perceived stigma, diagnosis-related self-esteem, recovery and views about diagnosis. The case series pre- and post-group had 23 participants across three groups. The Brief Illness Perception Questionnaire, views on Manic Depression Questionnaire, Bipolar Recovery Questionnaire and author-constructed questions were completed pre and post. Twenty participants completed the group. An intent-to-treat repeated measures multiple analysis of variance showed significantly improved perceived recovery and improvements in sense of control and understanding around their diagnosis. Other specific questions such as understanding of triggers and impact of thinking patterns also improved. However, there was no change in the perceived stigma or self-esteem associated with living with BD. CBT-based psychoeducation groups may help improve perceived recovery and factors such as sense of control in BD. However, there appears to be no impact on stigma and self-esteem, and the role of non-specific factors needs to be examined further.
Key learning aims
(1)To raise awareness of the impact of stigma and self-esteem in bipolar disorder.
(2)To understand the content and structure of CBT-based psychoeducation groups.
(3)To consider the potential benefits of CBT-based psychoeducation groups beyond symptoms and relapse reduction on factors such as perceived recovery.
To assess the perception of Ghanaian medical students about factors influencing their career interest in psychiatry and to explore gender differences in these perceptions.
This is a cross-sectional quantitative survey of 5th and 6th year medical students in four public medical schools in Ghana. Data were analyzed with descriptive and inferential statistics using SPSS version 20.
Responses were obtained from 545 medical students (response rate of 52%). Significantly, more male medical students expressed that stigma is an important consideration for them to choose or not to choose a career in psychiatry compared to their female counterparts (42.7% v. 29.7%, respectively). Over two-thirds of the medical students perceived that psychiatrists were at risk of being attacked by their patients, with just a little over a third expressing that risk was an important consideration for them to choose a career in psychiatry. There were no gender differences regarding perceptions about risk. Around 3 to 4 out of 10 medical students will consider careers in psychiatry if offered various incentives with no gender differences in responses provided.
Our study presents important and novel findings in the Ghanaian context, which can assist health policy planners and medical training institutions in Ghana to formulate policies and programs that will increase the number of psychiatry residents and thereby increase the psychiatrist-to-patient ratio in Ghana.
The prevalence of common mental disorders has not declined in high-income countries despite substantial increases in service provision. A possible reason for this lack of improvement is that greater willingness to disclose mental disorders might have led to increased reporting of psychiatric symptoms, thus masking reductions in prevalence. This masking hypothesis was tested using data from two trials of interventions that increased willingness to disclose and that also measured symptoms. Both interventions involved Mental Health First Aid (MHFA) training, which is known to reduce stigma, including unwillingness to disclose a mental health problem.
A cross-lagged panel analysis was carried out on data from two large Australian randomised controlled trials of MHFA training. The first trial involved 1643 high school students in Year 10 (mean age 15.87 years), who were randomised to receive either teen MHFA training or physical first aid training as the control. The second trial involved 608 Australia public servants who were randomised to receive either eLearning MHFA, blended eLearning MHFA or eLearning physical first aid as the control. In both trials, willingness to disclose a mental disorder as described in vignettes and psychiatric symptoms (K6 scale) were measured pre-training, post-training and at 12-month follow-up.
Both trials found that MHFA training increased willingness to disclose. However, a cross-lagged panel analysis showed no effect of this change on psychiatric symptom scores.
Greater willingness to disclose did not affect psychiatric symptom scores. Because the trials increased willingness to disclose through a randomly assigned intervention, they provide a strong causal test of the masking hypothesis. It is therefore unlikely that changes in willingness to disclose are masking reductions in prevalence in the population.
Pakistan is a lower middle-income country, which to date has had very little research and policy making to address the challenge of dementia. This study aims to explore the perceptions of dementia in a group of Pakistani adults. A series of focus group discussions were completed during 2017 with men and women in two metropolitan centres in Pakistan (Lahore and Karachi) (N = 40). Two vignettes, depicting someone with mild dementia and someone with severe dementia, were used to facilitate discussions. An induction-led thematic analysis was completed. Five themes were identified, reflecting (a) dementia awareness, (b) responsibility, (c) barriers to health care, (d) identified support needs, and (e) religion. Most participants had little awareness and knowledge about dementia, commonly understood to be a disease of forgetting or just normal ageing. Thus, there is an urgent need of a nation-wide campaign to raise dementia awareness in Pakistan, though this needs to be accompanied by improved, accessible health and social care services.
Outbreaks of emerging infectious disease are a constant threat. In the last 10 years, there have been outbreaks of 2009 influenza A (H1N1), Ebola virus disease, and Zika virus. Stigma associated with infectious disease can be a barrier to adopting healthy behaviors, leading to more severe health problems, ongoing disease transmission, and difficulty controlling infectious disease outbreaks. Much has been learned about infectious disease and stigma in the context of nearly 4 decades of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome pandemic. In this paper, we define stigma, discuss its relevance to infectious disease outbreaks, including how individuals and communities can be affected. Adapting lessons learned from the rich literature on HIV-related stigma, we propose a strategy for reducing stigma during infectious disease outbreaks such as Ebola virus disease and Zika virus. The implementation of brief, practical strategies such as the ones proposed here might help reduce stigma and facilitate more effective control of emerging infectious diseases.
Family education programs (FEPs) target caregiving-related psychological distress for carers of relatives/friends diagnosed with serious mental health conditions. While FEPs are efficacious in reducing distress, the mechanisms are not fully known. Peer group support and greater mental health knowledge are proposed to reduce carers' psychological distress by reducing stigmatising attitudes and self-blame, and strengthening carers' relationship with their relative.
Adult carers (n = 1016) who participated in Wellways Australia's FEP from 2009 to 2016 completed self-report questionnaires at the core program's start and end, during the consolidation period, and at a 6-month follow-up. Those who enrolled early completed questionnaires prior to a wait-list period. We used linear mixed-effects modelling to assess the program's effectiveness using a naturalistic wait-list control longitudinal design, and multivariate latent growth modelling to test a theory-based process change model.
While there was no significant change over the wait-list period, psychological distress, self-blame and stigmatising attitudes significantly decreased, and communication and relationship quality/feelings increased from the core program's start to its end. Changes were maintained throughout the consolidation period and follow-up. Peer group support significantly predicted the declining trajectory of distress. Peer group support and greater knowledge significantly predicted declining levels of self-blame and stigmatising attitudes, and increasing levels of communication.
This is the first study to quantitatively validate the mechanisms underlying the effect of FEPs on carers' psychological distress. Peer group support is key in modifying carers' appraisals of their friend/relatives' condition. Continued implementation of FEPs within mental health service systems is warranted.
Objectives: To evaluate the attitudes and perceptions of psychiatrists and psychiatry residents regarding neurosurgical procedures for treating psychiatric disorders and to identify potential barriers to patient referral. Methods: A survey consisting of 25 questions was created using SurveyMonkey and was distributed to psychiatrists and psychiatry residents in Quebec. The study was approved by the McGill University Health Center’s Research Ethics Board. Descriptive statistics and Friedman’s test were performed using SPSS software. Results: A total of 99 participants, including 64 residents and 35 psychiatrists, completed more than 75% of the survey and were included in data analysis. Overall, participants were significantly (p < 0.0005) more comfortable in referring patients suffering from treatment-resistant obsessive–compulsive disorder than from treatment-resistant major depressive disorder and preferred to refer patients for deep brain stimulation (DBS) rather than for anterior cingulotomy/capsulotomy (AC). Only 11.43% of psychiatrists had ever referred a patient for AC or DBS, and 34.69% of respondents felt that these procedures were dangerous. Lack of knowledge (82.83%) was viewed as the principal limiting factor, and 57.58% of respondents identified ≥6 different barriers to patient referral. The majority of participants (69.39%) were interested in improving their knowledge on psychiatric neurosurgery, and 82.65% felt that this subject should be included in the psychiatry residency curriculum. Conclusion: Overall, participants acknowledged having many limitations to referring patients for neurosurgical interventions. While informative conferences discussing neuromodulation/neuroablation could easily address many barriers, further studies are required to assess how these could change attitudes and patterns of referral.
Refugees report elevated rates of posttraumatic stress disorder (PTSD), but are relatively unlikely to seek help for their symptoms. Mental health stigma is a key barrier to help-seeking amongst refugees. We evaluated the efficacy of an online intervention in reducing self-stigma and increasing help-seeking in refugee men.
Participants were 103 refugee men with PTSD symptoms from Arabic, Farsi or Tamil-speaking backgrounds who were randomly assigned to either receive an 11-module online stigma reduction intervention specifically designed for refugees (‘Tell Your Story’, TYS) or to a wait-list control (WLC) group. Participants completed online assessments of self-stigma for PTSD and help-seeking, and help-seeking intentions and behaviors at baseline, post-intervention, and at a 1 month follow-up.
Intent-to-treat analyses indicated that, compared to the WLC, TYS resulted in significantly smaller increases in self-stigma for seeking help from post-treatment to follow-up (d = 0.42, p = 0.008). Further, participants in the TYS conditions showed greater help-seeking behavior from new sources at follow-up (B = 0.69, 95% CI 0.19–1.18, p = 0.007) than those in the WLC. The WLC showed significantly greater increases in help-seeking intentions from post-intervention to follow-up (d = 0.27, p = 0.027), relative to the TYS group.
This is the first investigation of a mental health stigma reduction program specifically designed for refugees. Findings suggest that evidence-based stigma reduction strategies are beneficial in targeting self-stigma related to help-seeking and increasing help-seeking amongst refugees. These results indicate that online interventions focusing on social contact may be a promising avenue for removing barriers to accessing help for mental health symptoms in traumatized refugees.
There is a growing population of ageing individuals living with the human immunodeficiency virus (HIV). Older adults living with HIV often contend with intersecting stigmas including HIV stigma, ageism and, for some, homonegativity and/or racism. Although the HIV stigma literature is quite robust, research on the relationship between HIV stigma, social support and mental wellbeing among older adults living with HIV is limited. This study begins to address this gap by examining how intersectional stigma affects social support and mental wellbeing among rural-dwelling older adults living with HIV. Qualitative interviews were conducted by phone with 29 older adults living with HIV, over the age of 50, living in rural areas of the United States of America. Interviews were transcribed verbatim and analysed using thematic content analysis in MAXQDA qualitative analysis software. Analysis revealed three primary themes. The first had to do with gossip and non-disclosure of HIV status, which intersected with ageism and homonegativity to exacerbate experiences that fell within the remaining themes of experiences of physical and psychological isolation and loneliness, and shame and silence surrounding depression. The prevalence of social isolation and the effects of limited social support among older adults living with HIV are prominent and indicate a need for tailored interventions within the HIV care continuum for older adults living with HIV.
Our aim was to investigate patterns of change in public knowledge, attitudes, desire for social distance and reporting having contact with people with mental health problems in England during the Time to Change (TTC) programme to reduce stigma and discrimination 2009–2017.
Using data from an annual face-to-face survey of a nationally representative quota sample of adults, we evaluated longitudinal trends of the outcome measures with regression analyses and made assumptions on the basis of a simple random sample. We tested interactions between year and demographic subgroups.
There were improvements in all outcomes in 2017 compared with baseline measures (2008 or 2009). Reported in s.d. units [95% confidence interval (CI)], the improvement for knowledge was 0.17 (0.10–0.23); for attitudes 0.25 (0.18–0.31); and for social distance 0.29 (0.23–0.35). A higher likelihood of reporting contact was also associated with most recent survey year (odds ratio 1.47, 95% CI 1.27–1.71). Statistically significant interactions between year and region of England suggest greatest improvements in attitudes and intended behaviour in London, where both outcomes were significantly worse in the early years of the survey. However, for attitudes, this interaction was only significant among women. Other significant interactions suggest that attitudes improved most in the target age group (25–44).
The results provide support for the effectiveness of TTC across demographic groups. However, other societal changes may influence the results, such as the increasing prevalence of common mental disorder in young women.
Retention of participants has been an issue in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). It has been suggested that the perceived value of WIC may affect whether participants remain in the programme. The present study aimed to explore this phenomenon.
Using a constructivist approach, thirty-one individual in-depth interviews were conducted. Transcripts were analysed using constant comparative analysis. Social, cultural and environmental factors that contribute to the value of WIC were explored as the phenomenon of interest.
Eight WIC clinics across the State of Illinois, USA.
Thirty-one caregivers of children enrolled in WIC for at least 6 months.
Several factors influenced perceived value of WIC at the interpersonal (level of social support), clinic (value of WIC services v. programme administration issues), vendor (shopping difficulties), community and systems levels (other programme use, stigma and restrictions on food choice). Other themes existed along continua, which overlapped several levels (continuum of perceived need and perceived value of infant formula).
Many caregivers value WIC, especially before their child turns 1 year old. Improvements are needed at the clinic, during shopping and within the food packages themselves in order to increase perceived value of WIC.
Although palliative care is critical to managing symptoms, pain, and transitions to end-of-life care among those facing serious or chronic illness, it is often underused, which may be due to stigma associated with palliative care representing giving up fighting one's illness. The goal of the present studies was to test the theoretical framework of stigma within the context of palliative care to inform future work on intervention development that addresses potential barriers to palliative care utilization.
In study 1, participants (n = 152) had an oncologist describe two treatment options to a terminally ill cancer patient: (1) palliative care and (2) chemotherapy. Participants were then randomly assigned to read that the patient chose palliative care or chemotherapy. In study 2, these stereotypes about those receiving palliative care were examined as a potential mediator between perceived palliative care stigma and prospective palliative care use. Participants (n = 199) completed self-report measures of palliative care stigma, negative stereotypes about palliative care users, and prospective use of palliative care. Mediation analysis tested the mediational effects of stereotypes on the relationship between palliative care stigma and prospective usage of palliative care.
In study 1, those in the palliative care condition endorsed significantly higher levels of negative stereotypes about the patient, viewed the decision more negatively, and saw the patient as less afraid of death. In study 2, palliative care stigma was associated with less prospective usage of palliative care for self and for one's family member. This relationship was mediated by negative stereotypes about individuals receiving palliative care.
Significance of results
Results suggest that palliative care stigma exists (study 1) and that this stigma may be a barrier to the utilization of palliative care (study 2). Future research should examine stigma reduction as a potential intervention target to improve palliative care utilization.
Since 2008 England's anti-stigma programme Time to Change has lobbied media outlets about stigmatising coverage and worked with them to promote accurate and non-stigmatising coverage. While this may have an impact on coverage and hence attitudes, it is also possible that coverage can change in response to improving attitudes, through the creation of a market demand for less stigmatising coverage. This study evaluates English newspaper coverage of mental health topics between 2008 and 2016.
Articles covering mental health in 27 newspapers were retrieved using keyword searches on two randomly chosen days each month in 2008–2016, excluding 2012 and 2015 due to restricted resources. Content analysis used a structured coding framework. Univariate logistic regression models were used to estimate the odds of each hypothesised element occurring in 2016 compared with 2008 and Wald tests to assess the overall statistical significance of the year variable as the predictor.
The sample retrieved almost doubled between 2008 (n = 882) and 2016 (n = 1738). We found a significant increase in the proportion of anti-stigmatising articles (odds ratio (OR) 2.26 (95% confidence interval (CI) 1.86–2.74)) and a significant decrease in stigmatising articles (OR 0.62 (95% CI 0.51–0.75)). Reports on all diagnoses except for schizophrenia were more often anti-stigmatising than stigmatising.
This is the first clear evidence of improvement in coverage since the start of Time to Change. However, coverage of schizophrenia may be less affected by this positive shift than that of other diagnoses. The increase in the level of coverage identified in 2016 requires further investigation, as it may also influence public conceptualisation of what constitutes mental illness, attitudes to mental illness in general and/or specific diagnoses. While most anti-stigma programmes are not diagnosis specific, we suggest their evaluation would benefit from a diagnosis specific approach to allow fuller interpretation of their effects. This could include media analysis driven by hypotheses based on diagnoses to ascertain whether variations by diagnosis over time occur both in the nature and in the proportion of coverage.
As reported from studies conducted in Nepal, between 15% and 57% of adults had ever consumed alcohol and between 1.5% and 25% of adults have alcohol use disorders (AUD). Few studies in Nepal have identified the correlates of consumption or described the help-seeking patterns and stigma among those affected with AUD.
Interviewers administered the Alcohol Use Disorders Identification Test (AUDIT) as part of population-based surveys of adults in Chitwan District between 2013 and 2017. We conducted a secondary analysis to identify sociodemographic and health-related correlates of recent alcohol consumption using the χ2 test, to identify correlates of total AUDIT scores among men who drink using negative binomial regression, and to describe the treatment-seeking and stigma beliefs of men with AUD.
Over half (53.7%, 95% CI 50.4–57.0) of men (n = 1130) recently consumed alcohol, and there were associations between being a drinker with age, religion, caste, education, occupation and tobacco use. Nearly one in four (23.8%, 95% CI 20.2–27.8%) male drinkers screened positive for AUD, and AUDIT scores were associated with age, caste, marital status, occupation, tobacco use, depression, functional status and suicidal ideation. Few (13.3%, 95% CI 11.7–15.0) women (n = 2352) recently consumed alcohol, and 5.3% (95% CI 3.0–9.1) of female drinkers screened positive for AUD. Among AUDIT-positive men, 38% spoke to another person about their problems and 80% had internalized stigma.
This study revealed that nearly one in four men who drink likely have AUD. Higher AUDIT scores were associated with depression, suicidality, dysfunctionality and internalized stigma.
Medicalizing beliefs about schizophrenia (biogenetic causes and psychiatric labels) are connected to the belief that people with schizophrenia are dangerous and to discriminating intentions towards them. In this research, we draw on the Social Dominance theory and we examine these beliefs as legitimizing myths that are connected to the individuals’ social dominance orientation (SDO) and that legitimize discrimination. In total, 238 Humanities students participated in the current research (Mage = 20.4; SD = 3.03; 107 male and 131 female). A vignette presenting a person with schizophrenia symptoms that offered no labels or explanations about the depicted person’s condition was presented to research participants. A structural equation modeling analysis was carried out, in order to confirm our hypotheses in accordance with social dominance theory. Participants’ social dominance orientation (SDO) was associated with higher endorsement of medicalizing (β = .16, p < .01) and dangerousness beliefs (β = .22, p < .001). In turn, medicalizing beliefs were connected to dangerousness (β = .21, p < .001) and higher discriminating intentions, both for desired social distance (β = .15, p < .05) and for deprivation of sociopolitical rights (β = .14, p < .05). Dangerousness was highly associated with both these measures (β = .28, p < .001 and β = 43, p < .001 respectively) while SDO was not significantly associated with discriminating intentions. Our model showed good fit to the data. This study confirms the role of SDO in schizophrenia stigma and the fact that ideological and power factors underpin the stigma of schizophrenia.
Nearly 33 million female youths have an unmet need for voluntary family planning (FP), meaning they are sexually active and do not want to become pregnant. In Ethiopia, age at marriage remains low: 40% and 14% of young women aged 20–24 were married by the ages of 18 and 15, respectively. Despite increases in FP use by married 15- to 24-year-olds from 5% in 2000 to 37% in 2016, unmet need remains high at 19%. Supply-and-demand factors have been shown to limit FP use, yet little is known about how stigma influences FP use among youth. This study validates an anticipated stigma (expectation of discrimination from others) index and explores its effect on unmet need. A cross-sectional survey was implemented with 15- to 24-year-old female youth in Ethiopia in 2016. The analytic sample included married respondents with a demand (met and unmet need) for FP (n=371). A five-item anticipated stigma index (Cronbach’s α=0.66) was developed using principal component factor analysis. These items related to fear, worry and embarrassment when accessing FP. The findings showed that 30% agreed with at least one anticipated stigma question; 44% had an unmet need; 58% were married before age 18; and 100% could name an FP method and knew where to obtain FP. In multivariate regression models, youth who experienced anticipated stigma were significantly more likely to have an unmet need, and those who lived close to a youth-friendly service (YFS) site were significantly less likely to have an unmet need. Interventions should address anticipated stigma while focusing on social norms that restrict married youth from accessing FP; unmet need may be mitigated in the presence of a YFS; and the anticipated stigma index appears valid and reliable but should be tested in other countries and among different adolescent groups.
To develop an educational video to reach elderly Latinos in order to improve understanding and encourage evaluation of cognitive changes by 1) using focus groups to identify dementia knowledge gaps, health communication preferences and trusted advisors for health concerns; 2) collaborating with elderly Latino community members to create a video; and 3) collecting survey data regarding community response to the video.
Grounded theory qualitative approach using focus groups; collaborative community based model to create the video and anonymous survey at community screenings.
Community senior centers in East Harlem, New York.
A team of low-income mono and bilingual elderly Latino community residents, researchers, clinicians, and a film professional.
Thematic analysis of focus group transcripts; three item survey.
A collaboratively produced video and initial assessment in 49 Latino elders that indicated the video had a positive effect on interest in obtaining a brief memory screening at outreach events (71%).
The project demonstrates the feasibility of this interdisciplinary partnership to create a culturally and linguistically sensitive video to promote service use concerning memory loss and cognitive evaluations among elderly Latinos. Initial survey results suggested a positive response and an increase in interest in memory screening.
Recently the Norwegian Health Minister ordered the creation of medication-free treatment wards as a result of the lobbying by patients’ groups and activists. The idea behind this is that patients should have the right to choose their treatment, but for the first time, with this arrangement, the user/patient does not choose between treatment options; he literally determines by himself what efficacious treatment is. In our opinion this is another step towards a ‘reverse stigma’ which denies patients the right to be considered as such and eventually kicks them out of the health care system, deprives them of the right for proper treatment and care and instead puts them at the jurisdiction of the much cheaper and ineffective social services.