Racial-Ethnic Differences in Mental Health Stigma and Changes Over the Course of a California Statewide Campaign

Abstract

Objective:

This study examined whether shifts in mental health-related stigma differed across racial and ethnic groups over the course of a California statewide anti-stigma campaign and whether racial and ethnic disparities were present at the beginning of the campaign and one year later.

Methods:

Participants had taken part in the 2013 and 2014 California Statewide Survey (CASS), a longitudinal random-digit dialing telephone survey of California adults ages 18 years and older (N=1,285). Surveys were administered in English, Spanish, Mandarin, Cantonese, Vietnamese, Khmer, and Hmong.

Results:

Compared to whites, Latino-Spanish and Asian non-English interview respondents who preferred to take the survey in their native language exhibited higher levels of mental health-related stigma on a number of domains at the 2013 CASS. Specifically, Latino-Spanish and Asian non-English interview respondents were more likely to report social distance, prejudice, and perceptions of dangerousness toward people with mental illness than white respondents. These racial and ethnic disparities persisted one year later at the 2014 CASS. Latino-Spanish respondents did experience significant decreases in social distance over the course of the campaign but not to a degree that eliminated disparities at the 2014 CASS. Disconcertingly, Latino-Spanish respondents experienced significant increases in perceptions of dangerousness between the 2013 and 2014 CASS.

Conclusions:

Future research is needed to better understand which components of anti-stigma campaigns are effective across racial and ethnic minority groups and whether more targeted efforts are needed, especially in light of the persistent and growing racial and ethnic disparities in mental health care.

Mental health-related stigma is a significant public health concern (1–3). Described as the “most formidable obstacle” to progress in mental health by a former U.S. Surgeon General (3), mental health-related stigma can not only discourage people from initiating and adhering to treatment (4–7), but can also create a climate in which people with mental illness are shunned and deprived of opportunities to become full contributing members of society (5, 6, 8).

The pernicious effects of stigma may be particularly severe for racial and ethnic (hereafter abbreviated as racial-ethnic) minorities who may be deterred from treatment because of “double stigma”– prejudice and discrimination resulting from the two stigmatized social identities of minority status and having a mental illness (9, 10). Moreover, some have posited that mental illness may be more highly stigmatized in racial-ethnic minority communities, given different cultural conceptualizations of mental illness and treatment (11–14). Remarkably, whether stigma is more prevalent among racial-ethnic minority groups has been subject to limited investigation. With the exception of one study that found no significant differences between whites and non-whites (15), the few studies conducted with nationally representative U.S. samples have consistently found that blacks, Latinos, and Asian Americans harbor more negative beliefs, primarily related to perceptions of dangerousness, toward people with mental illness (16–18).

Perceptions of dangerousness along with social distance (i.e., reluctance to interact with members of devalued groups) are two domains of stigma that have been the most difficult to shift in both the U.S. and other Western countries (19, 20). To investigate the cumulative impact of local and national stigma reduction campaigns in the U.S., Pescosolido et al. (2010) examined whether shifts in stigma occurred between the years of 1996 and 2006 (race-ethnicity variations were not explored). Although positive shifts occurred in mental health treatment attitudes, concomitant improvements in perceived dangerousness and social distance were not observed (21).

Whether population shifts in stigma differ across racial-ethnic groups has been subject to even less empirical investigation. One of the few studies to examine differential changes in stigma across racial-ethnic groups involved an evaluation of contact-based educational programs (22). Findings revealed that Asian and Latino American participants showed greater reductions in stigma than whites based on comparisons of pre-presentation and immediate post-presentation surveys. However, this study was limited to individuals who self-elected to attend educational presentations about mental illness. In England, where a national stigma and discrimination program has been running for more than a decade, positive shifts in stigma were observed in 2017 compared to baseline surveys in 2008–2009, but these shifts did not appear to differ across racial-ethnic groups (23).

In a landmark effort to reduce mental illness stigma and discrimination in California, a statewide, multifaceted initiative targeting institutional, societal, and individual factors was funded by the Mental Health Services Act and managed by the California Mental Health Services Authority (24). The initiative was implemented through community organizations and included social marketing campaigns in English and Spanish, distribution of informational resources, efforts to improve media portrayals of mental illness, and thousands of contact-based educational presentations. At the evaluation baseline (Spring 2013) most organizations were still building capacity and implementation and reach were limited (25). Statewide surveys conducted at that point and repeated one year later indicated that social distance decreased during this period while perceived public stigma increased (26). However, it is unknown whether shifts in stigma differed across racial-ethnic groups. According to U.S. Census projections, racial-ethnic minorities are expected to become the majority population in less than three decades (27) and in some states like California racial-ethnic minorities already constitute the majority (28). To the authors’ knowledge, no U.S. study has tracked longitudinal shifts in stigma across racial-ethnic groups in the general public during a population-based anti-stigma campaign.

The purpose of this study is twofold: to examine whether shifts in mental health-related stigma during a population-based anti-stigma campaign differed across racial-ethnic groups, and to assess whether racial-ethnic disparities in stigma were present during the start of the California initiative and one year later. This study reanalyzed data from the aforementioned surveys, the 2013 and 2014 waves of the California Statewide Survey (CASS), a surveillance tool following a longitudinal cohort that was developed to track attitudes, beliefs, and behaviors related to mental illness.

METHODS

Sample

Participants were 1,285 individuals who completed both the 2013 and 2014 CASS, a longitudinal telephone survey of California adults ages 18 years and older enrolled through random-digit dialing to landlines and cellphones. The Field Research Corporation administered surveys using their computer-assisted telephone interview system. The baseline CASS was conducted May-September 2013 with 2,006 individuals enrolled May through June, with surveys administered in English or Spanish. An additional oversampling of 567 black, Chinese, Vietnamese, Cambodian, and Laotian Americans, whose phone numbers were identified through purchased targeted lists, were surveyed August-September 2013. Most Asian Americans of this oversample chose to complete the survey in their native language (i.e., Mandarin, Cantonese, Vietnamese, Khmer, and Hmong). The follow-up 2014 CASS was conducted one year later (May-September 2014); 1,285 adults (50% of baseline participants) were re-interviewed. Institutional review board approval and informed consent were obtained.

Measures

Survey items were largely drawn from prior studies that developed surveys to track mental health-related stigma at the population level (17, 20, 29–32). The 2013 and 2014 CASS assessed the following stigma domains (33): social distance, traditional prejudice, perceptions of dangerousness, treatment carryover, and disclosure carryover. Perceived public stigma and courtesy stigma were also assessed (33).

Social distance the desire to distance from persons with stigmatized statuses was assessed by asking participants to rate their degree of willingness to “move next door to”, “spend an evening socializing with”, and “start working closely on a job with “someone who has a mental illness (21, 33). Response options were dichotomized (0=probably/definitely willing; 1=probably/definitely unwilling).

Traditional prejudice (negative stereotypes or beliefs about people with mental illness) was assessed with the item, “People who have had a mental illness are never going to be able to contribute to society much.” Perceptions of dangerousness was assessed with the item, “I believe a person with mental illness is a danger to others” (17). Perceived public stigma (beliefs about the public’s attitudes and behaviors toward people with mental illness) was measured with the items: “People with mental illness experience high levels of prejudice and discrimination”(31) and “People are generally caring and sympathetic to people with mental illness”(17). The aforementioned measures employ a five-point Likert scale and response options were dichotomized (0=strongly/moderately disagree/neither agree nor disagree; 1=moderately/strongly agree).

Treatment carryover a belief that public knowledge that an individual has obtained mental health treatment would diminish one’s status within the community, was measured with the following items (31, 34): “Would you put off seeking treatment for fear of letting others know about your mental health problem?” and “If you had a serious emotional problem, would you go for professional help?” Response options were dichotomized (0=probably/definitely not; 1=probably/definitely would).

Disclosure carryover a belief that disclosing a stigmatized condition such as a mental illness will incur negative responses, was assessed with the following: “Would you try to hide your mental health problem from family or friends?” and “Would you try to hide your mental health problem from co-workers or classmates?” (31). Response options were dichotomized (0=probably/definitely not; 1=probably/definitely would).

Courtesy stigma occurs when those with social ties to individuals with mental illness incur devalued status, also referred to as “stigma by association” (35–37). Courtesy stigma was measured with the question, “If someone in your family had a mental illness, would you feel ashamed if people knew about it?” (38, 39). Response options were dichotomized (0=probably/definitely not ashamed; 1=definitely/probably ashamed).

>Exposure to the social marketing portion of the anti-stigma campaign was assessed with eight items in the 2014 CASS asking respondents if they had been exposed to different marketing activities during the past 12 months. Endorsement of any of the activities was coded as 1 (exposed) and endorsing none was coded as 0 (not exposed).

>Race-ethnicity and language. Based on self-reported race, ethnicity, and preferred language of interview, we categorized participants according to the following groups: white, Latino-English, Latino-Spanish, Asian-English, Asian non-English, and black.

Analyses

Weights were applied to align sample characteristics with the characteristics of the California population. Attrition was higher for all non-white respondents. Inverse probability weights were used to account for these differences. The resulting sample is roughly representative of the general California adult population though somewhat fewer Latinos were represented as indicated by the 2013 census (40). We report the weighted percentage of respondents that positively endorsed each stigma domain at baseline and follow-up by race-ethnicity and language. To test for significant shifts in stigma between the baseline and follow-up surveys, we employed separate logistic regression analyses for each of the racial-ethnic groups predicting each stigma item at follow-up, controlling for its baseline value. To assess whether racial-ethnic disparities were present at the beginning of the initiative and/or one year later, we conducted separate logistic regression analyses predicting each stigma item at baseline and at follow-up from the racial-ethnic groups with whites as the reference group. Exploratory analyses examined whether any observed disparities at follow-up remained after controlling for exposure to social marketing aspects of the campaign.

RESULTS

Sample characteristics are provided in Table 1. Changes in mental health-related stigma between baseline and follow-up surveys varied by racial-ethnic language group (see Table 2). Decreased stigma occurred in all groups except white and black respondents. Latino-English, Latino-Spanish, and Asian-English respondents all exhibited reductions in social distance. Asian non-English respondents exhibited decreases in disclosure carryover. Interestingly, increases in stigma were observed for white (perceived public stigma), Latino-English (traditional prejudice), Latino-Spanish (dangerousness and disclosure carryover), and Asian-English respondents (disclosure carryover). See Online Supplement for weighted percentages, standard deviations (SDs), chi-square test statistics, and p-values.

Table 1.

Descriptives of Sample (N=1,285)

Variables	Unweighted N	Weighted %
Female	665	51
Age
18–29	195	23
30–39	171	17
40–49	215	19
50–64	401	25
65 and up	303	16
Race-Ethnicity/Language
Latino English	146	18
Latino Spanish	117	14
Asian English	58	5
Asian non-English	111	8
Black	183	5
White	584	45
Other	86	6

Table 2.

Weighted Percentage of Respondents Endorsing Stigma-Related Beliefs in Seven Domains, by Race-Ethnicity and Language (2013 and 2014 California Statewide Surveys)

	White English			Latino English			Latino Spanish			Asian-English			Asian non-English			Black English
	2013	2014		2013	2014		2013	2014		2013	2014		2013	2014		2013	2014
Social Distance
Unwilling to move next door	26	25		32	22	−	56 a	53 a		45 a	29	−	62 a	56 a		29	23
Unwilling to spend an evening socializing	13	13		19	12	−	61 a	52 a	−	16	10		33 a	32 a		14	19
Unwilling to start working closely on a job	25	24		21	22		53 a	41 a	−	27	21		53 a	51 a		25	23
Traditional Prejudice
Never going to contribute much to society	5	6		4	10	+	39 a	37 a		11	9		41 a	43 a		12 a	8
Perceptions of Dangerousness
A person with mental illness is a danger to others	19	17		20	20		42 a	51 a	+	16	17		60 a	61 a		22	21
Treatment Carryover
Would delay treatment for fear of others knowing	11	13		18	22		16	12		29 a	28		10	11		10	14
Would go for professional help	94	94		93	93		98	97		91	85		78 a	89		93	95
Disclosure Carryover
Would hide MI from co-workers or classmates	56	60		52	52		11 b	18 b	+	44	65	+	32 b	19 b	−	50	45 b
Would hide MI from family or friends	23	26		22	19		12	15		29	32		17	14		22	18
Perceived Public Stigma
People are caring and sympathetic to PWMI	34	34		37	32		53 b	46		44	44		92 b	89 b		48 b	43
PWMI experience high levels of prejudice	76	82	+	73	79		80	80		76	73		61 b	68		63 b	77
Courtesy Stigma
Would feel ashamed if family had mental illness	6	5		4	7		3	3		10	11		13 a	13 a		2	1

Note: + indicates significant increases in stigma between survey waves; − indicates significant decreases in stigma between survey waves; p<.05. All significance tests were adjusted to control the family-wise error rate at 5% within each stigma domain and wave using Holm’s method (55).

^aSignificant disparity (stigma level higher among racial-ethnic minority group compared to whites), p<.05.

^bReverse disparity (stigma level lower among racial-ethnic minority group compared to whites), p<.05.

Significant racial-ethnic disparities occurred at baseline, with the greatest number of differences from whites observed among Latino-Spanish and Asian non-English respondents (see Table 2). Latino-Spanish and Asian non-English respondents exhibited significantly higher levels of stigma on all three social distance items. Compared to white respondents, Latino-Spanish and Asian non-English respondents were more than twice as likely to be unwilling to move next door, to socialize, or work closely with someone experiencing a mental illness. They were also about three times as likely to perceive people with mental illness as dangerous and six to seven times as likely to say they are never going to contribute much to society. Additionally, Asian non-English respondents expressed greater levels of treatment carryover and courtesy stigma than white respondents. Reverse disparities were also observed among Latino-Spanish and Asian non-English respondents who exhibited lower levels of disclosure carryover and perceived public stigma than white respondents. No disparities were observed among Latino-English respondents. Asian-English respondents experienced disparities from whites in social distance and treatment carryover. Black respondents were more likely to endorse traditional prejudice but less likely to endorse perceived public stigma than white respondents.

One year later, all of the disparities documented among Latino-Spanish and Asian non-English respondents at the start of the initiative persisted, with the exception of treatment carryover stigma in the Asian non-English group (see Table 2). Baseline reverse disparities among Latino-Spanish (i.e., disclosure carryover) and Asian non-English respondents (i.e., disclosure carryover, perceived public stigma) also persisted at follow-up. For Asian-English respondents, baseline disparities (social distance and treatment carryover) were no longer present at follow-up.

Exploratory analyses revealed differential exposure to the social marketing aspect of the campaign, with 47% Latino-English, 48% Latino-Spanish, 26% Asian-English, 28% Asian non-English, 50% black, and 35% white respondents reporting exposure (Chi-square=31.54, df=6, p<.001). Asian non-English respondents had lower (p=.03) and black respondents higher (p=.02) exposure than whites. After controlling for exposure, only a single disparity at follow-up was no longer significant; namely, the Latino-Spanish disparity on social distance (unwilling to work closely).

DISCUSSION

This is the first U.S. study to assess whether shifts in mental health-related stigma during the implementation of a population-based anti-stigma campaign differed by race-ethnicity and language. Our findings indicate clear group differences with decreases in stigma occurring in both language groups of Latino and Asian respondents but no decreases among white or black respondents between the 2013 and 2014 CASS. Moreover, Latino (English and Spanish) and Asian (English only) respondents exhibited a more complex pattern with increases and decreases across varying stigma domains. Findings raise questions about whether the campaign might have been less effective for white and black respondents and for certain stigma domains among Latino and Asian respondents. Findings also highlight how associations between stigma domains may differ across racial-ethnic groups. For instance, Latino-Spanish respondents showed significant increases in perceptions of dangerousness but decreases in social distance. Prior studies show positive associations between perceptions of dangerousness and social distance, but correlations have ranged from 0.2 to 0.6 indicating that these two stigma domains tap distinct underlying beliefs (41, 42). It is unclear whether this pattern of findings of Latino and Asian respondents exhibiting both improvements and exacerbation in stigma levels is indicative of racial-ethnic differences in the interrelationships between stigma constructs or in the impact of the campaign across different stigma dimensions.

Nonetheless, persistent disparities across several stigma domains were apparent among Latino-Spanish and Asian non-English respondents, who reported greater levels of social distance, perceptions of dangerousness, and traditional prejudice on the 2013 and 2014 CASS. Latino-Spanish respondents did experience reductions in social distance but not to a degree that eliminated disparities at the 2014 CASS. Findings underscore the importance of accounting for intragroup differences within racial-ethnic minority groups. Treating interview language as an approximate and imperfect indicator of acculturation, it appears that reducing stigma disparities may be particularly challenging among immigrant groups with lower levels of acculturation. Non-English respondents, who are likely immigrants who arrived in the U.S. as adults, may maintain cultural conceptualizations of mental illness from their native countries that may shape their attitudes toward people with mental illness. For instance, conceptualizations of mental illness in Asian and Latin American countries may be limited to more severe forms of mental illness such as psychotic disorders (43–45), which may be related to perceptions of dangerousness. This is consistent with prior research showing racial-ethnic minority groups in the U.S. and other Western countries harboring greater perceptions of dangerousness compared to their majority counterparts (46).

None of the racial-ethnic minority groups exhibited greater levels of disclosure carryover or perceived public stigma than white respondents; in fact, Latino-Spanish and Asian non-English respondents were less likely to endorse these stigma domains. Immigrants may prefer to turn to family and friends first for help with mental health problems than mental health professionals (47), which may account for non-English respondents being less likely to endorse potentially hiding a mental illness from others. However, despite the observed reverse disparities, Latino-Spanish respondents exhibited increases in disclosure carryover between survey waves, which may reflect acculturation to (negative) views of mental illness in the U.S.

Altogether, findings underscore the importance of cultural influences on not only the salience of particular domains of stigma but also potentially on shifts within these stigma domains. The intransigent disparities observed among non-English groups on social distance, prejudice, and perceptions of dangerousness may negatively impact the recovery and integration of people with mental illness who reside within these communities. Non-English respondents likely immigrated from Latin America and Asia where hospital-based care versus community-based care is more prevalent and experiences of people with mental illness being fully integrated into society may be more limited (48, 49). Immigrant groups may need more frequent, higher doses, or better quality contact with people who have recovered successfully from a mental illness to override disparities in negative conceptualizations of mental illness that may be prevalent in their native country and current ethnic enclaves where public disclosure of mental health problems is even less the norm than in broader U.S. society (50). Public stigma may translate into internalized stigma and lead to premature termination from treatment; addressing stigma within the course of treatment, especially with racial-ethnic minorities, may be critical to ensuring successful outcomes (51, 52). Though culture has been identified as a key factor that shapes stigma (9, 48), there has been limited research in this arena. Much of the research has documented cultural variations in the prevalence of stigma, but few have examined why these differences occur (46); such information could be critical to tailoring effective anti-stigma interventions for culturally diverse populations.

Certain study limitations should be considered. Our study’s use of single-item measures, though drawn from prior population-based surveys, may have limited reliability. The study’s sample of Asian and Latino groups were not sufficiently diverse or powered to examine potential intragroup differences. Even though the documented shifts in stigma occurred during the time of the campaign, it is uncertain if they were a direct result of the campaign. Secular trends in stigma or events occurring during the campaign (e.g., high profile suicides) may have affected public attitudes. The statewide initiative featured other components tailored for African American (e.g., faith-based initiative to create mental health friendly congregations), Asian (e.g., in-language radio public service announcements) and Latino (e.g., family forums) communities, which could have contributed to shifts in stigma. Moreover, the baseline CASS was administered while the anti-stigma statewide initiative had already been underway and may not have captured true estimates of stigma pre-intervention, resulting in a potential underestimation of change. Future studies may be better able to link changes to campaign efforts by simultaneously implementing intervention activities in certain regions, while withholding activities in others to manufacture a control comparison region as in a prior study in Germany (53).

CONCLUSION

This study documented racial-ethnic variations in shifts across multiple domains of stigma in a population-based sample. Prior population-based studies examining racial-ethnic differences have focused on only a few dimensions of stigma (16, 18) and rarely investigated shifts during an anti-stigma campaign. Evaluating which components of anti-stigma campaigns are effective across racial-ethnic minority groups are warranted for future research to know whether more targeted efforts are needed, especially in light of the persistent and growing racial-ethnic disparities in mental health care (54).

Highlights.

• This is the first U.S. study to assess whether shifts in mental health-related stigma over the course of a population-based anti-stigma campaign differed by race-ethnicity and language.

• Compared to white respondents, Latino-Spanish and Asian non-English interview respondents reported significantly higher levels of stigma (i.e., social distance, prejudice, and perceptions of dangerousness) at the start of the campaign and one year later.

• Further research is needed to better understand which anti-stigma campaign components are effective across racial and ethnic minority groups and whether more targeted efforts are needed.